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DOCUMENT RESUME

FD 034 339 EC 004 653

Compr=hensivP Stai-ewile Planning Project for "ocational Rc.habilitation Services; Molltana. Final Report. -rrc-T-TI-TO" Montana Div. of Vocational Fehabilitation, Helena.

cwv7.5 AaRNCY Rehabilita+ion Services Administration (DHFW), Washington, P.C. pUm nhmy 'Iov P 1,T0-71.7 /47n.

7717:s DT)-rrp FDRS Price '1F-1.75 HC-4'21.40 '113CPTPrrOPS Community Surveys, Demography, *Exceptional Child Services, Financial Support, *Handicapped Children, Tncidence, Tnsi-itutions, Professional Personnel, Program Planning, Regional Planning, Rehabilitation Centers, rehabilitation Programs, Sheltered Workshons, State Agencies, *State Programs, *Vocational Rehabilitation TDEMmTFTERS Montana

ABSTRACT A report of vocational rehabilitation planning is introduced by the history and principles of rehabilitation, a discussion of legal provisions, sources of funds, planning objectives, and project population and organization. Demographic information, statewide recommendations, and descriptions of state institutions and agencies are included along with the methods used for estimating the potential of inmates. Additional information concerns the disabled and handicapped in the state, the five planning regions, the rehabilitation facilities (treatment centers, halfway houses, and sheltered workshops), and project studies (involving Physicians, nurses, professional personnel, school personnel, and a closed caseload study). Related programs on the aging, correctional rehabilitation, economic opportunity, facilities and workshops, military rejectees, public assistance, the rural disabled, social security, workmen's compensation, voluntary organizations, and coordination of programs are also discussed. Five appendixes and a summary of recommendations are provided. (3M) let* 111 ALmaw

COleREHENSIVE STATEWIDE PLANNING PROJECT MR VOCATIONAL REHABILITATION SERVICES

MONTANA

Division of Vocational Rehabilitation 507 Power Block Helena, Montana 59601

T. J. Witham Project Director

Inclusive Period of Planning Project December 1, 1966 - November 30, 1968

Date of Preparation November 30, 1968

This planning program was supported by a grant, under Section4(a)(2)(b), from the Rehabilitation Services Administration, Social and Rehabilitation Service, Department of Health, Education, and Welfare, Washington, D. C.

U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE

OFFICE OF EDUCATION

THIS DOCUMENT HAS BEEN REPRODUCED EXACTLY AS RECEIVED FROM THE

PERSON OR ORGANIZATION ORIGINATING IT.POINTS OF VIEW OR OPINIONS

STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICE OF EDUCATION POSITION OR POLICY. DISCRIMINATION PROHIBITED -- Title VI of theCivil Rights Act of196k states: "No person in the United States shall, on the groundsof race, color, or national origin, be excludedfrom participation in, be denied the benefits of, or be subjected todiscrimination under any program or activity receiving Federal financialassistance." Therefore, all programs and activities receivingfinancial assistance from the Department of Health, Education, and Welfare must beoperated in compliance with this law.

ii ditzTr.tita

MONTANA STATEWIDE PLANNING PROJECT FOR VOCATIONAL REHABILITATION SERVICES

517 POWER BLOCK HELENA. MONTANA 59601 TEL. 442-3260. EXT. 263

WM. WALTERSKIRCHIN. CHRM. JOHN STRIZ:CH. M.D.. CHRM. T.J. WITHAM POLICY BOARD EXECUTIVE COMMITTEE PROJECT DIRECTOR September 27, 1968

TO:The Honorable Tim Babcock

It is with pleasure that the final report of the Governor'sPolicy Board of the Statewide Planning Project for Vocational Rehabilitation is presented to you and to the citizens of Montana.

This report represents the efforts of hundreds of citizens whohave generously given of their time and energies during the past 21 months so that the disabled children andadults of our State can fully share the opportunities that other Montanans enjoy.

Rehabilitation presents both a challenge and a promise.The challenge can be met if the governmentaland voluntary agencies coordinate their efforts and their resources in the years ahead. The promise will be fulfilled when each person, disabled due to physical, mental, or other conditions, becomes a socially and economically contributing member of our society.

Very respectfully submitted,

WM. C. WALTERSKIRCHEN Chairman, Policy Board

iii ACKNOWLEDGMW

Appreciation is expressed to thehundreds of interested Montanans who haveparticipated in the Project and given so willingly of theirtime and energies so that adequate programs for all disabledwill be available in the coming years.

T.J.W. TABLE OF CONTPNTS

Chapter Page

I. INTRODUCTION I

Principles of Rehabilitation History of Rehabilitation Legal Authority and Responsibility of Montana Division of Vocational Rehabilitation and Division of Blind Services Source of Funds Division of Vocational Rehabilitation and Division of Blind Services Need for Planning Objectives of Planning Project Population Project Organization

II. DEMOGRAPHIC INFORMATION 19

III. STATEWIDE RECOMMENDATIONS 29

IV. STATE INSTITUTIONS MD AGENCIES 125

Methods Used to Estimate Potential of Inmates for Vocational Rehabilitation Services Warm Springs State Hospital Galen State Hospital Mountain View School Montana Children's Center Montana State Prison Pine Hills School Boulder River School and Hospital State School for the Deaf and Blind State Agencies Summary

V. THE DISABLED AND HANDICAPPED OF MONTANA 167

Community Survey Method The Disabled of Montana: Estimates and Projections of Chronic Disability and Activity Limitations

VI. MONTANA PLANNING PROJECT REGIONS 185

PlanningRegion 1 PlanningRegion 2 PlanningRegion 3 PlanningRegion 4 PlanningRegion 5 CONTENTS (Continued)

VII. REHABILITATION FACILITIES 241

Rehabilitation and Treatment Cepters Harley Houses Sheltered Workshops

VIII. PROJECT STUDIES 261

Preface Physicians Survey Nurses Survey Professional Personnel. School P:a.sonnel Closed Caseload Study

IX. RELATED PROGRAMS 325

The Aging Correctional Rehabilitation Economic Opportunity Program Facilities and Workshops The Military Rejectee Public Assistance The Rural Disabled Social Security and Vocational Rehabilitation Workmen's Compensation Voluntary Organizations Inter-Agency Coordination of Service Programs Coordination with Other State Planning

X. SUMMARY OF RECOMMENDATIONS 341

Appendix A: Organizational Charts 355 Appendix B: Project Organization 361 Appendix C: Supportive Data 373 Appendix D: Maps 399 Appendix E: Project Activities 1407

vi LIST OF TABLES BY CHAPTER

Table Page

CHAPTER I

1 Source of Funds - DVR and DBS 8

CHAPTER II

2 Population - Growth Projections 21

3 Major Sources of Income 24

4 Non-Agricultural Employment Trends in Montana 24

CHAPTER III

5 Number of Employee Man-Years: And Numberof Persons Rehabilitated, Active Cases Served, and Referred Cases Processed Per Employee Man-Year -Region and Agency, 1967 32

6 Total DVR Federal Money. Available toMontana and State Appropriations... 43

7 Number of Handicapped Children in SpecialEducation Programs - By Handicapping Condition 87

CHAPTER IV

8 Number of Residents and Daily Per Capita Costs - Montana Institutions 126

9 Staffing Patterns - Montana Institutions 127

10 Patient Characteristics- WarmSprings State Hospital 134

11 Patient Characteristics-Mountain View School 140

12 Patient Characteristics Nbntana Children's Center.. 142

13 Patient Characteristics-Montana State Prison 145-3_47

14 Patient Characteristics-Pine Hills School 149

15 Patient Characteristics- BoulderRiver School and Hospital 153

vii TABLES (Continued)

Table Page

CHAPTER V

16 Overall Survey Returns 169

Characteristics of 10,555 Identified Disabled and Handicapped in Montana

17 Ages by Sex 170

18 Marital Status by Sex 171

19 Racial Characteristics by Sex 172

20 Employment Status by Sex 173

21 Employment Barriers by Sex 174

22 Disabilities by Sex 175

23 Disabilities by Sex 175

24 Disabilities by Sex 176

25 Disabilities Reported in Montana Survey 176

26 Selected Reported Disabilities by Region 178

27 Reporting Agencies - Sex Reported 179

28 Chronic Conditions and Activity Limitations in Mbntana 182-183

CHAPTER VI

29 Chronic Conditions and Activity Limitations - Region 1 189

30 Percentages of Physicians Indicating Rehabilitation Potential of Special Groups - Region 1 191

31 Educational Level of Respondents - Professional Survey - Region 1 193

32 Percentages of Professionals and School Personnel Making Referrals to DVR and MS - Region 1 194

33 Estimates of Vocational Rehabilitation Success - Professional Survey - Region 1 194

viii TABLES (Continued)

Table Page

34 Reasons for Non-Referral to Vocational Rehabilitation - Professional Survey - Region 1 194

35 Chronic Conditions and Activity Limitations - Region 2 199

36 Percentages of Physicians Indicating Rehabilitation Potential of Special Groups - Region 2 201

37 Educational Level of Respondents - Professional Survey Region 2 203

38 Percentages of Professionals and School Personnel Making Referrals to DVR and DBS - Region 2 204

39 Estimates of Vocational Rehabilitation Success - Professional Survey - Region 2 204

40 Reasons for Non-Referral to Vocational Rehabilitation - Professional Survey - Region 2 204

41 Chronic Conditions and Activity Limitations - Region 3 209

42 Percentages of Physicians Indicating Rehabilitation Potential of Special Groups - Region 3 211

43 Educational Level of Respondents - Professional Survey - Region 3 213

44 Percentages of Professionals and School Personnel Making Referrals to DVR and DBS - Region 3 214

45 Estimates of Vocational Rehabilitation Success - Professional Survey - Region 3 214

46 Reasons for Non-Referral to Vocational Rehabilitation - Professional Survey - Region 3 214

47 Chronic Conditions and Activity Limitations - Region 4 219

48 Percentages of Physicians Indicating Rehabilitation Potential of Special Groups - Region 4 221

49 Educational Level of Respondents - Professional Survey - Region 4 223

50 Percentages of Professionals and School Personnel Making Referrals to DVR and DBS - Region 4.. 224

ix TABLES (Continued)

Table Page

51 Estimates of Vocational Rehabilitation Success - Professional Survey - Region 4 224

52 Reasons for Non-Referral to Vocational Rehabilitation - Professional Survey - Region 4 224

53 Chronic Conditions and Activity Limitations - Region 5 231

54 Percentages of Physicians Indicating Rehabilitation Potential of Special Groups - Region 5 233

55 Educational Level of Respondents - Professional Survey - Region 5 235

56 Percentages of Professionals and School Personnel }taking Referrals to DVR and DBS - Region 5 236

57 Estimates of Vocational Rehabilitation Success - Professional Survey - Region 5 236

58 Reasons for Non-Referral to Vocational Rehabilitation - Professional Survey - Region 5 236

CHAPTER VIII

59 Physician Survey Responses 263 (Tables 59-A through 59-K- pages265-277)

60 Employment Characteristics of 493 Nurses 283 (Tables 60-A through 60-D- pages384-287)

61 Professional Personnel Survey (Non-School Related) 294 (Tables 61-A through 61-D- pages295-299)

62 School Personnel 301 (Tables 62-A through 62-D- pages302-305)

Non-Rehabilitated Client Characteristics - Closed Caseload Study

63 By Sex 314

64 Residence 314

65 Age at Closure 315

66 Number of Dependents Per Client - Bon-Rehabilitants 316 111 67 Educational. Level 316 TABLES (Continued)

Table Page

Ron-Rehabilitated Client Characteristics - Closed Caseload Study (Continued)

68 Disability Category 317

69 Reasons Not Serviced to Successful Conclusion 318

70 Related Problems of Significance in Case 319

71 "Do You Think This Client Could Have Been Rehabilitated if Unlimited Rehabilitation Resources and Funds Were Available to Him9" 320

72 "If Answer is 'Yes,' ChecAdditionalk: Services That Are Needed." 321

73 "Do Youu. Agree With the Counselor's Reasoning Used in Closing This Case?" 322

74 "How Much Money Was Fapended by the Division of

Vocational Rehabilitation?" , 322

75 "Is There Indication That Other Agencies Expended Funds?" 323

76 "If 'Yes,' What Agency?" 323

77 "Does the Case Indicate Awareness and Utilization of Related Agencies and Services?" (By the Counselor) 324

xi LIST 0?? MAPS

Man Page

1 Statewide Planning Districts 15

2 Statewide Planning Regions 16

3 Number of Persons Per Square Mile Montana Counties 20

4 Urban-Rural Population Distribution Montana - 1960 22

5 Montana Population Rate of County Increase or Decrease 23

6 Indian Reservations - Land Area and number of Inhabitants - Mbntana 25

7 Median Incomes of Families By County Abntana - 1960 26

8 Division of Vocational Rehabilitation Offices 4C1

9 Division of Blind Services Offices 401

10 Institutions 402

11 Special Education Classes By County Work-Study Programs 403

12 Facilities 403

13 Public Health Nurses 404

14 Nurses-Physicians 404

15 Resident Therapists 405

16 County. Welfare Department Social Workers As Of February, 1967 405 CHAPTER I

INTRODUCTION

Principles of Rehabilitation

The productive efforts of all citizens are required inany society

that is concerned with the economic, social, and personal well-being of its

members. Work, traditionally an integral part of the culture of America,

provides a means of satisfying many basic needs. It furnishes the necessary

subsistence to the individual and his family, while enabling psychological

and social needs to find expression in a creative manner. The dependence of unproductive individuals tends to debilitate not only the nation but the individual himself. Disability can result in costly dependence, but rehabilitation offers hope through the reduction or elimination of resultant conditions of dependency. The ethical and religious ideals of the Judeo-Christian faiths in this country have also influenced the philosophy of rehabilitation.

As a consequence we find the combination of work orientation and humanitarian principles in a social service program. These are the basic underlying concepts upon which rehabilitation programs have been developed in this country.

Disabled persons frequently present unique problems which require a wide array of professional services and facilities to overcome; theseare services which the average disabled person is ill-equipped to obtain without help. Specialized programs and agencies are needed if the disabled are not to be neglected in programs designed to serve the general population.

Rehabilitation has been defined in many ways, and each practitioner tends to accept the definition most descriptive of his function.This lack

1 of a standard definition contributes to thesegmentation and fragmentation

of programs. In its broadest, most practicalsense, rehabilitation is a

philosophy of the treatment of individuals, and consistsof the application

of certain principles in the achievement of specificgoals.

The first principle is that the individual mustbe treated as a total

being rather than a problem defined solely inphysical, social, economic, or

emotional terms. The second principle is the recognition of the worth of

the individual. The third is that each human being hasa right to those

services which will enable him to fulfill his greatestpotential, and the

fourth is that the community has a responsibility tosee that necessary ser-

vices are available to rehabilitate the individual.1

Rehabilitation is not, therefore, the sole responsibilityor preroga-

tive of any one agency or group, but is dependentupon the coordinated con-

tributions of many.

The State-Federal Vocational Rehabilitationprogram is the legal

expression of these principles.

History of Rehabilitation

The early history of the vocational rehabilitation movement inthe

United States was begun with the work of private agencies. In 1918, the first national interest was stimulated with passage of the Smith-Sears Actwhich provided for the vocational rehabilitation of disabledveterans. The Voca- tional Rehabilitation Act of 1920 provided fora rehabilitation program for civilians.

1 Armstrong, K. S., "What Constitutes Rehabilitation?", Rehabilitation 28:5-9, January-March, 1959.

2 A Vocational Rehabilitation program beganin Montana in 1921. These first programs were oriented towardvocational training of the physically handicapped. Since that time the programs have expandedin scope to include comprehensive diagnostic services, counseling,physical restoration, training, training supplies, maintenance, placement,tools and equipment, and initial stocks of supplies for those in self-employment.Almost any service which makes a substantial contribution tothe individual's rehabilitation can now be provided under the broadened programof the State Vocational Rehabilitation agency.

_Luc V4Irlaral Vocational Rehabilitation program continues to reflect the changing needs of thedisabled individual and his relationship to a society which is becomingincreasingly complex, but which offers more hope to the disabled than at anytime in the past.

"Only one Federal program approaches in concept theideal of an integrated manpower program: The Vocational Rehabilitation program. Like anything else in the real world, itfalls far short in practice of what it is designed to accomplish. Nevertheless, it is worth examining as a model of a single program designed to providethe full range of services required

112 by those facing handicaps in labormarket competition.

Reaffirmation of Vocational Rehabilitation programs as apractical alternative to a system of doles anddependency is reflected in the major reorganization of the Federal Department ofHealth, Education, and Welfare and the resultant amalgamation of fiveexisting agencies into the new

Social and Rehabilitation Service.

2Robson, R. T. and Mangum, G. L.,"Coordination Among Federal Man- power Programs," Critical Issues inEmployment Policy, p. 127, Princeton University, 1966.

3 DEPARTMENT OF NEALTN, EDUCATION, AND WELFARE Social and Rehabilitation Service Wet SecmtmySECRETARY Aunts.,ON* AdamIsItalms AmiiistalstsADMINISTRATOR SPECIAL ASSISTANTS:SISHPublicloIttsalmaRelosw 15411mi11otOtvtletmei I AssislmeAttain I OFFICE OF PROGRAM PLANNING I ANDOFFICE DEMONSTRATIONS OF RESEARCH ADMINISTRATION OFFICE OF Peesssi* sadRENAMLITATION SERVICES ADMINISTRATION I ovorsiola CHILDREN'S SOREAU onel I evorSoht Presotion 44 gase1 *wor ADMINISTRATION ON ACING Preemie., end psrI ovorslehi MEDICAL SERVICESADMINISTRATION Pr*vision ed said.... HI Stens .4 ASSISTANCE PAYMENTS ADMINISTRATION eat,ei the11 emiel moths, reervehs, 440,1410 prarision by Stew oral provitle. of tolsobilitetion solohis hr erevIsleabysheof theSalto pertvislen **Him 044 Isom, of molel porvelos, seetle ovidente to soak stowdro. lee Hallelcfit1*(411amid1 ha *I thethe servicessame petrtision setting i.e. bypOvielefl l edSW*sto. and ncI ilw sorvicos;et.tk timing orovisim Act) elby(Title sten/yds elSit atedocelXIX, end Soo.loe.1 hw snit,. clvdlwglere.1ohmloeI p44111 domeel *4tho ogee, ssisiorteWs HI toIn enieefteept ie ytnspress, 41.1.44K.M .11cfene spechi tn.. lisialotroelonreklmo to each ei *pone fllSeitt*CrippledOlsob W. In the Child... imrsors4lit= Int Iodi: Vse. Sm. Applicants ne et f*Jerol-Etoto11.41 ay. prooremsillsttaelSandie.rteiels tn. Is end eml0. evhsinistretIonChild Invtipstiom Hsolth cmia ovidmStowthe 440111101111190 to prove. such *lionessSot vices ed lotfemierl.in A peel vOld*.Aftericans Aet let: tentIss.endvitaeIS such medical Previsionend 15551155 rIvetoon esti' prooreges.I ouldancIn the 1515 lwlth retwdingC4V1411011MHoelitonetwhoHIM, oh 044the es prryetemneedreline! el el thesoviet the .0...Mob*" 411.1v11111pplIcnts IVal 111141..n el iambs tit sad Ma !NJ &HAMM 1114 Sreicbbratelly10111111 for Pone.Rma.. lotTWally Shad Sod SemvicmHealthMeentellvvenlloChild Serviat sonl W.V...w OelltvevracyAFDC Wont to Sorttsits StiteelPoodles' Coro0114w fitsier014.Ao Grervilpeeem. AsIstosto Servis I 'stonilyitmargookstlyellotIA* Work Vole ssistnto.meek'. Trsitilag Exproirrit N proiedicNelpsonts. prisommets on4 iriootio. Cox. ors, seaplittI11 pplittniens L. COMMISSIONERS REGIONAL implores@MepeoptemsDirects fatvse ead Il Stet.NMIIr. arpoevisos the siiviiles IIHm Rossi... tr1 ell This precedent has great implications for the future development of

the involved agencies and should, when fully implemented, result in better,

more adequately coordinated services for the individual.

Legal Authority and Responsibility of Montana Division of Vocational Rehabilitation and Division of Blind Services

The legal responsibility for vocational rehabilitation of the dis-

abled in Montana is vested in two agencies: The Division of Vocational

Rehabilitation under the State Board ofEducation3 (VocationalRehabilitation

Act of Montana, Chapter 8, Title 41, Revised Codes of Montana, 1947), and 4 the Division of Blind Services under the Department of Public Welfare (Public

Welfare aws, Chapter 14, Title 41, Revised Codes of Montana, 1947).

The law states that these agencies will provide vocational rehabilitation services to any individual who, because of a physical or mental condition, has an employment handicap.

Under Public Law 333 of the 89th Congress, the regulations issued by the Secretary of Health, Education, and Welfare pursuant thereto, and related state vocational rehabilitation legislation, the state vocational rehabilitation agencies have the followingresponsibilities:5

1. The administration and su ervision of a rots am of vocational rehabilitation services directly to the nation's physically and mentally handicapped youth and adults. Rehabilitation services include the provision,

3SeeAppendix A.

4Ibid.

5Councilof State Administrators of Vocational Rehabilitation, The State-Federal Vocational Rehabilitation Program Looks to the Future - A Statement of Mission and Goals, pp. 4-6.

5 whenever appropriate, of any or all of the following services: diagnosis,

physical restoration, counseling, training and relatedservices, and any

of the services listed above that are appropriate forthe determination of

the rehabilitation potential of a handicappedindividual over an extended

period of time. This program of direct services is the heart ofthe respon-

sibility of the state vocational rehabilitation agencies.

2. Development of a statewide plan for the provision ofcomprehen-

esivit vocational rehabilitation services to allwho need them.

This includes the development of a state plan for anadequate network of

rehabilitation facilities and workshops to serve handicappedpeople. Al-

though the general statewide planning effort is a stateresponsibility,

rather than a vocational rehabilitation agency responsibility,the agency

has been given prime responsibility for leadershipin such studies in most

states.

3. Working with other public and voluntarugencies andlocal communities to establish staff and o erate workshes andrehabilitation

facilities. A related responsibility is to act onapplications of local

communities for federal funds to support rehabilitationfacility projects.

4. Providing consultative services to workshops in thedevelopment

of workshop improvement and technical maisurolsaand recommending the

approval of such projects to the Secretary ofHealth, Education, and Welfare.

5. Developing contracts with, and providing consultativeservices to, worksho s and rehabilitation facilitiesmmsLIRIEsinAitnNoEEI supported by federal training grants and allowances toindividuals.

6. Conducting research and demonstration activitiesand_providing.

consultative services to comet unitoranizations develoi:research and demonstration ro ects and expansion programs. A related responsibility

6 is to act on applications for federalfinancial support for such projects when they involve services directlyto handicapped people. 7.Making certification to the usage and Hour Divisionof the United

StatesDepartment of Labor of individuals who are notcapable of openemploy-

ment butare capableof some production and making certificatio7.1 tothe De- partment of individuals that are undergoing evaluationand training programs in workshops. 8.Working with the United States 12gartment of Labor and theUnited

States ces and assis-

tive devicesto assure success of training of individuals underthe Manpower Development and Training Program. 9.Developing and carr-1,ng out programs directed standing of the numbers andclasses of handicapped people, their problems, the kinds ofservices needed to assist in thei3 rehabilitation,and the bene-

fits to the handicapped individuals and to societyresulting from such rehabilitation. 10.lie.1_piaLtaseate an asssting environment farhandicappedpeople

in the community and to remove or lowerbarriers to the fanparticipation of handicapped people in community life.

11. Working with other public agencies with relatedresponsibilities to assurethathandicapped peoplefor whom the various agencies share responsibility coordinate theirefforts to achieve a continuum of services directed toward meeting the totalneeds of handicappedpeople. Therehabilitation

agencies should initiate such cooperative programsand, where appropriate,

accept responsibility for coordinating the servicesof the agencies involved

inproviding the services. This includes the authority to work with local units of government. 12. Developing and conducting innovation programs, identifying and testing new and improved methods of providing rehabilitation services tc handicapped people. 13. Administeridolh-aeardActpp under which business opportunities are made available to blind people in federally administered buildings.

14. WorkinuLlith the Social Security Administration in making deter- minations of eligibility of applicants for OASDI benefits and in providing vocational rehabilitation services to beneficiaries of the Trust Fund.

TABLE 1. SOURCE OF FUNDS - DVR AND DBS

Funds for the administration of the State-Federal programs are provided on a matching basis. The State portion is provided through appropriated funds of the State Legislature, and these funds earn Federal monies -t the following rates:

PROGRAM STATE % FEDERAL79-1 Basic Program 25% 75% Establishment of Workshops and Facilities 25% 75% Expansion Grants 10'. $9.------Project Development 10% 90% Planning Grants - Workshops and Facilities 10% 90% Workshop Improvement 10% 90% ______Training Service 10% 90% Innovation 10% 90%7773/st3years 25% 7501- Next2 ears *25'0 75 First 15 months *40% 60%- Next12 months Staffing Grants - Facilities *55% 45%- Next 12 months *-70% 30%- Final12 months Maximum 51 months Workshop Technical Assistance 100% Construction (Hill-Burton) 33-1/3% to 66-2/3%!"

* Provided by recipient public or private agency Varies

8 Need for Planning

Rehabilitation estimates based upon data of the State vocational

rehabilitation agencies and the National Health Survey indicate that there

currently exists a backlog of 3.7 million disabled in America who need and

can benefit from rehabilitation services, and that an average annual incre-

ment of 500,000 or more people are added because of birth defects, disease,

and accidents.

The problems facing the disabled and vocationally handicapped person

it Montana are not revealed in such statistics, and more definitive informa-

tion most be gathered and assessed if meaningful programs are to be developed.

The programs of all social and rehabilitation oriented agencies, public or private, ha' ;e evolved to meet the immediate, obvious needs within the communities. Consequently, duplication of services and programs has resulted, in certain instances, in a dearth of equally vital services needed to rehabilitate the disabled. A broader assessment of the total problem of services, manpower, facilities, social and educational opportunities, and employment is needed if the full potential of the disabled person is to be realized.

Montana, like most states, has not developed programs in accord with any plan. The total spectrum of forces which affect rehabilitation has never been considered, but development has occurred piecemeal. Public and private rehabilitation sub-systems have developed and have tended to leave the individual who seeks assistance in a quandary of conflicting programs and with minimal coordinated direction.

It is difficult enough for an individual community to plan for all the needs of its disabled. Planning on a State level is much more complex.

9 Functions and philosophies of agencies vary. Priorities to meet needs are

difficult to assign.

Rehabilitation entails the provision of specialized services by a

diverse group of complex organizations and professions. An inherent diffi-

culty in rehabilitation is coordination of these services for the benefit of

the individual. In few instances does the rehabilitation of the handicapped

person occur through the use of a single service.

Change is necessary and certain, and vocational rehabilitation will

not continue as it has in the past; therefore, planning for the future

becomes imperative.

An overview of the many and diverse services utilized in the rehabili-

tation processes can be gained from the following list:

Community Social Services Related to Rehabilitation Classified by Use in Restoration Fid Adjustment Processes A Check List Types of Service Processes of Restoration and Adjustment Physical Social Vocational Adjustment Adjustment Adjustment CORRECTION Court social services Probation Parole Protective aftercare EDUCATION Formal education elementary x secondary x technical higher School social work x School guidance x Health services x

6 Vocational Rehabilitation Administration, The Rehabilitation Agency- and Community Works - A Source Book for Professional Training, pp. 115-116,

10 A CHECK LIST(Continued)

Types of Service Processes of Restorationand Adiustment

Physical Social Vocational Adjustment Adjustment Adjustment

EMELOYNENT Job finding Employment counseling Psychological testing x Vocational rehabilitation x Job engineering Placement and follow-up

BEAITH Physical health (in-patient and out-patient)

Dentistry Medicine and surgery Nursing Occupational therapy x Orthotics-Prosthetics Physical therapy Mobility instruction x Speech pathology and audiology Social Work Casework x Group work x

Mental health In-patient Nursing Psychiatry Psychology Social work Therapeutic recreation Other hospital services x Out-patient: Community mental health

Private practice of x psychiatry Treatment centers x x Clinic services x Aftercare centers

PUBLIC HEALTH Treatment facilities and x x convalescent and nursing home care

11 A CHECK LIST (Continued)

Types of Service Processes of Restoration and Adjustment

Physical Social Vocational Adjustment Adjustment Adjustment

HOUSING Residential facilities Housing for those with special disabilities Housing for the aged Public facilities for use of the disabled (echools, theatres, stores, etc.)

SOCIAL WELFARE,- Child Welfare Adoption services Crippled children's services Foster home placement Maternal and child health services Protective service Residential treatment Homemaker and housekeeper service Public Assistance Aid to the Blind Aid to theDisabled Aid to Families with Dependent Children General Assistance Medical Assistance Medicaid--Title XIX

SOCIAL INSURANCE Health Insurance for the x Aged (Medicare) Old-age survivors and disability insurance Public employees retirement Railroad retirement, unemployment, and disability Temporary disability insurance x Workmen's compensation

in varying degrees, the services listed under "Health," are offered in conjunction with these social welfare services. Social casework or group work is usually offered in conjunction with all of them.

12 Objectives of Planning

The planning activities were designed to accomplish three general

objectives:

1. To bring into being a well-defined picture of

state resources for rehabilitating the disabled,

and a clear picture of foreseeable needs.

2. To help assure an orderly growth and development

with a minimum of duplication.

3. To arrive at an organized statewide plan by which

all disabled persons needing rehabilitation ser-

vices can receive them by 1975.

Project Population

The delineation of the population on which data was gathered presents

immediate and difficult problems of definition. The primary emphasis of the

Project was directed toward the individual who has traditionally formed the

clientele of the Vocational Rehabilitation agencies, in addition to certain

groups included under the new categories of persons who are to be extended

services in accord with the Vocational Rehabilitation Amendments of 1965.

At no time was an attempt made to identify all disabled in Montana.

Such an endeavor goes far beyond the intent of the Project.Disability, regardless of its nature or extent, does not in itself constitute a need

for the services of Vocational Rehabilitation.The existence of a disability constitutes only one factor having relevance to the determination

13 of need for rehabilitation. Social and economic factors, motivation, age,

etc. must be considered in the assessment ofwhether the condition creates

a handicap to employment. Therefore, the limitation of activity imposedby

a physical, mental, or othercondition must be reviewed in the contextof

other seemingly extraneous conditions if adetermination as to numbers of

persons who will take advantage ofrehabilitation services is attempted.

Project Organization

The Governor designated the Division ofVocational. Rehabilitation as the agency responsible for the conduct of theProject, as required by the

Vocational Rehabilitation Act Amendments of1965 (Public Law 89-333). This

Act authorized a two-year program of grantsto states to help plan for the

development of comprehensive rehabilitation services in eachstate. 7 The appointment of an eleven-member PolicyBoard, representative of broad rehabilitation interests, was completed bythe Governor in December

of 1966. At the first meeting of the Board, a Chairman andCo-Chairman were

selected. An Executive Committee was appointed fromthe membership to serve

as the functional unit ofthe Board. Selection of a Project Director was made by the end of December and he, in turn,employed an analyst and secre- 8 tary.

Public and private groups felt to be concernedwith the disabled were selected, and they wereinvited to name a representative to the Citi-

zens Advisory Committee ofthe PlanningProject.9

7See Appendix B. 8 Ibid.

9Ibid. The State was divided on the basis of the same thirteenunits utilized by the Community Mental Health Planning Committee andthe Montana

Mental Retardation Planning Committee.These thirteen Districts were utilized to facilitate the gathering of data, and as an effort tocoordi- nate planning and development activities.

A Chairman for each of the thirteen Districts was enlisted, and these Chairmen selected a representative frceach county in their Dis- trict.1°The county representative had a major responsibility in the survey work and as a liaison withcommunity agenciez in the development of recommendations.

MAP 1. STATEWIDE PLANNING DISTRICTS

I °SeeAppendix B.

15 Ultimately, the thirteen Districts werereorganized into the same five Regions as utilized by the twopreceding study committees and the

Division of Hospital Facilities of theState Department of Health.

MAP 2. STATEWIDE PLANNING REGIONS

This basic structure was supplementedlater in the Project through

the addition of two special sub-committeesto the Policy Board: the Work-

11 shops and Facilities Sub-Committee, which also served as a committee to the Workshops and Facilities Project of the Divisionof Vocational Rehabili- 12 tation, and the Architectural BarriersSub-Committee. The Sub-Committee

on Workshops and Facilities wascomposed of individuals currentlyengaged

or demonstrating stronginterest in rehabilitation facilities. The Barriers

1J-SeeAppendix B. 12 Ibid.

16 representative and wasconstituted to Sub-Committee wasgeographically to the disabled inbuildings. study the problemsof physical barriers twenty-four monthProject This report, then,is the result of a 30, 1968. It repre- initiated December 1,1966 and concluded November

of Montanans whohave given sents the dedicatedefforts of hundreds disabled child andadult can be better freely of theirtime so that the in the State. served by the publicand private agencies

17 CHAPTER II

DEMOGRAPHIC INFORMATION

Montana is the fourth largest state in land area of the United States.

It is bounded on the north by Canada, on the east by North Dakota and South

Dakota, on the south by Wyoming, and on the south and west by Idaho.

The extreme length of the state, east to west, is about 550 miles, and the greatest width is approximately 325 miles, north to south.The total distance along the boundary is 1943 miles. Montana is more than three times the size of Pennsylvania. The total area is 147,138 square miles, of which

145,878 square miles are land area.-

As of June, 1964, 29.56% of this land was federally owned, 5.63% was

Federal Trust Indian land, 5.70% was state owned, and 59.02% was privately owned.1 2 In 1960, Montana had a population of 674,767. The average population density was 4.6 persons per square mile compared to the national average of 50.5, excluding Alaska and Hawaii. Just two states were more sparsely populated, Wyoming with 3.14- persons per square mile and Nevada with2.6 persons per square mile.

In the ten years prior to 1960, the population increased by14.2% compared to a national average of 18.5%. Growth in the years from 1960 to

1970 is projected at the rate of 9.9%.

1Department of Planning and Economic Development, First Bank Stock Corporation, Montana Statistical Review, p. 27.

2 Ibid., p. 35.

19 MAP 3. NUMBER OF PERSONS PER SQUAREMILE* MONTANA COUNTIES

1960

0 less than 2.0 re:q 5.0 to 9.9

MI 2.0 to 4.9 A 10.0 or greater

Beaverhead 1.3 Granite 1.7 Powell 3.0 Big Horn 2.0 Hill 6.4 Prairie 1.3 Blaine 1.9 Jefferson 2.6 Ravalli 5.2 Broadwater 2.3 Judith Basin 1.6 Richland 5.1 Carbon 4.0 Lake 8.7 Roosevelt 4.9 Carter 0.8 Lewis & Clark 8.1 Rosebud 1.2 Cascade 27.6 Liberty 1.8 Sanders 2.5 Chouteau 1.9 Lincoln 3.4 Sheridan 3.8 Custer 3.5 McCone 1.3 Silver Bow 64.9 Daniels 2.6 Madison 1.5 Stillwater 3.1 Dawson 5.2 Meagher 1.1 Sweet Grass 1.8 Deer Lodge 25.3 Mineral 2.5 Teton 3.2 Fallon 2.4 Missoula 17.1 Toole 4.1 Fergus 3.3 Musselshell 2.6 Treasure 1.4 Flathead 6.4 Park 5.0 Valley 3.4 Gallatin 10.3 Petroleum 0.5 Wheatland 2.1 Garfield 0.4 Phillips 1.2 Wibaux 1.9 Glacier 3.9 Pondera 4.7 Yellowstone30.0 Golden Valley 1.0 Powder River 0.8

*Source: Montana Statistical Review

20 TABLE 2. POPULATION - GROWTH PROJECTIONS'

1960 1970 1975

775,000 All Ages 675,000 741,000

Under 18 years 260,000 277,000 277,000

282,000 18-4h years 224,000 254,000

45-64 years 125,000 144,000 146,000

65 years and over 65,000 66,000 70,000

Source: U. S. Department of Commerce, Bureauof the Census, Population Estimates, Series P-25, No.326.

In 1960, 50.96% were males. This percentage is not changedmaterially in the projections for 1970-75; (50.6% in 1970, 50.58% in 1975). Histori- cally, Montana has been considered arural state. In 1870, the population was 84.9% rural. Each decade since that time, thispercentage has decreased.

the succeeding In 1950,56.3% of the population was considered rural 5 blIt in ten years urban population overtookthe rural,which by 1960 had dropped to

force, con- 49.8%. In 1960, agriculture stillemployed 17,.7% of the working trasted with only 637% nationally.

The distribution and pattern ofpopulation in Montana presents not only problems of government but hasimplications for the development ofpat- terns of service to meet the needsof a rural population. Only Great Falls and Billings meet the requirementsof the Federal government fordesignation as standard metropolitan areason the basis ofpopulation.

21 MAP 4. URBAN - RURALPOPULATION DISTRIBUTION-

MONTANA -1960

r---1 100% Rural (either Rural Farm or NonFarm Rural)

0.3 Some Urban but over 50% Rural goSome Rural but over 50% Urban

% Urban %Urban Urban Powell 66.9 Beaverhead 51.3 Granite 57.6 Prairie IND Big Horn 27.9 Hill Ravalli Blaine Jefferson Richland 43.5 Broadwater Judith Basin Roosevelt 30.6 Carbon Lake 72.2 Rosebud Carter Lewis & Clark Sanders - Cascade 78.5 Liberty Lincoln 22.6 Sheridan Chouteau Silver Bow 86.4 Custer 73.1 McCone Stillwater - Daniels Madison Meagher Sweet Grass - Dawson 57.3 - MP, Teton Deer Lodge 64.7 Mineral Toole 50.8 Fallon Missoula 69.2 Treasure - Fergus 52.8 Musselshell 58.1 62.5 Valley 37.5 Flathead 39.8 Park 51.3 Petroleum Wheatland Gallatin 0I Phillips Wibaux Garfield Yellowstone 82.7 Glacier 39.2 Pondera 34-.8 Golden Valley Powder River

-Source: MontanaStatistical Review.

22 MAP 5. MONTANA POPULATION RATE OF COUNTY INCREASE ORDECREASE

1950 - 1960

El Population Decreased

EM Population Increased

Beaverhead 7.8 Granite 8,7 Powell 11.1 Big Horn 1.9 Hill 30.6 Prairie -2.5 Blaine -5.0 Jefferson 7.1 Ravalli -5.8 Broadwater -4.0 Judith Basin -3.6 Richland 1.3 Carbon -18.8 Lake -5.3 Roosevelt 22.5 Carter -10.9 Lewis & Clark 14.1 Rosebud -5.8 Cascade 38.5 Liberty 20.4 Sanders -1.5 Chouteau 5.4 Lincoln 44.2 Sheridan -3.2 Custer 4.5 McCone 1.9 Silver Bow -4.1 Daniels -4.8 Madison -13.1 Stillwater 2.0 Dawson 35.4 Meagher 25.8 Sweet Grass -9.1 Deer Lodge 12.6 Mineral 45.9 Teton 0.9 Fallon 9.2 Missoula 25.8 Toole 15.1 Fergus o.o Musselshell -9.6 Treasure -4.1 Flathead 4.7 Park 9.7 Valley 50.4 Gallatin 18.9 Petroleum -12.9 Wheatland -5.1 Garfield -8.8 Phillips Wibaux -11.0 Glacier 19.9 Pondera 19.7 Yellowstone 41.4 Golden Valley-10.0 Powder River -7.7

1Source: Montana Statistical Review

23 TABLE3. MAJOR SOURCE) OF INCOME - MONTANA

1960-1967 (In Thousands of Dollars)

Contract Agriculture Mining Lumber Manufacturingo Constructio

1960 $422,986 $178,854 $ 80,072 $205,629 $133 438

1961 379,318 183,344 79,942 212,621 194,616

1962 433,326 190,657 89,457 229,148 192,543

1963 445,435 182,018 95,076 236,230 153,962

1964 422,777 211,435 88,911 272,000 184,655

1965 471,558 228,159 102,590 284,809 218,572

1966 567,783 245,238 105,544 NA 220,409 ** 1967** 574,981 186,162 NA NA 268,944

"Preliminary Estimates

Source:Montana Statistical Review

*M. TABLE 4. NON-AGRICULTURAL EMPLOY/ENT TRENDS IN 1431iTANA--

NUMBEROF WAGEAND SALARIED WORKERS 1964-1967

Transpor- Finance Year Manufac- Mining Contract tation Trade Ins. & Service Govt. turing ConstructioUtilities Beal Est. Misc.

MM,600 11 400 1hoo 43. 00 6 is 2 000 hhCO

MI 22 200 a e 12 000 1,111111111,101111 000 MIMI

IM1000 600 11 600 1 00 44200 200 00

22 le 600 .u.600 1 .800 44 700 $1 Si 0

Preliminary Estimates ** -Source:Montana Statistical Review

24 MAP 6. INDIAN RESERVATIONS

LAND AREA AND NUMBER OFINHABITANTS, ION:CANA

lickfeet

Area Indians Reservation Tribe Sq. Miles Within Boundaries

Blackfeet Blackfeet 1536 6,700

Crow Craw 2460 4,690

Flathead Salish, Kootenai 973 2,756

Fbrt Belknap Gros Ventre, Assiniboine 933 1,636

Fbrt Peck Sioux, Assiiliboine 3125 6,728

Northern Cheyenne Northern Cheyenne 696 2,100 700 Rocky Boy's Chippewa, Cree 168

9891 25,310

Source: Montana Statistical Review

25 MAP 7. MEDIAN INCOMES OF FAMILIES' BY COUN1Y

MONTANA - 1960

$5,880- 6,879 EE4 $4,480- 5,079 $5,080- 5,879 Q $3,300- 4,479

Beaverhead $4998 Granite $4937 Powell $5384 Big Horn 4375 Hill 6210 Prairie 4470 Blaine 4416 Jefferson 4989 Favalli 3819 Broadwater 3988 Judith Basin 5332 Richland 4462 Carbon 4336 Lake 4183 Roosevelt 4562 Carter 4199 Lewis & Clark 6461 Rosebud 4399 Cascade 6032 Liberty 5858 Sanders 4969 Chouteau 5610 Lincoln 5483 Sheridan 14.550 Custer 5160 Mc Cone 3915 Silver Bow 5283 Daniels 4488 Madison 4470 Stillwater 4790 Dawson 5554 Meagher 4949 Sweet Grass 4333 Deer Lodge 5022 Mineral 5788 Teton 5267 Fallon 4694 Missoula 5769 Toole 6023 Fergus 4992 Musselshell 4927 Treasure 4538 Flathead 5392 Park 5253 Valley 5325 Gallatin 5360 Petroleum 5418 Wheatland 5400 Garfield 3311 Phillips 4353 Wibaux 3431 Glacier 5169 Pondera 5078 Yellowstone 6150 Golden Valley 4044 Powder River 4797

Source:Montana Statistical Review

26 In 1960, the median family income in Montana was $5403.00. In 1967, Montana's per capita expenditure for Vocational Rehabilita- tion was $1.398 to rank it 32nd among the states.This was an increase of 40% over the preceding year when Montana spent $.997 per person.

27 CHAPTER III

STATEWIDE RECOMMENDATIONS

The recommendations that follow, the result of the study and efforts of hundreds of professional and lay persons in Montana, are a reflection of what they consider to be some of the most pressing problems facing the disabled person who needs services.

The recommendations emanated from the District meetings, the Citizens

Advisory Committee meetings, the Workshop and Facilities and Architectural

Barriers Sub-Committees, and the meetings of the Policy Board.Recommenda- tions from the local communities, as expressed in the District meetings, were reviewed and correlated by the Advisory Committee and were approved by the Policy Board.

29 RECOMMENDATION 1

IT IS RECOMMENDED THAT THE DIVISION OFVOCATIONAL REHABILITATION AND THE

DIVISION OF BLIND SERVICES TAKE ADDITIONAL STEPS TOASSURE THAT REHABILI-

TATION SERVICES ARE AVAILABLE TO ALL DISABLED OF THESTATE, PARTICULARLY

TO THOSE REQUIRING MORE INTENSIVE AND CONTINUOUSSERVICE. SPECIAL CON-

SIDERATION SHOULD BE GIVEN TO SERVICE FOR PERSONS IN THESTATE CUSTODIAL

INSTITUTIONS. A REALISTICCOUNSELOR/CLIENT RATIO FOR EACH COUNSELOR IS

NECESSARY.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: DIVISION OF VOCATIONAL REHABILITATION

DIVISION OF BLIND SERVICES

LEGISLATURE

STATEMENT OF THE PROBLEM:

The initial accessibility of the disabled person tothe rehabilitative services of the Division of VocationalRehabilitation (DVR) and the

Division of Blind Services (DBS) is related to the caseloadof the current counseling staff and the geographic area each counselormust cover. The counseling process from inception to placement of theclient in employment depends upon the establishment and maintenanceof a one-to-one relationship.

The nature of this relationship dictates the numberof clients with whom one counselor can workeffectively.This client/counselor ratio is further affected by the geographic area of each counselor andhow often he can visit any community.The following table compares, on the basis ofemployee man-years

31 and the surrounding the caseloads in Montanawith the national averages states.

TABLE 5. NUMBER OF EMPLOYEEMAN-YEARS: AND NUMBER OF PERSONS REHABILITATED, ACTIVE CASESSERVED, AND REFERRED CASES PROCESSEDPER EMPLOYEE MAN-YEAR REGION AND AGENCY,19671

Per employee man-year r Referred Region Persons Active cases and reha- cases rocessed a enc bilitated served

U.S., total General, total

total4

Region VIII (Denver) - General, total - - -- 2 Colorado 43 Idaho 75 Montana 39 Utah 17 Wyoming 16 Blind, total 2 Idaho 1.3 14 Montana 7.1

counselor caseload in The average Division ofVocational Rehabilitation of 76 in referred and Montana, as of June 1,1968, was 249 persons, composed typical of a specializedcounselor 173 in active status. Smaller caseloads are part-time specialeducation- working statewide with thementally retarded and by The Division of BlindService counselor personnel in schoolwork-study programs. population in counselors maintain averagecaseloads of 141. The average general 28,565 to 76,282 with an average o the counselor service areasof DVR ranges from

6,206 to 151,283, with an averageof 112,453. 61,338. The DBS ranges from

Statistics - State Vocational 1Social & Rehabilitative Service, Caseload of Health, Educa- Rehabilitation Agencies - FiscalYear 1967, U. S. Department Administration, Division ofStatistic tion, and Welfare,Rehabilitative Services and Studies, p.38.

32 The substantially greatergeographic areas covered in Montana by each counselor must be considered in thedetermination of a suitableclient/counselor ratio. The geographic area of the DVRcounselors range from 4,808 to

31,752 square miles, with an averageof 13,224. The DBS counselor's area ranges from19,374 to 25,796, with an average of24,244.

The current staffing patterns areinadequate to meet the needs of the institutional population.

The very nature of the disabilitywhich results in institutionalization requires that more frequent andintensive counseling services be available.

COMMENTS:

The existence of this problem wasidentified as a major deterrent to rehabilitation by 5 of the 13 districts, bythe Citizens Advisory Committee, and by several of the state agencyadministrators whose programs utilize the

services of Vocational Rehabilitationcounselors. Attempts thus far to meet these demands have been directed tomeet the most immediate and pressingneeds, and have not been the result of overallplanning.The changing nature of caseloads and the increased knowledge nowavailable to assist in the rehabilitation

of special disability groups indicates aneed to utilize specialized counselors with a high degree of competency inspecific disability categories. Precedent for this has been established by theutilization of a counselor with a clientele

of mentally retarded, and in the pastfor the mentally ill. The success of the Division of Blind Services ineffectively working with one disability

group further demonstratesthe soundness of this approach forcertain groups.

33 The unique problems encountered in the provision of services in rural areas, specifically Montana, is clearly delineatedin this statement:

There is a special social and economic cost of space for services to people in a sparsely populated area. This cost becomes more apparent and more demanding as the level of service becomes higher and prevention and rehabilitation becomes a goal. These expenses for a sparsely populated area include the economic aspects, space costs,including also the cost of neglect and delayed services. Poorer, inadequate, and intermittent service is often associated with high space costs. Neglect, too, becomes a cost, especially when rehabilitation is thwarted.2

The responses of the professional persons surveyed indicate that counseling, the main forte of the rehabilitation counselor, is one of the most needed services of their clientele. These same clientele groups constitute a major source of referrals to the rehabilitativeagencies.Of 378 professional respondents, 125 indicated their clientele could benefit fromindi- vidual rehabilitation counseling, 121 indicated need for parental andfamily counseling, and 59 a need for group counseling. Similarly, of the 493 respondent nurses, 250 indicated they were aware of patients who could benefit from individual rehabilitation counseling, and 95 stated thatpatients could benefit from group counseling.Of the 431 physicians who completed the questionnaire, 178 were of the opinion that rehabilitation should expand services compared with 41 who felt the status quo should be maintained and

12 who felt the program should be reduced. The remainder of physicians returning the survey expressed no views on thequestion.3

2Kraenzel, C. F., and Macdonald, F. H., A Study of Mental Patients in Sparsely Populated Montana and its Meaning for Federal-State Cooperation - An Interim Progress Report to Interested Citizens of Montana.

3Refer to Chapter VIII, Project Studies. Specific requests for rehabilitation offices came from committees in

Kalispell, Butte, Miles City, and Glasgow.

RECOMMENDATION 2

IT IS RECOMMENDED THAT THE DIVISION OF VOCATIONALREHABILITATION ADOPT AN

OPERATIONAL POLICY WHICH WOULD EXTEND COUNSELING AND PRE-VOCATIONAL SERVICES

TO SEVERELY DISABLED PERSONS WITHOUT REGARD TO A MINIMUM AGE, ANDTHAT THE

DIVISION OF VOCATIONAL REHABILITATION AND THE DIVISION OF BLIND SERVICES

EXTEND VOCATIONAL SERVICES TO ALL DISABLED AS RAPIDLY AS RESOURCES PERNIT.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: DIVISION OF VOCATIONAL REHABILITATION

DIVISION OF BLIND SERVICES

DEPARTMENT OF PUBLIC INSTRUCTION

LEGISLATURE

STATEMENT OF THE PROBLEM:

The federal regulations under which DVR and DES operate do not impose any eligibility restriction for services based on age. The state plans of the two agencies were amended in 1966 to conform with federal requirements. Sec- tion 8.2(d) of these plans states: "No upper or lower age limit will be established, which will in and of itself, result in a finding ofineligibility."

The DVR section does include: "Individuals accepted for service must, at time of completion of rehabilitation services, be of employableage." The ramifications of this provision are such that this section has not been adhered to because of the existing resources of staff and funds, which have been limited.

35 Full implementation of these sectionsis contingent upon the availability of resources; however, theDBS has initiated a program whichworks with blind children and their parEts. This counseling program has proven to be an extremely valuableservice.

The certainty with which one canpredict the wide variety ofproblems

that which a severely disabled youngstermust overcome makes it mandatory recognition of these problems bemade as early as feasible. If proper counseling and guidance areavailable early, many otherwisedifficult or insur- of 16 mountable problems could beprevented. The cr,rutional lower age limit used by DVR and 14 ly DBS isalso a reflection of the originsof rehabilita-

does tion as a vocationally-oriented programsince entry into the labor market not ordinarily occur before age16. Such arbitrary limits do notrecognize other important components oftotal rehabilitation; that is,the value of early diagnosis and treatment,prevention, and family counseling.

COMMENTS:

This recommendation wasspecifically cited by two districtsand by

several agency heads. In all districts, recognition wasgiven to the need for providing all services as soon aspossible to children exhibitingproblems because of physical, emotional, orother conditions. Disabled children in

to effect the community and in theinstitutions do not have services necessary The 11 a transition from asheltered environment into theworld of work.

cooperative DVR - School DistrictWork-Study programs provide anexcellent means of accomplishingthis, but they are presentlygeared primarily to meet

36 The social adjustmentand work the needs of theeducable mentally retarded. of ser- habits gained in such programsare but a partof the total spectrum vices needed. diagnostic services of a Early counseling,physical examination, some of theservices psychological and vocationalnature, and restoration are severely orthopedicAny that would be ofsubstantial benefit tothe retarded, the the blind. Certain handicapped, the neurologicallyimpaired, the deaf, and the orthopedicallyhandicapped services of this nature arecurrently provided to

the Child HealthServices Division, by the CrippledChildren's Program under

Department of Public Health. and behavior patternsearly in The development ofundesirable attitudes handicapped child. Services at life is often accentuatedin the case of the social3y, as well as inschool. an early agewill prevent dropouts has Some evidence of thenature of disabilityin the age group 0-17

by the DistrictCommittees.4 Forty- been gained throughthe survey of agencies in the under-17 age group,and six percent of thetotal number identified were 1,511 mentally retarded,710 speech by broad categories weregrouped as follows: problems, 466 visualproblems, problems, 685 orthopedicallyimpaired, 530 hearing These individuals, and 260 identified asexhibiting delinquentbehavior. and in theinstitutions, would together with the manyothers in the community

vocational adjustmentif services have a greaterlikelihood of satisfactory

were available. services at an early age The extension ofcounseling and pre-vocational duplication of any existingservice by the rehabilitation agencywould not be a seriously disabledchild. but would enhancetotal servicesFb. to the Refer to Chapter V,"The Disabled ofMontana."

37 The concern for extension of VR services to the younger age groups is

based on the conviction of many professionals that the impact of disability

is less acute if services are available at an early age.Preventative rehabil-

itation can be the most effective and economical rehabilitation.

Programs have been developed in other states in recognition of the

need to provide services as early as possible, particularly those of a pre-

vocational or adjustive nature. A special project in Bourbon County, Kentucky

of DVR and a small public school system in a rural area was conducted to

initiate a training program for educable retarded youth.All regular rehabil-

itation services 1.-ere extended to 60 students in the vocational group with an

IQ range of 50-75 and with a chronological range of 16 to 21. The pre- vocational group of similar students with a chronological age range of 13 to

16 years received course work in occ a)ational education, social relationships, and homemaking.It was concluded that 10 of the 17 students manifested improvement and 26 students were rehabilitated on a full time employment basis as a result of the program.5

A study of cerebral palsied youth also stressed the need for early and continuous guidance and counseling with parents, together with a program of stimulation of home and outsideinterests.6One conclusion of this project was that pre-vocational services through curriculum modification at the junior high level and a pre-vocational unit were necessary for those disabled students who would enter the special high school program.

5Bourbon County School, Cooperative Efforts of Schools and Rehabilitation Service for the Ment; ly Retarded, Paris, Kentucky, Author 1967: VRA Grant #1285. 6 Elizur, A. and Elkayam, G. S.,"Psychological Aspects," Cerebral pally in Adolescence and Adulthood, A rehabilitation Study; Medical, Social, Psychological and Vocational Aspects, 1 Voc. Rehab. Admin. Project No. 0.V.R.-7-61.

38 The Institute for theCrippled and Disabled found,in a project which adults, that pre- determined the vocationalpotential of cerebral palsied young vocational counselors whenthe vocational activitiesshould be determined by clients are 10 to 12 yearsold.7

RECOMMENDATION 3

TO APPROPRIATIONS SHOULD BEINCREASED AT THE STATE LEVELTO ENABLE MONTANA

MONIES NOW AVAILABLE, BUTUNUSED, RECEIVE TIE MAXIMUMFEDERAL REHABILITATION

SO THAT MORE DISABLEDCAN BE ADEQUATELY SERVED.

SCHEDULE FORIMPLEMENTATION: IMMEDIATE

INITIATOR: LEGISLATURE

STATEMENT OF THE PROBLEM:

support of Vocational The legislatureappropriates funds for the varying rates; however, Rehabilitation programs. This money is matched at The state rehabilitation the basic ratio is75% federal funds and25% state. monies available; agencies have never receivedthe full federal matching of Montana have consequently, funds that couldhave benefited the disabled

basic support program as been diverted to otherstates. This is true of the for the development ofwork- well as of those fundsavailable, but unmatched, construction, and other shops, program expansion,rehabilitation facilities

Palsied: 7Moed, M., and Litwin, D., "The Employabilityof the Cerebral 24:9!266-2711 A Summary of Two RelatedStudies," Rehabilitation Literature, 276, September, 1963.

39 for facility staffing grantsand programs. Certain funds, such as those Burton money, can be matched rehabilitation facilityconstruction using Hill- means of developing pro- by private agenciesand are intended to serve as a needs in the privatesector. grams andfacilities to meet rehabilitation

Programs concerned withthe economic and socialwell-being of received a rather individuals, other thaneducation, have traditionally limited insignificant portion of thestate tax dollar. The competition for has been intense state funds to meet the manypressing needs in other areas

The costs of purchasingrehabili- and will undoubtedlybecome even more so. greater rate than haveother tation services haveincreased at an equal or

costs because of thenature of the servicesutilized. surgery, Services utilized extensively arethose of medical diagnosis, All of these hospitalization and otherrestoration, training, andequipment. increases in cost in the services are among thosereflecting the greatest

past several years. substantial, no legit- While the costs ofrehabilitation services are Cost-Benefits imate assessment of the programexpenditure can be made unless a

rehabilitants closed in thefiscal Ratio is made. Such a study was made of lifetime earnings year 1966.Only one major monetarybenefit, the increased the state-federal program, of the recipients ofrehabilitation services under earners willreturn in earnings was considered. The 127,824 rehabilitated wage

$30.50 for each dollar expended forrehabilitation.8

Statistics and 8Vocational RenabilitationAdministration, Division of Studies, An EuloratorzCost-Benefits Analysis ofVocational Rehabilitation, U. S. Department ofHealth, Education, andWelfare.

4o The proven effectiveness ofrehabilitation as a philosophy and a pro-

Those gram of returningdependent persons toproductivity is irrefutable. tax dollar for sup- making the choices that mustbe made in apportioning the port of public programsmust be cognizant of thisfact.

That Montana is receivingmaximum use of the availablerehabilitative

Montana ranks 24th dollar is substantiated bycomparison with other states. and 16th in the number in the nation in numberof rehabilitants per 100,000

served per 100,000. Montana expended2.9% of the available funds for adminis- 58.5% tration compared to4.9% nationally, and 70.1% for case services vs.

26.1% vs. 26.7% nationally. nationally. Guidance and placement costs were workshops, and The remainder was expendedfor small business enterprises, than facilities. That these latter categories areall proportionately less facilities are not national figures reflectsthe fact that workshops and

available for the severelydisabled in Montana.Montana counselors rehabil-

the national aver- itated an average43 persons per fiscal year compared to

age of 37, despitethe gross lack of specializedfacilities and the large

geographic distances that eachmustcover.9

The needs of the disabled inMontana for services, programs,and facil-

ities are great.The favorable federal matchingratio for programs makes

expenditures for rehabilitation anextremely wise investment onthe basis of not both economic and humanitarianreturns. The demands for services do consider needs and allow all programs to beeffected, so priorities that tax dollar are to costs must be established ifthe maximum returns of the

be realized.

9Social and Rehabilitation Service,Rehabilitation Service Administra- Data, U. S. Department tion, State VocationalRehabilitation Agency Program of Health, Education, andWelfare. Obviously, not all persons who are institutionalized in Montana can benefit from rehabilitation service directed to their returningto the community in a self-sustaining status. Many could be, however, if institutional rehabilitation programs were dynamically promoted.The average daily cost of maintaining a person in an unproductive, dependent statusin institutions in Montana is $6.09 at the Children's Home,$5.54 at the Boulder River School,

$14.08 at the Mountain View School, $11.25 at Pine Hills, $8.80 at Deer Lodge,

$21.68 at Galen Hospital Unit, $4.51 at Galen Retarded Unit and $7.36 at 10 Warm Springs Sate Hospital.

THE 1966 TAXDOLLAR WHERE IT GOES

ALL TAX SOURCES

*SOURCE: STATE BOARD OF EQUALIZATION

10Department of Institutions, Report to the Governor,1966-67. Montana ranks 32nd of all statesand the Virgin Islands, Guam,and

Puerto Rico in the per capitaexpenditures for vocationalrehabilitation.

The per capita expenditure ofstate and federal funds is$1.40. The national 11 average is$1.53. The amount of Federal moneyallotted to Montana for

Rehabilitation and the LegislativeAppropriations are indicated in thefollowing table.

TABLE 6. TOTAL DVR

FEDERAL MONEY AVAILABLE TO MONTANA ANDSTATE APPROFRIATIONSt

,780.0o 129,321.00 1961 3o1 101.00 171,235.00 90,000.00 65.62 217 .00 1 .00 258 B. 2 .00 .00 ;1.00 1 1.00 =111117;.00 1 TOLLis.00 02125" 1300000.00000 ,915.00 , .00 818,114.00 425,182.00 130,000.00 2 5,279.00 8..,246.00 1 261,522.00 160,coo.00 -69.54 000.00 may 18.00 1.7 1 18.00 nIZZO:g 160 000.00 7 .00 imp 1 1 72.00 10: 1 74 2 .00 1` .00 7 .00 700.00 221.00 Fl 100.00 .00 00.00 1 s: 02 .00

6 711.00 TOTALS 120 781.00 8 1.00 1 242 o64.co 7070.00

t ALL FEDERAL MONEY FOR DVR AND DBS WITH17% ALLOCATED TO DBS.

The potential funding forrehabilitation is, therefore,contingent upon

the funds appropriated by thelegislature to match federal monies.However,

development of any program shouldbe based on meeting the needs.If the needs

exceed the ability of the federalgovernment to match according to aformula,

the state itself as the ultimatebeneficiary of rehabilitationshould consider

11 Source: State Board of Equalization.

113 meeting human needs through additional state expenditures. It is unfortunate that, in Montana where the needs of disabled people are equal to otherstates, 12 and the costs of providing services are greater, Montana is not receiving maximum utilization of the financial revenues available.

RECOMMENDATION

PLANNING, TO BE EFFECTIVE, SHOULD BE BROAD IN SCOPE, FORMAL, ANDCONTINUOUS.

A PERMANENT COMMITTEE, BROADLY REPRESENTATIVE OF REHABILITATIONINTERESTS,

SHOULD BE APPOINTED FOR THE PURPOSE OF PROVIDING ADVICE, COUNSELAND SUPPORT

TO THE DIVISION OF VOCATIONAL REHABILITATION AND THE DIVISION OFBLIND SER-

VICES.THE COMMITTEE WOULD ALSO HAVE RESPONSI3ILITY FOR REHABILITATION

PLANNING ACTIVITIES AND FOR THE PROVISION OF INFORMATIONAL SERVICESTHROUGH

THE UTILIZATION OF A PROFESSIONAL PLANNING COORDINATOR.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: LEGISLATURE

STATEMENT OF THE PROBLEM:

The scope of services and agencies who have involvementin rehabilita- 13 tion is extremely broad. The state rehabilitation agencies have a legal responsibility for rehabilitation of individuals and, consequently, must'lave a close and vital working relationship withnot only the social service agencies listed but other segments of society.Planning also must, of necessity, be

12Kraenzel,C. F., and Macdonald, F. H., The Social Cost of Space as a Criterion in the Distribution of Federal Grants.

13Refer to Chapter I,p. 10.

44 broad enough to allow consideration of the program developments and planning

in related fields. Programs to be effective must be constantly (%valuate.i if

they are to keep pace with the factors of change in any society. Progress in

technical knowledge and methods in related fields such as medicine, education,

and psychology precipitate changes which affect the disabled. The changes

which occur in the community itself in new technological advances which create

new jobs and eliminate old ones; the shifting emphasis in welfare programs

and Social Security; the changes in population characteristics, the economy,

and in social values, these are but some of the forces that bear upon rehabilitation programs.Agencies must keep pace if their programs are not to stag- nate and if the social demands of people are to be met.

Planning can be as effective a tool in the social service field as it has proven to be in industry.

Federal grants available to Montana for programs of the Department of Health, Education, and Welfare totaled $23,809,185.00 for the fiscal year

1967.Almost 1.5 million of this amount was for support of Vocational Re- 14 habilitation.

The increasing population with its attendant complexity of individual problems assures that these expenditures will increase in the future. The judicious use of available funds to alleviate human problems and to return the disabled to productivity implies coordination of programs and development of services in accord with an overall plan. The development of programs in the past has occurred without consideration of allied programs and with little, if any, regard for coordination. The result has been duplication, wasted resources, and fragmented rather than comprehensive services.

14 U. S. Department of Health, Education, and Welfare, 1967 Annual Report. be they preventative,diag- When individualrehabilitative services, and disorganized, man- nostic, therapeutic, orvocational are uncoordinated power, time,effort, and skillscannot be fully utilized.

COMMENTS:

Montana by a permanent The conduct of broadrehabilitation planning in state government wouldinsure committee or commissionwith official status in field would reflect the that coordinated planningin the rehabilitation and would also interests of the many groupsconcerned with the disabled,

the DVR, DES, andother public serve as overallcoordinating function between have legal authorityin rehabil- and private agencies.As the two agencies also advice and counsel of a repre- itation in Montana, theycould benefit from the

sentative group. component of thecommittee A professional staffwould be the functional activities but and would, under theirdirection, carry out notonly planning

informational services which areessential components ofrehabilitation. should be drawn The membership of thisofficially constituted group

who have demonstrated from the disabled andthe public and private groups

active interest inrehabilitation planning. agencies which will be Funds could be madeavailable through the two regular program required to conduct planningactivities as part of their Rehabilitation Act of1968. according to proposedamendments of the Vocational

Boren, remarking on theneed for planning forhealth facilities, states

principles that have equalapplication to rehabilitationplanning:

services be established 1. ....Ithat facilities and solely in accord with provenunmet needs;

46 2. that each facility or program shouldbe developed in terms of a specific geographic areawhich may be shared with others;

3. that care should be comprehensiveand continuous and may often involvejoint action by service institutions;

4. that each program should provide-ufficient volume of service to achieve quality and economyand that the public be kept fully informed about allexisting or projected service and facilities.

The ultimate decision concerning thedevelopment or exoansion of new

facilities and services is properly theresponsibility of the general public whose members will pay for thesedevelopments. In application of these prin-

ciples he further states that a fulltime professional staff is needed and

that sponsorship and support bypublic representatives arerequired.15

RECOMMENDATION 5

THERE IS A NEED FOR A FORMAL,ON-GOING PROGRAM OF INFORMATION ANDEDUCATION

BY THE DIVISION OF VOCATIONALREHABILITATION AND THE DIVISION OF BLINDSERVICES

THIS PROGRAM WOULD SERVE TO BETTERINFORM THE DISABLED, THE PROFESSIONALSIN

RELATED FIELDS, AND THE PUBLIC OFREHABILITATION SERVICES. IT WOULD CREATE

AN AWARENESS OF THE PROBLEMS OF THEDISABLED AND ASSIST IN DEVELOPINGAN

ATMOSPHERE OF ACCEPTANCE OF Lit DISABLED INTHEIR COWUNITIES.THIS ACTIVITY

COULD BE A FUNCTION OF THE COMMITTEEREFERRED TO IN RECOMMENDATION4.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

.1111011...

15Roren, R. C., "Areawide Planning is Here to Stay," Modern Hospital, August, 1964.

47 INITIATOR: DIVISION OF VOCATIM31 REHABILITATION

DIVISION OF BLIND SERVICES

LEGISLATURE

STATEMENT OF THE PROBLEM:

The provision of informationis a necessary part of any agency program that provides services to people. If those people whom the agencyis to serve are not Tully awareof the resources and programsavailable to them, then obviously one of the most basic purposes ofservices to people is being thwarted.

The information is necessary not onlyfor those who will consume theservices but for those providing services. The tremendous advancements intreatment methods, new services, and the increased resourcesavailable nationwide are also becoming more accessible tothe disabled of Montana. Those persons in the helping professions must keepabreast of these developments ifthey are to make appropriate individualreferrals to other agencies.As society becomes more complex, so will theproblem of communication in regardto the resources that are available to help people.It is also incongruous thatwhile Montana lacks many of the services that areessential to total rehabilitationof the disabled, long established programs ofdemonstrated excellence often arenot fully utilized. That additional problems exist iswell-defined in the following statement: common roadblock in allcommunity work related to health and welfare, including that ofrehabilitation, lies in the widespreadignorance on the part of the generalpublic as to what health andsocial services are, where they are to be found, and howthey can be used to raise thelevel of living

Ify for the entire citizenry.Constant interpretation and demonstration must be carried on through education, usuFaly of theinformal variety. Planned attacks on negative attitudes toward the disabled caninclude such informal devices as come-and-see tours, through whichstudents, or adults who are influential in their particular spheres such asbusinessmen, company officials, plant foremen, personnel directors, civic clubmembers, are taken on tours of sheltered workshops, rehabilitaion centers, orfactories employing handicapped workers, where they can actually see the processesand the results of rehabilitation.Education is involved in curriculum planning which can include teaching of such subjects as socialstudies and civics, a study of the interdependence of people and the values to ourdemocracy of providing

.16 adequate health, welfare, and rehabilitation servicesfor all people.'

The assumption of responsibility for the health andwelfare of the handicapped in our society has a legal as well as a moral basis. That this same responsibility has been assumed inthe economic, emotional, and social areas of society is not reflected inthe empirical evidence nor in that evidence presented by many studies which have been conducted. A summary of a series of studies by Roger Barker delineates theattitudes which must be overcome if the handicapped personis to be accepted in society. "Public verbalized attitudes toward disabled persons are, on the average,mildly favorable; an appreciable minority openly expressed negativeattitudes.

Indirect evidence suggests that deeper unverbalized attitudes are more

-1.°Vocational Rehabilitation Administration, Rehabilitation Agency and Community Work - A Source Book for Professional Training, U. S.Department of Health, Education, and Welfare, Chapter II, p. 41,1966.

149 clear that the attitudesof frequently hostile - theevidence is rather to be extreme moreoften than parents towards theirdisabled children tend been a tendency onthe towards normalchildren.' Only recently has there function of their program,the part of public socialagencies to accept, as a educational materials to dissemination of informationand the provision of

persons withwhom they deal. The the general publicand to the professional information programs,and it is private agencies havelong utilized public level of acceptanceof the dis- largely through theirwork that the current Those governmentalagencies abled by the generalpublic has beenachieved.

such as those in Fishand Game work or who do not dealwith people per se, utilize public informationand in highway construction,all effectively mission in the most educational programs as a meansof accomplishing their

expeditious manner.

COMMENTS:

in this That there aresignificant problems inthe area reflected districts, by theCitizens recommendation was recognizedby seven of the A. large Advisory Committee, andthe administratorsof related agencies. need for information onrelated body of professionalsalso have expressed a this is indicated inthe results rehabilitation programsand services, and of the respondents. The surveys of the Project surveysand by the comments in Montana indicatedthe conducted among the nursesand other professionals

surveyed indicated thatthey did not following results: 112 of 493 nurses

to Physical 17Barker, R. G., Wright, B. A., Gonich,M. R., Adijustment Psychology of Physiqueand Eandi212.and Illness: ASurvey of the Social Disability, New York Social ServiceResearch Council,196:

50 refer to the rehabilitation agencies because they were notfamiliar with them.

Of these respondents, 246 indicated they felt that disabled people did not receive needed services because they did not have knowledge orinformation regarding them. The nurses indicated a considerable interest in learning more about the Division of Vocational Rehabilitation(170 nurses), and about the

Division of Blind Services (101 nurses). A surprisingly large number felt the need for information on services in the medical and related fields: physical therapy (95), occupational therapy(132), recreational therapy (113), speech therapy (83), audiology (65), psychiatric social work(153), prosthetics (100). A lesser number of other professionals indicated that they did not refer the disabled to Vocational Rehabilitation and the Division of

Blind Services because they did not know about the agencies(25 of 378 respondents); however, 206 of the total number of the respondents to the professional survey felt disabled persons were not receiving services because of lack of information on the part of the client. This group of 378 persons indicated that they wished additional information as follows: Division of

Vocational Rehabilitation (139), Division of Blind Services(52), physical therapy (57), occupational therapy (103), recreational therapy(69), speech therapy (73), audiology (44), psychiatric social work(108), prosthetics (51).

The responses of a segment of the target group for any information-educational program indicates their receptivity to such a program andthat it would fulfill an actual need which would eventually result in betterservices to the disabled individual in Montana.

The importance of medical participation in rehabilitation is stressed by the report of the Committee on Rehabilitation of the American Medical

Association; however, a survey showed that physicians possess relatively little knowledge about the state rehabilitation agencies. As physicians see the

51 agencies and their program injured and the ill early,their knowledge of the 18 early referrals are tobe made. is significant indetermining whether or not finding and referral and Informational programs aretherefore related to case

the basic problemaffects all disability groups. 3 problems of the deaf, In a report deliveredat a special workshop on good case finding system aspro- Vescovi listed thefollowing components of a information acquaintingthe posed by Ogles in1962:19 1. Public education and

2. Reaching the dis- public with the objectivesand services of the agency; similarly acquainting them abled through any mediaavailable to the agency and Interpreting the same objectivesand with such objectivesand services; 3. disabled persons, among services to coimnunity resourceswhich normally serve must be involved others in their service program.Some continuous procedure develop- because of agency personnelturnover; 4. Constantly promoting the helping the disabled toreach ment and maintenanceof specific channels for

the agency. reoccuring in Recognition of the need forinformational programs is

Conference on Rehabilitationin the literature.For example, the Research cooperation of the school nurse Cardiac Disease indicatedthat the education and important in dealingwith and physical educationinstructor become vitally while this can children who have cardiacrestrictions.20 They emphasize that

Rehabilitation, "The State- 18American Medical Association, Committee on American Medical Federal Program of VocationalRehabilitation," Journal of the Association, 171:8:1107-1109,October 24, 1959. The 19Vescovi, G. M., "Case Finding, Referral, andPreliminary Survey," Report of a Workshop onRehabili- Vocational Rehabilitationof Deaf People - A Education, and Welfare tation for the Deaf, pp.5:15, U. S. Department of Health, and Adolescent 20Zaver, A.,"Rehabilitation Problems in Pediatric 151, Research Confer- Cardiac Patients," Rehabilitationin Cardiac Disease, p. 1967. ence, TuftsUniversity School ofMedicine, November,

52 be achieved by lea,er from the physician to the individual patient, that a

more suitable approach is through lectures, publications, and instruction

which could be disseminated via the Department of Education.

RECOMME NDATION6

A COMPREHENSIVE PROGRAM IS NEEDED TO ENCOURAGE THE EMPLOYMENT OF DISABLED

WORKERS IN MONTANA'S BUSINESS AND INDUSTRY BY ENLISTING THE SUPPORT OF

EMPLOYERS, LABOR ORGANIZATIONS, SERVICE ORGANIZATIONS, THE CHAMBER OF

COMIERCE, AND OTHER INTERESTED GROUPS.

SCHEDULE FOR IMPLEMENTATION: INTERMEDIATE

INITIATOR: DIVISION OF VOCATIONAL REHABILITATION

DIVISION OF BLIND SERVICES

EMPLOYMENT SERVICE

PERMANENT ADVISORY COMMITTEE

STATEMENT OF THE PROBLEM:

Placement of the handicapped worker in Montana is difficult, pidnoi- pally because of lack of knowledge on the part of employers and lack of a broad field of employment opportunities due to the few industries present in the state.

Resistance to hiring the handicapped stems from many preconceived ideas concerning their ability to perform, the hazards involved to all concerned, and the reluctance of other workers to accept the disabled.When the handicapped employee is hired, too often it is on the basis of pity and conscience rather than expectation that he will perform in a manner which

53 When the handicapped arehired will make him anasset to the enterprise. there is a tendency tolet them in periods ofrelatively high employment, worker's actual go early in anyreduction of activity.In many cases, the treated, after beingemployed, performance is not closelyevaluated, and he is discharged vithout sufficient according to preconceivedideas, and sometimes than other workers reason.Often the handicapped arepaid a much lower wage educational effort isrequired to for comparable duties.A great deal of connected with employment. overcome theattitudes of resistance of persons disabled is on the part of Often the only effort insecuring work for the In order to change manyof a placementofficer working with theemployer. much broader approach the attitudes discriminatoryto the handicapped, a

to the problem isindicated.

While Montana has a dearthof light industrywhich might provide industries are on the suitable employment to thehandicapped, the service and capable increase and should offer manyopportunities to the well-trained

worker. is necessary Concerted effort of all groupsinterested in the disabled

accepted practice throughoutthe if employment of thehandicapped is to be an

state.

COMMENTS:

statewide Citizens Advisory This recommendationoriginated with the recognized in Montana,and Committee and District 7. The problem has been

the Handicapped makes someeffort a Governor'sCommittee on Employment of Periodically to encourage consideration of the disabled for employment.

Potentially, the committee could be a veryimpoltant factor if it were composed of broad representation of those vitally interested in the disabled, and if it conducted an active and continuous program throughout the year.

Many studies have been made which show the handicapped worker to be 21 equal to, or in some respects superior to, the non-disabled. Where hiring is done on a realistic basis of the worker's ability to perform in a particular job and where employers make minor physical arrangements, results are usually satisfactory. Employers who have had experience with disabled workers are most likely to hire more of them. It appears that workers with orthopedic disabilities are more readily hired than those having epilepsy, heart conditions, mental retardation, and those in the upper age brackets, It is in these latter categories particularly that much work is needed in overcoming employer resistance.

An article in the Rehabilitation Record states that more than one million epileptics in the United States are potentially capable of being tax- payers if given the chance.Although studies have shown that the controlled epileptic is more careful than the average worker, has less accidents on the job, and is absent from work less frequently, employment agencies report they 22 are seldom successful in placing more than2% of such persons.

In a speech at the Oxford International Seminar, William Evans said that a major obstacle to vocational rehabilitation is the resistance of

2 /Universityof Minnesota, The Measurement of ent Satisfactoriness, Minnesota Studies of Vocational Rehabilitation, No. 1 3. 22_ rabing, H. A., "Legal Discrimination Affecting Employment of the Epileptic," Rehabilitation Record, 1:5:19-22, September-October, 1960.

55 employers to employees who have had heart attacks.While the patient,

medically certified as fit for a given occupation, can compete favorably 23 with healthy workers, employers still view him as a risk.

Reasons given for not hiring the mentally retarded include the belief

that their physical appearance bothers most people and that they have many 24 emotional problems.

Problems specific to the older disabled group are employer resistance

to hiring older people, problems of insufficient education or out-of-date

skills, and reduction of flexibility anj_ mobility due to the aging process.

To balance other problems, older workers often have the assets of superior

judgment based on experience, dependability, loyalty, steadiness, and more

mature attitudes toward work.Thirty percent of clients rehabilitated into

competitive employment by the New York State Rehabilitation program in 1962 25 were 45 or over.

Industrial accident legislation must also be changed if acceptance of

the disabled is to occur.

A drawback to hiring the ex-mental patient or other handicapped individuals is the lack of a second injury law in some states. Such a law frees the employer of responsibility for physical or mental disability which develops in relation to previous disability, but leaves him responsible for

23Evans,W., "Employment and Rehabilitation of Patients With Heart Disease," Rehabilitation, Journal of the British Council for Rehabilitation of the Disabled, 54:7-15, July- September, 1965. 24 Phelps, W. R., "Attitudes Related to the Employment of the Mentally Retarded," Occupational Information for the Mentally Retarded - Selected Readings, pp. 615-630, 19

S. L., "Vocational Rehabilitation of the Older Disabled Person," Rehabilitation of the Older Disabled Worker- TheAcademician's Eaponsi.tatv Report of the Proceedinaof a Conference on the... November 12-14, 1965, pp. 13-15. U. S. Vocaticaal RehabilitationAdministration, 1"Vocational Administration grant 4'63-114) .

56 handicapped person is inhis employ- any new conditionwhich occurs while the individuals, ment. Such a lair encourages employersto hire many handicapped who has been mentally such as an employee whohas had a heart attack or one 26 ill.

Montana's second injury law isconcerned only with loss ofbody members.

than that The safety record of thehandicapped is as good or better

The subjects of of non-handicapped workersaccording to numerous studies. 27 these studies range from employeesof small firms to thefederal government.

Yuker, Campbell and Blockdiscuss implications ofresearch findings Examinations are regarding the value of pre-employmentmedical examinations. who will not used as a selection deviceto: (1) Eliminate potential employees physical disabil- be productive because ofexcessive absence due to illness or

conditions make them likely tobe ity; (2) Screen out those whose physical physical accident prone; and(3) Determine whether the candidate possesses characteristics necessary to performthe job.The experience ofAbilities

examina- Incorporated, a manufacturing company,refutes the validity of such pre-employment tions for these purposes inmanufacturing. This company has no physical and, in fact, employsonly those who are physicallydisabled; i.e.,

those who probably could not pass anaverage pre-employmentphysical.Abilities

Incorporated employees have betterrecords than industry as awhole in both

absenteeism and in safety. The employee absenteeism rateis 1.2 days per 100

26Industrial Panel, Frost, E. S.,Moderator, Industry in theMental Hospital; a Workshop, Aril 1964, Hotel New Yorker, New York City; Proceedings.

27McCahill, W. P., "Incidents of Accidents Among HandicappedWorkers," Congress Disability Prevention, Rehabilitation;Proceedings of the Ninth World Disabled, Copenhagen, of thP International Societ.for Rehabilitation of the Rehabilitation Denmark, June 23.29, 1'.5, pp.53-56, International Society for of the Disabled,1965.

57 work dayn vn. 3.1 per 100 in industry, over a seven-year period with a current work force of /too, Four compensable accidents occurred in that time. Insur- ance premiums based on experience are less than50% those of comparable com- 28 pan es. Similar experiences are reported by Cowing on the employment exper- 29 ience of Repeal Brass which has 30% handicapped in its labor force.

RECOMMENDATION 7

IT IS RECOMMENDED THAT CONSIDERATION BE GIVEN TO THE EXTENSION OF REHABILI-

TATION SERVICES AND PROGRAMS TO THOSE INDIVIDUALS WHO ARE UNABLE TO FUNCTION

SOCIALLY, ECONOMICALLY, OR EDUCATIONALLY IN SOCIETY, IN THE SAME MANNER IN

WHICH SERVICES HAVE BEEN EXTENDED TO THE PHYSICALLY HANDICAPPED, EMOTIONALLY

DISTuRBED, AND MENTALLY RETARDED INDIVIDUAL.SUCH PROGRAM MODIFICATION

SHOULD BE ENCOURAGED AS RAPIDLY AS RESOURCES PERMIT.

SCHEDULE FOR IMPLEMENTATION: INTERMEDIATE

INITIATOR: DIVISION OF VOCATIONAL REHABILITATION

STATEMENT OF THE PROBLEM:

The federal laws and regulations that affect the administration of the Vocational Rehabilitation program have tended to broaden eligibility requirements to include those persons who are vocationally handicapped due

28 Yuker, H. E., Campbell, W. J., Block, J. R., "Selection and Placement of the Handicapped Worker," Industrial Medicine and Surgery, 29:9-419-421, September, 1960.

2 9Cowing,F., "What Personnel Has Learned From the Handicapped at Repcal Brass Co.," Reports on Employment of the Handicapped; Personnel and Industrial Relations, Two Doctors, the Safety Engineer, pp. 9-13, Government Printing Office, 1958.

58 to other than Physical or mental conditions. The 1966 Revision of Regulations

in reference to implementation of the1965 Amendments to the Vocational Rehabil-

itation Act (Pb 89-333) states in Section 401.1(o): "'Physical or mental

disability' means a physical or mental condition which materia3lylimits, con-

tributes to limiting or, if not corrected, will probablyresult in limiting

an individual's activities orfunctioning. It includes behavioral disorders

characterized by deviant social behavior or impaired ability to carry out

normal relationships with family and community which mayresult from vocational,

educational, cultural, social, environmental or otherfactors."30

Despite the recognition that rehabilitation programs can beapplied with effect to alcoholics, delinquents, habitualcriminals, and others who can be classified according to the above definition, theMontana program has not been able to extend services to other than those withclearly defined physical

or mental conditions.To extend services to all disabled is presently beyond

the resources of the state agency.

A. program of services to a select number of individualswithin this broadened category was initiated by the State Department ofInstitutions, utilizing federal funds available through the Division of VocationalRehabili-

tation. The Swan River Youth Forest Camp has received substantialequipment and programs to enable rehabilitation services to beprovided delinquent youth. Legislative appropriations to the state agency have not beenadequate

to enable full implementation of Vocational Rehabilitationservices to all such persons in Montana.

30Vocational Rehabilitation Administration, Federal Register, Revision of Regulations, 31:9:2:499, Department of Health,Education, and Welfare, January 14, 1966.

59 The number of individuals inthe community who are eligible andwould utilize services under thisbroadened definition is unknown; however, many of those in the custodialinstitutions could benefit from theservices of

Vocational Rehabilitation.

The experiences of otherstates' rehabilitation agencies havedemonstrated the efficacy of applyingrehabilitation techniques to theproblems of alcoholics, the aged, thedelinquent, and the publicoffender.

COMMENTS:

The failure of our society indealing with the individualhaving behavior problems emanating fromvocational, educational,social, and similar factors is reflected in theincrease in school dropouts,deviant social behavior, alcoholism, and in theincreasing costs of publicassistance. This feeling was expressed directlyin the recommendation ofsix of the Districts, of individual and by those agency administratorswho deal with the end result and societal deficiencies. be Wessen clearly makes the point: "In a sense, rehabilitation may said to have been made necessarybecause of the failuresof prior institutions, of those whose physical for it is the aim of the fieldto overcome the handicaps inadequacies make it impairments, psychological maladjustments,or vocational impossible for them to leadindependent, productive lives. It has been an assumption of our culture that theprimary socializing andtreatment institu- function as to tions - the family, the school,medical practice - should so create and maintain responsibleadults."31

31Wessen,A. F., "The Apparatus ofRehabilitation - An Organizational Analysis," Socioloa and Rehabilitation, p. 153.

6o Florida's Alcoholic Rehabilitation programfound that alcoholics required assistance in the areaof employment to a degree equalwith their

need to find ways to controltheir drinking. Despite the complex problems faced by alcoholics, one-thirdof all individuals referred tothe program were satisfactorilyemployed. The remainder were not acceptedfor service Of as they did not meeteligibility requirements in effect atthat time. the total number accepted for service,68% were rehabilitated.Inability

to tolerate the stresses of thenormal work setting, rather thanemployment per se, was found topresent a major problem in thevocational adjustment 2 ofalcoholics.3

Weil and Price concluded thatof those persons in the Baltimorecity

jail for drunkenness, vagrancy,and disorderly conduct, mostrequired a

minimal amount of medical care but amaximum of social, emotional, and voca- 33 tional rehabilitation andreintegration into the community.

South Carolina has a program ofrehabilitation for public offenders,

and by applying the services andtechniques long used with otherhandicapped months of persons, 100 offenders werereturned to jobs in the first eighteen

the program.Medical, psychological, andvocational services are initiated

as soon as the prisonsentence is begun, as part of acoordinated treatment

311 provides the full and rehabilitation program. A Wyoming DVR pilot project

32Williams,J. H., Florida Project onFollowup Adjustment of Alcoholic Referrals for Vocational Rehabilitation, p.59,Vocational Rehabilitation and Administration ResearchdizarEt 1472-P, Department of Health, Education, Welfare.

33Weil,T. P., Price, C. P.,"Alcoholism in a Metropolis," Crime and Delinquency, 9:60-70, 1963.

Program," Rehabilitation 3igdon,11R D., "South Carolina's Public Offender Record, 8:4:26-29, July-August,1967.

61 scope of services to inmatesmeeting eligibility requirements, and a special 35 pre-release orientation component is part ofthe program.

The low income family is the focus of aspecial project of the Georgia

DVR, and over 4,000 families each year receiveevaluation, assessment of work potential, and necessary medical andpsycho-social services. Suitable employment is the major goal of this programwhich serves individuals from

16 to 65 years ofage.36

RECOMMENDATION 8

THE IMMEDIATE DEVELOPMENT OF SPECIALCLINICS AND CAMPS SHOULD BE UNDERTAKEN

TO SERVE THE DISABLED CHILD IN THEPRE-TEENAGE GROUP. CHILDREN AFFLICTED

WITH CONDITIONS SUCH AS DIABETES, EPILEPSY,MENTAL RETARDATION, BLINDNESS, OR

DEAFNESS REQUIRE SPECIAL ASSISTANCE IN PERSONALAND SOCIAL ADJUSTMENT TO THE

DISABILITY, IN ESTABLISHING AND MAINTAININGAN tiliitCTIVE SELF-CARE PROGRAM,

AND IN FOLLOWING A PROPM MEDICAL REGIMEN.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: PUBLIC HEALTH

PRIVATE GROUPS

STATEMENT OF THE PROBLEM:

The disabled child is often subject toeither over-protection or isolation. Be must overcome not only the primarylimitations imposed by the

35Stugart, D. B., "Helping the Public Offender," Journal ofRehabilita- tion, 33:4;13-14, July- August,1967.

3 6Jarrell,A. P., "New Start for Atlanta'sPoor," Rehabilitation Record, 7:3;27-36, May -June, 1966.

62 disabling condition, but often thegreater obstacles of negative attitudesof his family and his peers. The presence of such attitudes at thecritical stage of the child's development canadversely affect subsequent personal, social, and vocational adjustment.The availability of an effectiveself-care program at an early agecould prevent the development of secondary disabling conditions.

Special clinics have proven effectivein the identification and clari- fication of problems in initiatingtreatment programs, in providing parental counseling, and in coordinating futureplanning for the child.

Camps provide an opportunity forparticipation in recreational, social, and developmental activities undercompetent professional supervision.

Through structured group activitiesat a level commensurate with functional limitations, a more positive andrealistic self-concept can be developed.

The capacity of a disabled person tofunction is often inhibited more by attitudes than by the functionallimitations of the condition. A. poor self-concept will likely result in a poorsocial adjustment. Positive attitudes, together with medicalsupervision at an early age, canminimize or eliminate the need for more costlyrehabilitative services later in life.

COMMENTS:

The programs operating under theCrippled Children's Service of the

Montana State Department of Health havedemonstrated the value of clinics for disabled children. These programs, which were originallydeveloped to serve ortho pedically handicapped children, nowprovide diagnosis and treatment tothose with

orthopedic or neurological conditions,congenital heart disease, neoplasms,

63 and rheumatic fever.In addition, that agency provides services to children with cleft palates. These programs are primarily treatment oriented, but

offer the potential for greater expansion to include more disability categories

and additional adjustive services, if resources were available.Children

suffering from cardiac conditions, diabetes, epilepsy, blindness, deafness, and mental retardation would benefit from similar programs.

Voluntary health agencies have long sponsored special camps for certain disabilities. The American Diabetes Association has established standards for camps for children and lists 39 camps in the UnitedStates.37

These camps provide experiences emphasizing self-reliance, basic habits for maintaining good health, regulation of diabetes, and a balanced social adjustment in addition to recreational activities.Diabetes can be controlled, but to do so requires a planned diet, exercise and, when necessary, insulin.

The National Epilepsy League states: "The child with epilepsy wants and should be treated in a completely normal way with emphasis on wholesome living. A healthy, happy, and active life reduces the likelihood ofseizures."38

Similar programs are of paramount importance to other disabled children.

Private agencies and service clubs should be encouraged to sponsor camps, under competent professional leadership, to meet the unioue needs of children with disabling conditions.

37AmericanDiabetes Association, Inc., Facts About Diabetes, p. 22, 1966. 38 National Epilepsy League, "Advice for the Parents of an Epileptic Child," Horizon, p. 3.

64 The ready availability of suitable camp sites in Montana should

facilitate the development of these activities for thedisabled child. The

Montana Association of the Blind and the Divisionof Blind Services sponsor

a saner school for the adult blind on the campus of Montana State University,

and it incorporates some of the functions ofcamps. The Easter Seal Society

has initiated camps in Montana for orthopedicallyhandicapped children.

RECOMMENDATION 9

Tan IS A NEED FOR CONTINUED AND STRENGTHENED COOPERATIONAND COORDINATION

AMONG AGENCIES TO PREVENT COSTLY DUPLICATION AM TO PROVIDETIE BEST POSSIBLE

SERVICES AT A REASONABLE COST.IT IS THEREFORE RECOMMENDED THAT THOSE

GOVERNMENTAL AGENCIES WHICH PROVIDE SERVICES TO DISABLED PEOPLE TAKETHE

NECESSARY STEPS TO INSURE THAT THIS COOPERATIONEXISTS.

SCHEDULE FOR INPLEMENTATION: IMMEDIATE

INITIATOR: PRIVATE AGENCIES

PUBLIC AGENCIES

LEGISLATURE

STATENENT OF THE PROBLEM:

The achievement of complete cooperationmay be unrealistic and imprac-

tical for many reasons; however, determined efforts mustbe made by all agencies

and professionals at all levels if the focus of allprograms - the handi-

capped individualis to receive maximum benefit. The problem of coordination and cooperation is a universal one and hasmany ramifications.Ropchan

65 conducive to developingcooperative relation- listed fiveconditions which are among agencies,fostered by each agency ships: (1) A spirit of cooperation convictions regardingits individual program; having clearlydefined goals and assistance to publicagencies, in, voluntary agencies canprovide practical the public agencyand providing oppor- e.g., financingdemonstrations within interpret its programsand needs; (2) Will- tunities for the publicagency to to larger commoninterest, ingness to subordinateinterest of own agency (3) Willingness to sharecredit instead of jealouslyguarding prerogatives; (4) A strong central planningorganization for results ofcooperative action; the agencies withthe central with competentstaff; and (5) Identification of their own programswith the organi- planning body; memberagencies should clear participating in theplanning activities, zation, assumeresponsibility for recommendations that comeout of theplanning give seriousconsideration to

process, andhelp finance theoperations.39 4o Health andRehabilitation Benney relates experiencesat the Altro Altro Health andRehabilitation Services Services as follows: Experience at the rehabilitation is importantat four levels: has shown thatintegration in intra-agency, (3) family, and (1) interagency, (2) interprofessional and agencies is implicitin any integrated (4) individual. Cooperation between finding throughtreatment andfollow-up. scheme of servicesfrom initial case described in one source as: (1) the Stages in interagencycooperation have been cooperation where one competitivtl. Jr chaoticstage; (2) awkward attempts at

Rehabilitation 39 "The Need of Integratingthe Community Ropchan, A., 26:3:4-7, 45-47, May-June, Agency andDisciplines," Journal ofRehabilitation, 19b0. Rehabilitation," Journal ofRehabil- 40Benney, C., "Integrative Aspects of itation, 25:3:13-15,24-25, May -June, 1959.

66 agency makes a plan and expects anotherto carry it out; and ( 3 )routine

divisions of cases on the basis of territory, nature of need, etc.described

E's "joint trafficagreements" among agencies. A fourth stage, representing

truly integrated working relations, is based on responsibilityand deepened

understanding, rather than contractual agreements.Altro Workshops Incor- porated of New York City and the New York City Welfare Departmenthave

established a cooperative relationship whereby Altro clients coming from

all districts of New York City are centralized in onespecial service office

of the Welfare Department, with two investigators interviewing thepatients

at the workshop as necessary. This cooperative effort has insured that patients quickly receive necessary assistance; further, it has decreased

absenteeism due to welfare office visits, and promoted the rate ofrehabilitation.

COMMENTS:

All Districts recognized that cooperation and coordinationof service activities and programs are not adequate. The problems of communication which result from conflicting philosophies, standards, procedures,and termi- nology are not readily overcome. Common objectives are not sufficient to

eliminate the problem.What is more necessary is the recognition that cooper-

ation will enable each to better achieve its goals andobjectives. Informal rather than formal meetings have proven effectivein facilitating communications.

67 RECOMMENDATION 10

COORDINATION AND TO IMPROVE IN ORDER TO PROMOTEINTER-AGENCY COOPERATION AND RECOMMENDED THAT AS OFFICE THE DELIVERY OF SERVICESTOTHOSE IN NEED, IT IS TO LOCATE ALL SOCIAL SPACE IS LEASED OR CONSTRUCTEDIN MONTANA, PLANS BE MADE OF RELATED AND HEALTH AGENCIES WITHINTHE SAME BUILDING.THIS CLOSE PROXIMITY PERSONNEL WHO COULD AGENCIES WOULD ALSO FACILITATETHE POOLING OF SPECIALIZED

FUNCTION FOR MORE THAN ONEAGENCY.

SCHEDULE FOR IMPLEMENTATION: LONG RANGE

INITIATOR: LEGISLATURE

STATEMENT OF THE PROBLEM:

conditions, a Inter-agency coordination is,under the most ideal of

smooth communication process as difficult process. As many deterrents to a operational staff possible should be eliminated. The ready accessibility of important than of the related agencies toeach other is perhaps even more interaction at the administrative orpolicy level. The delivery of services

in harmony with overall to the handicapped personby related agencies must be

Objectives, must be timely, andshould be as comprehensive asthe needs demand

A concentration and the resources of theseveral involved agenciespermit. to have many advantages of agencies at theoperational level has been proven oriented service which are particularly apparentwhen related to rehabilitation involves the and agencies. The process ofrehabilitation; by its very nature,

68 41 In coordination of many and variedservices in behalf of theindividual.

benefits are realized, addition to expediting deliveryof services, other and energy opportunities for strengtheningcooperation are enhanced, time

staff members becomes feasible. are conserved,and sharing of critical

COMMENTS:

whether The types and number ofservices utilized in rehabilitating, certainly con- vocational or general in nature,is formidable, and at times, 42 While prac- fusing and frustrating to theindividual seeking assistance. used, many others tical considerations precludegrouping some of the services this centralizing by can be placedtogether. More by accident than design, has built or function has occured in otherstates, notably Oregon, which leased state office buildingsin the communities.Agencies which should be accessible to each otherbecause of common cases andreferral problems

public health, mental health, are in the fieldsof correction, employment, welfare, rehabilitation, andsocial insurance. Such a concentration of programming of ser- services has been the keyingredient of successful total rehabilitation vices. Its worth has been demonstratedin medical clinics, in successful in centers, and in mentalhospitals. It has been most notably In Cleveland, Ohio in the VocationalGuidance and RehabilitationService. agencies, it was Cleveland, which has a traditionof consolidation of social

felt necessary to move thefacilities of several privateagencies under one rwmr.firraraNnemor

41NOTE: Caseload Study indicates, of casesreviewed, 56.8% received could have funds from other agencies,6.8%had a lack of resources that been provided by otheragencies, and 4.8% were nothelped because resources were not availablethrough DVR.

42,Referto Chapter I, p. 10.

69 T

of its operation andBoards, roof. Each maintains itsautobriomy and integrity and coordinationpossible, and dis- but all benefitthrough the cooperation 43 than would otherwisebe possible. abled persons receivefar better services Annex has enabled a The construction ofthe MissoulaCounty Courthouse More positive interagencyrela- grouping of agencies neverbefore possible. referral of clientsand case coordin- tionships have resultedin greater cross other Montana citieswhere agencies ation. The oppositesituation exists in problems for mutualclients are scatteredthroughout the city,with conseauent Lack of publictrans- and wasted staffefforts in effectingcoordination. discriminates against theindividual most portation in such asituation often

the agencies. often Leeding thecoordinated services of

RECOMMENDATION 11

SYSTEM TAKE THEINITIATIVE IN TRAINING IT IS RECOMMENDEDTHAT THE UNIVERSITY OF THE MENTAL HEALTHFACILITIES, PERSONNEL TO MEET THESTAFF REQUIREMENTS IN THE REHABILITATIONFIELD. ALLIED PROFESSIONALAGENCIES, AND PROFESSIONS

SCHEDULE FORIMPLEMENTATION: INTERMEDIATE

UNIVERSITY SYSTEM INITIATOR:

STATEMENT OF THE PROBLEM:

in the health,social service, and The shortage oftrained personnel national magnitude;however, such rehabilitation professionsis a problem of .4e. Program for'People Renewal," 43Ginn, R. M.,"Cleveland Initiates Unique 1966. Journal of Rehabilitation,32:1:41-42, January-February,

70 :thorLappn have an impact. that isparticularly felt in rural areas whereIhr stm-lage orLen means not a lesserdegree of service but no service at.an.

This is the case in several ofMontana's counties where there are nophysicians, speech therapists, physical therapists,public health nurses, and otherswho are vital to health andrehabilitation. Unfortunately, prospects for services by these people in most areas of thestate seem dim unless new and innovative methods directed towards the training ofthese people and the utilizationof the existing manpower are soon implemented. The Department of Labor estimates that total demands for those in the healthfield will continue to rise and estimates are that between 3,735,000 and3,979,000 persons will be needed 44 by 1975.

While certain professional careers can only beoffered in Universities with medical school affiliations, others canbe incorporated in non-medical academic settings.Training and programs initiated by theUniversity system, in cooperation with public and privateagencies, could be further expanded to include training at both the professionaland sub-professional level.

Some progress in this direction is being made;however, the existing programs have not beendeveloped, to the extent they must be tomeet demands for professionals in Montana.

According to the latest available information onthe numbers of professional people in Montana who are connectedwith rehabilitative endeavors, there is one physical therapist toeach 14,120 persons; there is one occupational therapist to each41,529; there is one speech therapist to each

Welfare, Health Manpower 144.U.S. Department of Health, Education, and Perspective 1967, p. 15.

71 33,619; there is one pro- 16,045; there is a DVR orDBS counselor to each 965; fessional social worker toeach 12,836; thereis a physician to each and there is onepublic health nurse toeach 5,883.

COMMENTS:

with this problem, as All of the Districtcommittees were concerned devastating effects onservices shortages of personnelcreate immediate and through speech therapy,physical ranging from treatmentof a medical nature therapy, social work,special education, andnursing. stated. "Highereduca- Acker in commenting onthe problem of personnel

controversial institutionin our tion, a multi-faceted,complex, and often particularly germane society, has manyresponsibilities. Two among them are current manpower crisisin general and to a considerationof its role in the responsibility to prepare in rehabilitation inparticular: these are its assist in the classificationand students for public servicecareers and to rehabilitation, therefore, solution of public problems. In the field of the community with everincreasing higher education ischallenged to provide It appears, unfortunately, numbers of adequatelytrained practitioners. from within its ownconfines, to less often challenged,by the community or which, after all, should examine critically theobjectives of rehabilitation how to best meetsociety's manpower provide the basis uponwhich it determines

needs ."45 of the specific needsof That academic trainingwithout consideration is emphasized byMott who those at the operationallevel is not adequate,1/ Crisis in Rehabili- 45Acker,M., "Higher Educationand the Manpower 1, April,1968. tation," RehabilitationManpower in the West, p,

72 points out that the fundamental problemwith graduates ofprofessional schools is a lack of adequate understanding ofthe organization into which they come to work and of the professionalrelationships within which they mustperform effectively. They often have a'limited concept of their placein the complex of health services andinstitutions and lack understanding ofthe functioning of the rehabilitation team.116 A program reported on by Younie describes a program of ColumbiaUniversity which introducedrehabilitation 11-7 materials and philosophy into thecurricula for special educationteachers.

RECOMENDATION 12

IT IS RECOMMENDED THAT THE DIVISION-OF VOCATIONAL REHABILITATION PLACE IN-

CREASED EMPHASIS ON THE ROLE OF THETOTAL FAMILY IN ME REHABILITATIONPRO-

GRAM OF THE DISABLED PERSON THROUGH THEPROVISION OF FAMILY COUNSELING.

CONSIDERATION OF TIE TOTAL FAMILY, AS ANINFLUENTIAL FACTOR, WOULD OFTEN

HELP TO INSURE A MORE SUCCESSFUL,INDIVIDUAL REHABILITATION PLAN.

SCHEDULE FOR IMPLEMENTATION: MEDIATE

INITIATOR: DIVISION OFVOCATIONAL REHABILITATION

DIVISION OFBLINDSERVICES

MINC111111=1, 46Mott, B. J., "Some RelationshipsBetween Rehabilitation Facilities and Universities," Selected to ers,Thirteenth and Fourteenth Annual Work- shops, November19647TTO;72ther1 pp. 21, 22.

47Younie,W. 3., Connor, F. P., Goldberg,I. I., "Teaching Teachers About Rehabilitation," RehabilitationRecord, 6:3 :32 -38, May-June,1965. STATEMENTOF THE PROBLEM:

The emphasis of all treatment,whether of a medical;15sychologicall or vocational nature,has traditionally beendirected toward the problems evidenced and expressed by thedisabled person, to the exclusionof many other vital considerations. The family and its effects onthe ultimate course Despite the of the rehabilitation program hasincreasingly come under study. recognition that the family is often asubstantial positive or negative influence, there is no formal mechanismthrough which the family ofthe disabled child or adult can receivecounseling. The social work profession particularly has stressed theimportance of including thefamily in any

to a degree, available planning. The services of family counseling are, agencies. With through the clergy, the mentalhealth clinics, and the welfare the exception of the mentallyill, however, there is nospecific statewide ser-

disability groups in vice that extends familycounseling services to other of disabled, Montana.To insure that such a programis available to a majority consideration should be given toincorporating such a program inthe vocational rehabilitation agencies.

COMMENTS:

The large service gap in the areaof family counseling wasparticularly a concern of theCitizens Advisory Committee andtwo of the Districts. A professionals in the review of rehabilitationliterature confirms that many helping professions identifythis area as one which is vitalin working with the disabled. It also appears to have receivedlittle in the way of programming

714- to allevia'.e it. The total family is ultimately affectedby disability of any member of the family,be they wage earner, wife and mother, orchild.

The consequences are felt economically,socially, psychologically, and particularly so in instances of sudden,substantial disabilities.

The Closed Caseload Study48indicated that in 13% of the cases, the lack of interest by the family was asignificant deterrent to rehabilitation

to the degree that the program hadto be terminated. In addition, in 17.1q

of the cases, the individual's attitudes,which can be presumed to be influenced by the family, stood as a deterrent. The evaluators also felt that

on the basis of case filedata, family counseling and social casework were

needed services.

Gelfand in describing personal problems andfamily adjustment of the

cardiac patient stated: "Apparently, when the patient relinquishes his role

as the major providerin the family, the family unit itself changes.Marital

discord and other family problems become moremarked."49Garrett, in speaking

of the employment of the cerebral palsiedindividual, flatly states that the most important single factor whichpredicts vocational success in vocational rehabilitation is family solidarity and familysupport.5°The family and its

relationship to the epileptic child was describedthusly: "Directly influencing

the epileptic is the family's tendencytoward blamefinding, and as the child

grows older he may blamevirtually everyone for his condition. During the

"Refer to Chapter VIII.

49Gelfand,D., "Factors Related to UnsuccessfulVocational Adjustment of Cardiac Patients," Rehabilitation in CardiacDisease, p. 106, Research Conference, Tufts University School of Medicine,March 3-7:7176.

50Garrett, J., "Total Life Planning for the Cerebral Palsied-NewConcepts of Vocational Rehabilitation," Total LifePlanning for the Cerebral Palsied; New Concepts of Vocational Rehabilitation; Proceedingsof the Professional Training Institute, United Cerebral Palsy Association, June3-6, 1964...Michipn State University, East Lansing: Kellogg Center for Continuing Education,Michigan State University, 1964. 75 early days of life, a child learns where his parents are vulnerable,where he may have power over them, so in a family where the family attaches great importance to the seizure, this will influence the relationship within the

family . The family may worry, wonder, feel jealous, rejective and guilty. "51 Experiences at Pioneer Fellowship House, a halfway house for alcoholics, led to the employment of a family therapist who worked withthe family, and particularly wives, in developing understanding, cooperation, and 52 positive rehabilitation activities.

Neser and Tillock in relating the role of the social worker toquadri- plegic patients note that because of the severe physical limitation,it is difficult for the patient to accept reality regarding his disabilityand its permanence. The family too may find it difficult to accept and mayreinforce

53 the patient's efforts to deny reality.

McFarland suggested the vocational rehabilitation counselor counselwith the family as well as the client to overcome family attitudes thatdeter rehabilitation, but recognized that the average vocational counselor has notbeen trained to deal with such specialized work or family counseling,and that the time demands on the counselor precludes counseling indepth. He suggested that 54 a family counseling specialist be included onvocational rehabilitation staffs.

51Falther, A., "Family, Friends, and Frustrations," in TotalRehabilitation of Epileptics, p. 42., U. S. Department of Health,Education and Welfare. 52 Adamek, R., "The Family Therapist as an ImportantAdjunct to a Halfway House Therapy Program," Report. of 2nd AnnualConference Association of Halfway House Alcoholism Programs of North America,Inc., Seattle, Washington, Octo- ber 22-25, 1967, pp.6574.

53Neser, W. B., Tillock, E. E., "Special Problems Encountered in the Rehabilitation of QuadriplegicPatients," Social Casework, 48:3:125-129, March,1962.

54McFarland,D. C., "The Importance of Family. Attitudesin Vocational Rehabilitation," New Outlook for the Blind,51:10:442-445, December, 1957.

76 RECOMMNDATION 13

IT IS RECOMMENDED THAT WAGE SCHEDULES BE ESTABLISHED AT A LEVEL THAT WOULD

INDUCE NEEDED PERSONNEL IN THE THERAPEUTIC AND SOCIAL SERVICE PROFESSIONS

TO SEEK EMPLOYMENT IN MONTANA AND WOULD RETAIN EXISTING PERSONNEL. THIS IS

ESSENTIAL IF THE EXISTING AND ANTICIPATED NEEDS OF THE DISABLED ARE TO BE

ADEQUATELY MET.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: PUBLIC AND PRIVATE AGENCIES

LEGISLATURE

STATEMENT OF THE PROBLEM:

The shortages of trained personnel in these fields have been well docu- mented by others and by empirical evidence, as reflected in agency personnel turnover. It is recognized that manpower presents complex problems, and no one aspect alone assures that necessary personnel will be available to serve

Montana's disabled. To attract new personnel and to retain those now employed, public and private agencies must consider salary schedules competitive with the urban centers where many of the training facilities are located and where other attractions exist.While many of the professionals in Montana are here because of other advantages, the competition with other states for them is on a predominantly economic basis. Three of Montana's counties have no resident physicians; 13 counties have no academically trained social workers. The total of academically trained (M.S.W.) social workers within the state is 55.

These are not adequate to meet the special casework needs of the mentally ill,

77 needing medical orpsychiatric the retarded, thealcoholics, and other groups 56 counties, 46 do nothave a resident physicalthera- services. Of the state's professionals. pist, one of the mostbasic and necessaryof the rehabilitation sufficient numbers tomeet the Speech therapists arenot available in

needs of childrenand adults adequately. other more lucrativejobs seems The migration oftrained people into staffed by men. Physical therapy exemplified in thosefields traditionally

is such a field.

COMMENTS :

Legislature and conductedby The personnel studyauthorized by the hopefully provide abasis of equit- J. L. Jacobs & Co.will, if implemented, the State of Montanain the therapies able treatment forthose employed by

and other serviceprofessions. listed by an "Competition from other agenciesand low salaries were which cause the mostdiffi- overwhelming majority(of agencies) as the factors counselors."55 culty when trying torecruit rehabilitation that salary, The results of theProfessionalSurvey%did not indicate expressed by thepreponderance of in itself, is ofparamount importance, as

The survey does not,however, indicate the the employed groupwho responded. working because ofsalary, and thereis no number of thenon-respondents not

low salary as afactor in not working. way ofascertaining the role of

55Western Interstate Commission on HigherEducation,"Rehabilitation Survey," RehabilitationManpower Counselors for the West: Report of Regional In the West, pp.49-52, April, 1968.

Refer to ChapterVIII.

78 RECOMMENDATION 1h

IT IS RECOMMENDED THAT INCREASED FUNDS BE MADE AVAILABLE BY BOTH THE STATE

AND FEDERAL GOVERNMENT FOR IN-SERVICE TRAINING PROGRAMS AND SERVICES, BOTH

IN AND OUT-OF-STATE, AND THAT THE DIVISION OF VOCATIONAL REHABILITATION ADOPT

A PROGRAM WHICH PROVIDES FINANCIAL ASSISTANCE AND ENCOURAGEMENT TO PROFESSIONAL

STAFF WHO WISH TO UPGRADE THEIR JOB SKILLS AND PROFICIENCY.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: DIVISION OFVOCATIONAL REHABILITATION

DIVISION OFBLIND SERVICES

STATEMENT OF THE PROBLEM:

The academic training which the rehabilitation worker receives provides a basis of understanding and knowledge. It offers a starting point for professional development which is constantly being modified by the demands of the job, the new methods of treatment being developed, changes in societalpatterns, and other influences. The backgrounds of those employed are often diverse and of varying degrees of experience. In order that overall program objectives can be realized, it seems imperative that methods bedevised to assure that a continuing program of staff development and training be implemented. Pro- fessional isolation from new ideas and concepts is particularly acute in a sparsely populated area such as Montana, and this can be alleviated to a degree by both in-state and out-of-state professional training programs.

79 COMMENTS:

District committees. The This recommendation wasmade by two of the to the surveyindicated that they are majority ofprofessionals responding however, 42% indi- permitted to taketime from employmentto attend courses;

not have in-servicetraining programs. cated that theiremploying agency did formal academictraining theyreceived These respondentsrecognize that the meeting the demandsof employment and Prior to employmentis not adequate in 213 of the 378respondents said they this is substantiatedby the fact that in school but hadlearned more on thejob. had gainedconsiderable knowledge amount was learnedin school, and107 An additional44indicated a minimal gained in the classroom. indicated most or allof their knowledge was in employment. The unique Specialized trainingis often necessary the blind, deaf,retarded, or problems of certaindisability groups such as training andsophistication if compre- mentally ill require ahigh level of

hensive care services areto be extended. (formerly Vocational Rehabil- The RehabilitationServices Administration in-service trainingopportunities itationAdministration) provides numerous personnel. Some of theseopportunities in specialized areasto rehabilitation state or private agencyis not able to provide stipends;however, often the because of shortagesof personnel andcost allow staff membersto participate

related factors. Vocational Rehabilitationfor staff Funds available tothe Division of 1967, and $770.00 wasavailable to the training was$2,667.00 in fiscal year These funds areobviously Division of BlindServices for the sameperiod.

inadequate for the purpose.

8o The sponsorship of training institutes and seminars by the staterehabil- itation agencies would allow those professionals in related fields to become more effective in the identification andreferral of the disabled; in the application of new rehabilitation knowledge and techniques, and in becoming more aware of the unique problems presented bydisability, That there is a need for such programs can be inferred from the results of theProfessional

Survey.An analysis of the responses indicates a rather significant number of professionals with less than three years of professional experience, apparently with a great deal of responsibility for case decisions, but having a minimal amount of supervision. The considerable number of persons indicating a need for more information on relatedprofssions should also be considered in assessing the need for such in-service training programs.

Angers presents guidelines for the vocational counselor working with epileptics, and points out the obvious, but not so often followed tenet, that he first must have knowledge. Be must know the facts on epilepsy, the medica- tions utilized, and how to deal withseizures.57Similar knowledge is needed with other disabilites. DiMichael cites a proposal to meet the shortage of trained personnel which advocates the employment of persons with aBachelor's 58 Degree, with work-graduate training programs an integral part of the employment.

In the present Division of Vocational Rehabilitation staff, three members hold Masters' Degrees - one each in rehabilitation counseling, counseling

57Angers, W. P., "The Challenge of the Epileptic to the Vocational Counselor," The Vocational Guidance Quarterly, 12:3:175-178, Spring, 1964.

58DiMichael,S. G., "New Directions and Expectations in Rehabilitation Counseling," Journal of Rehabilitation, 33:1:38-39, January-February, 1967.

81 psycholtyry, and music. Sixteen have Bachelor's Degrees, one in biological

rcience, one in politica:. science, six in sociology,two in journalism, two

in business aciAinistraIon, three ineducation, and one in psychology.

In the Division of Blind Services staff, fourmembers have Masters'

Degrees, two in rehabilitation counseling, one ineducational counseling, and one in social welfare.Four have Bachelor's Degrees, three in education,and one in social work.

RECOMMENDATION 15

ELKeORTS AIMED AT THE PREVENTION OF DISABILITY ANDHANDICAPPING CONDITIONS

THROUGH EDUCATION, EARLY DETECTION, AND REFERRALARE ESSENTIAL ASPECTS OF

REHABILITATION, AND NECESSARY STEPS MUST BE TAKEN TOINITIATE SUCH PROGRAMS.

SCHEDULE FOR IMPLEMENTATION: INNEDIATE

INITIATOR: DEPARTMENT OF HEALTH

DEPARTMENT OF PUBLIC WELFARE

DEPARTMENT OF PUBLIC INSTRUCTION

MENTAL PEALTH AUTHORITY

STATEMENT OF THE PROBLEM:

Permanent disability can often be prevented or minimized if programs of education, early diagnosis, and prompt referral areavailable to all individuals in the state. The necessity for treatment and rehabilitation programs, often of a long, costlynature, can be eliminated in certain

82 The programs that must instances if promptattention is given tothe cause.

direction, but broad inapplication, if be developed shouldbe specific in through education,study of they are to be effective.Accident prevention environment has contributedto hazardous conditions,and modification of and in society generally. significant accidentreductions in industry Programs should Existing programs mustbe strengthenedand expanded. prenatal care for expectant be developed with anemphasis on education and

at school, inindustry, and during mothers, accidentprevention in the home, referral of the disabledfor recreational activities. Early detection and the best efforts of a pre- treatment is vital when acondition occurs despite which, while excellent ventative program.Existing agencies offer programs consequent neglect ofsignificant in content, are oftenlimited in scope, with

areas whichcontribute to the problemof disability.

COMMENTS:

of preven- Comprehensive rehabilitation programsmust include programs which could benefitfrom tion. Chronic diseases accountfor 88% of all cases 10% are due rehabilitation; congenitalconditions for2%; and the remaining

home, or on thehighway.59 Volun- to accidents andinjuries on the job, in the offered programs toincrease public tary health agencieshave traditionally for similar programs of and professional awareness. A. public agency noted Montana Department ofHealth which education, detection,and treatment is the specifically communicablediseases, has an extensive programin certain areas, services, cleft palate, andhearing maternal health care,crippled children's

and 59Building America's Health,America's Health Status, Needs Resources, Vol. II.

83 retarded received coric'rvation. Comprehensive services for the mentally needed impetus through a MentalRetardation Planning and Implementation

Project. Silbstantiaiion of the need for programs of prevention,early detection, and refeiral has beenestablished in the Military RejecteeProgram of the State Department of Health.A study of the 1,004 individualsdis- qualified in 1966 for military serviceindicated that knee injuries resultant from athletics were a major causeof rejection. This finding has resulted in new and increasedattention to methods of preventionof injuries in school hearing, Programs. Other leading causes of rejectionsuch as obesity, hernias, cardiac, and back conditions couldhave been modified, had earlydetection 60 and treatment been available.

Professional services such aspsychological testing and evaluation are needed to identify problemindividuals and those who exhibitpre-psychotic to identify behavior patterns. Speech and hearing evaluations are necessary problems which, if untreated, cansubstantially affect academic andvocational

and can lead to the arrestof Progress. Visual examinations are essential conditions resulting in visualimpairment and blindness. Oberman reports an increasing prevalence of blindnessand visual impairments andemphasizes the 61 need for adequate detection andtreatment programs. Nadas and Zaver point out the ramifications of undetectedcardiac problems in pediatric andadol- escent patients and the essentialnature of early detection and carein the 62 ultimate rehabilitation of thisdisability. In the same report, Jezer points

6o Montana Health Referral Servicesfor Medical Rejectees,Progress Report, Montana State Department ofHealth, July,1966,

61Oberman, J. W.. "Vision Needs ofAmerica's Children," The Sight- Saving Review, 36:4:217-226, Winter,1966.

62Zaver and Nadas, 22. cit., p. 71

84 out, tho experience of AiLro Workshop in assessing, the signifiraneeoe extra

cardiac conditions, notably length of illness, in rehabilitation success.

Patients with periods of inactivity in excess of three years were found to

be rarely rehabilitated, which was felt to be indicative not only of the

severity of the organic disease but of other factors, primarily of an emo-

tional nature. This finding suggests as does that ofAagaard,63that if the

degree of disability is to be minimized, rehabilitation should begin as soon

as possible.

It is necessary that the identification of disability be highly effective

in order that rehabilitation can begin very shortly after onset, since the

physical and emotional degeneration which occurs can rapidly become irrever-

sible.

Muller summarizes the widespread inadequacy of current health practices

in preventative rehabilitation when he cites the functions of rehabilitation

as requiring: (1) an extended concept of rehabilitation from a vocational

orientation to one of prevention; (2) programs to assist other health workers

to move beyond the narrow confines of a disease oriented approach to a

functional concept of rehabilitation; and(3) the encouragement of compre-

hensive and continuous health services as the basis of sound rehabilitation."

6Aaraard,G. N., "Rehabilitation," Northwest Medicine)._ 57:8:997-1000, August, 1958.

61liguller, J. N., "New Concepts for Rehabilitation- APreventative Medical View," Journal of Rehabilitation, 29:2:39, March-April, 1963.

85 RECOYMENDATION

IT IS RECOMMENDED THAT LOCAL SCHOOLDISTRICTS ESTABLISH 1EW PROGRAMS, OR

EXPATID EXISTING PROGRAMS, OF SPECIALSERVICES AND CLASSES FOR CHILDREN WITH

SIGNIFICANT PROBLEMS OF A PHYSICAL, EMOTIONAL,OR EDUCATIONAL NATURE.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: SCHOOL DISTRICTS

DEPARTMENT OF HEALTH

DEPARTMENT OF PUBLIC WELFARE

OFFICE OF ECONOMIC OPPORTUNITY

DEPARTMENT OF PUBLIC INSTRUCTION

MENTAL HEALTH AUTHORITY

STATEMENT OF THE PROBLEM:

The movement toward development ofspecial programs to meet the needs of exceptional children has receivedconsiderable impetus through federal programs, notably under TitleVI of the Elementary and SecondaryEducation Act of

1965, as amended. Responsibility for such development is vestedin the office of the Superintendent of PublicInstruction, Special Education Department.

Extra financial assistance through theschool foundation program is provided the school districts that have specialeducational programs. The formula provides essentially three times the regularpayment for special education classes.

The number of handicapped children who wereenrolled in public school special education programs during the1965-1966 school year, are listed in the

86 65 following table by major handicapping conditions:

TABLE 7. NUMBER OF HANDICAPPED CHILDREN IN SPECIAL EDUCATION PROGRAMS - BY HANDICAPPING CONDITION

, t I

ainable EducableSpeech Hard ofSpeech, Other entally MentallyImpairedHearingHearing CrippledHealth TOTAL etarded Retarded Impairment Impaired

39 628 383 12 7 61 3 1102

. _

As of the close of the school year 1967-68, there were 687 elementary and 168 high school districts in Montana. This number is expected to decrease by ten within the next year, due to annexation and other reasons. Of this vast number, only 41 of the districts operated state-approved special education programs. On the basis of a survey conducted on a random basis in 14 schools by the Supervisor of Special Education, it was found that 625 children of a total school population of 6,167 surveyed, were reported to be handicapped.

On the basis of these figures, 20,014 school-age children are estimated to be handicapped in the state. These figures closely approximate national incidence figures which, when applied to Montana, could indicate 20,899 or 10.60% of the children to be so considered. The estimated cost to provide adequate educational services to all handicapped children in the state is $6,867,000.00.

65 Montana State Department of Public Instruction, State Plan to Initiate, Expand, and Improve Properams and Projects for the Education of the Handicapped Children, under Title VI of the Elementary and Secondary Education Act of 1965 as amended, February67178.

87 CONICNTS:

The basis of the treatment of the disabled child and the ultimate

effects it has on total life adjustment, often is formulated during the school years, and availability of special education programs is crucial. The benefits of medical treatment, counseling, and therapy can be negated if special

concern is not extended by the school for the educational problemswhich may be evidenced as a facet of the disabling condition. Experience has demonstrated that, whenever possible, the education of the exceptional child should be accomplished in as normal an environment as can be provided, rather than in an institutional setting. Some conditions of disability lend themselves to education in a regular classroom under the guidance of a knowledgeable and understanding teacher.Other conditions, because of their complexity and the special educational techniques required, demand special classrooms. Both approaches must then be considered in the determination of suitable educational

Programs. In either case, maximum social integration must be achieved with children in the regular classrooms.Hamilton, in referring to the epileptic child, observes that some epileptic children require special school auspices, even when optimum medical services have been supplied, but many canbe taught in regular classes if more effective orientation of teachers in the handling of the seizure victims isprovided.66The child with cardiac disease should, whenever his intellectual capacity permits, be placed in a regular school setting and be permitted to participate in non-competitive physical activities 67 to the level of his tolerance.

66Hamilton, L., Bernd, J., "Education," Rehabilitation of Seizure Patients; One Day Institute, November 17, 1959, sponsoredla...and the Montreal Neurological Institute in Cooperation with the Department of Neuro-Psychiatry, Hotel Dieu, pp. 17-21.

67Zaverand Nadas, sm. cit., p. 146.

88 Local school boards ultimately havethe responsibility for the establishment of adequate programs to meetthe needs of the disabled child aswell as the non-disabled, andthis responsibility extends tosecondary schools as well. Cooperative special education -Vocational Rehabilitation programs are an effective means ofbridging the gap between the schooland the community.

Frankel discusses special school programswhich emphasize pre-vocational training beginning at the elementary schoollevel, and points out that inview of the fact that mentally retardedchildren need more rather than less preparation for adult life, that it is-unfortunate that less than10% of them remain 68 in school through the twelfth year. Generally speaking, the schooldistricts have not adjusted their programs tomeet the needs of the disabledchild in

Montana.

Programs of benefit to the disabledchild include: work experience programs, pre-vocational programs,guidance and parental educational programs, personal development programs, and homeeconomics programs.

RECOMMENDATION 17

IT IS RECOMMENDED THAT THEEMPLOYMENT OF., OR CONTRACTING FORSERVICES OF,

TRAINED PERSONNEL BE MT INTEGRALPART OF PROGRAMS DEVELOPED INTHE SCHOOLS TO

ASSIST THE EXCEPTIONAL CHILD INORDER TO ASSURE THAT SUCHPROGRAMS ARE

IMPLEMENTED AND DEVELOPED EFFECTIVELY.

68Frankel, W. A., "The Role of theWorkshop in Relation to Special Education," Work Evaluation and Preparation Services for Mentally Retarded Adults: A Report on the Institute onSheltered Workshop Services for the Mentally Retarded, Universitzof Kansas....atrasEz5-6-7, 1961, pp.7739.

89 SCIEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: DEPARTMENT OF HEALTH

DEPARTMENT OF PUBLIC INSTRUCTION

OFFICE OF ECONOMIC OPPORTUNITY

MENTAL HEALTH AUTHORITY

STATE/ENT OF THE PROBLEM:

The recognition that problems of disabled children exist and reauire attention is but the starting point for program development. The complex problem of disability as experienced in the educational systems ofthe state can only be resolved through the employment oftrained individuals who have a primary responsibility for special programdevelopment. It is not adequate to assign responsibility of meeting the unique needs of theexceptional child to staff members who must afford him a low priority because of otherdemands upon them, or to staff members who do not havethe necessary professional skills.

Trained personnel in the fields of special education, speech therapy, psychology, and counseling are in short supply; however, the developmentof methods for providing high quality services through the better utilization of trained persons is essential. Utilization of existing trained personnel in a supervisory capacity for those staff members withminimal training should be considered in preference to having minimally trained persons assume total responsibility for individual cases.

90 employment of When personnel shortages donot permit the independent

should be given to the trained persons by aschool district, consideration

contractual basis. sharing of these personsbetween districts on a

Specialists are also neededto deal with visualproblems, mental

problems retardation, visual difficulties,speech, hearing, and other encountered in a classroomsetting. service programs for The sensitivity requiredto develop and provide training, be it attained exceptional children demandspersonnel with proper by a complete academic program,or throughin-service training.

COMMENTS:

in sparsely The acute shortage oftrained personnel, particularly

which offers pro- populated areas, has resultedin a program in Montana fessional services to schoolsin a ten-county area. The Pupil Personnel

Hill, Blaine, Phillips, Services Project servingGlacier, Toole, Liberty, services to schools Valley, Pondera, Teton, andChouteau Counties offers through three centers at BigSandy, Harlem, and Conrad. The staffs of

reading specialists trained psychologists, socialworkers, counselors, and will soon by joined byspeech therapists. Services are primarily of a individual and group diagnostic and consultativenature at this time, with

counseling being provided whenfeasible.Consultation with school per- to meet the sonnel can result inspecially developed, individual programs

highly unique needs ofthe exceptional child.

91 RECOMMENDATION 18

SCHOOL DISTRICT, HAVE TO INSURE THAT ALL EXCEPTIONALCHILDREN, REGARDLESS OF PROGRAMS, IT IS RECOMMENDED EQUAL ACCESS TO SPECIALTREATMENT AND EDUCATIONAL SCHOOL PROGRAMS, AND THATSTATE THAT A COMPREHENSIVE STUDYBE MADE OF EXISTING AND OPPORTUNITY THAT EFFORTS BE MADE TO CORRECTTHE INEQUALITIES OF SERVICE

CURRENTLY EXIST FOR SUCH CHILDREN.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: LEGISLATURE DEPARTMENT OF HEALTH

OFFICE OF ECONOMIC OPPORTUNITY

DEPARTMENT OF PUBLIC INSTRUCTION

MENTAL HEALTH AUTHORITY

STATEMENT OF THE PROBLEM:

for the The inequality of theavailability of special school programs apparent when it is exceptional child in many partsof the state is readily 41 considered that of the855 elementary and secondaryschool districts, only for the offer special educationof some type. The majority of classes are classes for the educable mentally retarded child with39 districts offering palsied and ortho- retarded, 4 for the trainableretarded, 2 for the cerebral problems, and i for thehard pedically handicapped, 7for those with speech 69 offer most of the of hearing. As would be expected,the larger communities

69Department of Public Instruction, Montana Special EducationTeachers 1967-68 Directory, Preliminary List,State of Montana.

92 special classes, but, increasingly, smaller districts arebecoming cognizant of their responsibilities in these areas and are implementing programs.

Even in the larger communities, programs are not availablefor many cf the different disability categories.Missoula, for example, has 5 classes for the educable mentally retarded(EMR) child, none for the trainable (TMR),

1 for the speech handicapped, and 1 for the hard of hearing. Butte has 5 classes for the EMR, 1 for the TMR, and none for the speechhandicapped or the hard of hearing child. Great Falls has 9 EMR classes, no TMR classes, and

1 for the cerebral palsied or orthopedically handicappedchild. Billings has

10 classes for EMR children, 3 for TMR children, and 1 forthe cerebral palsied and orthopedically handicapped.The directory does not indicate the existence of any special classes in Montana for the child withlearning disabilities, nor for the emotionally disturbed child. There are 197,576 school children in Montana, and of the 20,014 considered to be in needof special education, only 1,101 in a select few areas are able to gain fullbenefit from the public school programs that currently exist. The majority of programs are at the elementary level and, withthe exception of cooperative work-study

Programs, little is being done at thesecondary school level.

COMMENTS:

The state plan for Elementary and Secondary Education Actof 1965,

Title VI, acknowledges the need for changes in state legislationto extend services to those with learning disabilities, and suggests theneed for a comprehensive legislative review in this area.The 1966 Biennial Report of the Superintendent of Public Instruction, State ofMontana, recommends:

93 1. . Increased recoiibition be riven tothe special educational needs of handicapped children,and that opportunities available to these childrenbe broadened through provision of increased servicsand state financial aid for special education.

2. That education of children youngerthan six years be recognized not only as amorthwhil.=. expenditure of public funds but as an importantopportunity to increase the value of the investmentthat later will be made in their education. Statutory provision especially should be made to permitthe early education of handicapped children bylocal school districts, and the provision should be repealedwhich now prevents the State School for theDeaf and Blind from accepting children under five yearsof age.

Thescope of the problem,and the implications of programdeficiencies for the handicapped child and hisfamily, require an immediate and comprehensive study. Texas has a comprehensiveeducational-vocational program for the educable mentally retardedwhich is geared to smooth the wayfor more retardates from ages 6 to 21, from schoolinto vocational training and ultimately competitive employment.A seven-step program from pre-primaryschool

activities through eventual placement byvocational rehabilitation is substi- 70 tuted for the traditional twelve gradeeducational program. Such innovative programming as exemplified by that programshould be considered for alldis-

abled children in Montana.

Moses in discussing a rationale forproviding counseling to the handi-

capped high school student makes twoassumptions which have validity in the

entire field of special education andrehabilitation:

(a) every societal member has aninherent right to the opportunity to earn a living and ...... 70Eskridge, C. S., Partridge,D. L., "Vocational Rehabilitation for Exceptional Children through SpecialEducation," Occupational Information for -112s Mentally Retarded: SelectedReadings, pp.39;--406,

911- best it can, society has anobligation to equalize, as (b) a living the disabledperson's opportunity to earn equal to theopportunity of thenon-disabled.71 logical starting point. An equitable educationalsystem provides a

RECOMMENDATION 19

IT IS RECOMMENDEDTHAT LEGISLATIONBE ALL CHILDRENSHOULD ATTEND SCHOOL. APPOINT THREE ORMORE PRO- ENACTED PROVIDING THATLOCAL SCHOOL AUTHORITIES CONDITION PREVENTS FESSIONAL PERSONS TODECIDE WHETHER ORNOT A HANDICAPPING

THESE PERSONS SHOULDBE REPRESENTATIVES THE CHILD'S ATTENDANCEAT SCHOOL. SOCIAL SERVICE PROFESSIONS. FROM MEDICINE,EDUCATION, AND THE

SCHEDULE FORIMPLEMENTATION: INTERMEDIATE

DEPARTMENT OF PUBLICINSTRUCTION INITIATGR: LEGISLATURE

STATEMENT OF THE PROBLEM:

Constitution of theState of ARTICLE XI.EDUCATION. Section 7 of the

Montana states: shall be open to The public freeschools of the state of six and all children andyouth between the ages twenty-one years. 1947, defines the"Excep- Section 75-1401, RevisedCodes of Montana,

tional child" as: because One requiring specialfacilities or instruction deviation from of physical, mental,emotional, or moral the average.

for Handicapped 71Noses, H. A., "A Rationale forProviding Counseling 1966. Students," Journal ofRehabilitation,32:6:14-15, November, December,

95 Section 75-2901, states in part:

School attendance shall beginwithin the first week of the school term, unlessthe child is excused fromsuch attendance by the superintendentof the public schools, in city and other districtshaving such superintendent, or by the clerkof the board of trusteesin districts not having such superintendent,or by theprincipal of the private or parochialschool, upon satisfactoryshow - in that the bodily or mentalcondition of the child does not permit of itsattendance at schoolor that the child is beinginstructed at home by a person qualified, in the opinionof the superintendent of schools in city or otherdistricts having such superintendent., to teach the branchesnamed in this section; provided, that the countysuperintendent may excuse children from attendance uponsuch schools where, in his judgment, the distancemakes such attendance anundue hardship.In case the county superintendent,city superintendent, principal, or clerkrefuses to excuse a child from attendance at school, anappeal may be taken from such decision to thedistrict court of the county, upon giving a bond, within ten(10) days after such refusal, to the approval of saidcourt, to pay all costs ofthe appeal; and the decisionof the district court inthe matter shall be final.Any parent, guardian, orother person having the care orcustody of a child betweenthe ages of seven(7) and sixteen (16) years, who shallfail to comply with the provisionsof this section, shall be deemed guilty of a misdemeanor,and upon conviction. thereof shall be fined not lessthan five dollars($5.00) nor more than twentydollars ($20.00). instruction - trans ortation Section 75-1406.2/212.21ed children - home tax levy.

The board of trustees of anyschool district, at its discretion, is authorized toassist the education of crippled children of five(5) to sixteen (16) years of age, who, because ofphysical handicap cannot regularly attend public school byfurnishing home tutorial service for such crippledchildren or by furnishing transportation to and from adequateschool facilities locally or elsewhere withinthe state, whichever best meets the child's needs asdetermined by the said board of trustees together with thesuperintendent of schools based upon recommendationsof the division of service for crippled children of theMontana state board of health, and if in any schooldistrict there is a need

96 children located of such 5.pecialprovision for crippled levy therein then the boardof county commissionerr may a tax not toexceed one(1) mill on the dollar on all addition to taxable property,within the district, in all other levies, forschool purposes, forthe support and maintenance ofsuch crippledchildren's education, Provided that the boardof school trusteesof any such distric., requiring suchlevy must call anelection in levies for the manner prescribedby law for such extra the purpose ofobtaining the approvalof the district fur- to the making of suchadditional levy and provided the 1st day ther that such electionmust be held before of truly. underlined would seemto allow The wording of theabove cited laws as

to the degree that theseverely latitude in assessingability to attend school right to classroomatten- handicapped child would notreceive the benefit and dance. needs of certain exceptional The laws of Montanaadequately consider the could be enhanced bybroadening children once schooladmission is granted, but Section 75-5006 to read: the language of Section75-5004, Section 75-5005, and disturbed." "Mentally retarded, physicallyhandicapped or emotionally of Section 75-5003 Similarly, questions areraised regarding the language

by the board oftrustees in each which requires thatspecial classes be formed children within school district when there arenot less than 10 exceptional

rural population, itis not un- that district. In Montana, with its large development of special reasonable to assume thatthis eliminates the ready programs for manyexceptional children.

COMMENTS:

The existing laws couldbe improved by:

1. Requiring that thedetermination that children can

attend (Section75-2901) be made in the same fashion as

97 required in Section 75-5003; that is, by theState

Superintendent using medical,psychiatric, and psychf...lop.i,:al

consultations and thereby makeit less discretionary onthe

part of the localdistricts, The problem here is gaining

admission to regular school,and not with thedeterminatUn

that special educationis needed after admission. This

screening process would seemto eliminate from school pro-

grams some ofthe most severely disabled.

2. Giving consideration to thechildren in smaller

districts who may not, inaggregate, total 10.

3. Broadening the language ofSection 75-5004, 75-5005,

and portions of 75f-5006 to read: "mentally, physically, or

emotionally handicappedchildren." pertaining to A thorough legal analysisshould be made of the laws interpretation would this recommendation todetermine if additional legal modify the need for newlegislation.

98 RECOMMENDATION 20

THERE SHOULD BE AN INCREASE IN THE COOPERATIVEWORK-Tuld PROGRAMS FOR

EXCEPTIONAL CHILDREN AT THE SECONDARY SCHOOL LEVEL. EXISTING PROGRAMS FOR

THE MENTALLY RETARDED AND THE PHYSICALLYHANDICAPPED HAVE DEMONSTRATED THE

VALUE OF THIS TRAINING AND ADJUSTMENT IN THEPLACEMENT OF YOUNG PEOPLE IN

PRODUCTIVE POSITIONS IN THE COMMUNITY.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: DEPARTMENT OF PUBLIC INSTRUCTION

DIVISION OF VOCATIONAL REHABILITATION

LOCAL SCHOOL DISTRICTS

STATEMENT OF THE PROBLEM:

It has long been recognized that many children do not progresssatis- factorily in the regular school curricula, and many have extremedifficulty in transferring from the school environment to the worldof work. This is particularly true of the mentally retarded and severely physicallydisabled.

In the 1967-68 school year, just41 school districts had special education programs, or about5% of the total 855 districts.

COMMENTS:

Billings and Helena pioneered in school-work experience programsat the secondary level in Montana, and in the' 1967-68 school year 11schools had this program. This is a cooperative effort between the school andDVR, in which

99 time betweenclassroom studiesand special educationstudents divide their interrelated in astructured manner on-the-job training. School and work are transition from onelife area so that thepupil can make asmooth, successful to another. vocational continuum is William J. Younie saysthat the educational-

competence iscomposed of many factors based on theassumption that vocational program,beginning in earlyschool which must be providedfor in an educational provides for acontinuity of thementally years. Such a continuum program consistency of purposeis insured retarded child's schoolexperiences so that carefully specifiedgoals. To be and a acriniteprogression is made toward

successful, such a programmust: the time of (1) be designed forthe retarded from identification untilplacement in adultlife;

(2) interrelate specialeducation and vocational rehabilitation;

the use of longand (3) stress sequence through short range goalsthat are compatible;

provide (4) insist on excellenceat all levels and for constantcommunication betweenlevels;

that can be clearly seenby (5) provide an outcome child, parents andteacher.

last phase of theeducational vocational The school-workstudy program is the part to the school-workstudy program as a continuum. Emphasis must be given teachers at all levelsof the of the continuous process,and to this end, 72 structure, functions,and goals. continuum must be awareof the program's

OM/ Establishing School -WorkStudy 72Younie, W. J.,(Ed.), Guidelines for Youth, 70 pp., VirginiaState Programs for EducableMentally Retarded Service, 1966. Department of Education,Special Education

100 RECOMMENDATION 21

THE PERSON DISCHARGED FROM STATE CUSTODIALINSTITUTIONS BACK TO COMMUNITY

LIVING REQUIRES ADEQUATE SUPPORTIVE AND THERAPEUTICSERVICES IF A SATISFACTORY

ADJUSTMENT IS TO BE MADE.PROGRAMS PROVIDING SUCH SUPPORT, INCLUDING FAMILY

COUNSELING, MUST BE DEVELOPED IN THE COMMUNITIES.

SCHEDULE FOR IMPLEMENTATION: INTERMEDIATE

INITIATOR: DEPARTMENT OF INSTITUTIONS

DIVISION OF VOCATIONAL REHABILITATION

STATEMENT OF THE PROBLEM:

Transition from life in a custodial institution to asatisfactory and rewarding life in the community is a major problem inrehabilitation of institutionalized people. Quite often, the sudden change from a dependencystatus to one of independence is overwhelming for the vocationallyhandicapped.An individual leaving a hospital or other institution with a chronicdisability is in need of professional help in overcoming the problemsassociated with the disability. Adjusting to changes in community life providesadditional problems.

Ralph Notman says that factors in the community canprevent effective rehabilitation and these include: unavailability of a setting which will accept the patient with residual disabilities when thesedisabilities are not so great that hospitalization isrequired, and lack of access to resources which are transitional between a hospital-centeredand a community-based existence.

Provision for these needs must be made and the patient must be awarethat resources will be available; otherwise,it is reasonable for him to settle for

101 Close collaboration "hospital -based rewards" and toaccept his dependence. must be maintained, between the hospital-basedand community-based resources for the patient, anddis- because the transitionis extremely threatening can make thetransition continuity or impersonalityin the referral process impossible. face is the role the Another problem which therehabilitation team must The family plays in thepatient's successful orunsuccessful rehabilitation. difficult to work withand can family who encouragespathology is often very be essential inminimizing be extremely destructive. Community agencies may interested the negative role thefamily may play, andin the absence of an the family, their role becomes evenmore importantin that they must support 73 patient's transition into thecommunity.

COMMENTS:

transition from Community-based facilities andservices may ease the The New institution to community. One such facility isthe halfway house. the only such facility now Horizon Halfway House foralcoholics in Helena is

operating in Montana. Others are in the planningstage. Educa- An effective program isthe COVE(Community Oriented Vocational sheltered tion) project in the state ofWashington. The COVE program is a handicapped individuals living arrangement in thecorrmlunity for vocationally At COVE, theseindividuals who are in need of socialand vocational retraining. basic needs of shelter,food, find a comfortable livingsituation where their

Rehabil- 73Notman, R. R., "Problems of RehabilitationProgram Development," Social and Economic Aspects; aSymposium of the itation of the Mentally Ill; Association for the American Psychiatric Association,Sponsored hy the...American Society... December 29-30, Advancement of Science and theAmerican Sociological 25,E, pp. 57-70.

102 :ellowship, and warm support are met. This permits their energier. to be directed toward understanding and overcoming theirvocational and social problems.

From this setting, the client may sample competitive jobsin the community. He receives only a token wage, because the objective ofthe experience is vocational and social education, not remuneration.Each client has free choice regarding the kind of work he wishes to experience. He may try several occupations. After a realistic choice has been made and the client has demonstrated his capability to function competitively, hestarts the job- seeking phase of the program. The program staff gives assistance in finding a job in his community.

Often a client demonstrates potential for a vocation in whichhe does not possess adequate training orskills; In these cases, DVB, which is a program sponsor, provides a training programto develop skills he needs to be employable.Following a client's discharge from COVE, there is anactive follow-up program by staff members. This is an effort to give support to the client in his transition to competitive work and living.

RECOMMENDATION 22

AFTERCARE SERVICES FOR YOUTHFUL PATIENTS RELEASED FROMWARM SPRINGS STATE

HOSPITAL SHOULD BE PROVIDED ON THE SAYE BASIS AS SERVICESNOW BEING PROVIDED

OTHER INSTITUTION DISCHARGEES.

SCHEDULE FOR IMPLEMENTATION: INTERMEDIATE

INITIATOR: DEPARTMENT OF INSTITUTIONS

DIVISION OF VOCATIONAL REHABILITATION

103 STATEMErd OF THE PROBLEM:

Problems confronting young patients releasedfrom a mental care institution are very similar to those faced by their peersreturning to the community from other institutions. In addition, of course, is the continuing need for therapy and medication due todisability. Preparations for return to the community need to be initiated longbefore the patient is released, and where adequate plans have been made,early release is often possible. If the patient has a satisfactory home environment,it is necessary to work with the parents as soon as possible. When such an environment is not present,it is necessary to find foster or group homes, and to prepareto provide the functions normally assumed by parents. Continuous observation and counseling is needed to insure that the patient isprogressing, or to determine if he needs additional institutional care.Often the mental patient is in need of private tutoring and additional help with schoolwork. Like other dischargees, he needs guidance and assistance in leisuretime activities. He needs help in adjusting to the community and the world of work.

COMMENTS:

Juvenile Aftercare has been highly successfulwith children released from the Pine Hills School, the Mountain ViewSchool, and the Montana Children's

Center. During the 1966-67 fiscal year, 323 boys and girls werereleased to the Aftercare program. Just 59 were returned to the institutions forviolation of their aftercare agreements, while 199 weregranted discharges by the Depart- ment of Institutions. New counselors are being strategically locatedthrough- out the state, a situation which will strengthenthe program and allow for improved individual attention.

104 The emphasis in the programis on the individual'sresponsibility, on

flow of pride of accomplishment, and onindividual integration into the community activities.

RECOIRENDATION 23

PUBLIC HEALTH LOCAL MID COUNTY AUTHORITIESSHOULD BE ENCOURAGED TO EMPLOY

BETIP,K SERVICES NURSES AND OTHER TRAINED SOCIALSERVICE PERSONNEL TO PROVIDE

TO DISABLED CHILDREN ANDADULTS IN THE COMMUNITIES.

SCHEDULE FOR IMPLEMENTATION: INTERMEDIATE

INITIATOR: SCHOOL DISTRICTS

LOCAL AUTHORriltS

STATEMENT OF THE PROBLEM:

determination to pro- Recent health legislationstresses our nation's vide all persons withadequate medical care. There are many indicators such as the draftrejection rate (in Montana -24.4%) which points to inadequate The work of public health care of the young,both in diagnosis and treatment. nurses in the schoolsand the communities is animportant factor in early referral to detection and care of potentiallyhandicapping conditions, and in

school boards to employ the proper agencies. In Montana, legislation allows for school nurses, and countycommissioners to employ county health nurses duties pertaining to maternal andchild health. The State Department of Health is designated to superviseand regulate school, county,and public health nurses in the performance of theirduties and to make and enforceregulations pertain-

ing to the nurses and their work.

105 Although they are authorized by lawto employ public health nurses,

22 counties in Montana do not havethis service and several haveonly part- time nurses.

COMMENTS:

The importance of public health nursesin the home, in public health clinics, in the school, in thecommunity, and in industry has been proven wherever the service is available. Insofar as practicable, it shouldbe available to all citizens.

RECOMMENDATION 24

FOSTER HOME CARE OR OTHERTRANSITIONAL LIVING ARRANGEMENTSSHOULD BE CONSIDERED

FOR THOSE DISCHARGEES FROM WARMSPRINGS STATE HOSPITAL WHOREQUIRE SUCH SER-

VICES AS A MEANS OF RE-INTEGRATIONINTO THE COMMUNITY.

SCHEDULE FOR IMPLEMENTATION: INTERMEDIATE

INITIATOR: DEPARTMENT OF INSTITUTIONS

DIVISION OF VOCATIONAL REHABILITATION

STATEMENT OF THE PROBLEM:

Adjustment from any dependent rolein the hospital to an independent role of citizen and worker inthe community is a verytraumatic experience for

the patient does not have many mental patients. This is particularly true if Lack of an environmentwhich is understanding andsupportive of his efforts. a good environment oftenimpedes the patient's progressand may be responsible for his return to the institution.

106 COMICHTS:

Authorities believe that halfway houses or other transitional facil-

ities are necessary for many mental patients to successfully re-integrate

into the community.

Milton Greenblatt says that there are a number of advantages to the

development of transitional facilities to ease the shock of movement from

the hospital to the community for the mental patient. First, the patient's

discharge can be arranged earlier in his clinical course if such facilities

exist. Graded steps to final community responsibility can be developed to

fill the patient's level of improvement and degree of "ego strength" at any

given period. The patient can remain in contact with the hospital therapeutic program for a longer time and can receive its benefits until he is firmly rooted in the community. The hospital with transitional facilities is able to concern itself more actively with many aspects of community rehabilitation of its patients and will pay more attention to overall integration of hospital and community services.At the same time, greater participation and responsibility of the community in relation to the mentally ill will be fostered by the presence of transitional facilities, and these facilities can provide alternatives to hospitalization for certain 74 new or relapsing cases.

74Greenblatt, M., "Transition From Hospital to Community," Rehabilitation of the Mentally cit., pp. 117-118.

107 RECOMMENDATION 25

BE DEVELOPED BETWEEN IT IS RECOMNENDED THATEFFECTIVE WORKING RELATION8HIPS INSTITUTIONS, AND THE TWO STATE REHABILITATIONAGENCIES, THE STATE CUSTODIAL JOINT STAFF MEETINGS THE AFTERCARE DIVISION OFTHE DEPARTMENT OFINSTITUTIONS.

ARE NECESSARY TO ESTABLISHWORKING AGRMENTS, DEVELOPA COMMON PHILOSOPHY, IN THE INSTITUTIONS ADD TO PLM xar.tiECTIVEREHABILITATION PROGRAMS FOR THOSE

AND DISCHARGEES INTO THECOMMUNITY.

SCHEDULE FOR IMPMENTATION: IMMEDIATE

REHABILITATION INITIATOR: DIVISION OF VOCATIONAL

DIVISION OF BLIND SERVICES

DEFtRTMENT OF INSTITUTIONS

STATEMENT OF TIE PROBLEM:

discharged to the The Problem of providingadequate services to persons agencies whose pr5mary community from the institutionsis recognized by all the responsibility is to assure thetotal adjustment of thedisabled to a productive capacity.

Initial steps at the administrativelevel have been taken todelineate

an6 responsibilities of the respectivedepartments in community placement

of Institu- follow-up. It is recognized that theobjectives of the Department but differ in tions and the rehabilitationagencies are similar in nature, The methodology because of inherentdifferences of basic responsibility.

108 enhanced with thedevelopment of n effectiveness of botha'encies will be continuous staff best be effectedby regular and commonphilosophy which can meetings of keyadministrators andcounselors.

COMMENTS:

has only recentlybegun to Aftercare or follow-upin the community crucial step in therehabilitation receive the attentionit deserves as a be negated and treatmentin an institution may process.The best of care the same environmentwhich precipitated if the individualis returned to institutions themselvesmust be active institutionalization. The custodial process, asrehabilitation pro- participants in thefollow-up or aftercare that institution with therecognized objective grams mustbegin in the

eventual communityadjustment must occur. are thatthe patientrequires Basic assumptionsof aftercare programs and that he isentitled to help in one or moreareasfollowing discharge, which purports tobe complete. help as part of anytreatment program as part ofaftercare are Special areas thatmust be considered

(which should begin intheinstitution), recrea- vocational rehabilitation routine of living,assistance withfamily tion, assistancein the daily required. relationships, andfurther treatment as chronic, long-term,institution- Without effectiveaftercare, the and opportunity forcomplete adjustment alized individualhas a minimal

rehabilitation.

109 RECOMMENDATION 26

OF DISABLED AND VOCATIONAL TRAINING FACILITIESTHAT WILL CONSIDER THE NEEDS

OTHER LIMITED PERSONS SHOULD BEPROVIDED : :N MONTANA.

SCHEDULE FOR IMPLEMENTATION: INTERMEDIATE

INITIATOR: LEGISLATURE

STATE BOARD OF REGENTS

LOCAL SCHOOL DISTRICTS

STATEMENT OF THE PROBLEM:

for the able- The recognition thatvocational training is reauired increasing attention in bodied, non-college boundindividual has received given to those Montana in the past several years.Equal recognition has been often vocational train- working with the disabledindividual to the fact that is not geared to meet the ing, as offered by manyfacilities now available, needs of individuals withlimitations.

With the rapid growth intechnological developments, thetrend in curriculum for vocational traininghas been to upgrade fromthe trade level

the needs for training of to the technical level. This trend tends to ignore highly technical knowledge, as a less technicalnature for jobs not requiring mental limitations who well as the needs ofindividuals with some physical or do have considerable aptitudeand potential.

It should not be necessary,as has occurredin the past, to establish trades and vocations standards of admission andperformance for certain common

110 at a level commensurate withthose that are to be expectedat the four-year college level in a vocationally-relatedfield.Adaptations of programs to meet the needs of persons withlimitations does not mean loweringstandards, rather it requires setting standardsat a realistic level which assures adequate training while consideringthe individual, his abilities,and the requirements of employment.

COMMENTS:

Vocational training is an absolutelyessential service in rehabilitation, as well as in educationgenerally.

Each component as represented by theschool and the rehabilitation agency has differentorientations which must be reconciledin behalf of the disabled person.

The opportunities existant inMontana at this time to developmeaning- ful vocational training programsfor all citizens, including thedisabled, are better than everbefore.Recognition of total needs, includingthose of the disabled, in planning the areavocational school is vital, andthe responsibility for the needs of thedisabled is incumbent upon thoseplanning the schools. The endless possibilities forproductive programs through coordination of interests has beendemonstrated in other states.

Borchert, reporting on a project inNorth Dakota, remarks on the success of a program whichtrained blind students with sightedstudents in a trade-technical school, andwhich ultimately drew studentsfrom such

111 rar away r:: "Now 11-1:ey, Florida, and :irt gon. inry)Vni,l1P planning would tend to enhance the base of support forschools incorpor- ating programs that would attract out-of-state students.

RECOMMENDATION 27

IT IS RECOMMENDED THAT FREQUENT INTER-STAFFTRAINING PROGRAMS BE CONTINUED

AND EXPANDED AT BOTH THE STATE AND LOCAL LEVEL, AS A MEANSOF INSURING THAT

COORDINATION BETWEEN THE DIVISION OF BLIND SERVICES, DEPARTMENTOF PUBLIC

WELFARE, DIVISION OF VOCATIONAL REHABILITATION, AND PUBLICHEALTH PERSONNEL

CONTINUES IN ITS CURRENT SATISFACTORY MANNER.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: DIVISION OF BLIND SERVICES

DEPARTMENT OF PUBLIC WELFARE

DIVISION OF VOCATIONAL REHABILITATION

PUBLIC HEALTH DEPARTMENT

EMPLOYMENT SERVICE

STATEMENT OF THE PROBLEM:

The coordination of activities and programs by majorpublic agencies has always been necessary to assure the continuity ofservices for the disabled person. Recent federal legislation has had the effect of stimulating rapid program changes which, in turn, have tended to obscure someof the

75Borchert, C. R., "Blind Trainees Succeed in Industry," Rehabilitation Record, 7:5:32-36, September-October, 1966.

112 administrative and functionalboundaries of these agencies. The possibility

time in of duplication of services betweenagencies is greater than at any

has been the broadening ofthe the past. Concurrent with these developments traditional role and clientele ofeach agency to includeindividuals who can receive similar services fromseveral agencies. The position in which the agencies are placed because ofthese rapid changes dictatesthat, a high level mission of assist- of coordination be maintained,if each is to accomplish its ing the individual in the mostexpeditious and economical mannerpossible.

Inter-staff training sessions,if properly developed andregularly scheduled, can be an effective toolin maintaining coordination andcooperation.

COMMENTS:

many The special expertise andcompetency that has been developed over years of providinghealth, welfare, and rehabilitationby each of these agencies within their areas can be meldedinto an effective andcomprehensive program,

each can pro- if clear understanding isdeveloped as to the specific function vide in a comprehensive rehabilitation program.

Inter-staff training has beenutilized by the Division ofVocational

Rehabilitation and Division ofBlind Services, by the Divisionof Vocational

Rehabilitation and the Departmentof Public Welfare, as well asby the Division

of Blind Services and theDepartment of Public Welfare. An expansion of such

training programs to involve otheragencies would be beneficial toall.

The pooling of availabletraining funds would permit anupgrading of

training staff and staff materials.

113 RECOMMENDATION 28

RESIDENCY REQUIREMENTS, WHICH NOW EXIST FOR SERVICESIN STATE WELFARE DEPART-

MENTS, CONSTITUTE A BARRIER TOTHE EFFECTIVE REHABILITATIONOF THOSE DISABLED

IT WHO MUST CROSS STATE LINES TORECEIVE NECESSARY TREATMENTAND TRAINING.

IS RECOMMENDED THAT ACTION BETAKEN TO REMOVE THESEREQUIREMENTS.

SCHEDULE FOR IMPLEMENTATION: LONG RANGE

INITIATOR: FEDERAL GOVERNMENT

STATE WELFARE DEPARTMENTS

STATEMENT OF THE PROBLEM:

disabled in Our increasingly mobilesociety has had an effect on the by virtue of two major areas: (1) The indigent disabled child or adult can,

public assistance benefits, and an interstate moveby the family unit, lose

(2) The imposition of residency requirementstends to limit access to necessary

treatment and rehabilitationservices not available in hishome state.

Montana, as a state withlimited rehabilitation resources,must utilize

the facilities of larger statesfor medical treatment of aspecialized nature security pro- and for vocational trainingfacilities. The fear of loss of the movement to a state vided by public assistance inthe home state, through development and offering opportunities forrehabilitation, has inhibited the recipients. acceptance of suitable long-rangerehabilitation plans for welfare

The policy of some states todiscourage the immigration ofwelfare

undue hardship recipients for rehabilitationtraining in their centers, creates

nit on the individual,often resulting in total disruptionof the plan to the degree that future rehabilitationefforts are fruitless.

COMMENTS:

The fact that federal support ofall programs is increasing to the point where the state share is minimal, is anindication that the imposition of arbitrary barriers to rehabilitation,such as resident requirements, has little validity. Such requirements were imposed when thelarge portion of program funds camefrom the state and served as a device toprotect state resources for stateresidents.

The emphasis should become oneof changing the individual's status

from one of dependency to independence,and whatever available resources, wherever geographically located, should bebrought to bear on that basic problem.

RECOMMENDATION 29

INDIVIDUALS WHO ARE REFERRED FOR REHABILITATIONSERVICES AR ACCEPTED OR

REJECTED ON THE BASIS OF THE EXAMININGPHYSICIAN'S REPORT. THIS REPORT OFTEN

REFLECTS THE EXAMINER'S INTERPRETATIONOF THE RELATIONSHIP OF THE MEDICAL

CONDITION TO A VOCATIONAL HANDICAP. IT IS RECOMMENDED THAT A STUDYBE MADE

OF SUCH REJECTED CASES TO DEItHMINE IFOTHER RELATED CONDITIONS CREATE

PROBLEMS THAT REQUIRE ATTENTION.

115 SCHEDULE FOR IITLEMEgTAT.T.Og: INTERMEDIATE

INITIATOR: DIVISION OF VOCATIONAL REHABILITATION

DIVISION OF BLIND SERVICES

STATE BOARD OF HEALTH

STATEMENT OF THE PROBLEM:

The Division of Vocational Rehabilitationand the Division of Blind

Services as programs that are concerned withthe disabled individual who has a vocational handicap have, as afirst step in the determination ofeligibil- ity, required a medical examination by aphysician who is most often a family doctor. If additional examinations are requiredto determine the existence of a disability and the functionallimitations that are resultant fromit, the services of a specialist can beutilized, as requested by the examining physician or by the medical consultant of thestate agency. In either instance, where a physical or mental condition issuspected, the physician examines the individual to determine:

1. The existence of a physical or mentalcondition.

2. The functional limitation imposed bythe condition.

3. The course of treatment considered necessaryto alter, alleviate, or eliminate the condition.

It is not generally understood by theexamining physician, as has been determined by the responses received fromthe Physicians' Survey, that thevocational counselor and the medical consultant ofthe state agency make the determination as to whether thecondition, as described by the examiningphysician, constitutes a vocational handicap. Factors affecting this decision, inaddition to the condition and the limitation offunction it imposes, are previous work

116 related physi(sal r psychological oxperiPnce, educationalbackground, age, relate to theindividual's ability or racLors, and otheraspects that may economically productivesetting. inability to functionwithin an determination ismodified to aconsiderable In practice,however, this statement is physician. If a positive degree by the reportof the examining individual is nothandicapped, thecounselor made by thephysician that the basis of accept such astatement on the frequently has noalternative but to based on Frequently, such astatement may be the medicalevidence presented. demands of of the vocationalaspects and the physician'slay interpretation It is un- they relate tothe individual. the currentemployment market, as therefore become avocational expert, realistic to expectthe physician to

skills he must possess. in addition tothe maoy other

COMMENTS:

and the relationship of themedical condition The entire areaof the vocational handicapis the basis of functional limitationsthat create a program, asapplied to the eligibility for theVocational Rehabilitation It is an areaof mutual concern physically andemotionally disturbed person. It is an areawhich and the medicalcommunity. and uncertaintyby the agency to be if the disabledperson is not requires clarificationand understanding Two typicalcomments ofphysicians denied neededrehabilitation services. "One patient wassent The first commentfollows: serve toillustrate this. thought were verygood reasons. (i.e., referred byphysician) for what I from hepa- had experienced aslow recovery She had fivechildren to support, She should havehad rehabilitation titis, and hademotional problems.

117 state more service::, but was tunred down. This will, in the end, cost-the

!I illustrated money. The opposite view andunderstanding of the program is for the program by this comment: "It (MR) should stop recruiting people of who have minor physicalabnormalities and no actual handicap - many

the ones that come to me arein this category. Concentrate on those who

really need it - rehabilitationof stroke, cancer, and cardiac cases par-

tioularly."

The physicians were asked,"Are you aware that your professional

opinion is the major determinatein the action taken by theoffice of

"no," Vocational Rehabilitation?" "Yes" was the reply of 170, 159 said

and 45 did not respond. This indicates that a highpercentage are not

aware of theirsignificance to the program.When asked, "Do you have any

patients with emotional or socialhandicaps that might be moreproductive

members of society if the aboveservices (rehabilitative servicesof many

types) were available to them?"--189 physiciansindicated they did have

n 11 such patients, 90 said no, and 95 did not respond.A significant num- by these ber of the respondents acknowledgedthat limitations are imposed

other non-medically relatedconditions.

An intensive study of casesrejected due to non-eligibilityfor

medical reasons would be veryilluminating and would provide asound

basis for program modification. It would also clarify certaincrucial

areas, which ultimatelyshould result in better services tothe disabled

and in a stronger, more effective,agency-physician relationship.

118 RECENDATION 30

THERE IS A NEED TO DEVELOPPROGRAMS OF ACTIVITIES FOR THELEISURE TIME OF

USTAIN EMPLOYED INDIVIDUALS NBCREQUIRE STRUCTURED SOCIAL SITUATIONS. THE

MENT.ALLY RETARDED ADULTS OR THOSEDISCHARGED FROM INSTITUTIONSPLACED IN

EMPLOYMENT IN THE COMMUNITY OFTENHAVE NEED FOR SUCHACTIVITIES.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: PRIVATE AGENCIES

SERVICE CLUBS

STATEMENT OF THE PROBLEM:

The average worker spends1/3 of his day in employment,1/3 asleep and the remaining eight hours inleisure or non-productive(economically) pursuits. problem for many The effective utilization ofthis period of time constitutes a institutional dischargee it can persons, but for thementally retarded adult or period when problems prove to be lonelyand unrewarding.It more often can be a long detrimental to rehabilitation candevelop. The person who has spent a each day can period in an institution withstructured activities throughout upon placement on ajob in the community, have adifficult time filling this the vacuum. Studies have shown that thesenon-working hours can provide weakest portion of a totalrehabilitation program.

COMMENTS:

Facilities and structured programsand activities if availableto the communities could be effective inassisting the retarded individual orthe

119 ex-,nentai naticht to adjust to community life and todevelop meaningful relatiomhips with members of the community.

Grob reports on the effectiveness of social,therapeutic clubs as a mechanism to provide support of this type to these persons. The Center

House Foundation worked with ex-mental patients and providessocial activities, outings and excursions, planned meetings. educational groups,art groups and other activities. Personnel consists of ex-patients and volunteers, as well as professional staff members. Success has been determined by the increased social-emotional adjustment of the membersand the attain- 76 ment of employability of2/3 of the members.

Similarly the Manhattan Aftercare Clinic found in studyingrecently hospitalized ex-mental patients that organized activityimmediately follow- 77 ing hospital release was needed.

RECOMMENDATION 31

EXISTING LEGISLATION RELATING TO THE ELIMINATION OF ARCHITECTURALBARRIERS

IN PUBLIC BUILDINGS (SECTIONS 69-3701 TO69-3719, REVISED CODES OF MONTANA,

1947) REQUIRES STRENGTHENING TO ASSURE COMPLIANCE WITH THE STANDARDS WHICH

HAVE BEEN ADOPTED

SCIEDULE FOR IMPLEMENTATION: INTERMEDIATE

INITIATOR: LEGISLATURE

76 Grob, S., The Social Therapeutic Club: A Tool for Vocational Rehabili- tation, Center House Foundation, 1

77 Kantor, R. E., "Implications of Process-ReactiveSchizophrenia for Rehabilitation," Mental .rgiene, 48:4:644-652, October, 1964.

120 STATEMENT OF THE PROBLEM:

House Bill 345 of MontanaSession Laws 1965(Section 69-3701 through

public Section 69-3719, R.C.M.,1947) sets forth standards tc insure that for buildings would be usable by thedisabled. However, the bill provided exceptions which are open tointerpretation.

Section 1.Application of act. (1) The standards arid specifications set forth in this actshall apply to all buildings and facilities used bythe public which are con - structed in whole or in part by the useof state, county, or municipal funds, orthe funds of any politicalsubdivision of the state. All such buildings and f?.cilitiesconstructed in this state after theeffective date of this act from any one of these funds or anycombination thereof shall conform to each of the standards andspecifications prescribed herein except where the authorityresponsible for the proper construction for theparticular governmental department, agency, or unit concernedshall determine, after taking,all circumstances into consideration,that full compliance with any particular standard or specification,is impracticable.

Responsibility for enforcement isstated in Section 19 asfollows:

Section 19.Responsibility for enforcement. The responsibility for enforcement ofthis act shall be asfollows:

(1) Where state school funds areutilized -- state superintendent of public instruction.

(2) Where state funds are utilized --state controller.

(3) Where funds of counties,municipalities or other political subdivisions are utilized --by the governing bodies thereof.

State school funds are not normallyutilized in construction ofschools.

involve state Many of the university buildings areself-liquidating and do not funds.

121 COMMENTS:

The report of the National Commission onArchitectural Barriers to

Rehabilitation of the Handicapped says: "The Commission recommends that all states be urged to enact new laws or amendpresent laws so that the law will be specific and will be based on thestandards issued by the United

States of America Standards Institute. The legislation should include strong enforcement provisions and shouldprovide for the establishing and financing of a small unit in a single state agencywhich is assigned full responsibility for enforcing thelaw."

RECOMMENDATION 32

A STATEWIDE BUILDING SURVEY SHOULD BE PLANNEDAND CONDUCTED IN MONTANA TO

ASSIST IN PLANNING FOR NEW STRUCTURES ANDREMODELING OF EXISTING BUILDINGS

TO MAKE THEM USABLE BY AND ACCESSIBLE TO THEHANDICAPPED.

SCHEDULE FOR IMPLEMENTATION: IMMEDIATE

INITIATOR: MONTANA ASSOCIATION FOR REHABILITATION

STATEMENT OF THE PROBLEM:

The majority of people, including thosewho direct, supervise, or influence the planning and building of publicbuildings, are apathetic concerning architectural barriers. This is largely due to lack of knowledge and effective publicity.Education is necessary if the problem is tobe understood and if steps are to be taken toimprove existing structures and plan effectively for new buildings.

122 -LI:0 important to the handicapped thac they know what faeilPie-:

1re provid-A rf.T. them prior to their going into unfamiliar surroundings.

COMMENTS:

A community purvey of public buildings and the subsequent publication

of a r-uide for the handicapped is an effective way of focusing community

atLention upon architectural barriers, stimulating interest in barrier-free

construction, and at the same time providing a valuable service to the dis-

abled individuals within a community.

In addition, the actual process of surveying buildings is an excellent way of introducing volunteers, on a first-hand basis, to the problems that

architectural barriers present to the handicapped, as well as educating volun-

teers to the practical application of the United States of America Standards

Institute specifications in planning barrier-free construction.

An intensive publicity campaign is an important part of the plans for

a survey and guide, greatly increasing the educational impact of the project upon the community.

123 CHAPTER IV

STATE INSTITUTIONS ANDAGENCIES

institutions con- The patients, inmates,and students of the state who can benefit from stitute a substantialnumber of the disabled persons treatment vocational rehabilitationservices. The changing concepts of traditional role of the in- as a community-basedfunction will modify the

there will be many individualswho will stitution. However, for some time require treatment and carein these facilities.There will remain a significant need for rehabilitationwithin them. The current needs of this being adequately population for vocationalrehabilitation services are not

to meet the unique needsof such met. Rehdoilitation programs developed overall individuals have demonstratedconsiderable success as part of an treatment and rehabilitation programin many states. Persons, formerly considered to be totallydependent, have been returnedto a productive shown marked status in their communities. Rehabilitation programs have demonstrated value gains in the past few years;however, many programs of can be initiated asresources of staffand funds become available.

Many of those in theinstitutions will not beself-sufficient be- marital status, or other cause of theseverity of the disability, age,

this time be considered for voca- reasons. Consequently, they cannot at tional rehabilitationservices. elicited from The recommendationsfor rehabilitation services were Boulder River School and the superintendents ofWarm Strings State Hospital, Hospital, Mountain View Hospital, Mbntana Children'sCenter, Galen St_ ate School as presented tothe School, Montana StatePrison, and the Pine Hills

125 Governor's Policy Board of the Planning Project by the Directorof the State

Department of Institutions, Edwin Kellner. Floyd McDowell, Superintendent of the School for the Deaf and Blind, met with the Policy Boardleelative to needs for rehabilitative services at his school.Other state institutions under the Department of Institutions are not included in thefollowing table as their populations were not considered tobe candidates for vocational rehabilitation (Montana Veterans' Home, Montana Center for theAged) or were not functional during the period of this Project(Eastern Montana Facility for the Retarded at Glendive, Swan River Youth ForestCamp).

TABLE 8. NUMBER OF RESIDENTS AND DAILY PER CAPITACOSTS MONTANA INSTITUTIONS

Institution Average # ResidentsPer Capita Costs

Montana Children's Center 139 $ 6.09

Boulder River School and Hospital 860 5.54

Mountain View School 49.3 14.08

Pine Hills School 144 11.25

Montana State Prison 535.69 8.806

Galen State Hospital 137 21.68

Warm Springs State Hospital 1428 7.36

Total 3292 $ 12.11

*Source:Montana State Department of Institutions Report,1966-67.

NUMBER OF RESIDENTS - SCHOOL FOR THE DEAF AND BLIND

Avg. Avg. Avg. g Deaf and Blind Deaf Blind

1 79 4o

126 Warm TABLE 9 - STAFFING PATTERNS - MONTANA INSTITUTIONS Springs * * Galen ViewMtn. HillsPine Boulder Deaffor the and BlindSchool Children's Center Prison State TherapistsPhysicians Physical C,3 4P.2 C6 P 6 11111 C P C P C P 2 Co C P 1C 1 3 Con. 1 .2022apational IndustrialSpeech NM 26 mearamems IIIII IliiIIII inn 1111111111.1 1 NM 43 Nurses Recreational 9 10 1 3_ 6 1 Attendants LPNRN NM 310 1523 4050 1514 1514 1 lin11111 1 2 RIM11111 160 2 111111 25 360 1530 1 1 1 15 1 1 Teachers AcademicVocational 1 2 8 IIIIII 12 5 1012 11111 12 1 20 r 2 28 8 10 4 8 Psychiatrists 9 CounselorsPsSocial cholotists Workers 865 15 w INCEN11111111111111 3 5 IlliiiiIIIIMMIlli1 3 2 IIIIMIKIMIN 6 21 41 2 41 Other PersonnelProfessional 111111111111 MI 10 11111 15 11111 1925 In 19 6 1 MEMI 11111111 1 -MHC .0 - CurrentP - Projected - Mental Hygiene Clinic MEM IIIIMIIIIIIII MN -- Methods Used to Estimate Potential of Inmatds For Vocational Rehabilitation Services

The estimates of the nnmber of inmates with apotential for vocational rehabilitation services was based on the subjectivejudgment of

Project staff and institutional personnel. A definitiveassessment of potential of each of the 3,292 inmates of the state institutionsobviously was not practical or possible.It must be strongly emphasized that these estimates are to be considered very rough and therefore mustbe evaluated on that basis.The actual determination of vocational potential must be left to an individual diagnostic and evaluative process by ateam of professional persons with rehabilitation philosophy in theinstitutional setting. The screening process used in making this estimate is inopposi- tion, therefore, to basic rehabilitation philosophy which is notto screen- out but rather screen-in those who have potential for greaterself-realization and development.

Unless specifically noted, because of institutional ordiagnostic differences, the group consists of those persons meeting thesecriteria:

1. Under 60 years of age.

2. An IQ of 50 or above.

J. Institutionalized less than 10 years.

4. Having a defined physical or mental condition, according to ease records.

It was felt that generally those eliminated presented aminimal rehabilitation potential.

In the case of the School for the Deaf andBlind, it was considered that all 120 students could ultimately benefit from somerehabilitation services.

128 Warm Springs StateHospital

private institution Warm Springs StateHospital, which began as a The purpose is toprovide in 1877, was purchasedby the state in1912. ill residents of thestate, custodial care and treatmentfor the mentally current who are committed bythecourts.1 As of Nuvember 14, 1967, the vas reported patient load was1,400 persons.Age range of the population primary mission of as several daysold to 100 years. In addition to the

services includingpsychiatric care and treatment,the staff offers other services to inmates of evaluations for courtauthorities, psychiatric of severely retardedand Montana State Prison andother institutions, care complicated medicaland/or physically handicappedchildren and patients with unit offers a five-weektreat- surgical problems. The alcoholic treatment the Unit System in1967; this con- ment program. The Hospital implemented the EasternUnit.2Intake sists of the Western Unit,the Central Unit, and psychological testing, services include a generalmedical examination,

psychiatric examinations. social service interview,and neurological and in effect, and An in-service training programfor personnel is now

raise in grade ascompensation. employees who upgradetheir skills receive a but must utilize The institution has nopatient follow-up services, provided other agencies for thisimportant function. The services currently the Division of BlindSer- by the Division ofVocational Rehabilitation and of the patients atthe vices are not consideredadequate to meet the needs well as an in- Hospital. A full-timecounseling service is requested, as necessary hospital rehabilitation program.Other services identified as

1966-67, p.25. 1Department of Institutions,Report to the Governor,

I 2 Ibid.

129 and to rehabilitate morepatients are halfway houses,shelteredworkshops, the proposedComprehensive Mental HealthCenter facilities.The patient load is expected to drop asfacilities for treatment becomeoperational

Hospital is currently served in the communities. The Warm Springs State Rehabilitation who has an by one counselor of theDivision of Vocational caseload of office on the Hospital groundsbut who also serves a general

150 disabled in threesurroundingcounties.

RECOMMENDATION 1

PATIENTS AT THE WARM SPRINGS IT IS RECOMMENDED THAT ASHELTERED WORKSHOPFOR

STATE HOSPITAL BE DEVELOPEDON THE HOSPITAL GROUNDS,AND THATTHE INDUSTRIAL

THERAPY PROGRAM BE INCREASED.

COICENTS:

The need for a workshopfacility on the grounds wascited by the

Superintendent and staff as beingof primaryimportanceto the Hospital. within Such a facility would provide anopportunity to evaluate patients

of test procedures. It a simulated worksetting and through application patients lack would provide an opportunityfor work experiences that many

entirely; it would developwork and personal habits necessaryfor -place- opportunity ment in employment in thecommunity; and it would provide an integral part of for vocational training. Such a facility, utilized as an would greatly facilitatethe a total treatmentand rehabilitation program,

discharge of patients intothe communities. Anon-grounds workshop could multiple-disability work- establish cooperative workingagreements with the This would offer a shops which are contemplatedin the :,.urger communities.

130 transitional step in a workshopsetting for those patientsshowing vocational potential.

Despite the fact that shelteredworkshops for all disabilitieshave

Proven of valuein rehabilitation, little hasbeen done in Montana to stimu- late the development of suchfacilities. In a survey of490 sheltered workshops in communities of the UnitedStates, it was found that90% of the 329 who responded indicated thatthey serve at; least some clientswhose emotional disturbance is not secondary to aphysical disability. This same survey indicated that the one workshop in Montanareported that they had 16 physically handicapped and 3 emotionally disturbed persons.This, of course, is not re- motely meeting the needs ofeither group in Montana.Workshops in 45 states responded to the survey, andMontana ranks 45th in the numberof emotionally 3 disturbed served per 100,000 inworkshops.

Multiple - disability shops arepractical and most prevalent inthe

United States.Workshops within an institutiontend, by their very nature/ to be single-disability shops.

Hunt contends, as have others,that much of the disabilityresult- ing from mental illness is notintrinsic to the illness but isthe result of certain extrinsic factorsthat can be remedied. Social rejection and He the effects of institutionalizationitself are contributing factors. points out that even in atreatment-oriented institution, thepatient experiences an increased amountof directed activity ratherthan opportunities

3Altro Health and Rehabilitation Services, Inc., Directoryof Shel- Survey and tered Workshops Serving theEmotionally Disturbed - Statistical Report, Kase, H. M.(Ed), VRA Research Grant, RD1471, pp. 78-1

131 4 with other to practice self-direction. A morkshop setting, coordinated treatment and rehabilitation programsand techniques, can offer much to patients at the Hospital in overcomingthe negative aspects inherent in institutionalization.

RECOMMENDATION 2

IT IS RECOMENDED THAT THE DIVISIONOF VOCATIONAL REHABILITATIONPROVIDE

Sui.n.Cikaff COUNSELING STAFF TO FUNCTIONWITHIN THE IN-PATIENTSERVICE OF

THE WARM SPRINGS STATE HOSPITAL ANDALSO IN 'ilk, MENTAL HEALTH CENTERSAS

THEY BECOME. OPERATIVE. THIS WOULD REDUCE THE TIME BETWEENREFERRAL AND

INITIATION OF SEfiviCE AND WOULD ENABLETESTING, PRE-PLACEMENT EXPERIENCES,

TRAINING, JOB PLACEMENT, AND Ott%It COUNSELING FUNCTIONS TO BEPROVIDED THE

EMOTIONALLY DISTURBED PATimuS.

COMMENTS:

At the present time, theDivision of Vocational Rehabilitation counselor assigned to the Hospital alsocarries a general caseload in three counties and serves on anitinerant basis at the Prison andGalen as well. The Hospital staff indicates thatthe time interval from referral to acceptance can extend from oneand one-half to two months. The nature of mental illness and thenature of institutional rehabilitation programs demands acounseling staff with small caseloadsand special training.

Hunt, R. C., "RehabilitationPotential of the MentallyIll," Reha- bilitationofthe Mentally Ill; Social and EconomicAspects; A Symposium of the American Psychiatric Association,pEaredSox by the...American Association for the Advancement of Scienceand the American Sociolo&ical Socaety, 111).25J6:

132 The potential for an expanded VocationalRehabilitation program is indicated by the number (500) currently inthe Industrial Therapy work Pro- gram at the Hospital. Job development and placement activitiesoutside the

Hospital constitute a major portion of adequateinstitational rehabilitation programs. This service of Vocational Rehabilitation is verydemanding of counselor time but is effective; toaccomplish it adequate numbers of

Vocational Rehabilitation counselors are needed. The Hospital staff estimates that six to eight vocational counselorscould be effectively utilized at the Hospital.

A pilot study by Vocational Rehabilitationand an intensive treatment unit of a mental hospital was reportedby Martin. He points out that rehabilitation in psychiatric illness dealswith the patient's remaining abilities rather than his disability; therefore, thefocus is upon developing assets. The project began in 1955, and an experiencedDivision of

Vocational Rehabilitation counselor was assignedto the hospital staff.

Through association with the social servicedivision of the hospital, by reviewing cases, and attending staff conferences, aclose working relationship was developed. The counselor became a vital member of theteam, and shared decision-making responsibilities.This program resulted in more rehabilitation of psychiatric patients than anyother single type of disability handled by the state agency that year. The program was therefore incorporated into the state Vocational Rehabilitationprogram.5

5Ibid., Martin, H. R., "A Philosophy of Rehabilitation," p.47-56.

133 TABLE 10. PATIENT CHARACTERISTICS

WARM SPRINGS STATE HOSPITAL

Acute and Transient Chronic PsychotiPsycho- Personalityituational Mental "Without Totals Age Brain Disorde neurotic Disorders rsontlityDeficiencyMental Syndrome Disorders Disorders Disorder SIIRMB

Under 5 yrs 12 0 0 0 0 1 - 0 13

5 - 17 56 2 0 0 0 22 1 81

,18 - 19 4 2 0 1 0 2 0 9

20 - 44 43 92 0 u 0 39 1 196

45 64 57 166 2 17 1 24 1 268

5 and over 67 90 0 4 1 12 2 176

Totals 239 352 2 43 2 100 5 743

finder 5 yrs

- 17 4 6 g8 19 3 4

*:s 44 33 69 2 9 1 22 0 136 I

45 64 38 170 3 5 1 31 0 248 I

and over 84 6 1 1 10 0 188 I totals 2O 324 I u j 16 5 69 0 633

NOTE: It vas not possible to apply the criteria referred to previously due to the nature of the data received.

134- Galen State Hospital

Galen State Hospital has as its primary functionthe treatment of

tuberculosis and silicosis, but has geared itself fortreatment of other

chronic respiratory diseases.In addition, a medical-surgical program is

furnished for patients who are referred for care and treatmentby other

public state institutions.The Hospital also maintains a unit of approximately 100 beds for the care of mentally retarded who would otherwisebe

housed at the Boulder River School and Hospital, if space inthat institu-

6 tion were available. Admission to the Hospital is by physicianreferral

and court commitment. Persons needing the services of the Hospital are

admitted without regard to age. Intake services include medical and dental

examination. Treatment is the sole program offered.

The patient load of 140 is expected to continue withlittle change to 1975. No formal follow-up service in the community is availableto the

discharged patient who has the option of returning to the Hospital for

routine 4wIlow-up exsmination or contacting the family physician.

RECOMMENDATION 1

IT IS RECOMMENDED THAT MORE COUNSELOR TIME BE MADEAVAILABLE TO THE PATIENTS

AT GALEN STATE HOSPITAL.

COMMENTS:

The counselor who now visits the Hospital hassimilar responsibilities to the Prison and Warm Springs State Hospital, as well as ageneral caseload.

6Dept. of Institutions, Report... 2.. cit., p. 12.

135 Programming in the past has includedvocational assessment, utilizing a formal evaluation technique.There is a definite need fortraining persons once an evaulation ismade; otherwise, the patientoften returns to the same environment inthe community which was a factorin his requiring hospitalization.

The case review by Project staffand Hospital staff illustrates the

apparent advantage in developing acloser relationship between theDivision of Vocational Rehabilitation andHospital staff to identify at an early

stage potential candidates forVocational Rehabilitation, and to extend

Vocational Rehabilitation services tofeasible cases who otherwise would not have access to services thatthe Hospital is unable to provide.An

example is a patient who is a possiblecandidate for heart surgery after the arrest of the tubercularcondition. Consideration should be given to

the possibility of a VocationalRehabilitation counselor sitting in on medical staffings as a resource personfor other rehabilitation services.

The possibility of an alcohol treatment programshould be considered because of the relatively high numberof admissions who are reported tobe

alcoholics. The Alcoholics Anonymous programat Warm Springs State Hospital

is not usable because of thepossibility of tubercular contamination.

Characteristics of Patients Considered to Have Vocational Potential

Galen State Hospital

Male

Of the 27 patients whose records werereviewed at Galen State Hospital,

21-45, and 15 are 22 were male. Seven of these individuals are between ages

136 between 56-64. Of these patients, 10 are married, 5 aredivorced, 1 is separated, 1 is widowed, and 5 are single. Arelatively high proportion of Indians was found, with 8 of that race,13 Caucasians, and 1 identified as "other."

The review of the records indicated agenerally stable employment history for this group prior tohospitalization.Of these, 13 were usually employed on a full-time basis, 2 were usuallyemployed part-time, 3 were seldom employed, 1 had never been employed(because of age), and the employment histories of the other 3 were unknown.

The educational level of these males waswell distributed in terms of years of education. One each had completed 4,8, or 9 years of schooling, two had completed 10 years, two hadcompleted 11 years, three had completed

12 years, and one had completed 13 years.All 22 males had a primary disability of tuberculosis but, in addition, hadthe following secondary disabilities: orthopedic - 2, arthritis - 1, visual impairments -3, amputations - 2, cardiac condition - 1,diabetes - 1, alcoholism - 9, mental illness - 1, and 5 had other impairments. The relatively high proportion of multiple-disabilities was apparent in thateight of these individuals had three or more disabilities and five hadtwo or more disabilities.

Female

Only five of the 27 patients considered tohave rehabilitation potential were female.Three of them were in the21-45 age range, one was between

18-20, and one was in the 46-64 age range. Two of them were single, two were divorced, and one was a widow. Of the five women, three are Indian andtwo are Caucasian. Their employment status prior tohospitalization was very diverse.One was considered to be generally employedpart-time, one was

137 never employed-although in thelabor market, one was a student, and the employment status of the last patient was unknown. The educational level, with the exception of one individual, was rather limited. On two patients, the records do not show the level of education, onehas 10 years of schooling, one has completed9years of schooling, and thelast patient reported a total of 20 years of schooling.

All five a-te diagnosed as being tubercular and, inaddition, one has a heart condition, one is anepileptic, and one has other disabilities.

One of the individuals had a total of threedisabilities, and another had two disabilities.

Mountain View School

The Mountain View School was established in1893 and was originally part of the Boys' and Girls' Industrial School atMiles City. In 1919 it was transferred to its presentsite in Helena. The purpose of the school is to provide care, education, and rehabilitationfor girls between the ages of 10 and 21 years who are committedby the juvenileCourts.7 These girls, in addition to having been adjudgeddelinquent, are often academically retarded. Intake services consist of social service interview,psychological testing, and counseling. Medical and dental examinations are provided by the school if not previously provided through the court.Institution programs include treatment, group therapy, basic education,and vocational training.

Staff in-service training was being planned at thetime of the staffing pattern survey. No method of compensating employees who upgradetheir skills

7Department of Institutions, Report...a. cit., p. 14.

138 is available. The inmate load of 68 is expected to increase slightly in the next two years. Community follow-up of discharged inmates is accomplished by the Aftercare Division of the State Department ofInstitutions.

The services of the Division of Vocational Rehabilitation are not considered to be adequate in meeting the inmate needs of the institution.

Work programs in the community, with resident care provided by the school, are suggested.This function would capitalize upon the expertise and other services of Vocational Rehabilitation.

RECCHMENDATION 1

IT IS RECOMMENDED THAT A PART-TIME DIVISION OF VOCATIONALREHABILITATION

COUNSELOR BE ASSIGNED TO THE MOUNTAIN VIEW SCHOOL.

COMMENTS:

The services of a counselor, regularly scheduled at the institution on a part-time basis, should enable adequateservices to be extended.

Counseling and vocational training after discharge can be developed on an individual basis, with subsequent job placement and follow-up in the communities. TABLE 11. PATIENT CHARACTERISTICS MOUNTAIN VIEW SCHOOL

Total Number of Inmates - 55

Admission Age Race Educational Level

0-5 6-17 18-20 Cauc. Indian Mex. -4 5 -8 9-11 NR

0 55 0 30 22 3 0 29 25

IQ RANGE

Below 6060-69 7077 80-8 0- 100-1110-11*120-12 !%1;0*NR

2 3 5 11 16 7 0 0 5 6

DISABILITIES

Ortho-Arth- isualAmp.Hear*eart TB r.ilepsiSpeechDia- 0 herNR pecticritis ing etic

1 0 3 0 1 0 0 2 0 Montana Children's Center

The Montana Children'sCenter was established in1893 for the support and care of the orphans,foundlings, and destitute childrenresident within the state. The primary function of theCenter is the support and care of dependent or neglected children whorequire separation from their families or foster families orfor whom foster care cannot beobtained.8

All children are admitted on thebasis of court commitment; however, referrals emanate from physicians,welfare agencies, families, and probation officers.Age range is 6 to 20 years;however, those younger must be admitted if no other arrangements arepossible. The children are, because of thecir- cumstances which led to admission,physically and emotionally deprivedand often evidence the effects of suchloss. Intake services include medical and dental examination, socialservice interview, psychological testingwhere needed, and counseling. Center programs include limited treatment, group therapy, basic education, and work programsfor selected children.

The staff does not have in-servicetraining programs available to upgrade their competency. The current patient load of147 children is expected to increase to 190 by 1975. The Center indicated that no follow-upservices for discharged children wereavailable. Halfway house facilities were suggested as a means of getting theindividaal back into the community.

RECOMMENDATION 1

IT IS RECOMMENDED THAT A DIVISIONOF VOCATIONAL REHABILITATION COUNSELOR

BE PROVIDED THE MONTANACHILDREN'S CENTER ON A REGULARLY SCHEDULEDBASIS.

8Department of Institutions, Report...a, cit., p. 10. COMAENTS:

The nature of the population at the Center in terms of age, problems,

etc. is such that regular, itinerant service should beadequate to meet the

present needs.

TABLE 12.PATIENT CHARACTERISTICS MONTANA CHILDRENIS CENTER

Total Number of Residents - 147

Educational Level 1 Sex Age at Admission Race M F 0-56-17I 18-201NR Cauc. Ind. Mex. NR 1-45-89-11NR

43 1 77 15 7869 15 129 0 3 97 j 2 5 , 30

IQ RANGE OF RESIDENTS

Below 130+FR 60 60-69 70-79 80-89 90-99 100-109110-119120-129

36 18 1 1 ! 2 11 22 40 4

DISABILITIES

Orthopedic Visual Hearing Heart Epilepsy Speech Other NR

1 12 1 2 5 7 116 3 i Montana State Prison

prison in 1867. The present Prison wasdeveloped as a territorial

The Prison and The present walled compound wasbuilt in 1893 and1894. and treat- staff has as their primaryresponsibility the custody, care, men and women, ment of inmatesconvicted by the courts ofMontana.8 Both medical examina- age 16 and over, arein custody. Intake services include job placement. tion, social service interview,counseling, and testing for education, limited Present programs includetreatment, group therapy, basic vocational training, and aPrison work program.

In-service training isprovided staff members. Current inmate popu-

The Prison itself lation is 513, withprojected increases to600 in 1975. This aid is provided has no program forfollow-up of dischargedinmates. Vocational Rehabili- through the field officersof the Board of Pardons. is provided on an tation services are notconsidered adequate as service Vocational programs are itinerant basis by thecounselor at Warm Springs. is indi- limited to meat cuttingand carpentry.Expansion of trade training

considered necessary toeffect satis- cated. Halfway house facilities are

factory placement in thecommunity for certain inmates.

RECOMMENDATION 1

EMPLOY A IT IS RECOMMENDEDTHAT THE DIVISION OFVOCATIONAL REHABILITATION TO WORK PERSON ON THEIR STAFFWHO IS TRAINED INCORRECTIONAL REHABILITATION

WITH INDIVIDUALS AND TODEVELOP COOPERATIVE PROGRAMSAT THE PRISON.

8Department of Institutions, Repost...a. cit., p.19.

114-3 COMMENTS:

People, both in the correctionaland vocational rehabilitationfields,

and mental condi- have been aware that manyoffenders have serious physical rehabilitation tions. Much work has been donein the past in correctional in other states. It has been possible forseveral Vocational Rehabilitation and training to agencies to bring the servicesof counseling, restoration, those public offenders bothin and out of institutionswho otherwise would have proven the not have had access to them.Many demonstration projects Oklahoma has had a co- efficacy of correctionalrehabilitation programs. operative project at McAlesterwhich offers vocationaltraining, group and individual counseling, andfollow-up services after jobplacement.

RECOMMENDATION 2

INITIATE A SPECIAL IT IS RECOMMENDED THAT A STUDYBE MADE OF THE NEED TO

THE INMATES AT PROJECT TO DETERMINE THEREHABILITATION POSSIBILITIES OF

MONTANA STATE PRISON.

COMMENTS:

the Prison population A pilot project couldbe initiated to screen which to assess individual vocationalpotential and to devise programs Such studies would expedite placementof the dischargee inemployment. is an emerging are particularly valuablesince correctional rehabilitation by Levis field and new innovative programs arestill needed. A report

describes efforts of theMassachusetts Division ofVocational Rehabilita- rehabilitation and the correctionalinstitution at Walpole to develop a

that problems relating toparole tion program. Their experience indicated

144 and other custodialconsiderations should beclearly worked out.He con- the inmates eluded that successfulrehabilitation must start while are still in theinstitution.9

RECOMMENDATION3

FUNCTIONAL RELATIONSHIPS IT IS RECOMMENDED THAT STEPSBE TAKEN TO ESTABLISH DIVISION OF BLIND SER- BETWEEN THE DIVISION OFVOCATIONAL REHABILITATION,

VICES, AND THE STAFF OF THEMONTANA STATE PRISON.

COMMENTS:

Interest in rehabilitationhasbeenexpressed by staffmembers at been held with thePrison.However, no administrative-levelmeetingshave

DVR and DBS to establishworking relationships andto plan rehabilitation programswithin the Prison. In addition to meetingsof this type, it would and cooperation be helpful in broadeningthe basis of mutual understanding to have joint staff meetingsand trainingsessions between the involved agencies and the Prison.

RECOMMENDATION 4

REHABILITATION INITIATE IT IS RECOMMENDED THATTHE DIVISION OF VOCATIONAL INSTITUTIONS, AND CARRY OUT REHABILITATIONPROGRAMS WITH THE CORRECTIONAL POPULATION FOR SUCH IN RECOGNITION OF THEPRESSING NEEDS OF THE INMATE

SERVICES. .=ww.

9Levis, J., "Programs ofMassachusettsRehabilitation Commission in Rehabilitating the PenalOffender," Curriculum MaterialsDevelojed frara a Conference on Effective Aroaches to the Rehabilitationof theDisabled Public Offender,My10-12 1 pp.31-33.

145 COMNENTS:

the Prison indicatethat Information gatheredfrom the records of

inmates, 268 have beenidentified as having of the totalpopulation of 364 relationship to theirimprison- problems which canbe expected to have a information on ment. A study, donein 1964 by EmoryUniversity, gathered institutions in Florida prisoners, parolees, andprobationers at federal substantial need forvocational re- and Georgia.This study indicated a anticipated habilitation among the300 personsstudied.10It could be

be met within MontanaState Prison that similarrehabilitation needs can develops cooperative programs if the Division ofVocational Rehabilitation at that institution.

TABLE 13. PATIENT CHARACTERISTICS MONTANA. STATE PRISON

Total Number of Inmates -364

Race Age Afimittance Age Ne-0th Under Ind ro erIII M FNR 20 20-2 0- 40-4 0- 60+NRCau IN J252856 345163 51 178 79 36 15

Occupation of inmate Excessive Drinking Drug Addiction Semi-Um- Un- Un- Skid NR Yes No NRProf. 0 /es Nb f SI . l lfa: 2 29 82 231 20 232 91 31 10 26 207 99 32

10 Effort," Rehabili- National RehabilitationAssociation, "The Research tation Record, p. 27,November-December,1965.

146 TABLE 13 (Continued)

N RANGE

Below 130+ NR 60 60-69 70-79 80-8990-99100-109110-119120-129

14 5 2 261 3 9 16 15 18 21

Cardiac OtherER Ortho-Arth-VisualAmp.Hear- HeartTB &EpilepsySpeechDia- pedicritis ing StrokeResp. betes

63 240 16 1 4 1 6 5 18 1 1 0

Educational Level Prior Commitments

6 1-4 5-8 9-11 NR 0 1 2 3 4 5 NR

33 182 82 67 169 123 45 13 4 1 1 8

147 Pine Hills School for Boys

This school was establishedin 1893 by the Legislature forthe purpose of providing care,education, and rehabilitation forboys between 11 Intake ages 10 and 21, whohave been committed by theJuvenile Courts.

services include medical anddental examination, social serviceinterview, counseling, and aptitude testing, vocationaltesting, psychological testing,

basic education, religious orientation.Programs consist of group therapy,

limited vocational training,individual therapy, and a work program.

Occasional in-service training programs areavailable for the staff,

train lodge and immediate plans includecounselor seminars and plans to parents. The current population of116 is expected to remain relatively by the stable over the next ten years.Follow-up services are provided

Aftercare Division of the Departmentof Institutions. The vocational re-

habilitation needs of the inmates arenot being adequately met;however,

the establishment of aDivision of Vocational Rehabilitationoffice in

Miles City should alleviate thissituation somewhat. Employment oppor-

tunities and job development arefelt to be a critical need. Broadened

criteria for Vocational Rehabilitationeligibility would be beneficial, as

many at the Schoolwho could benefit from vocationalservices are not eli-

gible on the basis of a physical oremotional condition.

RECOMMENDATION 1

DEVELOPMENT OF CERTAIN IT IS RECOMMENDED THATCONSIDERATION BE GIVEN TO THE

VOCATIONAL TRAINING PROGRAMS AT THEPINE HILLS SCHOOL.

11Department of Institutions,Report...2. cit., p. 16.

148 COMMENTS:

A complete institutional rehabilitation program has many components.

However, vocational training, either on the grounds or at an accessible

trade school, is invaluable in preparing a person for a self-sufficient,

law-abiding existence upon discharge. A project in Oklahoma utilized ef-

fectively a program of one-half a day in academic work and one-half in vo-

cational training.The training program had to be restructured to shift

emphasis from production to training. In addition to using training stations of an on-the-job training type, teaching aids were purchased. Pro- grams were arranged so that credit earned could be transferred on discharge 12 to a regular trade school.

TABLE 14. PATIENT CHARACTERISTICS- PINE HILLS SCHOOL

Total Number of Inmates - 131

Age at Admission Race Educational Level

0-5 6-17 18-20 Canc. IndianMexicanNR 1-4 5-8 9-11NR

0 129 77 46 5 3 69 41 18

IQ RANGES

Below 60 6o-6 0- 80-8 o- oo- 0-1 - MI 6 10 17 17 10 23 111111 16

DISABILITIES

...... Ortho=ppmHear-Car- Speec , Dia- . . TB Epileps betesOtherNR

21 1 42 0 2 4 0 2 5 6 47

120klahoma Rehabilitation Service, Oklahoma State Reformatory, Rehabili- tation of the Young Offender - A Cooperative Program of CorrectionalRe-he:bill- tation.

149 Boulder River School andHospital

Boulder River School andHospital was established as atraining school and hospital forthe education, training,and care of sub-normal

of this school is the and epileptic persons. The purpose and the object mental, moral, and physicaleducation and training of sub -normal persons instruction and training whose defects prevent themfrom receiving proper

13 by court order, in public schools. Approximately 1% of admissions are but the majority is byvoluntary commitment. The age range of the patients Intake is from 4 to 68 years;the primary disabilityis mental retardation. services consist of medicalexamination, social serviceinterview, psychological testing, and parentalcounseling.Programs, available, in addition to treatment, include grouptherapy, basic education,vocational training, work programs, speech therapy,physical therapy, andrecreational programs.

The staff has available anin-service training program. The current

it will in- 1967 average caseload is884 persons, and it is estimated that with an increase by 1975 to1,200 persons. This increase is compatible in the crease of 300 inthe past five years.Patient follow-up services

community are provided by staff,and through the staffof other agencies.

The present services, as providedby the Division ofVocational Rehabili- adequate to tation and the Division of BlindServices, are not considered

Division of Voca- meet current needs. Cooperative programs between the Divi- tional Rehabilitation and theBoulder School have beendeveloped.

utilized for vocational sion of VocationalRehabilitation funds have been

training of selected patients,remodeling of trade trainingfacilities,

13Department of Institutions, Report...m. cit., p.6.

150 and for a summer program whereby the Division of Vocational Rehabilitation

sends retarded clients from throughout the state to the Boulder School for

evaluation and short-term training. One counselor is assigned to work ex-

clusively with the retarded in Montana, and the general counselors accept

retarded as part of regular caseloads. Considering the number of retarded

who could benefit from vocational rehabilitation, this arrangement has not

been adequate to meet state needs.

RECOMMENDATION 1

IT IS RECOMMENDED THAT THE DIVISION OF VOCATIONAL REHABILITATION ASSIGN A

COUNSELOR TO WORK AT THE BOULDER RIVER SCHOOL AND HOSPITAL, AND THAT THE

DIVISION OF BLIND SERVICES BE CONSIDERED FOR THOSE RESIDENTS MEETING ELI-

GIBILITY REQUIREMENTS.

COMMENTS:

Approximately 247 of 884 patients at the School fall within an IQ

range of 50-99. These persons offer varying degrees of rehabilitation potential, if proper services and facilities are available. Other indicators of caseload potential are: 375 are considered to have potential to benefit from institutional school programs; 285 are considered candidates for institutional work programs; and 183 are considered able to be placed in the community, in the judgment of the staff. From 285 to 183 individuals seem to meet the general criteria which would enable them to benefit from some form of Vocational Rehabilitation services.A minimum of one full-time counselor seems indicated. Only 3 of the total of 884 are identified as having visual problems; therefore, services. of the Division of Blind Ser- vices on an itinerant basis should be adequate.

151 MCOMENDATION 2

BOULDER RIVER IT IS RECOMMENDED THAT APLACEMENT UNIT BE INITIATED AT THE

SCHOOL AND HOSPITAL TO DEVELOPPLACEMENT OPPORTUNITIES AND TOPROVIDE

FOLLOW-UP TO DISCHARGEES IN THECOMMUNITY. THIS WOULD INCLUDE AN UPDATED

INSTITUTIONAL TRAINING PROGRAM.

COMMITS:

A unit on the grounds,especially geared to pre-releaseplanning

This could be and programs, would greatlyassist in placement activities. incorporated as a function of a function ofthe School staff or could be the Division of VocationalRehabilitation staff assigned tothe School.

Aftercare services are not adequateat the present time.

RECOMMENDATION3

IT IS RECOMMENDED THAT ANEXPANSION BE MADEaTHE CURREIffLY SUCCESSFUL

SUMMER PILOT PROGRAM OF THEDIVISION OF VOCATIONALREHABILITATION, THE

DIVISION OF BLIND SERVICES, AND THEBOULDER RIVER SCHOOL ANDHOSPITAL.

COMMENTS:

This program expansion has alsobeen requested by individual sin

competency and facilities the community.The program offers the special Retarded clients are now re- of the School to retardedin the community. ferredby general counselors of theDivision of VocationalRehabilitation. the School, with Those selected areprovided a13 week training program at the costs being paid by theDVR. Atthe completion of the summer program, competency to allow the client has gainedenough vocational and social

152 employment placement in the community by DVR. Thus far, results have been

encouraging, and exronsion of the program would enable many more retarded

to be rehabilitated.

RECONNENDATION 4

THE minor OF VOCATIONAL REHABILITATION SHOULD ENCOURAGE TIE DEVEJOPMENT

OF HALFWAY HOUSES TO ENABLE MORE RETARDED TO BE PLACED WITHIN THE COMAUN1TY.

CalMITS:

Halfway houses are an effectivemethod toease the transition of the institutionalized indrAdual back into the community. This subject is ex- plored more fully in Chapter VII, "Facilities."

TABLE 15. PATIENT CHARACTERISTICS BOULDER RIVER SCHOOL AND HOSPITAL

Total Number of Residents- 130

Sex Age Race

M F 6-17 18-2021-45 46-60 Cauc. Indian Mexican

81 57 18 54 1 119 9 2

Employment Status Disability

Gen.fGen. Car- FtllFullPart-Sel-NeverOrthoVis- iliacEpil-SpeeelDia- MR Ot. TimeTime 1.- 'it,

89 8 to 4 19 9 1 13o

To the best of your knowledge, has this individual ever been in contactwith DVR or DBS?

Yes No NR

1 127 2

153 Montana Sate School for the Deaf and Blind

The School for the Deaf and Blind was founded in 1893, and has as its primary purpose the education of the visuefly and acoustically impaired child in Montana who is unable to attend regular public school. The School, which is administered under the State Board of Education, admits children on the basis of physician, agency, school, and family referrals. The age range of the children in attendance is from 4 to 21 years. There is no lower age limit.

Intake services include medical examination, social service interview, psychological testing, and counseling. In addition to basic education at the elementary and secondary level, group therapy, vocational training,and a workstudy program are available.

An in-service training programisavailableto staff, andthose up- grading their skills are compensated by salary increases.The current attendance is 120 students, of whom 40 are visually impaired, 79 are acoustically impaired, and 1 has both disabilities.Enrollment is expected to increase to 130 students by 1975. No follow-up services are provided Frad- uates, except as needed and available through other agencies.

The Division of Vocational Rehabilitation is felt to be not adeouately meeting the needs of the acoustically impaired child. However, the Di-fsion of Blind Services is meeting the needs of the visually impaired child through a program which stations a counselor at the School to work with this disability group.

RECOMMENDATION 1

IT IS RECOMMENDED THAT A VOCATIONAL REHABILITATION COUNSELOR, 3KTLLED IN WORK-

ING WITH THE DEAF CLIENT, BE ASSIGNED TO THE SCHOOL FOR DEAF AND BLIND, AND

THAT THIS COUNSELOR ALSO WORK WITH THE DEAF POPULATION OUTSIDE THE SCHOOL.

154 COMMENTS:

The handicap imposed by deafness creates aunique problem, primarily of a communicative and socialadjustment nature, for which a specia)ly trained vocational counselor isneeded. The success of the program of the

Division of Blind Services at theschool is indicative of the gains tobe realized by using a special approach.A prouam of a similar nature,geared to the special problems of theacoustically impaired, is indicated.

The Blind Youth RehabilitationProject was begun in 1967, andinvolves the placement of a specialDivision of Blind Services counselor atthe School.

He works not only with the blindyoungster at the School, but withthe visu-

and ally handicapped throughoutthe state. Services consist of home visits case studies, counselingof child and parents, medicalexaminations, training and training materials,psychological testing, andevaluation.14

RECOMMENDATION 2

IT IS RECOMMENDED THAT CONSIDERATIONBE GIVEN TO CHANGING THE LAWWHICH

DELINEATES THE RESPONSIBILITIESOF sat SUPERINTENDENT OF THESCHOOL FOR

THE DEAF AND BLIND. THE RESPONSIBILITY FOR SERVINGAS PLACEMENT OFFICLR

AT THE SCHOOL, FOR COORDINATINGA CENSUS OF DEAF AND BLINDCHILDREN, AND

FOR FULFILLING OTHER DUTIESCANNOT BE ADEQUATELY MET WITHOUTADDITIONAL

FUNDS AND STAFF.

COMMENTS:

of the The increasingly complexadministrative duties of the office

Superintendent of the School for theDeaf and Blind make it mandatorythat

14Montana School for the Deaf andBlind, The Rocky MountainLeader, pp. 1-3, December,1967.

155 either the responsibility for placement of children beremoved from that office through cooperatiVd agteements andestablishment of workingrelationships with agencies, such as DVR or DBS, or that adequate funds and staff be provided the School so that this function can be carried out, as speci- fied by law. State Agencies

Many public agencies which provide services to people have a direct

relationship to, and interest in, the rehabilitation programs as provided through the Division of Vocational Rehabilitation and the Division of Blind

Services.

These vocational rehabilitation agencies have, over the years, established effective working relationships with many of these agencies, and

receive referrals of disabled from them.The understanding and coordination of programs on an inter-agency basis is becoming increasingly more complex because of changes in programs initiated at the federal level, and because of the changing requirements of the persons that all agencies serve.

The Policy Board of the Statewide Planning Project, in recognition of these facts, invited the administrators of the major state agencies to meet with them to determine the direction DVR and DBS should take to better 15 meet the needs of the disabled. Agency administrators responding to the invitation were:

W. J. Fbuse, Administrator Department of Public Welfare

John S. Anderson, M.D., Executive Officer Department of Health

Harriet Miller, Superintendent of Public Instruction (Represented by Roger Bauer, Special Education, DPI)

Jess C. Fletcher, Director, State Employment Service (Represented by Robert Miller, Special Applicant Service, LASES)

Edwin Kellner, Director Department of Institutions

15SeeAppendix C for interview format.

157 Robert Swanberg, Chairman Industrial. Accident Board

W. H. Fredricks, Coordinator Office of Economic Opportunity

J. C. Carver, Director Division of Vocational Rehabilitation

Emil. Honka, Director Division of Blind Services

Floyd McDowell, Superintendent School for the Deaf and Blind

The recommendations resulting fromlengthy testimony at this meeting, February 15-16,1968, are as follows:

1. The continued development of Districtoffices by the Division of Blind Services, as a means of bringing betterservices more rapidly to the blind and the visually handicapped, isrecommended.

2. It is recommended that a portion ofthe Aid to Needy Blind-Medical Services Program funds of the state bediverted to the Blind Services rehabilitation program to enable matching offederal rehabilitation funds, thus enabling more individuals tobecome rehabilitated.

3. It is recommended that inter-staff training programsbe continued and expanded at both the state and local level as a meansof insuring that coordination between the Divisionof Blind Services, Public Welfare Department, Division of VocationalRehabilitation, and Public Health personnel continues in its currentsatisfactory manner. Such meetings should be frequent.

4. Rehabilitation and training programs for thoseindividuals being discharged from state institutions should beincreased as one method of reducing welfare costs.

5. It is recommended that residencyrequirements existing between states in welfare departments, which tend tocreate barriers to rehabilitation, be removed.

6. It is recommended that a facility bedeveloped for the purpose of providing adjustment services and vocationaltraining to the visually impaired. Such services, if properly planned,could be part of a multipledisability facility.

7. It is recommended that steps be taken toreduce the time interval between referral of cases to the Division ofVocational Rehabilitation and contact of the individual by the DVR counselor,and that more follow-up services be provided clients by thecounselor.

158 8. It is recommended that better screening procedures be developed for use prior to placement on jobs within the community of those released from Warm Springs and Boulder.

9. It is recommended that Pre-vocational counseling by trained personnel be provided the handicapped in the schools.

10. It is recommended that the Division of Vocational Rehabilitation provide training and information to school counselors to insure better services to the disabled.

11. Cases referred for services are accepted largely on the basis of the examining physician's interpretation of the relationship of the condition to a vocational problem. It is recommended that a study be made of such rejected cases to determine if they have unmet needs as a result of other problems.

12. There is a need for development of rehabilitation plans for groups such as the retarded to consider and plan for the period of time when they are not functioning on the job; i.e., after working hours.

13. It is recommended that a team approach, utilizing the Division of Vocational Rehabilitation counselor and the Public Health Nurse at the community level, he implemented to assist in the community adjustment of those released from Warm Springs State Hospital.

14. It is recommended that the number of rehabilitation counselors be increased to enable better services to the rural disabled, and to work with the exceptional child after his school experiences are terminated.

15. Evaluation, diagnostic, and training facilities are necessary for both the disabled child needing sheltered employment and the child ultimately able to accept competitive employment.

16. Programs of information and education regarding disability should be directed at school personnel to enable them to more readily identify and refer children needing rehabilitative services.

17. It is recommended that psychological testing services be increased in the schools by attracting well-qualified professionals.

18. It is recommended that vocational training facilities be developed in Montana which will consider the needs of disabled persons.

19. It is recommended that formal programs to increase public understanding and acceptance of disabled persons be developed.

20. It is recommended that steps be taken to establish functional relationships between the Division of Vocational Rehabilitation, Division of Blind Services, and the staff of Montana State Prison.

159 21. It is recommended that the Division of Vocational Rehabilitation initiate and carry out rehabilitation programs with the correctional institutions, in recognition of the pressing needs of the innate population for such services.

22. It is recommended that the Division of Vocational Rehabilitation employ a staff person trained in correctional rehabilitation to develop cooperative programs at Montana State Prison.

23. It is recommended that a study be made of the need to initiate a special project at the Prison to determine the rehabilitation Poten- tial of the inmates.

21h It is recommended that the Division of Vocational Rehabilitation provide sufficient counseling staff to function within the in-patient service of Warm Springs State Hospital and the Mental Hygiene Clinics as they become operative within the state. This would reduce the time between referral and service and would enable work to be done in Pre-placement experience, testing, training, and job placement of patients.

25. It is recommended that sheltered workshops for patients at Warm Springs State Hospital be developed, and that the industrial therapy program be increased.

26. It is recommended that the socially disabled individual, such as those with whom custodial institutions work, be provided rehabilitative services.

27. It is recommended that suitable living facilities be developed for those discharged from the institutions into the community as a means of effecting a satisfactory transition back to the community.

28. It is recommended that a part-time Division of Vocational Rehabilita- tion counselor be assigned to the Vocational School for Girls.

29. It is recommended that more counselor time be made available to the patients at Galen State Hospital.

30. It is recommended that an expansion of the currently successful summer pilot program of the Division of Vocational Rehabilitation, the Divi- sion of Blind Services, and the Boulder River School, be made.

31. It is recommended that the Division of Vocational Rehabilitation assign a counselor to work at the Boulder River School, and thatthe Division of Blind Services be considered for those residents meeting eligibility requirements.

32. It is recommended that a placement unit be initiated at the Boulder River School to develop placement opportunities and provide foLLow -up services to dischargees in the community.

16o meetings be initiatedbetween the It is recommendedthat a series of of Blind Services, Division of VocationalRehabilitation, the Division to establish working agree- and the staffs ofthe state institutions effective rehabili- ments, develop a commonphilosophy, and to plan tation programs for thosein the institutions. mental retardation It is recommended thatinformational programs on 34. community and to those and sources of assistancebe directed to the working with the retardedindividual. the development of It is recommended thatconsideration be given to 35. for boys. certain vocational training programsat the Pine Hills School Rehabilitation coun- It is recommended that aDivision of Vocational 36. Center on an itinerantbasis. selor be provided theMontana Children's clarified between the Inter-agency workingrelationships should be 37. Aftercare Division of Division of VocationalRehabilitation and the responsibility for the Department of Institutionsto insure that the counseling is delineated. counselor, skilled It is recommended that aVocational Rehabilitation 38. to the School for the in working with thedeaf client, be assigned work with the deaf popu- Deaf and Blind, and thatthis counselor also lation outside the school. changing the law It is recommended thatconsideration be given to 39. Superintendent of the which delineates theresponsibilities of the School for the Deaf and Blind. The responsibility forserving as placement officer at the School,for coordinating a censusof deaf duties cannot be ade- and blind children, andfor fulfilling other quately met without additionalfunds and staff.

161 which necessitatesinstitu- The nature andseverity of a problem potential for rehabili- tional treatment mitigates anaccurate estimate of

and evaluation. tation on any basis but anindividual case assessment application of criteria General estimates can bemade, however, by the those meeting the standards that tends to delimitthe number of cases to established. and results, This approach has beenutilized for Project purposes therefore, are a grossestimate of approximately452 persons (excluding residing in institutions those at Warm SpringsState Hospital) who are now potential candidates for voca- referred to in thisChapter, and who are

tional rehabilitationservices of some kind. services, such as is If a broader definitionof eligibility for Rehabilitation Act, DOW permitted byrecent amendments tothe Vocational View is applied, then allthose persons in PineHills School, Mountain Children's Center could be School, Montana StatePrison, and the Montana and maladjustment considered eligible by virtueof the social conditions

resulting frominstitutionalization. probably preclude Present capabilitiesof funds and staff will

this approach toeligibility for some time.

No concerted effort hasbeen made to developcomprehensive pro- agencies for grams in theinstitutions by thevocational rehabilitation been made as resources per- the reasons cited.Excellent beginnings have Forest Camp, the mit. Outstanding examples are: the Swan River Youth School and cooperative Work-Experience programat the Boulder River River School, and the Hospital, an evaluationproject at the Boulder Blind Youth Project at the School for the Deaf and Blind. These programs

indicate current Vocational Rehabilitation-Institution cooperation. In

1947, Montana, Vermont, and Colorado had the distinction of pioneering

the first Vocational Rehabilitation programs in mental hospitals in the

United States.Vermont and Colorado have continued to expand such programs.

The urgent necessity for liaison and coordination between the institutions and the vocational rehabilitation agencies at all levels was emphasized in meeting with the agency and institution administrators. Staff, while a critical problem for all departments, could be mare effectively utilized through a clear delineation of function and responsibility, particularly in the areas of counseling and placement. The inadequate vocational training opportunities available in Montana for all disabled are especially acute when the needs of those discharged from the institutions and state schools are considered.

The advantages of having adequate numbers of trained Vocational

Rehabilitation counselors stationed at the institutions were pointed out by all administrators, and have been amply demonstrated to be essential in other states. The problems, unique to Montana and other rural states, of low population density and limited resources, dictates that well-planned pilot or demonstration projects be considered as one means of providing adequate services to the disabled, in the state.

The potential advantages of complete physical, psychological, and social evaluations on a uniform basis in the institutions were demonstrated by the difficulty of gathering similar data. The Western Interstate Com- mission on Higher Education project at the Boulder River School provided a considerable amount of pertinent up-to-date information for administrative

3_64 and planning purposes.If similar systems could be incorporated in the other institutions, it would conside'-ably enhance the treatmentand rehabilitation programs in these facilities.

The notable gains made in Montana in recent years must be continued if comprehensive rehabilitation services are to be made availableto those in the institutions.

165 CHAPTEZ V

THE DISABLED AND HANDICAPPED OF MONTANA

Planning to meet the present and future needs of disabledindividuals

necessitates that information, reflecting the extent andnature of the problem

and the characteristics of the individuals to beserved, be available tc pro-

vide a foundation for program devaopment.

Community Surysz

Following a study by Project staff of the techniquesthat could be

used in gathering meaningful information, withconsideration for the limita-

tions of staff time and funds, the Policy Board, staff,and consultants deter-

mined that a random household survey, which wouldbe representative of the

diverse and sparse population of Montana,was not feasible.Accordingly, a

survey conducted in the communities of the state, utilizing the "grass roots"

committee structure, was suggested. This method was felt to be advantageous

in that it would: (1) identify those individualswhose disabilities were

serious enough to present problems,as reported by major agencies and as veri- fied by case records; (2) identify individualswith good potential for rehabilitation; and (3) promote community involvementwith increased awareness of the problems of the disabled at the local level.

Method

An agreement was entered into with theSociology Department at Montana

State University to develop, in conjunction withProject staff, questionnaires to be distributed in the communities through the13 district chairmen and 1 the county chairmen. A formal orientation meeting was held in each district by Project staff, with district and county participantsand agency representatives in attendance, to explain the purpose of the survey and to cover methods to be followed in the distribution andcompletion of survey forms. In addition to utilizing a narrated slide presentation, written materials accompanied the survey materials. The completed questionnaires were mailed to the Sociology Department forIBM processing, tabulation, and elimination of duplications. (Tabulations were presented by county and statewide totals. The material was then compiled to compare to the five regions. These regions had assimilated the 13 districts originally serving as the functional structure of theProject.) Throughout Montana, 10,555 disabled individuals were identified by this survey.

It is recognized that the method used had limitations, as do all survey techniques, although it is felt that the survey wassuccessful in identifying the particular population concerned in rehabilitation planning.

The primary source of survey information is derived from the case records of the major state agencies and from the schools in the state. This approach provided an identification of a group of individuals to whom rehabilitation services would be most beneficial and meaningful.Over 500 direct referrals to the Division of Vocational Rehabilitation and the Division of

Blind Services resulted from this survey. Guidelines for the survey emphasized the vocational nature of the programs, and consequently had bearing on the types of individuals identified.This tended to exclude those not

1 See Appendix C.

168 in the labor market because of age, unless supplementary employment was required to maintain adequate living standards.

Geographically, the percentage of individuals identified in each regional population was very uniform.It can be assumed that this is an indication that the method used adequately oriented survey participants to survey purposes and to the type of individuals the Project wasseeking to identify. The application of survey procedures would also seem to have been quite uniform.

TABLE 16 - OVERALL SURVEY RETURNS

Region 1960 Number Percent of Total Population Identified Population = 1 125,527 2,035 1.62%

2 147,636 2,111 1.43%

3 151,283 2,487 1.64%

4 1h4,698 2,260 1.56%

5 105,576 1,662 1.57%

These figures are considered to be conservative, as an indication of the number of disabled who could benefit from vocational rehabilitation.

Some categories were not adequately represented - children not in school, severely disabled receiving care at home, and those without obvious conditions or conditions elusive of diagnosis such as hearing impairments, cardiac conditions, alcoholism, and mental illness.

169 Although participating agencies werein general very thorough in conducting the survey, it can beassumed that many disabled werenot identified indi- due to the voluntary natureof the task.This was evident in several vidual countles. at least 1.5% The most important factevidenced by the survey is that

disabilities of the state population, 10,555individuals, are known to have .25% whidh are substantial andwhich impose limitations. This compares -4-:th from the two of the population, 1,777, whoreceived rehabilitation services

vocational rehabilitation agenciesin fiscal year1967-68.

The number of Montanans whocould benefit from services,compared to

those now receiving services,is indicative of the Programactivity needed

in all phases of rehabilitationin the coming year.

CBARACTERISTICS OF 10,555 IDENTIFIED DISABLEDAND HANDICAPPED IN MONTANA

TABLE 17 - AGES BY SEX

64+ Total 0-5 6-17 18-20 21-45 46-64 RegionMFMF M F M F M F M F M F 64731220 815 1 2415 465288 9841 331182 238216 4 78 741288823 2 3128455 322 7954 321164 324181

321179149571549938 3 32 31691468 10770 249133 931344916 4 71 53 784509 9040 159125 182 96 58

77461003659 5 44 23327238 69 52 248150 238150

82242634364044151 TOTAL 20215027221825 4432571308754 1303

170 COMMENTS:

Of those identified, 60.67% were male and 39.32% female; as compared to a sex ratio in the general Montana population of50.73% male and 49.27% female. The 43% in the 6-17 age category is indicative of the future demands that will be placed upon ehabilitative services, as these children enter the labor market. This would tend to substantiate the need, not only for adequate treatment, but additional special education and work-study programs in the schools. It should be noted that, generally speaking, on a percentage basis of the total reported by age groups, Regions 1, 2, and 5 were very similar.Regions 3 and 4 showed a preponderance of those in the

0-17 group, primarily because of the large number of identifications by the schools in Region 3 and by Public Health in Region 4.

TABLE 18 - MARITAL STATUS BY SEX

No Resonse Single Married Separated Divorced Widowed MFMFMF M F M F M F

Region 1137195 747368 300 98 7 17 27 70 861

Region 2 0 10 778460 368141 25 36 73 80 33107

It gion 3 12 5 1009621 380141 19 26 89 61 3787

Region 4 2 3 1067646 202 79 15 13 40 84 1198

Region 5 0 2 634397 296120 13 20 36 40 26 78

TOTALS 151215423524921546 579 79 112 265 335 115431

171 CoMMENTS:

Of those reported, 63.7% were unmarried,which is a reflection of the large number of young personsreported by the survey. There were 20.1% of the total reported as married, andthe balance reported were separated, widowed, or divorced.The large number of "no" responsesin Region 1, 16%, can be ascribed to the mannerin which the questionnaire wascompleted by an agency reporting alarge number of children.The majority of responses there would tend to increase theunmarried category of Region 1.Regions 2 and 5 reported the highest percentageof married disabled,24% and 25% respectively.

TABLE 19 - RACIAL CHARACTERISTICSBY SEX

No Negro Mexican Other Response Cauc. Indian M F MFMFMF M F M F Region 1 26 17 968539217254 0 0 3 3 3 5 1 Region 2 46 24 1000652"223143 5 2 5 1 9 8 Region 3 21 13 1470882 25 36 3 0 21 6

Region 4 9 la 1161804121 75 2 1 46 24 3 3

4548 Region 5 4 6 799495 155 .103 0 1 2 4

r A . 68 59 TOTAL 106 71 53983372 741 611 10 4 77 38 .

COMMENTS:

The total statewide percentageof Indians reported by the survey was

12.8% as compared to an Indian composition inthe general Montana population

the of 4.5%. This may be substantiation offindings of other studies that incidence of disability among Indiansis higher than among Caucasians, orit

172 may be a reflection of the reportingby the t:ommunity Action Programs on

the reservations in Regions 1 and 5.Region 1 reported 23% Indian, and

Region 5 reported 15.5%. In Region 2, which has the Blackfoot Reservation,

17.3% were Indian; however, the identification there was apparently made

by public agencies on the reservation, other than theCommunity Action

Program.

TABLE 20 - EMPLOYMENT STATUS BY SEX

No Full GenerallyGenerally Seldom Never Response Time Full TimePart Time Employed Employed M F M F 14 F MFMFMF

Region 1 153203100 6 119 22 141 30 111 73 594483

Region 2 14 19 54 16 195 41 181 60 185 96 658 592

Region 3 22 1312232 224 59 105 45 133 64 941 727

Region 4 12 7 46 11 82 27 101 29 160114 941 730

Region 5 11 3 7314 82 21 130 40 188104 521475 L , TOTAL 21224539579 702 170 658204 777451 36553007

COMMENTS:

It will be noted that the high number of thosereported "never

employed" is due to the large number of individuals under age18 reported

in the survey. On a percentage basis by Region, the range was73.8% in

Region 4 to 38% in Region 1, which also had the highestpercent of "no

response" answers, 17%. This is probably due to the same reason.

173 TABLE 21 - EMPLOYMENTBARRIERS BY SEX

No Definitely Definitely Yes PossiblyUncertainDoubtful No Response 4- MIFM M F M FM1FMF 1 113295 Region 1 178208 496 173 27381 81 31 84 26

I 69 32 Region 2 53 34 560 414 359206131 75 116 62 i 70 42 Region 3 23 13 514 320 538283257 175147105 49 Region 4 24 18 657 457 381243121 85 92 64 69

37 14 Region 5 17 11 588 403 264164 73 48 26 17

663 414465274 358432 TOTALS 290284281517671815978

COMMENTS:

Statewide, 43.4% of those reported werefelt to definitely have a barrier to employment due to thecondition of disability, and26.5% were judged to possibly have a barrier. Thus, 69.9% were judged to haveemploy- ment problems related to thecondition. The remaining 30.1% fellwithin the other categories. It is recognized that response tothis question is on a highly subjectivebasis unless substantiated byhistory of unemployment in case records. This question is not relevantto the majority of cases reported by theschools, and is of doubtful relevanceto those reported by other agencies, such asPublic Health. The Employment Service,

of their Public Welfare DepartmentjandCommunity Action Program, by virtue

case recordingpractices, can be considered to havesubstantiating information of this type available.

174 TABLE 22 - DISABILITIES BY SEX

No Ortho- Visual Ammta- Hearin g Response pedic Arthritis ufairments tions Im airments N F M F M F M 14 F

Region 1 4 3 165 70 46111 94 53 3611 66 49

82 Region 2 0 0 232122 79 66134 69 54 7 138

137 72 Region 3 230149 76 55 141 76 4214

Region 4 27 33 221150 35 64137 3 137

999 52 Region 5 4 1 137 81 49 65114 72 26

354 ITOTALS 39 985 572 285 -01 620 360 17741 577

TABLE 23 - DISABILITIES BY SEX

Cardiac - TB & Speech Im- Alco-1 Resp. Epilepsypairments Diabetes holism

M F F M F M F MF

Region 1 141 100 3 19 36 31 120 68 4247 8941 Region 2 120 92 17 45 47 127 83 4042

81 38 Region 3 177 122 16544 3922 79 45 4441

Region 4 114 90 6 36 6744 168 97 32 25 44 15729 Region 5 136 66 16 24 27 129 72 28

TOTALS 688 470 379 211171 623 365 186199 431146

175 TABLE 24 - DISABILITIES BYSEX

Drug Mental Mental Re- Delin- Habitual 0',- AddictionI ln .s tardatio enc C *uina M M F M M F MF M F 165 121 Region 1 16 10 6562 244184 10922 7 1 0 186 131 Region 2 1 1 72 78 213 182 26 8 8 5 0 371257 Region 3 1 1 67 205141 266 2 1 155 113 Region 4 5 0 76 57 351213 6615 0 103 69 Region 5 3 2 81 238244 2216 3

25 2 980696 TOTALS 26 14 3611111111111111964 24967

TABLE 25 - DISABILITIESREPORTED IN MONTANA SURVEY

Rate Per Percent of Thousand of Disability Total Montana's Identified * General Population 2.20 Ortho edic 1 .750 .91 Arthritis Visual Imairment 9.2V 1.3: .30 Amutations 2.0 1.31 Hearin:. Imairment .87Sf Cardiac and stroke 10.9 I, .72 TB and Resirator 0 .5 -. 1.39 Seech Imairment . Diabetes 74-- ..1 Alcoholism IIIIIIIIIMBNAIIIIIIIIII Dru Addiction IMIIIIIIMMINIMII11111111111111.MIIIIIIIIIINI ., .97 Mental Illness .. 0 Mental Retardation 20.9; 3.13 Delinquency 2.9 . .03 Habitual Criminal .22 °, 2.02 Other 13.51'. 11 No Response 73

* Total percentage is over 100,due to multiple disabilities.

176 There was a total of18.48 disabilities per 1,000 population reported.

When adjusted for multiple disabilities on anindividual case basis, there were reported15.66 disabled individuals per 1,000 generalpopulation.

COMMENTS:

Statewide, the highest percentageof disabilities reported were mental retardation, 20.98%, and orthopedicconditions, 14.75%. Cardiac conditions, including stroke, constituted10.97% of all disabled reported. Speech problems were 9.36%, and visual problems,9.28% of all disabilities. No infer- ence can be made thatthese figures represent an indicationof incidence of conditions in the general population, asthey relate only to those reported by the survey. The low percentages of individualsidentified in certain categories is an inherent deficiencyof any survey method, as conditions not of an obvious nature, or conditionswhich have a connotation of morality or prejudice, are never adequately reported. In the first category could be included cardiac respiratory conditionsand diabetes; in the second, alcoholism, epilepsy, mental illness,addiction,and anti-social behavior.

On the basis ofregional reporting, considerablevariations as to disabilities reported arenoted; generally, the variationsare greater in the category of disability than in other surveycategories. This can be explained on the basis of abiasof the reporting agencies towardcertain conditions as much as on thebasis of actual variations of disabilityincidence rates.

Other factors involved are the awarenesscreated by prior projects, notably the State Mental RetardationPlanning group, and/or local or regionalactivity such as the Eastern Montana MentalRetardation Association and the concern for alcohol problems on the reservationin Region 5.

177 surveyed as being retarded, For example, Region 5reported 29% of all

16.8% orthopedic, followed by versus13.9% in Region 3. Region 2 reported lowest number of Region 4 with16.4% orthopedic.Region 1 reported the Region is an area of orthopedic problems,11.5%, despite the fact that the logging and other heavyemployment activities.

TABLE 26

SELECTED REPORTED DISABILITIESBY REGION

Hear-Alco- Mental Ortho- Arth- Speechirg hol Other RegionRetarda-pedic CardiacritisVisual tion

9c2% 5.7%3.8%40.9% 1 21.0% 11.5% 11.8% 7.7% 7.2% 9.9%10.4 6.2%38.8% 2 18.7% 16.8% 10.0% 6.9% 9.6%

8.7% 5.0% 8.4%4.9%48.6% 3 13.9% 15.2% 12.0% 5.3% 11.7%10.4 2.8%37.6% 4 24.9% 16.4% 9.0% 4.4% 10.0%

6.9% 11.2% 12.2% 9.1%11.2%36.0% 5 29.0% 13.1% 12.2%

due to multiple NOTE: Percentages in each Regiontotal more than 100, disabilities.

178 TABLE21 -REPORTING AGENCIES - SEX REPORTED ......

i Region Region Region Region Region TOTALS 1 2 3 4 5 M 1 0 1 1 No Response 1 14 ... g...... T7 M 1 0 259 12o 232 27 1031 210 I 920 delfare F 152 1 13 23. i M 205 167 80 513 20T 1173 243 136 66 383 151 J 979 Public Health ' F 111111110 28 11=111inIMEMPER "I. 4 Emilovment Service 1 F 2 0 6 mom 1c o 6 16 111=111i1 o School OM 02 MUM 1 8 16 _j_qo 14 80 0 nWEIMIIIIMIIIIMMIll 4 Probation Parole; F 6 0 ' 111111111111 MEM M 16 26 86 1110111 18 Communit Action_ F 88 6 60 6 o 2 M 26 46 1 21 h 128 CountExtension F 2 10 HIM= _ ) 10 1144 f 8- 1 M 186 Other FWM1111111E11111 84 MMIII

COMMENTS:

Variations by reporting agencies wereconsiderable, as would be expected of a voluntary survey which wasdependent on a rather high degreeof interest in the Project and in thedisabled individual with whom it wasconcerned. The

completion of survey forms, whilerequiring a minimum of time individually,did) in many instances require aconsiderable expenditure of time on the partof

already overworked agency personnel.That the response was so great underthese

circumstances is one of the mostencouraging signs for the future cfrehabilita-

tion of the disabled, as itreflects an inordinate degree ofinterest in the

needs of the disabled at theoperational level.

Review of the tabulations reportedabove must be made with the awareness

that not all agencies receivedquestionnaires and that, because ofpersonnel

shortages in known instances,it was not possible to have formscompleted by

all agencies.

179 THE DISABLED OF MONTANA: ESTIMATES AND PROJECTIONS OF CHRONIC DISABILITY AND ACTIVITY LIMITATIONS

The estimates of chronic disabilities and activity limitations for

Montana, and for the five planning regions, are derived from national rates

2 compiled by the National Center for Health Statistics. Data is collected

through household interviews in the Health Interview Survey, a continuing

program of the National Center for Health Statistics. Each year interviews

are conducted in a sampling of approximately 42,000 households, which com-

prise 134,000 people.This is a sampling of the civilian non-institutional population of the United States. It does not include members of the armed

services or United States Nationals living in foreign countries.

The application of national rates to particular areas introduces possible error due to difference in regional characteristics. Also, the assumption that disability rates will remain constant in projecting to future years is subject to error due to constant change in population characteristics and new treatment methods.

However, the application of national rates to Montana and its regions can be helpful in overall planning for vocational rehabilitation services and facilities.

National rates used for Montana estimates are those resulting from interviews between July, 1961 and June, 1963. Four categories were reported from these interviews: (1) with no limitation in activity; (2) with limitation but not in major activity; (3) with limitation in amount or kind of activity; and (4) unable to carry on major activity. Major activity. was

2Public Health Service, Chronic Conditionsand Activity Limitations; United States - July, 1961- June,1963, United States Department of Health, Education, and Welfare.

180 defined as "...the ability to work, keephouse, or engage in schcol or pre- school activities." Estimates derived for Montana and its regions arebased on the two most limitingconditions since they are assumed to moreclosely coincide with requirements for services from theDivision of Vocational

Rehabilitation and related agencies.

For each disability category used, the rate perthousand of population was computed from nationalfigures and applied to the population ofMontana and the five planningareas.3

In some cases, the estimates of numberof disabled people may be high due to persons reporting more than onedisability. Conversely, only selected conditions are reported.Population projections used are Series 1Destimates of the Bureau of the Census, United StatesDepartment of Commerce, and are the most conservative projectionsappearing in their SerieP-25, No. 326, dated February 7, 1966.

3Totals in the regional figures for 1960 and 1970 do not agree exactly with the state figures, as their derivation wasbased on percentages in each disability category.

181 CHRONIC CONDITIONS AND 1960 TABLE 28 ACTIVITY LIMITATIONS IN MONTANA 1970 i 1975 in amountLimited Unable tocarry on I in amountLimited Unable to. I Limited Unable to carry on . in amount carry on of major or kind activity major Total of major or kind i activity major Total i of major or kind activity major Total BenignMaliTuberculosis nant and neo.lasms unspecified all forms - -- activity 359359 170 01 7 o 262 ...... 1..~.0..... activity 39 914 186 a 111M011 580 activity 412 12 4613.'. 607 neo.lasms I -5-T MentalDiabetesAsthma-ha and nervous fever 111111"h2M11° 111 1 033 2003379 2 17 5 649 12 1332 493 7220 9547 _L. 2; 3 ol 516 727230 M 1 913 746 . Heart conditionsconditions 7 095 1 3590 760 10 ..1 4 733 I 7,73 451 9 1 745 5 196 1 3 609 1 -4 321 1 825 5 434 Hypertension without heart 134 120.0 ' Varicose veinsinvolvement 1 2123 874 84 13 723370 1 3232 155 _232 271 alai_ 14 503087 1 1 32 3000 2:975 14 275 74 OtherHemorrhoids conditionslat°112XELIT of circu- 1 482 629 880 5 2,362 411 1 626 90 , 203 6 2 5.2 =93 722 213 935 OtherChronic conditions bronchitissinusitistor of and s stem respira- 1 212 8 8 525355 1 1423 567 1,331 -86 576390 1 721 1,7011 1031 392 1 010 408 12,711 800 Pe tic ulcer 1.07 12.4 5 1 1: ----4757 146.01,62 1 237 .2 478 , lOther conditionsHernia digestive system of 21 3066 7 k 417 226416 2,9921 795 21 268 79 1 017 491 31,97o 285 E 1 5G t 372 1 063 §151,63451 _Lulu_ 21 715Ool 17"7"Ir frweripur.7.-r75Tr=7"Irr".1.7.-17"",--'-72.*:, ' 0,74 - 1960 TABLE 28 (Continued) 1.970 1975 1 ! Limited Unable to 1 ofin majoramountor kind carry onmajor Total 1 in amountorLimited kind Unable tocarry onmajor Total in amountLimitedor kind Unable tocarry onmajor Total. Conditions of genito- activity activity activityof major activity ' activityof major activity Arthritis andurinar rheumatism s stem 7 2095 200 2 09 880 9 37 080 7 27 4169 2 : 966 3 382 i 2 526 1 21 9.5010 3 536 CO Other diseasesbones of and 'oints muscles, 1 662 340 2 002 i 1 824 373 10 53 11 1 1 w I Hearin: imVisual japairments airments 1 931 2 007 95 3 93. 11111011111 2 120 2 203 702 2 197 323 00 I -----F22_2171 907 2d .w n7-"r"389 2 296 Paralysis, completeartial or 1 621 WIEN 2,833 111111111111 1 779 1. I 877 797 Impairments sis(except of back or spine paraly- 3 907 602 4 509 I 4 28 661 4 3950 110 4,4851 3.2 1 860 'Impairments1 except paraly- 691 ral 5 176 ! extremitiessis and absence) and shoulders of upper 808 185 9.3 887 1 Impairments 7c7e17.---tpe)araly-sis and absence) of lower 203 1 090 928 213 1 141 1 extremities an11====. 2 6 11111111111 3 651 2 957 1 051 4 008 1 3 0`3 1 0.9 TOTALS 49,485 22,167 71,652 54,323 24,332 78,655 56,816 25,448 82,264! 41921 i On the basis of the foregoingestimates, then, it can be considered

that 71,652 Montanansare limited in activity due to chronicconditions.

Program expeidence has demonstrated,however, that not allpersons who have

functional limitationsare in need of the services of the state-federal

rehabilitation program. Additionally, thereare those who may need services

but do not desire to acceptsuch services. The characteristics which ultimately determine whether theperson will enter a rehabilitationprogram and derive benefit from itare contingent on a multiplicity ofpersonal, social, and economic factors.

The systems of referral,diagnosis, evaluation, and entry intoa prescribed program are all integralparts of the screeningprocess. The success of the program following acceptanceis determined by factors which include the nature and extent ofdisability, the clients perceptionand acceptance of his problems, theexistence of secondary physicalor mental conditions, the influence offamily and peer attitudes, the economicpressures existent, the attitude andacceptance by the counselor ofthe client, age, education, and prior work andlife experiences. CHAPTha VI

MONTANA PLANNING PROJECT REGIONS

The information in this Chapter is provided with the hope that

it will be of value and guidance in planning for the Regional development of special programs to meet the uniaue needs of each area, as expressed in the District meetings.

The development of programs and facilities, of benefit to the disabled on a statewide basis, should be in accord with the statewide plan. A proliferation of uncoordinated programs will result in needless duplication and waste of available resources.

The estimates of disabled by Region, as indicated in the Chronic

Conditions and Activity Limitations table, are based on the data of the

National Health Survey, and have the same basis as the statewide data as is projected in ChapterV.1The same limitations apply; however, caution should be exercised in the application and interpretation of data to small units.Regional differences, inherent in a state such as Montana, 2 tend to accentuate the original survey limitations.Regional projections are given only to 1970, as suitable countygeneral population figures were not available beyond that time when projections were made.

In addition, a general compilation of the most significant characteristics of disabled persons, as individually identified in the Community

Survey, are presented in narrative form and are derived from Table28 in

Chapter V.

1Public Health Service, Chronic Conditions and Activity Limitations: United States- July,1961- June,1963, United States Department of Health, Education, andWelfare.

2, Dureau of the Census, Population Estimates, Series P-25, No. 326, (Series 1D).

185 11 The recommendations in this Chapter are those resulting from the

second meeting held within each District; they represent the needfor

services as expressed by the professionals and citizens of the various

communities.

In recognition of the vital importance of the attitudes of the

practitioners in medicine, rehabilitation, and related fields,as they bear upon the future development of rehabilitationprograms, selected

survey questions, responses, and respondent characteristics are presented

in this section. Complete data derived from thesurveys is presented in

Chapter VIII.

The 102 recommendations from thesesources, then, together with those of the special committees, were assimilated and developed into the statewide recommendations by the Citizens Advisory Committee. The basic

Project recommendations are, therefore, preserved and presented inthis manner, as it is felt that they represent the sincere and considered opinions of hundreds of individuals who have firsthandknowledge of the problems of the disabled in Montana.

186 Planning Region 1

Region 1 consists of Lincoln,

Flathead, Lake, Sanders, Mineral,

Missoula, and Ravalli Counties.

This Region contains same of

the most rugged terrain inthe United

States. Its transportation routes run

along the valleys, parallel to the

mountain ranges. Route U.S. 2, in

the northern part of the Region,

serves east-westtraffic in Lincoln

and Flathead Counties. Interstate 90

serves the centralportion, consisting

of Missoula and Mineral Countiesin

east-west travel. U.S. 10A is an east-

west route for Missoula and Sanders

Counties. Highway 93 is the north-southroute through Ravalli, Missoula, of the area is Lake and Flathead Counties. Bus service to a greater part provided in both east-west andnorth-south directions.

Principal industries are lumber,wood products, fruit growing, limited mining, agriculture,livestock, dairying, andmanufacturing.

The principal cities areKalispell and Missoula. Missoula is the trade center for western Montanaand is the location of theUniversity of It is also con- Montana and the U.S. FbrestService Region I headquarters. sidered the medical centerfor western Montana.

187 Region 1 had a population of125,5273in 1960, and is projected to be

r.4)4 144,27 in 1970. It contains 19,374 square miles of land area, with a popu-

lation density of 6.4 persons per square mile. In 1960, there were 63,675

males and 61,852 females, with 47,398 persons under 18 years of age, and

13,453 over 65.

In 1960, the median family income was$5,230, and median education of

those over 25 was 11.3 years. In April of 1968, there were 32.7 welfare re-

cipients per thousand ofpopulation.5 Sixteenpersons per thousand were

identified in the statewide survey as potential rehabilitation cases. Re- ported work injuries were 5 per thousand of total population in1966-67.6

Region 1 has six available facilities, as utilized and designated by the Division of Vocational Rehabilitation Workshops and Facilities Project.

They are all situated in Missoula:

1. Missoula Crippled Children's Treatment Center.

2. University of Montana Speech and Hearing Clinic.

3. Missoula Mental Hygiene Clinic.

4. Opportunity School.

5. University of Mbntana Testing and Counseling Center.

6. Missoula Child Development Center.

The Division of Vocational Rehabilitation had a total of448 clients in this Region during the fiscal year 1967-68.

3Public Health Service, Chronic...22. cit.

4Department of Planning and Economic Development, Montana Statistical cit.

5Source: Montana Department of Public Welfare.

6 Source: Montana Industrial Accident Board.

188 TABLE 29. CHRONIC CONDITIONS AND ACTIVITY LIMITATIONS - REGION 1 1_970 activityofin amountmajorLimitedor kind Unableactivity to carry onmajor Total ofinactivity amountmajorLimitedor kind Unable to activitycarry onmajor Total TuberculosisAsthma-hayBenignMalignant and neoplasms feverunsrecified necTlasms all forms ,7 67 3237 112142 99 277796 364386 139163_113 MentalHypertensionHeartDiabetes andconditions nervous without conditions heart 4320 ,38 192 8 7002.117126 2 020 88109510 1 518 6220442 119806 40 2 124 0_35.5.-..- VaricoseC`therHemorrhoids veinsconditionsinvolvement of circulatory 934 c: 160 5.Q_,__ 694 . 615 181 796 Chronic sinusitiss stem and 225 16._ J X17 1813...... Other conditionsbronchitis of respiratory 66 1.. . .. Pe tic ulcerhernia . . 230 :s 8q. 319 .. (`theyConditions conditions systemof :enitourina of digestive s stem 3$4 172 . 5% 442 198 .. 640 0 VisualArthritisHearingOther impairmentsdiseases impairmentsandand rheumatism jointsof muscles, bones, 309 3P m 373 63: _172 732372: a 1 413 429 72 . 842427 Paralysis: complete or partial 141225_ 301129 27052( 3259163 34714A 313 (-)1:1 Impairmentsabsenceback shoulders(except or )ofseine paralysiS) upper extremities of and except paralysis and 150 14 184: : 171 19 2121. I Impairmearlexceptandr.lsence) hies paralysis of lower extremities TOTAL - ESTIMATED ALL DISABILITIES and 501 178 679 576 205 781 -Major Characteristics of the 2035 Disabled Id'ntified By the Community Survey Region 1

The survey showed that 40% of those identified as disabled were

female, 59% were male, and for 1% no sex was indicated.There were 72%

identified as single.

By race, 74% were Caucasian and 23% were Indian.By age, 39%

were under 18, 25% were in the 21-45 age group, and 29% were over 1±5.

In the larger categories of disability, 21% were mentally retarded, and

17% had cardiac conditions.

The agencies reporting the largest numbers were the schools, 26%,

and Public Health, 22%. The work status of those reported was as follows:

39% had never worked, 32% were felt to have a definite barrier to employment, and only 5% were reported as working full- tine.

Of the total Humber identified in the survey, 19% were from this

Region.

Physicians

The Physicians Survey shows that of 157 physicians in Region 1,

86 responded to the questionnaire. By category, they were grouped as follows: 37 general practitioners, 11 surgeons, 2 pediatricians, 4 orthopedists, 3 ophthalmologists, 1 psychologist, 13 internal medicine, 8 obstetricians, 3 psychiatrists, 2 neurosurgeons, 1 dermatologist, and 1 pathologist.

These physicians were asked what additional rehabilitation services were most needed in their communities. In order of priority, they listed lohysical therapy as the most needed service, occupational therapy as the second most needed service, and a rehabilitation center third.

190 In order to find outhow often they sent clients tothe rehabilitation services, they wereasked about referrals in the past year.Of 30.2% had these physicians,41.9% had made no referrals in that period, referred one to three persons,17.4% between four and six,9.3%more than six, and 1.2% did notrespond to this question.

Of the reporting physicians,68.6%wanted to be informed by the rehabilitation agencies as toaction taken in the cases theyreferred.

When asked to estimate the successof the rehabilitation agencies in rehabilitating theirpatients to a productive place insociety, 7.0% felt the success was excellent,22.1% said it was good, 11.6% said it was fair,7.0% said it was poor, 38.4% were unableto evaluate, and 12.8% did not respond.

Physicians' opinions concerning therehabilitation feasibility for certain special groups were asfollows:

TABLE 30. PERCENTAGES OF PHYSICIANS INDICATINGREHABILITATION POTENTIAL OF SPECIAL GROUPS - REGION1

Group Com- Partly Seldom Never Un- IR pletely certai

Habitual Criminal 15.1% 7.0% 10.5% 37.2% 16.3% 14.0%

Delinquent 16.3% 20.9% 39.5% 12.8% 1.2% 9.3%

Mental Retardation 16.3% 2.3% 514.7% 19.8% 3.5% 3.5%

Mental Illness 14.0% 12.8% 66.3% 3.5% - 3.5%

Drug Addiction 12.8% 8.1% 24.4% 46.5% 5.8% 2.3% 1.2% Alcoholism 12.8% 17.4% 34.9% 31.4% 2.3%

191 In giving an opinion concerning development of the rehabilitation

agencies/ 37.2% of the physicians said the agencies should expand ser-

vices, 17.4% recommended the present status,4.7% said services should

be reduced, 23.3% hAd no recommendation, and17.4% did not respond.

Nurses

In Region 1, 82 nurses responded to the survey questionnaire,which

was 16.6% of the total respondingstatewide. Of these nurses, 67.1% were

employed full-time, 25.6% part-time, and 7.3% were not employed.When

auestioned concerning experience, 12.2% replied that they had been employed

1 to 3 years, 7.3% from 4. to 6 years, 2.4% from 7 to 9 years,7.3% from 10 to 12 years, and 67.1% over 12 years.

Of the respondents, 58.5% were natives of Montana.

When asked to estimate the number of patients they had worked with

in the past year who could have benefited firm rehabilitation services, the nurses replied as follows:15.9% none, 34.2% between 1 and 5, 8.5% between 6 and 10, 2.4% between 10 and 20, 2.4% over 20, and 36.6% did not respond.

The nurses were asked to identify factors responsible for many disabled not receiving services: 29.6% said lack of knowledge about services,

23.5% said cost of effort necessary to get services, 13.6% said services were inadequate or not available, and33.3% blamed apathy on the part of the client or his family.

192 Professionals

In Region 1, 76 educators and other professionals whose work is related to rehabilitation responded to the questionnaire.Native Montanans accounted for 58.7% of the educators and 57.7% of other professionals.

TABLE 31.EDUCATIONAL LEVEL OF RESPONDENTS PROFESSIONAL SURVEY - REGION 1

High Some Some School College BA Graduate MA Pal NR

Professional 4.8% 9.5% 38.1% 16.7% 14.3%14.3% 2.4%

School Personnel 2.9% - 2.9% 20.0% 68.6% 4.4% -

This group was questioned as to the effect of disability on the wo::k activity of their clients. By broad numerical categories, they estimated how many were out of work or restricted in work activity. Of the respondents other than educators, 17.6% reported 0-9 clients, 16.8% said 10-19 clients,

4.8% said 20-29, 4.0% said 30 -39 clients, 24.4% said over 50, and 32.0% did not respond.

School personnel replied to this same question in a manner reflecting the age of their pupils: 45.7% said 0-9 of their disabled students were restricted from work, 8.7% said 50 or over, and 45.7% did not restiond.

Professionals, other than school personnel, felt that many disabled were not receiving services for the following reasons: 29.1% said lack of knowledge about the service, 15.2% said cost of effort necessary to get services, 27.9% said services were inadequate or not available, and 27.9% said apathy on the part of the client or his family. School personnel

193 responded as follows: 37.0% said lack of knowledge about the services,

7.4 said cost of effort necessary to receive services, 24.1% said services were inadequate or not available; and ?I.5% said apathy on the part of the client or his family.

TABLE 32.PERChWAGES OF PROFESSIONALS AND SCHOOL PERSONNEL MAKING REFERRALS TO DVR AND DBS - REGION 1

Division of Blind Services

None 1-5 6-10 11-20 NR

Professional 30.:e, 23.1% 3.9% - 42.3%

School Personnel 43.5% 10.9% - - 45.7%

Division of Vocational Rehabilitation

Professional 13.5% 40.4% 13.5% 11.5% 21.2%

School Personnel 23.9% 54.4% 6.5% - 15.2%

TABLE 33.ESTIMATES OF VOCATIONAL REHABILITATION SUCCESS PROFESSIONAL SURVEY -.RF.GION 1

Good Fair Poor Don't Know BR

Professional 55.0% 25.0% 2.5% 12.5% 5.0%

School Personnel 47.2% 27.9% - 27.8% 11.1%

TABLE 34. REASONS FOR NON-REFERRAL TO VOCATIONAL REHABILITATION PROFESSIONAL SURVEY - REGION 1

Age No Not below Age No barriers familiar VR over suitable to OtherNR with eligi- labor referral bilitv market system agency megy-

Professional 45.0% 10.0% - - 15.0% 30.0% -

School 50.0% 3.6% 3.6% .. 17.9% 25.0% - I RECO CH ATIONS - REGION 1

1. It is recommended that steps be takento eliminate duplication of services between the Department of PublicWelfare, the Employment Service, and the Division of VocationalRehabilitation.

2. There should be increased coordinationbetween agencies to assure that there is continuity of service to thedisabled.

3. Rehabilitation services should be extendedto heads of households, such as women receiving Aidto Dependent Children, who requirespecial services but who do not qualify forservices because they do not have a definable physical or mental disability.

4. An active program is necessary toincrease public and employer acceptance of the disabled as potential employeesand to develop Place- ment opportunities for the disabledindividual.

disabled individual is to be 5. Ftollow-up services are essential if the retained on his job.

6. A special program should be initiated to increase thesensitivity of school personnel to the needs of severelydisabled children, such as the retarded or epileptic.

7. There is a critical need for speechtherapy in the schools in Mineral, Sanders, and Ravalli Counties.These services should be availableat least two to three times per week foreach child requiring therapy.

8. The Division of Vocational Rehabilitationshould dynamically promote the development of services for the disabledin the schools and should extend services to those disabled in schools.

9. A Work -Study program should be developedby the Division of Vocational Rehabilitation and the school districtsto serve the retarded and other exceptional children at the high school level.

10. There is a need for a well-planned andstaffed workshop for the evaluation and training of the severely disabled.

11. Halfway houses should be established tofacilitate the transition of institutionalized persons back into the community,and as part of these services there should be family counseling aswell as individual counseling.

12. It is recommended that a Vocationalziehabilitation office be established in the Flathead area.

195 Planning Region 2

GLACIER A

- PONDERA 0 TETON L11140:1 0

Region 2 consists of Glacier,Toole, Pondera, Liberty,Hill, Blaine,

Teton, Chouteau, Cascade,and Judith Basin Counties.

This area is east of theContinental Divide, andis relatively flat. Travel is mostly east-west. The principal east-westhighway is U.S. 2.

North-south roads are U.S.highways 89, 91, 87, and 191,which is between

Lewistown and Malta.There is generally goodbus service in the Region.

Industries are diversified, including agriculture, livestock,smelt-

ing, flour milling, oil refining,and some manufacturing.

Rocky Boy's, Fort Belknap, andBlackfoot Indian Reservationsare in Region 2.

Great Falls is the largestcity in thearea, and is the trade and medical center of the Region. Great Falls is the locationof the College of Great Falls, NhImstromAir Fbrce Base, the smelterand electrolytic plant of the Anaconda Company, and near a series of damsgenerating power for the Montana Power Company. Havre is the second largestcity in the /097 area, and is thelocation of Northern Montana College.

Region 2 had a population of145,6367in 1960, and is projected to be175,7988in 1970. It contains 25,952 square milesof land area, with a populationdensity of 5.7 persons per squaremile. In 1960, there were

75,876 males and 71,760 females, with57,976 persons under 18 years of age, and11,663 over 65.

In 1960, the median familyincome was $5,729, and medianeducation for those over 25 was11.6 years. In April of 1968, there were43.1 welfare recipients per thousand ofpopulation.9 Fourteen people per thousand were identified asbeing potential rehabilitation casesin the statewide survey. Work injuries reported in1966-67 were 2.7 per thousand of total pvulation.

Region 2 has four availablefacilities, as utilized and designated by the Division of VocationalRehabilitation Workshops and Facilities

Project. They are arl situated in GreatFalls:

1. Easter Seal RehabilitationCenter.

2. Cascade County ConvalescentHospital.

3. State School for the Deaf andBlind.

4. Montana Heart Diagnostic andEvaluation Center.

The Division of VocationalRehabilitation had a total of604 clients in this Region during the fiscal year1967-68.

7Public Health Service, Chronic...op. cit.

8Department of Planning and EconomicDevelopment, Montana Statistical ..0013. cit.

9Source:Montana Department of PublicWelfare. 10 Source:Montana Industrial AccidentBoard.

198 TABLE 35. CHRONIC CONDITIONS AND ACTIVITY LIMITATIONS - REGION 2 1 60 V.M....1.00..4111.0.1611.10m1e 1 0 ofinactivity majoramountLimitedor kind Unableactivity to carry onmajor Total ofinactivity majoramountLimitedor kind Unable to activitycarry onmajor Total Tuberculosist.allt.ali,nantBenign and neo unsrecified lasms forms neoplasms 10.11109111111111....78 .11..P.M.I.41.M.250*01. 7$ -WON., 1;11' 07iCrJ "1 44 AsthmaHypertensionHeartMentalLiabetes -hay conditions and fever nervous without conditions heart (09225 1,d417# varicose,:morrhoids veinsinvolvement o2o 11 38'S AllerChronic conditionstiler sinusitissystcm conditions of an of drculatory 40 lyy5.1L :ternia System tic ulcer 19. in (ther conditionssystem of digestive f yly (ter::rthritisConditions diseases andand of jointsofrneumatism unitourinarmtemmuscles, bones, 1-N546 479 66;.;' 2.1jh 4(,70 6 1 cir (,Itc 40 VisualImpairmentsIaralysis1242pleteitearingirwents impairmentsback (except7e7a-15ITTOTor s ineor partial 1E6._421562_ 4 8'8 10927 1.411L 17%' Impairmentsabsence)of andabsence)shoulders(except hips paralysis ofupper lower extremities extremitiesand and except paralysis and 172 Major Characteristics of thg. 2111 DisabledIdentified By the Community Survey Region 2

The survey showed that 38% of those identified asdisabled were female, 61% were male, and for1% no sex was indicated. There were

58% identified as single.

By race, 85% were Caucasian and15% were Indian. By age, 25% were under 18 years of age,230 were in the 21-45 age group, and 35% were over 46. In the larger categories of disability,27% were mentally retarded and 22% orthopedic.

The agencies that reported the largest numbers werethe schools,

47%, and Welfare, 29%.The work status of those reported was as follows:

59% had never worked, 41% were felt to have a definite barrier to employment, and only 3.3% were reported as working fUll-time.

Of the total number identified in the survey, 20% were fromthis

Region.

Physicians

The Physicians Survey shows that, of147 physicians in Region 2,

66 responded to the questionnaire. By category, they were grouped as follows: 32 general practitioners, 6 surgeons,4 pediatricians, 3 orthopedists, 6 ophthalmologists, 5 internal medicine, 7obstetricians, 1 psychiatrist, 1 neurosurgeon, and 1 thoracic surgeon.

These physicians were asked what additionalrehabilitation services were most needed in theircommunities. In order of priority, they listed a

Psychologist as the most useful service needed, a psychiatricsocial worker as the second most needed service,and a medical social worker as the third most needed.

200 In order to find out how often they sent clients to therehabilita-

tion services, they were asked about referrals in the past year. Of these

physicians, 39.4% had made no referrals in that period,22.7% had referred

one to three persons,16.7% between four and six, 19.7% more than six, and

1.5% did not respond.

Of the reporting physicians,80.3% wanted to be informed by the re-

habilitation agencies as to action taken in the cases they referred.

When asked to estimate the success of the rehabilitation agencies

in rehabilitating their patients to a productive place insociety, 6.1%

felt the success was excellent,22.7% said it was good, 9.1% said it was

fair, 4.6% said it was poor,48.5% were unable to evaluate, and 7.6% did

not respond.

Physicians' opinions concerning the rehabilitation feasibility for

certain special groups were as follows:

TABLE 36. PERCENTAGES OF PHYSICIANS INDICATING REHABILITATION POTENTIAL OF SPECIAL GROUPS - REGION 2

Com- Un- Group pletely Partly Seldom Never certain NR

Habitual Criminal 21.2% 7.6% 13.6% 43.9% 9.1% 4.61 3.0% Delinquent 15.2% 18.2% 47.0% 12.1% 4.6

Mental Retardation 15.2% - 48.5% 28.8% 4.604 5.

Mental Illness 13.6% 3.0% 66.7% 13.6% - 3.

Drug Addiction 15.2% 16.7'10 22.7% 36.4% 3.0% 6.1:

Alcoholism 15.2% 22.7% 24.2% 30.3% 1.5% 6.1

201 In giving an opinion concerningdevelopment of the rehabilitation agencies, 43.9% of the physicians said theagencies should expand services, 18.2% recommended the present status,1.5% said services should be reduced, 22.7% had no recommendetion,and 13.6% did not respond.

Nurses

In Region 2, 119 nurses respondedto the survey questionnaire, which was 24.1% of the totalresponding statewide. Of these nurses, 69.8% were employed full -time, 21.0% part-time, and7.6% were not employed. When questioned concerning experience,10.1% replied that they had been employed

1 to 3 years) 7.6% from4 to 6 years, 9.2% from 7 to 9 years,8.4% from

IG to 12 years, and 63.0% over 12 years.

Of the respondents, 64.7% were nativesof Montana.

When asked to estimate the number ofpatients they had worked with in the past year who could have benefitedfrom rehabilitation services, the nurses replied as follows: 21.9% none, 21.0% between 1 and 5,10.9% between 6 and 10, 3.4% between 10 and 20,4.2% over 20, and 38.7% did not respond.

The nurses were asked to identifyfactors responsible for many disabled not receiving services: 38.3% said lack of knowledgeabout'services,

11.4% said cost of effort necessary to getservices, 17.0% said services were inadequate or notavailable, and 33.3% blamed apathy onthe part of the client or his family.

202 Professionals

In Region 2, 82 educators and otherprofessionals whose work is related to rehabilitation responded to the questionnaire.Native Montanans

accounted for 56.6%of theeducators and 65.45%of the other professionals.

TABLE 37.EDUCATIONAL LEM, OF RPONDENTS PROFESSIONAL SURVEY - REGION 2

Some

High Some BA Grad- MA PHD .IIR School College uate

Professional - 5.4% 46.0% 27.0% 21.6% - _

School Personnel - 4.9% 7.3% 24.4% 63.4% - _

This group wai, questioned as to the effect of disability onthe work

activity of tMeir clients.By broad numerical categories,theyestimated

how many were out of work or restricted in work activity. Of the respondents

other than educators 20.0% reported 0-9 clients, 29.1% said 10-19 clients,

1.8% sai.' 2C -29 cli -ants, 3.6%said30-39clients, 20.0% said over 50, and

25.5% d i dDt'esl.ont .

School personnel replied to this same question in a mannerreflecting the age oftheir pupils: 54.7%said0-9 of theirdisabled students were

restricted from work, and45.3% did not respond.

Professionals, other than school personnel, feltthatmany disabled were not receiving services forthe following reasons: 37.2% said lack of knowledge about the services,6.4%said cost of effort necessary to get services, 33.0%said services were inadequate or not available, and23.4%

said apathyonthe part of the client or his family. School personnel

203 services, 4.11, responded as follows: 34.7% said lack of knowledge about the said cost of effort necessaryto receive services,20.4 said services were client inadequate or not available, and40.8% said apathy on the part of the

Or his family.

TABLE 38. PERCENTAGES OF PROFESSIONALS ANDSCHOOL PERSONNEL NAKING REFERRALS TO DVR ANDDBS - REGION 2

Division of Blind Services

Pone 1-5 6-10 11-20 NR

Professional 29.1% 34.6% - 5.5% 30.9%

- School Personnel 50.9% 9.4% - 39.6%

Division of VocationalRehabilitation

14.6% 12.7 Professional I 27.3% 14.6% 30.9% 18.9% School Personnel 37.3% 34.0% 7.6% 1.9%

TABLE 39. ESTIMATES OF VOCATIONALREHABILITATION SUCCESS PROFESSIONAL SURVEY - REGION 2 ---____

Good Fair Poor Don't Know DR

7.0% 14.0% Professional 46.5% 27.9% 4.7% 23.3% 14.0% School Personnel 30.2% 27.9% 4.7%

TABLE 40. REASONS FOR NON-REFERRAL TOVOCATIONAL REHABILITATION PROFESSIONAL SURVEY - REGION 2

Age Not No below Age No familiaemploy VR over suitable with ment Other NR eligi-laborreferralagencybarrier bilit market stem

Professional 18.2% 15.2% 15.2% 9.1% 21.2% 21.2% -

School Personnel 57.9% - 7.9% 2.6% 7.9% 23.7% -

204 RECOMMENDATIONS - REGICN 2

1. It is recommended that emphasis begiven to programs of early detection of disability tohelp prevent thedevelopment of conditions that later require rehabilitation.

2. A combined Program offering services tothose in the 6-17 age group, and having speech or visual impairments oremotional problems, is needed.

3. Special education classes, with a provisionfor boarding care, are needed for the trainable mentally retarded.

4. The emotionally disturbed child, andthe adult with alcoholism and per- sonality problems, require specialservices. These should be provided within a mental health center or aspart of a community hospital.

to overcome the 5. Adequate psychological testing services are necessary current long delays in procuringtesting.

plans 6. It is recommended that considerationbe given to including in the of the Havre hospital the servicesof an orthopedic surgeon, an ophthal- mologist, a psychiatrist, an occupationaltherapist, and a specialist in ear, nose, and throat.

Vocational 7. It is necessary that a program beinitiated by the Division of Rehabilitation to present information onthe needs of the disabled and the fact that, properly trained, they canbecome effective workers.

8. In recognition of the difficultiesencountered in recruitment of professional people in all fields, it isrecommended that salaries be increased to a level which will allowMontana to compete with otherstates.

9. High standards of services and facilitiesmust be met if the disabled are to be properly served. Coordination of planning of those groupsdevelop- ing programs is necessary. Consideration should be given bycommunities to designate one agency to coordinateservices to the handicapped,and to function as a clearing house for servicesto the needy individual.

10. Many disabled persons require specialservices to return to employmerjt. Trade school facilities should bedeveloped for the training of thedisabled; and for those who have lessenedability because of mental conditions.

11. Halfway houses to assist alcoholics, thosehaving mental disorders, and those discharged from state institutionsshould be started in this Region.

job 12. Sheltered workshops to serve alldisability categories are needed for evaluation, work experience, training, andother supportive services necessary to enable theindividual to function productively inthe community.

205 Planning Region 3

Region 3 consists of

Lewis and Clark, Jefferson,

Broadwater, Meagher, Powell,

Granite, Deer Lodge, Silver

Bow, Beaverhead, Madison and

Gallatin Counties.

Most of this area is

east of the Continental Divide

and is mountainous terrain.

There are good highways between

cities and towns in this area

East-west highways include

Interstate 90, U.S. 12, and

U.S. 287. North-south travel

is by Interstate 15, U.S. 91,

U.S. 287, and U.S. 10.

Industriesinclude livestock, mining, agriculture, meat packing,

smelting, oil products distribution,and some manufacturing.

The main trade centers are Butte, Helena, and Bozeman.The largest

city is Butte, location of the large Anaconda CopperMining Company operation. The Montana College of Mineral Science andTechnology is located there. Helena is the second largest city in the Region. It is the location of the State Capitol and CarrfAl College. Montana State University

is in Bozeman.

26,/207 Region 3 had a population of151,28311in 1960, and is projected

to be1563916/2-in1970. It contains 25,796 square miles of land area,

with a population density of 5.8 per square mile. In 1960, there were

76,889 males and 74,394 females, with 54,094 persons under18 years of

age, and 15,732 over65.

In 1960, the median family income was$5,4121 and median education

of those over 25 was 11.3 years. In April of 1968, there were24.8 welfare

recipients per 1,000people.13

Sixteen persons per thousand were identified as beingpotential

rehabilitation cases in the statewide survey. Reported work injuries were 3.5 per thousand totalpopulation in1966-67.14

Region 3 has seven available facilities, as utilized anddesignated by the Division of Vocational Rehabilitation Workshops andFacilities Project:

1. Boulder River School and Hospital(Evaluation Unit), Boulder.

2. Butte Sheltered Workshop, Butte.

3. State Department of Health Speech and HearingClinic, Helena.

4. Shodair Crippled Children's Hospital, Helena.

5. New Horizon Halfway House, Helena.

6. Warn Springs State Hospital, Warm Springs.

7. Alcoholic Service Center, Warm Springs.

mhe Division of Vocational Rehabilitation had atotal of 439 clients

in this Region during the fiscal year1967-68.

13-Public Health Service, Chronic...2E. cit. 12 Department of Planning and EconomicDevelopment, Montana Statistical cit. 13 Source: Montana Department of Public Welfare. 14 Source: Montana Industrial Accident Board.

208 TABLE 41? CHRONIC CONDITIONS AND ACTIVITY ------6o LIMITATIONS - REGION 3 ofactivityin major amountLimitedor kind Unableactivity to carry onmajor Total ofactivityin major amountLimitedor kind Unable toactivitycarry onmajor Total Tuberculosis , all forms :* 11111111:11 111111=F111111:11 :1111,11111111111111=111 Asthma-hayMalignantBenign and nsalasmsfever unsrecifiednealasms 100 J. 80 4489 144169 10 8's 4691 150176 MentalDiabetes and nervous conditions 11111151111111111.111=1111111- 4t. , 6 HypertensionHeart conditionsinvolvement without heart 1.5$g 704. 84R196 .. 1,0602,42 IlintallIMIRMIE1,651 711 $76169 1,1o42,527 V7 VaricoseOtherHemorrhoids conditions veins of circulatory IIIIIIIIIMIIIIIIIIIIIIMIIIIIIMIIIIPISIIIIIMIIIIIIMIII 1:1111111=11111111 IIIMIIIIII.IIIIIIMIN ... :. ; ; OtherChronic conditions sinusitisbronchitiss stem of andrespiratory 2 A_ INIIIIIMMIIMIIIMIIIIP 0 282 82 ; HerniaPeptic ulcersystem 241103._201 11111= 317 .3, 318 209 122 131 64 OtterConditions conditionssystem of_genitoux of digestive 4 . 14c/...... Arthritisether diseasesand and }joints of muscles,rheumatism bones, 1,58q . 584 0 1.651 . . 607 2,?58 ImpairmentsVisualParalysis}Heari impairmentst i back .airments(exceptcomplete or soirie paralysis ) or partial of A 1110111111111111E41111111 . 11111V111111 ...111 . . . r o.; Impairmentsshouldersabsence)of upper extremitiesexcept paralysisand and 180 11111111111 41. 1 00 221 140 1 04* Impairmeptsandabsence) (except hi s of lower extremities paralysis and 188 .4 211 E ------2a-----r-a4- 11111111410:11:112216,028 626 16,653 848 Major Characteristics of the2487 Disabled Individuals By the Community Survey Region 3

The survey showed that37% of those identified as disabled were female, 62% were male, and for1% no sex was indicated. There were 65% identified as single.

By race, 95% were Caucasianand 3% were Indian. By age, 49% were under 18, 15% were in the21-45 age group, and 28%, were over1.5. In the larger categories of disability,21% were orthopedic, 17% were mentally retarded, and 16% had cardiacconditions.

The agencies reporting thelargest numbers were the schools,45%,

Employment Service, 11%, and Welfare,10%.The work status of those reported was as follows: 67% had never worked, 33% were felt to have a definite barrier to employment, andonly 6% were reported asworking full-time.

Of the total number identifiedin the survey,24% were from this

Region.

Physicians

The Physicians Survey showsthat of 173 physicians inRegion 3,

92 responded to the questionnaire. By category, they weregrouped as 2 ortho- follows: 44 general practitioners,14 surgeons, 4 pediatricians, obstetricians, 4 psy- pedists, 4 ophthalmologists,12 internal medicine, 5 chiatrists, 1 public health,1 pathologist, and 1proctologist. rehabilitation services These physicians wereasked what additional they listed were mostneeded in their communities. In order of priority,

210 a psychologist as themost needed service and a rehabilitationcenter

as second inimportance. In third place, also, was the need for a rehabilitation center.

In order to find out how oftenthey sent clients to the rehabilitation services, they were asked aboutreferrals in the past year. Of these physicians, 26.1% had made no referralsin that period, 23.9% had referred one to three persons,12.6% between four and six, and 16.3% more than six. A highpercentage, 21.7% did not respond to this question.

Of the reporting physicians,85.9% wanted to be informed by the rehabilitation agencies as to action taken in the casesthey referred.

When asked to estivate the success of therehabilitation agencies

in rehabilitating their patients to a productiveplace in society, 6.5% felt the success was excellent,27.2% said it was good, 17.4% said it was fair, 6.5% said it was poor,31.2% were unable to evaluate, and 10.9% did not respond.

Physicians` opinions concerning the rehabilitation feasibilityfor certain special groups were as follows:

TABLE 41. PERCENTAGES OF PHYSICIANS INDICATING REHABILITATION POTENTIAL OF SPECIAL GROUPS - REGION 3

Com- Un- Group pletely Partly Seldom Never certain NR

Habitual Criminal 12.0% 1.1% 13.0% 53.3% 7.6% 13.0%

Delinquent 12.0% 15.2% 57.6% 6.5% 1.1% 7.6%

Mental Retardation 10.9% - 55.4% 22.8% 3.3% 7.6%

Mental Illness 10.9% 12.0% 68.5% 2.2% - 6.5%

Drug Addiction 10.9% 7.6% 37.0% 33.7% 4.4% 6.5%

Alcoholism 9 4';', 16.3% 52.2% 18.5% - 3.3% In giving an opinion concerning development of the rehabilitation agencies, 51.1% of the physicians said the agencies should expand services,

3.3% recommended the present status,5.4%said services should be reduced,

29.11%had no recommendation, and 10.9%didnot respond.

Nurses

In Region3, 1110 nursesresponded to the survey questionnaire, which was 28.4%of the total responding statewide. Of thesenurses, 60.7%were employed full-time,23.6%part-time, and 12.9% were unemployed.When questioned concerning experience,7.9%replied that they hadbeenemployed

I to 3 years, 2.9% from4 to 6years,3.6%from 7 to9years, 10.0% from

10 to 12 years, and 72.1% over 12 years.

Of the respondents,61.4%were natives of Montana.

When asked to estimate thenumber ofpatients they had worked with in the past year who could have benefited from rehabilitation services, the nurses replied as follows: 22.1% none, 27.1% between 1 and 5,6.4between

6 and10,3.6%between 10 and 20,7.9%over 20, and 32.9% did not respond.

The nurses were asked to identify factors responsible for many disabled not receiving services: 32.14 said lack of knowledge about services,

17.1% said cost of effort necessary to receive services, 22.2% said services were inadequate or not available, and28.14blamed apathy on the part of the client or his family.

212 Professionals

In Region 3, 73 educators and other professionals whose work is re-

lated to rehabilitation responded to the questionnaire.Native Montanans

accounted for 55.6% of the educators and 50.8% of other professionals.

TABLE 43. EDUCATIONAL LEVEL OF RESPONDENTS PROFESSIONAL SURVEY - REGION 3

High Some Some School College BA Graduate MA PHD NR

Professional 2.3% 11.6% -9.5% 23.3% 20.9% 2.3% -

- School Personnel 4.9% i .1% 25.9% 55.5% 3.7% ,

This group -was questioned as to the effect of disability on thework activity of their clients. By broad numerical categories, they estimated how many were out of work or restricted in work activity.Of the respondents other than educators, 15.3% reported 0-9 clients,10.2% said 10-19 clients,

10.2%, said 20-29 clients, 30.5% said over 50, and 33.9% did not respond.

School personnel replied to this same question in a mannerreflecting the age of their pupils:41.7% said 0-9 of their disabled students were restricted from work, 5.6% reported 10-19,2.8% said 50 or over, and 50.0% did not reply.

Professionals, other than school personnel, felt that manydisabled were not receiving services for the following reasons: 29.1% said lack of knowledge about the services, 10.5% said cost of effort to receive services,

30.3% said services were inadequate or not available, and 30.3% said apathy on the part of the client or hisfamily. School personnel responded as follows: 47.9% said lack of knowledge about the services,5,,0% said cost effort necensdrk to receive services,22.5% said services were inadequate or not available, and25.0% said apathy on the part of the client or his family.

TABLE 44. PERCENTAGES OF PROFESSIONALS AND SCHOOLPERSONNEL MAKING REFERRALS TO DVR AND DBS - REGION 3

DIVISION OF BLIND SERVICES

None 1-5 6-10 11-20 NR

Professional 20.3% 30.5% - 6.8% 42.4% 10. LI School Personnel 47.2% 8.3% - - .-r.-r.0

DIVISIONOF VOCATIONAL REHABILITATION

11.9% 28.8% 23.7% Professional ' 18.6% 17.0%

lo 11;' School Personnel 36.1% 38.9% 2.8% 2.8% -.

TABLE 45. ESTIMATES OF VOCATIONAL REHABILITATIONSUCCESS PROFESSIONAL SURVEY - REGION 3

Don't Know ER Good Fair Poor

6.7% 13.2% Professional 48.9% 24.4% 6.7% 15.3% School Personnel 23.1% 15.4% 3.8% 42.3%

TABLE 46. REASONS FOR NON-REFERRAL TO VOCATIONALREHABILITATION PROFESSIONAL SURVEY - REGION 3

Age No below Age No Not barriers VR over suitable familiar to Other NR eligi- labor referral with employ- bilit market system aenc ment

Professional30.0% 10.0% 10.0% 20.0% 10.0% 20.0% -

School 37.5% - 16.7% 16.7% 20.8% 8.3% - RECOMMENDATIONS - REGION 3

1. There is a need for a program to identify and refer the disabledindividual at the earliest possible time, preferably at the pre-school level in the case of children, for treatment and rehabilitation services.

2. It is recommended that a formal system be developed to maintain identification of disabled persons in the increasingly mobile society, in order that case work continuity can be maintained.

3. Agencies requiring similar staff and performing similar service functions should consider steps to coordinate and to pool resources to procure ex- pensive personnel who are in short supply.

Ii. The Division of Vocational Rehabilitation should extend its servicesto those requiring them prior to age 16.

5. The full resources of the University system havenot been utilized for serving the disabled in Rbntana. It is recommended that the University system extend its programs for this purpose.

6. It is recommended that special education classes, specificallyplanned to meet the needs of the emotionally disturbed child, beincorporated in school programs.

7. Adjustment programs for the school-age child, such as work-study programs, should be promoted in local schools.

8. A formal, on-going program of public information is needed, as many persons who need services are not aware of them. Those in the helping professions should be provided current information to allow better services to the disabled. The Division of Vocational Rehabilitation and the Division of Blind Services should consider such a program.

9. Current services of speech therapy should be expanded to provide service to all who need therapy, regardless of age.

10. Halfway house facilities for the habitual criminal and the mentally retarded are needed to facilitate the transition back into thecommunity.

11. Additional mental health facilities are necessary to better meet the needs of the community.

12. A pre-parole center should be established in Fontana fordischargees from Montana State Prison.

13. A sheltered workshop for the mentally retarded is neededin Helena.

14. A study should be made to modify the standard commitment procedure now required at Warm Springs State Hospital.

215 15. One comprehensive rehabilitation centershould be constructed in a location with adequate medical facilities.

16. A treatment center offering speechtherapy, audiological screening, physical and occupational therapy would benefitthe disabled in this area. A concentration ofthese services is needed in the treatment of multiple-handicapped persons.

17. Follow-up and supportive services, includingfamily counseling, are needed to assure maximum benefit to thosedischarged from Warm Springs State Hospital.Aftercare service, on the same basis as is now provided dischargees from other institutions, isrecommended.

.18. Public Health nurses are able to provide follow-upin the community, and should be employed in each county.

19. It is recommended that community service councilsbe formed, where none exist, as a means of disseminating information toprofessionals, that will ultimately result in better service to thedisabled.

20. It is recommended that the Division ofVocational Rehabilitation establish a district office in Butte to better meet theneeds of the disabled in Silver Bow, Granite, Deer Lodge,Powell, and Beaverhead Counties.

21. It is recommended that the Division of VocationalRehabilitation and the Division of Blind Services be asked to providesufficient counselors to provide more intensive services to theseverely disabled in the district.

22. There is a great need for enforcement of legislationpertaining to architectural barriers in the construction of all newfacilities, but particularly in the new vocational-technicalschools.

216 Planning Region 4

Region 4 consists of Fergus, Petroleum,

Wheatland, Park, Sweetgrass, Golden

Valley, Musselshell, Stillwater,

Yellowstone, Treasure, Carbon, and

Big Horn Counties.

In general, travel is by good

highways. These include east-

west traffic on Irtterstates 90

and 914 and U.S. 12. North-

south traffic is carried by

U. S. routes 89, 212, 310,

87, and 91.

Industries are diversified and include agriculture, livestock, livestock marketing, meat packing, sugar refining, oil refining, trucking, mining, and some manufacturing.

Region 4 contains the Crow Indian Reservation and part of theNorthern

Cheyenne Reservation.

Billings is the largest city in the area, and is the trade and medical center for the Region and for northern Wyoming. It is also the home of Eastern

Montana College and Rocky Mountain College.

Region 4 had a population of144,69815in 1960, and is projected to be

163,16916in 1970. It contains 27,372 square miles of land area, with a population density of 5.3 persons per square mile. In 1960, there were 72,539 males

15Public Health Service, Chronic...op cit. 16 Department of Planning and Economic Development, Montana Statistical .22. cit.

217 and 72,159 females, with56,194 persons under 18, and 14,014 over 65. In

1960, the median family income was $5,548, and medianeducation for those over 25 was 11.5 years. In April of 1968, there were 30.7 welfarerecipi- 17 ents per thousand of population. There were 15.6 per thousand identified in the statewide survey as being potentialrehabilitation cases.Reported 18 work injuries were 2.7 per thousand oftotal -population in 1966-67.

Region 4. has four available facilities, asutilized and designated by the Division of Vocational RehabilitationWorkshops and Facilities

Project. They are all located in Billings:

1. Eastern Nbntana College Counseling Center.

2. Eastern Montana College Speech and HearingCenter.

3. Montana Center for Handicapped Children.

1. Handicapped Incorporated.

The Division of Vocational Rehabilitationhad a total of 448 clients in this Region during the fiscal year1967-68.

17Source: Montana Department of Public Welfare.

18Source: Nbntana Industrial Accident Board.

218 TABLE 47. CHRONIC CONDITIONS AND ACTIVITY LIMMATIONS .... - REGION 4 1 0 ofinactivity amountmajorLimitedor kind 11111190. Unableactivity to carry onmajor Total ofactivityin major amountLimitedor kind Unable to activitycarry onmajor Total nalicnantTuberculosis3enign and neoplasms unspecified neoplasms all forms 1.061.0ms0 .---...... ^. _26...... _36 96 42; 106 136...86 4841 156127 ,-_ ::iabetesAsthma-hay:._rental fever and nervous conditions 442 7 145 "A 138587 6 498 4' 123____gi4 662402 HypertensionHeart conditions without heart '4 : 4. ,,,,, 8 1 a42 involvement 9 ; .. Varicose:CherHemorrhoidsChronic conditions veins sinusitissystem of andcirculatory _21....Q4 134 . 24,2 20 59---.---33P----44 811...-1 Gther conditionssystembronchitis of respiratory .....312...... 7.88 ri.9. ,112 76 335 216292 12.6 85 342177.ga. PepticCtherHernia ulcerconditionssystem of digestive 4422In-_ 9589.. 64011910 8 260 2 100 08 3604 Conditions of genitourinary system 470 1:8 1 . 22 .....za.. ArthritisVisualNher diseases imTlairments andand rheumatism jointsof muscles, , bones, 1,18 355413aa 4298 2.026 6 84242'8 11711 166401 6301@4212 82 .autit 950483743 1212,I1251-MIEETEtsiaralysis conmlete or partial 163 c 34614a_ 111 _1.$4 163 151-- Impairmentsback ,excep or s.ine laralysis except paralysis and of 6.i6.. 128 1 964 _292 941 145 1 o88 LentIW .... .,. sliculelersal'sence)of upper extremities and 391681 i _nrairmecIts lexcPpt ~NO 1 !J1,..a ser,Qe) (f ...wer (2ytromlUes Ili Ls raral:Jsis and 17.3..... MANMAT inevret.l.saww,,, ...... 57_6_ =...... m...... '"'"tr..""' ___139. 204 ziEj2_651232. 861 Major Characteristics ofthe 2260 Disabled Identified By the Community Survey Region 4

The survey showed. that40% of those identified as disabled were female and 60% were male. There were 76% identified assingle.

By race, 87% wereCaucasian and 9% were Indian. By age, 63% were In the under 18, 13% were in the21-45 age group, and 19% were over45. larger categories of disability,25% were mentally retarded,16% were orthopedic, and 12% had speechimpairments.

lint The agencies reportingthe largest numbers werePublic Health, reported was as schools, 22%, and Welfare,21%. The work status of those

to have a definite barrier follows:74% had never worked, 49p were felt to employment, and only2.5% were reported as workingfUll-time.

Of the total number identifiedin the survey,21% were from this

Region.

Physicians

Region 4, The Physicians Survey showsthat of 151 physicians in

grouped as 85 responded to the questionnaire.By category, they were 6 ortho- follows: 27 general practitioners,10 surgeons, 6 pediatricians, 4 obstetricians, 3 psy- pedists, 10 ophthalmologists,13 internal medicine, pathologist, and 1 thoracic chiatrists, 3 neurosurgeons,1 dermatologist; 1

surgeon.

These physicians were askedwhat additional rehabilitationservices they listed were most neededin their communities. In order of priority, occupational therapy as the physical therapy as the mostneeded service and

and a treatment center second most needed service.Special education classes

were both cited asthe third most neededservice.

220 In order to find out how often they sent clients to the rehabilitation services, they were asked about referrals in the past year. Of these physicians, 37.7% had made no referrals in that period,28.2% had referred one to three persons, u.8% between four and six,20.0% more than siz, and 2.1 did not respond.

Of the reporting physicians, 81.2% wanted to be informed by the rehabilitation agencies as to action taken in the cases they referred.

When asked to estimate the success of the rehabilitation agencies in rehabilitating their patients to a productive place in society,5.9% felt the success was excellent, 22.4% said it was good,15.3% said it was fair, 3.5% said it was poor, 41.2% were unable to evaluate, and10.6% did not respond.

Physicians' opinions concerning the rehabilitation feasibility for certain special groups were as follows:

TABLE 48. PERCENTAGES OF PHYSICIANS INDICATING REHABILITATION POTENTIAL OF SPECIAL GROUPS - REGION 4

Com Group Partly Seldom Never NR pletely certUn-ain

Habitual Criminal 15.3% 3.5% 18.8% 36.5°4 17.7% 8.2,

Delinquent 15.3% 22.5% 47.7% 9.4% - .--;- ,

Mental Retardation 11.8% - 56.5% 21.2% 4.7% 5.9%

Mental Illness 11.8% 10.6% 63.5% 7.1% 1.20 ;.(Y;

Drug Addiction 16.5% 11.8% 17.7% 45.9% 3.5% 11.Z

Alcoholism 12.9% 16.5% 36.5% 28.2% 3.5% 2.V9

221 In- giving an opinion concerning development of the rehabilitation

agencies, 56.5% of the physicians said the agencies should expand services,

8.2% recommended the present' status, 2.4% said services should be reduced,

23.5% had no recommendation, and 9.4% did not respond.

Nurses

In Region 4, 96 nurses responded to the survey questionnaire, which

was 19.5% of the total responding statewide. Of these nurses, 67.7% were

employed full-time, 21.9% part-time, and 7.3% were not employed.When

questioned concerning experience, 9.4% replied that they had been employed

1 to 3 years, 4.2% from 4 to 6 years, 7.3% from 7 to 9years, 15.6% from

10 to 12 years, and 62.5% over 12 years.

Of the respondents, 53.1% were natives of Montana.

When asked to estimate the number of patients they had worked with

in the past year who could have benefited from rehabilitation services, the

nurses replied as follows: 21.9% none, 22.9% between 1 and 5, 10.4% between

6 and 10, 2.1% between 10 and 20, 2.1%over 20, and 40.6% did not respond.

The nurses were asked to identify factors responsible for many disabled not receiving services: 34.8% said lack of knowledge about services,

13.4% said cost of effortnecessary to receive services, 22.3% said services were inadequate or not available, and 29.5% blamed apathy on the part of the client or his family.

222 Professionals

In Region 4, 82 educators and other professionalswhose work is re-

lated to rehabilitation responded to the questionnaire. Native Montanans

accounted for 56.6% of the educators and64.7% of other professionals.

TABLE 49. EDUCATIONAL LEVEL OF RESPONDENTS PROFESSIONAL SURVEY - REGION 4

Some NA High Some RA Grad- MA PHD School College uate

Professional - - 15.8% 36.8%18.4%21.10 :.9%

School Personnel - - - 7.3% 31.710 58.5% 2.4% J -A

This group was questioned as to the effect of disability on the work

activity of their clients. By broad numerical categories, they estiaated

how :many were out of work or restricted in work activity. Of the respondents

other than educators, 15.7% reported 0-9 clients,21.6% said 10-19 clients,

3.9% said 20-29 clients, 2.0% said 30-39 clients, 25.5% said over 50, and

31.4% did not respond.

School personnel replied to this same question in a manner reflecting the age of their pupils: 45.3% said 0-9 of their disabled students were re-

stricted from work, 5.7% said 10-19, 3.8% said over 50, and45.3% did not respond.

Professionals, other than school personnel, felt that many disabled were not receiving services forthe following reasons: 37.5% said lack of knowledge about the services, 10.4% said cost of effort necessaryto receive services, 31.3% said services were inadequate or not available,and 20.8%

223 blamed apathy on the part of the client orhis family. School personnel responded as follows: 30.6% said lack of knowledge about the services,

15.3% said cost of effort necessary to receive services,31.9% said services were inadequate or not available, and22.2% blamed apathy on the part of the client or his family.

TABLE 50. PERCENTAGES OF PROFESSIONALS AND SCHOOLPERSONNEL MAKING REFERRALS TO MR AND DES - REGION4

DIVISION OF BLIND SERVICES

NR None 1-5 6-10 11-20

Professional 31.4% 35.3% 23.5% 7.8% 2.0%

School Personnel 47.2% 41.5% 11.5% - -

DIVISION OF VOCATIONAL REHABILITATION

Professional 17,7% 15.7% 31.4% 13.7% 21.6%

School Personnel 11.3% 39.6% 35.9% 7.6% 5.7%

TABLE 51. ESTIMATES OF VOCATIONAL REHABILITATION SUCCESS PROFESSIONAL SURVEY - REGION4

Don 't Good Fair Poor ffiri Know

Professional 48.7% 30.8% 5.1% 12.8% 2.7;f0

School 24.4% 19.5% - 34.1% 22.0%

TABLE 52, REASONS FOR NON-REFERRAL TO VOCATIONALREHABILITATION PROFESSIONAL SURVEY - REGION4

Age Age No Not No below over suitablefamiliarbarriers VR labor referral with to OtherNR eligi-market system agency employ- bility ment

Professional 35.5% 3.2% 6.5% 6.5% 12.9% 35.5%

School 48.8% - 9.8% 14.6% 12.2% 14.6% -

224 RECOMMENDATIONS - REGION 4

1. The Department of Public Welfare, in providing medical services to disabled clients, experiences a shortage of funds for this purpose for those not Qualifying for Medicaid. It is recommended that increased support of the medical care program be given.

2. In recognition of the fact that it is better to provide the disabled, needy, and indigent individual the necessary services to enable them to be self-sufficient rather than dependent, it is recommended that rehabilitation services be expanded to indigent and marginal individuals.

3. In recognition of the needs of the older arthritic indivddual for medical treatment, therapy, and training, it is recommended that emphasis be placed on developing programs for this group.

4. A formal program to overcome the lack of understanding and fear on the part of the public and employers regarding certain groups, such as epileptics, is necessary if rehabilitation is to occur.

5. It is recommended that services and facilities be developed for persons returning from institutions and for groups such as alcoholics. Such services would assist in the treatment and adjustment process facing persons attempting to procure and maintain employment.

6. The Department of Public Welfare is able to provide casework counseling to those persons who are on welfare rolls. This service should also be made available to those who could benefit but who are not yet eligible for categorical assistance.

7. The rehabilitative services available to other groups should be provided those aged persons who wish to remain active and productive in society. Services should also be extended to the culturally deprived and socially dependent individual.

8. There is a great need for evaluative services such as those which determine physical capabilities, work tolerance, and pre-vocational and vocational needs, in addition to psychological testing, for all disabled, but particularly disabled youth.Additional opportunities for job tryouts must be developed.

9. Services now utilized are available through various public and private agencies, and there is a need for continued coordination and cooperation in providing services and developing new services.

10. There is a need for more data regarding the capabilities of the disabled and the types of work that persons with limitations can do. It is recommended that additional research in the area of job descriptions and requirements be undertaken.

225 The person now workingin the helpingprofessions requires constant 11. particularly exposure to newideas and techniques inall areas, but In-service training would in the area of jobsfor the handicapped. help to alleviate thisneed. vocational training to 12. There will be increasingneeds in Montana for must be designed tomeet serve thedisabled.The vocational schools in fields suitable these needs; existingvocational training courses for the disabled areoften of too shortduration. of working with the 13. There is a need for aforma:, on-going program for the disabled. public and the employersfor development of jobs

Consideration should be givento assessing the effectof prior dis- 14. It is ability on the employer'sdecision to hire a disabled person. full recognized that a secondinjury law exists forthis purpose, but understanding of its intent maynot yet be known toall employers..

his proper productive 15. There is a need to preparethe disabled child for environs of school,through place in society oncehe leaves the sheltered special programs gearedfor the utilization ofprofessional services and this purpose. professional persons within 16.There is a shortage ofcertain, necessary school districts employ the school system. It is recommended that therapy, audiology, andnursing persons trainedin psychology, speech requiring such servicesand to better meet the needsof the children be initiated. to identify problemsearlier so that treatment can diabetic children is Since the inadequacy of programsand services for 17. development of ser- recognized, it is recommendedschools consider the vices for this group. barriers in the construc- The lack of recognitiongiven to architectural 18. instituted to remove tion of schools is to bedeplored. Steps should be by these barriers for thefull utilization ofpublic school facilities disabled children.

classes must be developedwith the needs 19.Additional vocational training of handicapped personsin mind. be developed in Sheltered workshops withdormitory facilities must 20. disabled are to be met. Montana if the vocationalneeds of the severely

retarded children andothers who are released 21. Halfway houses for mentally satisfactory transition into from state institutions arenecessary if a the community is to beaccomplished.

226 ThPrr. a need fu.' a completely newreconsideration of the need:: of the dinahlod i s. seek5ng and maintaining employment. This might include ,ticn ti:ingr as prov ing employer incentives in hiring the disabled. Minimum tlage laws present a significant problemin the administration and functioning of workshops, and a satisfactorysolution to the problem must be worked out through the federal andstate agencies involved.

23. Family counseling is a need in working with those with severedis- abilitiec.

24. Rehabilitation services of all kinds must be extended to those residing in rural areas, with consideration given to mobileclinics and teams to provide certain services.Transportation of the individual to certain facilities not suitable fordevelopment in rural areas must be provide'; e.g., physical therapy as a basicservice is not available to those in rural areas.

25. Rehabilitation services should be considered for age groupsfrom in- fancy on up. There should be no overlapping of service fromother agencies; however, there are some handicapping conditionswhere no services are rendered.

26. There are no services available for the mildlybrain-damaged child who has difficulty with the learning process(audio or visual perception difficulties).Educational opportunities are desperately needed for these children. Those who are more severely involved should be considered for Vocational Rehabilitation as they are generallythe school dropout.

27. Vocational Rehabilitation should be extended to those who are vocationally handicapped due to social circumstances.Specific groups are mothers receiving Aid to Dependent Children and juveniledelinquents.

28. A system for appeal by patients whohave been turned down by their own family doctor, or for those where aweak recommendation was made, should be set up. Many patients have lostout on a satisfactory rehabilitation program for this reason. Planning Region 5

Region 5 consistsof

Phillips, Valley,Daniels,

Sheridan, Roosevelt,McCone,

Richland, Dawson,Prairie,

Wibaux, Garfield,Rose-

bud, Custer, Fallon,

Powder River, andCarter

Counties.

This Region islargely

a plains areawith generally

good travel routes. East-west

highways includeInterstate 90 and 0 CART Eft U.S. routes 2 and12. North-south travel, POWDER RivER

is over in the northernpart of the Region,

In the State routes247, 13, 16, and24.

southern part of theRegion, north-southtravel

and State routes is over U.S.routes 212 and 312 and Carter Countieshave no commoncarriers. 7 and 22. Garfield, Powder River, beet production, Principal industries areagriculture, livestock, sugar

sugar refining,and oil production. Glasgow are the largercities. Miles City,Glendive, Sidney, and

City and Glendive. Junior colleges arelocated at Miles

c.,,,:.re229 Region 5 had a population of105,57619 in 1960, and is projected to 104,85020in 1970. It contains 46,973 square miles ofland area, with a population density. of 2.2 persons per squaremile. In 1960, there were 54,736 males and50,840 females, with 43,340 persons under18 years of age, and 12,086 over65.

In 1960; the median family income was$4,804, and median education of those over 25 was10.6 years. In April of 1968, there were 25.5 welfare recipients per thousand ofpopulation.21 Therewere 15.7 persons

Per thousandidentified in the statewide survey aspotential rehabilitation cases. Reported work injuries were 1.9 perthousand of total popula- 22 , 1n44 Kr7

Region 5 has no available facilities, asutilized and designated by the Tvivisirm ^f VocationalRehabilitation Workshops and Facilities

Project.This lack is typical of the shortage ofall services in this vast area. The Division of VocationalRehabilitation had a total of182 clients in this Region during the fiscal year1967-68.

The services provided clients bytha Division of Vocational Rehabili- tation and the Division of Blind Services canbe expected to show an increase, as within the past yearboth agencies have establishedfield offices in Miles

City. The means with which the counselorsmust effect rehabilitation will continue to be limited until resourcesand facilities, commensuratewith what is available elsewhere inMbntana, are developed.

19Public Health Service, Chronic... 2. cit.

20Department of Planning and EconomicDevelopment, Montana Statistical cit. 21 Source:Montana Department of Public Welfare.

22Source:Mbntana Industrial AccidentBoard.

230 TABLE 53. CHRONIC CONDITIONS AND ACTIVITY LIMMTATIONS 196o - REGION 5 in amountLimitedor kind Unable tocarry onmajor Total in amountLimitedor kind Unable to carry onmajor 1970 Total all forms ofactivity major 5 activity 26 ofactivity major activity TuberclarsisAsthma-haMaliBenign ',11e.nt, and neofever unsvenified ,:l ;Isms neo lasms 322 70 10 .11 101118 82 5 _____13 , _...... ia___ loo 81 HeartNentalHypertension conditions andabetes nervous without conditions heart 1 1 1.1 0 fiS72 ( 8 486 6 246_9P10 2424 2 Varicose veinsinvolvement 17.1448 2. IIIM 213580 0 8 82 1 680 etherHemorrhoids conditionssystem of circulatory '8 ,a61 12. 136 2. 8 125211 Chronic bronchitissinusitis and 18 5 244 MIMEi 18 55 242 6 pOther ptic conditionsulcers stem of respiratory .....------...... 166140 . 82 222 I1 16 81 230220 _systemCtherHernia conditions of digestive 210322 _70 6 2802 I 20' .9 277 Arthritis(tilerc"d1112112SLE2112141112.31!ntem diseases andand rheumatism joints of muscles, bones, 1,1 3 3 401144 1 -480466 '1 12 1 0 1 6 0 1 503 44. 6 VisualImpairmentsParalysisHearing impairments impairwents ,except paralysis ) comleLp or partial of ____3o1 ...... _122 18911 _313 ...ga_ 108 53 -1 11 1:729911;257 107 0 437225609309 Impairmentsbackabsence)ofshoulders or s ine upper extremitiesexcept paralysisand and 126609 2894 154703 I 125604 2893 1536 i Impairments wil1112§aosence)(excert. paralysis cf lower extromities TOTAL - ESTIMATED ALL DISABILITIES and 420 3. ja569 11.463 417 i148 11,070 565 Major Characteristics of the1662 Disabled Identified By the Community Survey Region 5

The survey showed that39% of those identified as disabled were gpmaJe and 59% were male. There were 62% identified assingle.

By race, 78% were Caucasianand 15% were Indian.By age, 39% were under18, 23% were in the 21-45 age group, and31% were over 45

In the larger categoriesof disability, 29% were mentallyretarded,

13% orthopedic, 12% had cardiacconditions, and 12% had speechimpairments.

The agencies reporting thelargest numbers were Welfare,29%, and the schools, 25%. The work status of thosereported was as follows:

59% had never worked, 59% were felt to have adefinite barrier to employment, and only 5%ligere reported asworking n111-tiMe.

Of the total number identifiedin the survey, 16% werefrom this

Region.

Physicians

The Physicians Survey showsthat of 68 physicians in Region5,

45 responded to the questionnaire.By category, they weregrouped as

3 pediatricians, 3 oph- follows:28 general practitioners, 5 surgeons,

thalmologists, 3 internal medicine,2 obstetricians, and Ipsychiatrist.

These physicians were askedwhat additional rehabilitationservices

they listed vere most neededin their communities. in order of priority,

physical therapy as the most neededservice, occupational therapy asthe

second most needed service, and apsychiatric social worker as thethird

most needed.

232 In order to find out how often they sent clients to the rehabili-

tation services, they were asked about referrals in the past year. Of

these physicians, 33.3% had made no referrals in that period,28.9 had

referred one to three persons,; 24.4% between four and six, and13.3%

more than six.

Of the reporting physicians, 82.2% wanted to be informed by the

rehabilitation agencies as to action taken in the cases they referred.

When asked to estimate the success of the rehabilitation agencies

in rehabilitating their patients to a productive place in society,2.2%

felt the success was excellent, 26.7% said it was good, 15.6% said it was fair, 6.7% said it was poor,37.8% were unable to evaluate, and

8.9% did not respond.

Physicians' opinions concerning the rehabilitation feasibility

for certain special groups were as follows:

TABLE 54.PERCENTAGES OF PHYSICIANS INDICATING REHABILITATION POTENTIAL OF SPECIAL GROUPS - REGION 5

Cam- Un- Group Partly Seldom Never DR pletely certain

Habitual Criminal 6.7% 4.4% 13.3% 53.3% 13.3% 8.9%

Delinquent 6.7% 28.9% 53.3% 4.4% 2.2% 4.4%

Mental Retardation 4.4(1 - 68.9% 13.3% 4./4 8.9%

Mental Illness 4.4% 2.2% 82.2% 6.7% - 4.4%

Drug Addiction 6.7% 17.8% 31.1% 40.0% 2.2% 2.2%

Alcoholism 4.4% 17.8% 53.3% 22.2% - 2.2%

233 In giving ani opinion concerningdevelopment of the rehabilitation

agencies,48.9%of the physicians said the agencies shouldexpand ser-

vices,8.9%recommended the present status,28.9%had no recommendation,

and13.3%did not respond.

Nurses

In Region5, 56nurses responded to the surveyquestionnaire, which was 11.4% of the totalresponding statewide.Of these nurses,67.9%were

employed full-time,26.8%part-time,and 5.4%were not employed.When

questioned concerning experience,7.1% replied that they had been employed

1 to3years,5.4%from4- to 6 years, 5.4%from 7 to 9 years, 1.8% from

10 to 12 years,and 80.4%over 12 years.

Of the respondents,48.2%were natives of Montana.

When asked to estate the number of patients theyhad worked idth in the past yearwho couldhave benefited from rehabilitation services, the nurses replied as follows:25.0% none, 32.1% between 1 and 5, 10.7% between6and 10,8.9%over 20, and23.2% did not respond.

The nurses were asked toidentifyfactors responsible for many disabled notreceiving services: 28.8%said lack ofknowledge aboutservices,

14.4%said cost of effort necessary to receive services,33.1%said services were inadequate or not available, and23.7% blamed apathy on the part of the client or his family.

234 Professionals

In Region 5, 51 educators andother professionals whose work is re-

lated to rehabilitation responded to thequestionnaire. Native Montanans

accounted for 40.0% of the educators and60.6% of other professionals.

TABLE 55. EDUCATIONAL LEVEL OF RESPONDENTS PROFESSIONAL SURVEY - REGION 5

Some High Some BA Grad- MA PHD NR School College sate

Other Professional 3.8% 23.1% 34.6%15.4% '23.173 - _

School Personnel - - 18.8%28.1%53.14 -

This group was questioned as to the effectof disability on the work activity of their clients. By broad numerical categories, theyestimated how :many were out of work or restricted inwork activity. Of the respondents other than educators, 24.2% reported 0-9 clients,15.2% said 10-19 clients,

3.0% said 20-29, 12.1% said 30-39 clients,12.1% said over 50, and 33.3% did not respond.

School personnel replied to this samequestion in a manner reflecting the age of their pupils: 45.0% said 0-9 of their disabled students were restricted from work, 2.5% said 10-19,5.0% said 50 or over, and 47.5% did not respond.

Professionals, other than school personnel,felt that many disabled were not receivingservices for the following reasons: 37.5% said lack of knowledge about the services,10.4 said cost of effort necessary to get services, 31.3% said services wereinadequate or not available, and20.8% blamed apathy on the part of the client orhis family.

235 School personnel responded as follows:36.4% said lack of know-

leuge about the services,9.1% said cost of effort necessary to receive

services, 27.5% said services were inadequate ornot available, and 25.0%

blamed apathy on the part of the client or hisfamily.

TABLE 56. PERCENTAGES OF PROFESSIONALS AND SCHOOLPERSONNEL MAKING REFERRALS TO DVR AND DBS - REGION 5

Division of Blind Services

None 1-5 6-10 11-20 NR

Professional 24.2% 33.3. 3.0% 3.O 36.1

School Personnel 57.5% 12.5% - - 30.0e,

Division of Vocational Rehabilitation

Professional 21.2% 27.3% 9.1% 15.2% 27.3%

School Personnel 35.0 45.0% - - 20.0%

TABLE 57. ESTIMATES OF VOCATIONAL REHABILITATION SUCCESS PROFESSIONAL SURVEY - REGION 5

Don't Good Fair Poor NR Know

Professional 38.1% 28.8% 19.0% 4.8% 9.5%

School 20.0% 10.0% 13.3% 36.7% 20.0%

IIIIII61101111.01111111s1.1111MIL

TABLE 58. REASONS FOR NON-REFERRAL TO VOCATIONALREHABILITATION PROFESSIONAL SURVEY - REGION 5

--1 Age Age No Not No below over suitable familiar barriers VR labor referral with to Other NR eligi- market system agency employ- bility ment

Professional 23.5% 5.9% 17.7% - 11.8% .1.2% -

School 36.1% - 2.8% 13.9% 33.3% 13.9% - t...... ,...... _.

236 RECOMMENDATIONS - REGION 5

1. It is recommended that smaller VocationalRehabilitation Districts be created to provide better service.

2. Comprehensive physical and occupational therapy is neededin this region. These services could be provided on a mobile basisin the sparsely populated areas.

3. Speech and hearing therapy should be expanded toinclude all areas of the state.At the present time, some communities do havethis service either through the Elks Speech and HearingClinic or in their local schools, but there are a good many areas which arenot covered. The people in these areas not covered must travelgreat distances to receive this type of service.

4. Education programs should be instituted for childrenconcerning the use of alcohol and drugs, glue sniffing,smoking, gas sniffing, and similar dangerous practices.

5. Existing services in the state should bebetter coordinated in order to provide closer working relationshipsand reduce duplication of services.

6. Vocational training should be available to thementally retarded after completion of special education classes.

7. Area trade schools are needed as an aid tovocational rehabilitation.

8. Some type of work-experience training should beimplemented in the schools for the mildly retarded. Such training could be part of the special education classes.

9. There is a need for alcoholic treatmentcenters, set up on a halfway house basis.

10. Halfway houses should be established fordischargees of the mental institutions, dried-out alcoholics, and convictsdischarged from Deer Lodge.

11. There is a need for foster home care for many ofthe patients discharged from Warm Springs.

12. The Division of VocationalRehabilitation and the Division of Blind Services should have additional staffto adequately cover the large, sparsely populated areas of thestate.

should 13. Case service monies of thevocational rehabilitation agencies be increased in order thatadditional federal monies be procuredfor the disabled in Montana. BouJqr.r- Rive.r School or VocationalRehabilitation and the lh. Th>> Divi::len prngrams such be encouraged tocontinue and expand and Horpita3 sh-,uld bringing the now functioning. The benefits of as the summer program adjustment and voca- retaraed to theSchool for anintensive program of tional evaluation arerecognized. should be encouragedto extend 15. The Division ofVocational Rehabilitation services to thoseless than16 years of age. needed to Qualifythose who need 16. A broader definitionof disability is but who do not have aclearly definedphysical rehabilitation services handicaps should bein- or emotionaldisability. Social and cultural eluded as disablingconditions. Hills nature is essentialfor those at thePine 17. Training of a vocational School. disabled is essentialif rehabilitationis 18. A trade schoolusable by the to occur. would help to meetthe vocationalneeds 19. Cooperative wwork-study programs between children within theschools. Cooperative programs of exceptional the schools, groups such asthe Division ofVocational Rehabilitation, be considered. iand NeighborhoodYouth Corps should of the basicrehabilitation Consideration should begiven to provision 20. Mobile teams or othermeans should therapies to personsin rural areas. physical, speech, andoccupational be considered andshould include therapy. services of thosewith 21. Early detection andreferral to professional is to be encouraged. disabling conditionsis necessary and of the disabled asgood workers 22, Programs to encourageemployer acceptance are needed. available to Many persons in this areaare not awareof the services 23. take necessarysteps to them, and VocationalRehabilitation should correct this situation.

and follow -upservices in There is a need forpsychological counseling 24. adjustment foralcoholics. the community forsocial and vocational

Commission and otherswho determineeconomic planning 25. The State Planning consider Montanafor factories. should encouragelight industries to motivated personsshould be The feasibility ofemploying well-trained, prominent in suchplanning.

238 26. There is a need for the schools and theState Department of Public Instruction to provide suitableeducational programs and services for the emotionally disturbed child. The programs in existence for the retarded do not meet the spE.Aalneeds of this group.

27. There is a need for psychiatric socialworkers in this District.

28. The schools should be encouraged toextend counseling through emplo- ment r,f trained persons, thesepeople to work at the elementary school level.

239 CHAPitit VII

REHABILITATION FACILITIES

The rehabilitation of disabled persons can be accomplished through

the use of many services selected to meet the particular needs of the

individual. These services need not be administratively under the same

agency to be effective, if they are coordinated in theindividual's total

rehabilitation program.

There are other services, however, which because of their complexity and nature should be provided within one physical setting or facility. Such

services, while of benefit to all disabled, are absolutely essential for the rehabilitation of the severely or multiple handicapped child or adult. For the purposes of this plan a rehabilitation facility is defined as:

...a facility, operated for the primary purposeof assisting in the rehabilitation of handicapped individuals, (1) which provides one or more of the following types of services: testing, fitting, or training in the use of prosthetic devices; prevoca- tional or conditioning therapy; physical or occupational therapy, adjustment training; evaluation, treatment, or control of special disabilities; or (2) through which is provided an integrated program of medical, psychological, social, and vocational evaluation and services under competent professional supervision, provided that the major portion of such evaluation and services is furnished within the facility, and that all medical and related health services are prescribed by, or are under the formal supervision of, persons licensed to practice medicine or surgery in the state.1

1Title 45 - Public Welfare Act, Chapter IV, Section 401.1(R), Vocational Rehabilitation Administration, United States Department of Health, Education, and Welfare.

...yyd/ 241 This broad definition includes,then, isolated servicesprovided by public or private agencies orindividuals of a medical, treatment,therapeutic, or evaluative nature,which are available to thehandicapped. These

services, while essential, are outsidethe scope of this Chapter, but were listed in the Statewide PlanningDirectory of Rehabilitation Servicesand

Facilities in Montana. Primary attention is given to those programsincluded

in part (2) of the definition.Specific facilities of concern are:

1.Rehabilitation and Treatment centers.

2.Halfway Houses.

3. Sheltered Workshops.

2 A special sub-committee of theGovernor's Policy Boardwas formed

jointly with the Workshop and FacilitiesProject of the Division ofVoca-

tional Rehabilitation to:

1. Determine what facilities, as definedabove, exist in Montana.

2. Determine the adequacy- of presentfacilities in meeting the needs of the disabled.

3. Develop recommendations forfacilities to meet the needs on an interim and long-rangebasis.

4. Suggest methods of implementing therecommendations by public, private, or acombination of agencies.

5. Establish priorities for thedevelopment of facilities.

2Refer to Appendix B.

242 Consultants were utilized by the committee in the areasof sheltered

workshops and halfway houses. A committee of thistype should be a permanent

advisory ce;omi ttee. The development of facilities should be on aregional basis wherever appropriate. A proliferationof facilities that cannot be

adequately supported must be avoided.

RECOMMENDATION 1

ALL REHABILITATION FACILITY PLANNING INMONTANA SHOULD INCLUDE TEE CONCEPT

OF INTERMEDIATE FACILITIES, HEREINAFTER REFERREDTO AS THE BASE - SATELLITE

SYSTEM.

COMMENTS:

The concept of a network of inter-related butautonomous facilities has been suggested as a method of overcomingthe many problems that are

inherent in the delivery of specialized and expensiveservices to a widely

dispersed population. The Facilities Committee vas acutely awareof the problems unique to a predominantly rural state. Further, the dearth of

existing facilities offers a unique opportunityfor the coordinated development of facilities, if cooperation can beelicited from the many groups, public and private, having interests in programdevelopment.

Facilities, be they rehabilitation centers or workshops,must be planned to receive the maximum benefits of thefinancial resources and personnel available in a particular geographic area.Patterns of transportation must be considered if those to be served areto benefit from

243 each facility programs. It is unrealistic andultimately self-defeating for community to independentlyplan and develop thespecialized facilities needed by the handicapped. which a large The base - satellite conceptthen offers a method through facility, well financed andstaffed, would provide acomprehensive program and consultant services as anintegral part of its function. The satellite units would be developed inselected outlying communities asthe ne7ids of disabled demand, and would have aformal, cooperative relationshipwith the

in the base unit.It is recognized that thisconcept offers great promise workshops. Selected area of rehabilitationin treatment centers and sheltered aspects of the concept can alsobe applied to halfway housedevelopment.

The basic unifying force wouldbe the voluntary agreementwhich could delineate relationships in itsvarious administrative andfunctional aspects.

and private facil- This type of relationship wouldenable the existing public of mutually ities to voluntarily participatein the network on the basis organization to accepted procedures andobjectives. This would enable each maintain the autonomy of itsboard, special projects,fund raising, and other

duplication of programs, allow activities. If implemented, it should reduce sharing of specialists, and wouldhelp to insure continuityof services at a high level.

Aspects which should be includedin the base-satelliteconcept are:

1. Complete reciprocity of referralsbased on a determination of which facilities can bestmeet the needs of theclient.

2. Representative governing boardcomposed of members of each participating unit. This would also permit jointboard orientation.

244 basis, and 3. Exchange and utilizationof staff on consultant centralized training for allstaff.

4. In the case of workshops,transfer of contracts on a sub.. contract basis.

of local boards in policy 5. Complete organizational autonomy matters, board selection, etc.

the 6. Agreement as to the coreservices to be .nrovided at base unit, the nature andextent of services to be provided by the satellite,subject to review and appeal,and the consideration of long-rangeplans to eliminate duplication.

7. Other coordinating activities asneeds arise.

8. Development wherever feasibleshould be in accordance with the five Regionsutilized by Statewide Planning, Mental Retardation, andMental Health.

Committee that if this It was the unanimousopinion of the Facilities concept is to be effective inthe coordinated developmentof facilities in

Montana, the public agencieswhich will assist in fundingand in providing Rehabilitation and on-going support(particularly the Division of Vocational those private the Division of BlindServices) will provide such support to with this concept and public groups which arewilling to associate themselves exemplified in this report. and the overall philosophyof rehabilitation as

Rehabilitation and Treatment Centers

Rehabilitation centers weredeveloped to provide a meansof organizing for the treatment and services into acomprehensive and integrated program patterns of centers can disabled individual.The organization and staffing combination of and do vary, and they mayhave a medical, vocational, or orientations. A commonly accepteddefinition, and one used bythe Conference

Department of Health, of Rehabilitation Centers andby the United States

245 Education, and Welfare follows: "A Rehabilitation Center is a facility in which there is a concentration of services, including at least oneeach from the medical, psycho-social, and vocational areas, which arefurnished according to the need, are intensive and substantial in nature,and which are integrated with each other and withother services in the community to u3 Provide a unified evaluation and rehabilitation serviceto disabled people.

This administrative definition does not emphasize one ofthe most important characteristics of a rehabilitation center, whichis the manner in which the concept of rehabilitation is made anintegral part of the daily operations and functions of the facility.

The perspective of staff in viewing the patient is alsoof considerable importance. The concept of rehabilitation that the whole personmust be treated, but with recognition of individual problems andneeds, must be inculcated in all staff to avoid segmentation of serviceswithin the facility.

The differentiation between rehabilitation centersand treatment centers is primarily in terms of range of servicesoffered. Treatment centers frequently have only one or two therapies, do not have amedical director, and accept physician referrals only. They tend to be limited to orthopedic cases and are limited to out-patient care.They can, with change, develop into comprehensive centers.

Redkey in the "Planning of RehabilitationCenters" identifies three kinds of centers - medical, vocational, andcomprehensive, which offer components of both the medical and vocational. He goes on to discuss seven types of centers found in the United States, and concludes withthe observation

3Redkey, H., Selected Papers, National. Conference of Rehabilitation Centers, Second Annual isea , October, 1953, p. 10.

246 that while they can differgreatly in scope, setting,emphasis, and function,

they are all rehabilitationcenters, and should be developedto meet the particular needs of the disabledin eacharea.4

The existing facilities commonlyconsidered to constitute rehabili-

tation or treatment centersin Montana are identified bythe Workshop and

Facilities Project of the Divisionof Vocational Rehabilitation as:

Billings - Montana Center forHandicapped Children

Helena - Shodair CrippledChildren's Hospital

Great Falls - Montana EasterSeal Rehabilitation Center

Center Missoula - Missoula CrippledChildren and Adult Rehabilitation

These centers are being utilizedwhenever possible by theDivision of

centers in other Vocational Rehabilitation, whichalso uses rehabilitation

states.

Centers utilized in the pastfive years include:

Elks Rehabilitation Center,Boise, Idaho

Craig Rehabilitation Center,Denver, Colorado

Gottsche RehabilitationCenter, Thermopolis, Wyoming

Woodrow Wilson RehabilitationCenter, Fisherville, WestVirginia

Arkansas Hot Springs RehabilitationCenter, Hot Springs, Arkansas

Minneapolis Rehabilitation Center,Minneapolis, Minnesota

Rancho Los Amigos, Downey,California

Northwest Regional RehabilitationCenter for the Blind,Seattle,

Washington

4Redkey, H., The Planning of Rehabilitation Centers,Papers Presented February 25 - March 1, at the Institute onRehabilitation Center Planning, 1957, Chicago, Illinois, pp.37-38.

247 Regional Rehabilitation Center, MinneapolisSociety for the Blind,

Minneapolis, Minnesota

University Hospital, Seattle, Washington

RECOMMENDATION 2

IT A COMPREHENSIVE REHABILITATIONCENIAR SHOULD BE DEVELOPED IN MONTANA.

SHOULD BE IN AN AREA WITH AN ADEQUATEMEDICAL COMMUNITY, SHOULD BE SUPPORTIVE

OF TREATMENT CENTERS IN ACCORDANCE WITHTIE BASE-SATELLITE CONCEPT, AND

SHOULD SERVE MULTIPLE DISABILITIES,INCLUDING THOSE WHO ARE VISUALLY IMPAIRED,

FROM ALL ONfish TIE STATE AND SURROUNDINGAREAS, AND SHOULD FUNCTION IN COOPERA-

TION WITH A UNIVERSITY.

COMMENTS:

The services of a rehabilitation center canbe of benefit to many disabled who do not have access to aconcentration of services.Any community

or agency undertaking thedevelopment of such facilities should becognizant of the fact that many of the patients will bethose with difficult medical problems, will be poorly motivated, andwill have a variety of problemswhich must be carefully handled. Those with lesser problems are oftennot candidates

for such a facility, or they can be cared for moreexpeditiously and economically in a hospital or elsewhere.

The Vocational Rehabilitation agency, aswell as other public agencies, has many clients who require the servicesof such a center; however, costsand

other factors make prohibitive to send all those needingsuch services to

an out-of-state facility.A study reported that one of thelargest unmet needs

248 of vocational rehabilitation was for rehabilitation services in the psycho.

5 social and vocational area.

Services appropriately included in a comprehensive rehabilitation

center program include thefollowing:6

CHARACTEKISTICS OF 65 REHABILITATION CENTERS

Medical (All 65 offered at least 1 medical service) OfferinLService

Physical and medical evaluation 87.7% Medical consultation 87.7% Psychiatric screening 43.1% Medical supervision 89.2% Physical therapy 96.9% Occupational therapy 93.8% Speech therapy 67.7% Audiological service 47.7% Recreational therapy 50.8% Psychiatric treatment 29.2% Nursing 55.5% Prosthetics 61.5%

Psychological (60 offered at least 1 psychological service)

Psychological evaluation 93.8% Personal adjustment counseling 8o,o% Group therapy 31.7%

Social (60 offered at least 1 social service)

Social evaluation 93.3% Social casework 88.3% Social group work 21.7% Recreation - non-medical 53.3% Vocational (61 offered at least 1 vocational service) Vocational evaluation 90.2% Vocational counseling 86.9% Pre-vocational experience 78.7% Special education. 36.1% Vocational training 37.7% Sheltered employment 29.5% Placement 62.3% Travel training (blind) 8.2%

5Redkey, H., Rehabilitation Centers Todza- A Report on the aerations of 77 Centers in the United States and Canada, pp. 22-23, Office of Vocational Rehabia itation and Secretary, Conference of Rehabilitation Centers, Department of Health, Education, and Welfare. 6 Ibid., pp. 37-57.

249 That few centers, even thoseconsidered to be comprehensive, are able to offer all services isindicated by an in-depth study of tenin-patient and out-patient centers. All ten centers had physical therapy,speech therapy, and occupational therapy departments.Nine centers had social service departments, eight had vocationalevaluation, seven had both psychological services and vocational counseling.Six centers had departments of medicine, six had workshops and all of thein-patient facilities, five, had nursing services, two provided recreation,two had vocational training, one 7 had group work, and one had dormitoryfacilities.

If a center in Montana offered a strong programin the major areas of services, it should prove adequate in meetingthe needs of the disabled, particularly if supportive treatment centers werestrategically located within each region. Treatment centers should be in-patient aswell as out-patient whenever possible.

If required in the highly rural, sparselypopulated areas of the state, mobile evaluative and treatment teams couldoperate from the treatment centers as a method of receivingreferrals, making initial assessments,and providing limited treatment of a therapeutic naturein outlying areas.

alfm1129122

Facilities that provide board and room, in asetting oriented to personal adjustment, are often required as atransitional step of the disabled person in his movementfrom a sheltered institutional environmentto complete social and economic independence in the caamunity. In the first category would be persons institutionalized because of mentalretardation, mental illness

7Mott, B. J. F., Financla and aerating Rehabilitation Centers and and Adults, Inc. Facilities, pp. 45-54, National Societyfor Crippled Children

250 penal offenses, or similar reasons. The second group includes alcoholics in the community; however, a facility for this group has greatertreatment orientation than that required by those in the first group who are presumed to have received treatment prior to coming to the house. The period of residence of the individual varies according to his needs and therapidity with which he is able to be assimilated back into the community. In any event, residence should be considered temporary if the transmittal character of the facility is to be maintained.

The concept of halfway houses in the United States is a relatively new one, and no clearly defined role or functionhas yet been ascribed to them, except in very general terms. Most have been established to meet the needs of a particular group such as alcoholics, mentally ill, andex-convicts, and therefore their operation and philosophy reflects a bias toward that group.

The New Horizon Halfway House in Helena is the first suchfacility in the state and has accomodations for 15 male alcoholics. It is currently being supported by the Division of Vocational Rehabilitation.As the program is very new, additional services are being considered.

The number of residents is generally small, approximately 15, in order to maintain a homey atmosphere. A notable exception is the 512 Fellowship in California which accomodates 500 persons in four hotels. The residents themselves contribute labor to maintain the household, and therefore the staff required is minimal. Access to professionally trained persons such as physicians, psychiatrists, psychologists, social workers, and vocational counselors is desirable to provide services of treatment, adjustment, and employment assistance to the residents.

251 Planning is a primary consideration asthe residents are not normally

able to provide their expenses initially, andonly to a limited degree later

as they become employed.

The active, interested support andacceptance of the community is

paramount to the success of such facilities.

The goals of halfway houses,socialization and vocational adjustment

of those whose disability and treatmentrequire a slow reintegration into

society, are important in successfulrehabilitation. A study of Rutland

Corner House, a facility for women with psychiatricproblems, demonstrates

the role of such facilities in rehabilitation. This facility, which has been in existence since 1877, has pioneeredthese transitional programs for mentally ill women and accepts predominantly those whohave received a high

degree of therapeutic effort.The median stay of the women studied wasfour months. Employment has been a major concern of thefacility, so its effectiveness in that area can be assessed. Of the 48 women studied, 32 had worked at some time since leaving the house.Another basis of evaluation used was the performance of the womenin the community. Thirty-five percent had been readmitted to the hospital at sometime since leaving the house, but were again living in thecommunity.Thirteen percent were in the hospital, 8 4% were in day hospital, and 48% had never been readmitted.

The Vermont State Hospital and VermontVocational Rehabilitation have long sponsored halfway houses,(with considerable success), for released mental patients.

8 Landy, D. and Greenblatt, M., HalfwayHouse - A Sociocultural and Clinical Ludy of Rutland Corner House, a TransitionalAftercare Residence for Female Psychiatric Patients, VocationalRehabilitation Administration, United States Department of Health, Education, andWelfare.

252 Granville House, a transitional house for the addicted woman in

St. Paul, works with both alcoholic and drug-addicted women through a program of post-treatment support.

Halfway house programs for parolees are being operated by the states of Michigan, New York, New Jersey, Oregon, Washington, Maine, Kansas, Vermont, the District of Columbia, and Puerto Rico. Other states, such as California and Illinois, use state funds to subsidize private agencieswho operate halfway houses.

Because of the origins of most houses by single disability groups, most are of that nature. However, the distinction becomes clouded when it is found that individuals with but a single disability are not at all common.

Multiple disability has been reported frequently in rehabilitation. Despite disagreement over the efficiency of mixing disability types, substantiation of the success of both approaches has been reported. It may be that the status of the individual in the treatment program has greater relevancethan the disability evidenced.

The Colorado Division of Vocational Rehabilitation has had a program since 1948, notable in its success for serving mixed disabilities and returning them to employment. The George Williams House in St. Louis, sponsored by the YMCA, mixed delinquents, probationers, and parolees with young people who simply had no place to live while completing their educations,with apparent good results. It is lomewhat incongruous that while halfway houses are a means of establishing contact andintegration with the community and its realities, that within its own confines segregation in terms ofdisability should occur.

253 RECOMMENDATION 3

BE DEVELOPED IN THE IT IS RECOMMENDED THATHALFWAY HOUSE FACILITIES

COMMUNITIES OF MONTANA FOR THOSERELEASED FROM THEINSTITUTIONS WITH RETARDATION, AND DISABILITIES OF MENTAL ILLNESS,PUBLIC OFFENSES, MENTAL MORE THAN ALCOHOLISM. TO DETERMINE ThT FEASIBILITYor FACILITIES SERVING DEMONSTRATION PROJECT ORE DISABILITY GROUP, IT ISRECOMbEND2D THAT A JOINT AND A PRIVATE BE UNDERTAKEN BY THE DIVISIOkiOF VOCATIONAL REHABILITATION

AGENCY FOR THIS PURPOSE.

COMMENTS:

regarding multi A great deal of disagreementis obvious in the field that it is better versus singledisability facilities. It is also recognized than have many ill-planned to develop and supportadeouate facilities, rather

and ill-managed enterprisesdie from lack of communitysupport.

Multi-disability facilities have beendemonstrated to offer advantages

be in other facilities of arehabilitative nature.A determination should

made regarding this inrelation to halfway houses.

RECOMMENDATION 4

INTERESTED IN DirTERENT IT IS RECOMMENDED THATCOORDINATION BETWEEN GROUPS AREAS OF RESPONSI- DISABILITIES BE ENCOURAGED FOR THEPURPOSE OF DELIMATING

BILITY AND TO PROMOTE `f'-{ESHARING OF STAFF, IF FEASIBLE.

COMMENTS:

The large number ofdisability groups able tobenefit from halfway

house facilities could, ifcoordination and cooperation isnot now exercised,

254 result in the establishment incertain communities of several single disability houses. Consideration must be given first to the disabledand his needs, but with the realization thatof all facilities; halfway houses by their very nature are dependent uponcommunity understanding and support.

Sheltered .11211i2h22E

"Since World War II, the sheltered workshop has emerged as astrong and unique element in the rapidly expandingnetwork of specialized rehabilitation services. There has been a slow but steady movement awayfrom the early concept of the workshop as acustodial care institution and a recognition that the proper workshop objectiveis the preparation of disabled

119 individuals for competitive employment and a regularearned wage. A definition of a workshop, adopted by the NationalAssociation of Sheltered Workshops and Homebound Programs, is as follows: "A sheltered workshop is a work-oriented rehabilitation facility, with a controlled workingenvironment and individual vocational goals, which utilizes workexperience and related services for assisting the handicapped person to progresstoward normal living and a pro-

If1 0 ductive vocational status.

A further distinction can be made whendiscussing workshop function.

The transitional workshops and the terminal orextended employment facility, each have a place in any comprehensiverehabilitation service. Each has been developed to facilitate two general groups ofdisabled: those capable of benefiting from intensive training and whoultimately will be placed in

IIIMIIIM1111111/11.

9National Association of Sheltered Workshops and Homebound Programs, Sheltered Workshops - a Handbook, p, 1.

10Ibid.

255 competitive empl:Iyment in thecommunity, awl tnose whc benefitfrom the workshop exnerience but oho, becauseof other factors, cannotbe expected

of client to compete in the labor market.Workshops accomodating both types are becomingwidespread.

The primary Purpose of workshopsbeing the preparation ofthe individual for e=loyment throughthe provision of workrelated experiences

to that end and not and training, it becomesmandatory that the emphasis be that of a school, hospital,rehabilitation center, or activitycenter. crucial fac- As in the planning and developmentof any facility, many tors must be assessed prior to programdevelopment. Paramount considerations with regard to workshops arethe assessment of need forthe facility within board. A determination a community; andselection of a strong, representative of the nature of the community, asit is related to the facilityin terms of support, is the availabilityof employment for thoseplaced from the shop. and also The type of suitable work that canbe procured from the community, must all be de- the type of training and thenature of supportive services, the workshop cided. It must be accepted early inthe planning that while will adhere to sound businesspractices, it is committed toserving severely disabled people.A reasonable subsidy ordeficit should be looked upon as the legitimate cost to thecommunity for a service it hasdecided to provide for the handicapped members ofitspopulation.11

Sheltered workshops can providesubstantial benefits to manypeople

patient, it is useful disabled by all conditions. In the case of the cardiac

placement assist- to observe work potential, measuretolerance, and to provide ance in the communityin an appropriate worksetting. The aged population

11 Ibid., p. 10.

256 is increasingly the beneficiary of suchprograms. The blind, for whom the

first workshop was formed in the 19th century,derive considerable assistance

from workshops. A study of 132 workshopswas reported by Suazo. These work-

shops, numbering 13,197 clients, served thefollowing genera" disabilities:

Physical disabilities (exclusive of visually impaired) !12%,mentally retarded

21%, emotionally disturbed 13%,disabled aged 10%, visually handicapped 8%,

and socially handicapped 6%. When it is realized that the vocationalrehabili-

tation agencies constitute the largest singlereferral source of the workshops

studied, 34%, it becomes apparent that workshopsare a significant tool in 12 the rehabilitation of the severely disabled.

Existing facilities that are considered to beworkshops are located in

only two cities in Montana, and neither offersthe range of services required

to adequately meet the needs of the disabled.Mbntana desperately requires

at least one workshop offering complete vocationalevaluation services to the

disabled.

The two existing Nbntana facilitiesare:

Butte Butte Sheltered Workshop

Billings Handicapped, Inc.

Out-of-state workshops utilized by Vocational Rehabilitationand the

Division of Blind Services include:

Goodwill Industries, Spokane, Tacoma, and Denver

Laradon Hall, Denver

Opportunity Workshop, Minneapolis

12 Suazo, A.C., "Sheltered Workshops and Planning," Estimating. Rehabilitation Needs- A Conference on Plannin5 for Vocational Rehabilitation, PP- 97-100.

257 RECO:INTIMATION 5

MONTANA MUST DEVELOP MULTI-DISABILITYWORKSHOPS ON THE BASE SATELLITECONCEPT

AND THE FACILITIES SHOULD BE SOSITUATED AS TO BE READILYACCESSIBLE TO THE

DISABLED IN THE STATE.STANDARDS OF PROGRAMS SHOULDCONFORM WITH THOSE

SUGGESTED BY THE NATIONAL INSTITUTE ONWORKSHOP STANDARDS AS SETFORTH IN

THE HANDBOOK OFD NATIONALASSOCIATION OF SHELTERED WORKSHOPSAND HOME-

BOUND PROGRAMS.

COMMENTS:

The Workshop and FacilitiesCommittee, and the consultantsutilized by the Committee, were unanimousin agreeing that in Montanait would be unwise and ultimately of little realvalue to the disabled ifspontaneous and

independent development of such facilities occurin the state.Workshops must be developed on a sound basisif the workshop movement is tobe advanced

in the state.The industrial base of the state,the funds available, the

sparse population,and the lack of trained staff allbespeak the necessity

of coordinated development on thebasis of multi-disabilityfacilities.

That the multi-disability approachhas greater advantages thansingle

disability facilities has been establishedpositively. A special project sub-

stantiated what has been empiricallydemonstrated by many workshops. Conclu-

sions of the project included: (a) that the severely disabled and mentally

handicapped are not fundamentallydifferent from other individuals,and that

(b) the such individuals with suitabletraining can become employable, and

mentally retarded, emotionallydisturbed, and the physicallyhandicapped can 13 work side by side. m11. for Persons 13Opportunity Center, Inc.;Occulational Adjustment Center With Mental Retardation, Emotional,=Ind t er Physical Disabilities,WiJming- ton, Delaware. 2,58 Kenneth Pohlman offers several advantages ip a multipledisability approach which has particular relevancy for Montana. The multiple disability shop as compared to the single disability facility draws upon alarger population, has an opportunity for greater social service, and promotes agreater 14 desire for higher level services as a result. Wilkerson agrees with this and further states that a single disability workshop is notfeasible except in the largest cities; even then it is probably not desirable becausethe objective is to provide the widest possible variety of workand service

9 opportunities.-1-

The base-satellite concept applied to workshops being consideredin

Minnesota on a regionalbasisl6seems to offer advantages whenapplied to

Montana.

The following guidelines are suggested by the FacilitiezCommittee of Vocational Rehabilitation and the Division of Blind Servicesin deter- mining where base workshops should be situated:

1. A network of rehabilitation facilities should be established to serve all types of vocationally handicappedcitizens in Montana.

2. This network should be patterned on a base-satellite concept, and it should be developed to serve multiple disabilities.

3. Communities interested as a base should indicate their ability to meet the following criteria:

a. Concentration of population.

14pohlman, K., Rehabilitation in Cardiac Disease, pp.87-88, Research Conference, Tufts University School of Medicine, November,1967.

15Wilkerson, A. M., "The Sheltered Workshop Movement - Management or Muddlement?", Journal of Rehabilitation, 31:2:20-22, March-April.

1 6Healy,M., Plan for Meetinjg the Long Term Sheltered n lo ent Needs of the Mentally Retarded of Minnesota, Unpublished Report, April,1 5.

259 0. Concentration of industry and business. c. Agencies available for providing supportiveservices. d. Presence of a Division of VocatioLalRehabilitation office (active orplanned). e. Transportation and communicationfacilities.

-P. Available housing. CHAPTER VIII

PROJECT STUDIES

Preface

Understanding and acceptance of the rehabilitation programsof the

Division of Vocational Rehabilitation and the Division ofBlind Services

by physicians, health personnel, educators, social workers,and related

rehabilitation practitioners is essential if maximum utilizationof avail-

able programs is to occur. The attitudes and awareness of those who work with the disabled give an excellent indication of currentand future utiliza-

tion patterns of the many services offered by all thepublic and private

rehabilitation programs. They also provide information to develop professional

and public information programs needed to strengthenservices, and offer direc-

tion to the future development of professional servicesand facilities.

To this end, a survey was conducted ofphysicians, registered nurses,

school counselors and administrators, audiologists,probation officers,

employment counselors, occupational therapists,physical therapists, speech

therapists, psychologists, rehabilitation counselors,social workers, and

special education teachers.

An examinationof disabled individuals not successfullyrehabilitated, )

through the study of case records, was consideredadvisable to determine char-

acteristics of non-rehabilitants with the hopethat program deficiencies could

be corrected.A study of Division of Vocational Rehabilitation casesclosed as

non-rehabilitated in the prior fiscal year wastherefore conducted in January

and February of 1968. Only cases of the Division of VocationalRehabilitation were studied since the number of these cases wasfelt sufficient to give an

indication of general problem areas.

Physicians Survey

The Physicians Survey was developed by the Project staff, in coopera-

tion with the Sociology Department of Montana State University at Bozeman and was pre-tested on ten physicians prior to mailingto all physicians licensed

to practice medicine in Montana. The list utilized was that of the State

Board of Health and included 731 physicians licensed as of August,1967. Each

questionnaire was accompanied by a letter signed by the physician representing

the Montana Medical Association on the Project Policy Board, andincluded a

stamped, self-addressed envelope. One follow-up mailing was made to non- respondents to the first mailing. Preliminary to this survey, official sanc- tion of the project was received through the House of Delegates of theMontana

Medical Association, upon the report and request of Dr. John W.Strizich.1

It was ascertained that 35 of the 731 physicians had moved or no longer resided in Montana, leaving 696 who actually received the questionnaire. There were 431 of the 696 remaining physicians, or61.92% of all physicians licensed and practicing iithin the state, who responded to the survey.

Of the 431 respondents, tabulations were made on only 374 for the following reasons: certain specialities were eliminated, as they have no direct referral relationship to the Division of Vocational Rehabilitation, onthe basis of past experience; specialities eliminated were urologists(7), radiologists (6), and anesthesiologists (7); 37 questionnaires wereincomplete to the degree that tabulation was not feasible.

1See Appendix C.

262 A differentiation was made onthe basis of responsesfrom specialists

alluded to in the comments. and general practitioners,and this distinction is

There were 44.9% of therespondents who were generalpractitioners, and 56.1% who were specialists.

Of the specialists group,12.3% were surgeons, 5.1% werepediatricians,

4.0% were orthopedists, 7.0% wereophthalmologists, 12.3% were ininternal medicine, 7.0% were obstetriciansand gynecologists,3.2% were psychiatrists,

0.5% were 1.6% were neurosurgeons,0.3% were Public Health physicians, thoracic surgeons,0.5% were dermatologists,0.8% were pathologists, and

0.3% were proctologists. number of responses The tabulated informationis presented on the basis of received within the five ProjectRegions, as well as by statewidetotals.

TABLE 59 - PHYSICIANS RESPONSE

Percent Total Number Percent Number inPercent Number in Number of of Total Private in in Non- I REGION in Respond-Respond-Practice Private Non- Private Practice ents ents Respond- PracticePrivate ing

1 157 86 54.7% 83 96.5% 3 3.5% 11 16.6% 2 147 66 44.9% 55 83.3%

78 84.8% 14 15.2% 3 173 92 53.1% 4 4.7% h 151 85 56.3% 81 95.3%

36 80.o% 9 20.0% 5 68 45 66.1%

TOTAL 696 374 53.7% 333 89.E 11.E of the total numberof 696 physi- It might be notedthat on the basis

questionnaire and knownto be residing inthe cians, actuallyreceiving the questionnaire was quiteuniform. Regions indicated,the response to the larger percentage Region 5 is oneexception and showsthat a s'ibstantially On the basis of1960 census figures, of the physiciansin that arearesponded. by Region is asfollows: the ratio of generalpopulation to physicians

Region 1 - 799 to 1

Region 2 - 1004 to 1

Region 3 - 874 to 1

Region 4 - 958 to 1

Region 5 - 1552 to 1

larger geographic area This has meaningwhen the disproportionately that the largerpercentage of Region 5 isconsidered. It could be assumed indication of physicianawareness of responding from thatRegion is some their interest instimulating substantial servicedeficiencies, and reflects is that20.5% of the respondents needed programs.Another possible factor be more responsiveto a were innon-private employment,and this group may personnel to the survey of thistype. The disparity ofother rehabilitation condition in Region 5and poses population needingservices is a general efforts in that largeRegion. great problems inall rehabilitation practice statewideis in federal The largest singletype of non-private

the total of41 physicians in thatcate- employment, whichconstituted 54.1% of

the state accountedfor 24.3% andphysicians gory. Physicians employed by 21.6%. employed by the cityand county governmentscomprised

264 TABLE 59A

A. How many physical, emotional/ orsocially handicapped patients have you referred to the Division of BlindServices or Vocational Rehabilitation in the last year? (Number of respondents, indicated byRegion.)

B. What is your estimate of the successof these agencies in rehabilitating your patients backinto the productive segment ofsociety?

REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5 Nye 36 26 24 2 MEI 2. 1 22 IllE111111110E11111 OA 1 11 11 0 21 58 8 13 15 17 6 59 No Res onse 1 1 ?' 2 1 Excellent 6 4 4,

2.2 . . , 1... ABIIIIIIMI Goad ; 1 2 12 Aillogig 22 7'.. 2 211 22. 111 26 rI24 4 i6 Falr ;l 10 6 1 .6°' 1111E11 B ANIMA r, 1 ANIFOREII / IIIMIIIIIIIIIIEIIIII 21 i 6 6 s , 1111111111M1 6. 111 r , 6. Unable to 32 29 17 146 Evaluate 33 -;95 39.01 °L 3i.4% 48e5% 31.2% 41,2% 37.81 v,...._, vuer 1 1 0 1 1 4 1.2'. 1t3377 O. 1.8" 2.2% 1:1% 4 No Res. ; 11 10 12.8'? .6' 10. se 10 6 8. All 1. 4;

Considering Montana as a whole,42.0% of the responding physicians made

no referrals or made no responseto Question A.One to three referrals were

made by 26.7%, four to six referrals weremade by 15.5%, and 15.8% made more

than six referrals.Apparently, over one-third of the respondentshave had

very little contact withthe vocational rehabilitation agencies.This char-

acteristic seemed to be more prominent in thespecialist category and also in

the less populous Regions, especiallyRegion 5. Region 5 has experienced a

dearth of services in the past, includingthose of the DVR and DBS.

Nc) 265 Concerning cuestion B, all Regionsland the state asa whole,had a con- siderably larger percentage of the respondents represented in the "unable to evaluate" category than in any one of the other categories.This demonstrates a lack of contact and communication between physicians and the rehabilitation agencies. This condition would seem to make it incumbentupon the agencies to pursue a program which will enable the physician tomore adequately assess and utilize the services offered.

Statewide, 5.9% of the respondents reported excellentsuccess, 24.1% reported good, and 5.6% said that results were poor.

Additional analysis of responses indicates that specialists generally are less familiar with vocational rehabilitation than are the general practitioners.

266 TABLE59.B

C. When one of your patients is referred tothe Division of Blind Services or the Division ofVocational Rehabilitation(either by yourself or someoneelse), you as- their doctor are asked to fill out amedical form relating to the nature of the handicap. (Not to be confused with Social Security Disability Determination formSSA-826).

1. Have you completed any of these formsin the last two(2) years?

2. If the answer to the above was"yes," do you feel the fee you received was:

3. Would you like to have the Agency inform youof their action in each individual case?

4. Are you aware that your professionalopinion is the major determinate in the action taken bythe Division of Vocational Rehabilitaion?

REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5 T-rill---0111. 4 20 MM. 28 }.4 118 - . - 2 ls Ade uate IIM1111111103111 C.2Inade!uate 1? 111111111 Other ErMill 2 0 =EMI No Revonse IIMIIIIIIIEMINIEMI 37 22 imam Yes C-3No 8 0 "5 1 111E1111 Uncertain 2 MEM3 MI 15 No Res onse IIMINISIMIIIMMIIII 11E11111 Yes 111M111111111111161011 25 170 C"Li No 6 0 1111111111IIMMINIUMUMMIll No Res onse 1 11111111.MMallgliMillill=111

In response to Question C-1,twice as many of the physicianswho

responded to this question hadcompleted one or more medical formsfor Voca-

tional Rehabilitation or theDivision of Blind Services as hadnot. General

practitioners replying in theaffirmative exceeded by about10.0% the number

of specialists who did, whichwould be Ls expected.

267 Question C-2 indicates approximately an equal number who feel fees

are adequate as compared to those who chose not to respond to this Question.

There were few comments on this question.Typical comments were "inadequate -

in some instances," "would prefer to make usual and customary charge for ser-

vices," "the fee for a specialist report should be as stated in M.M.A. average

fee schedule," and "fee should be left to doctor's discretion." The comments

indicate that not all physicians are aware that the M.M.A. fee schedule is

followed by the agencies.

The response to Question C-3 is evidence that the overwhelming majority

of physicians would like to be informed of the action taken on the cases with

which they have been associated.The comment section did not reveal agy

suggestions as to a method that would prove satisfactory and practical so

that this can be accomplished. The dilemma nosed_ by this question must be

satisfactorily resolved, and the current agency practices which are utilized

to notify individuals and agencies of case disposition and progress should be

re-evaluated. Obviously, physicians and others are less likely to utilize a

program for their patients if little "feed back" and communication exists.

The burden to resolve questions such as this, which are basic to assisting

the needy disabled, rests with both groups, with the initiative to effect the

necessary first steps being with the agency.

Question C-4 tends to indicate a large degree of uncertainty exists

as to the role the physician plays in the Vocational Rehabilitation process.

The agency should initiate a program that clarifies this relationship. The physician examines the client to determine the existence and nature of a physi-

cal or mental condition.This information is then evaluated by the counselor

and reviewed by the Medical Consultant of the agency to determine if the condi-

tion and related factors impose functional limitations of a vocational nature.

268 TABLE59-C

D. How many physically handicapped patients do you have that mightbenefit from service of a rehabilitative nature(who are not presently and have never been in contact with theseagencies)?Please indicate the number in each diagnostic area. (Number of disabled identified).

REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5

Orthopedic 78 59 90 68 48 343

Arthritis 61 63 91 66 44 325 Visual Impairments 24 41 47 38 37 187 Amputa- tions 15 14 23 11 10 73 Hearing Im.airments 23 61 47 24 49 204 Cardiac, Heart&Stroke 57 51 86 6o 54 308 TB&Other Respiratory 46 32 42 22 23 165

Epilepsy 22 34 43 29 30 158 Speech 36 31 34 156 Impairments 17 38

Diabetes 22 20 40 23 -1-)=i 150

Other 13 12 9 10 22 66

This question was included with the full recognition thatit would result in an extremely gross indication of physician awarenessof patient needs for rehabilitation. The response would be limited to those patients

the physician could recall at the time of completing the survey,and would further be limited by the qualification that these persons have not(to the physician's knowledge) been in contact with DVR or DBS. The difficult task

269 (75.0%) of physicians imposed on the physicianis reflected in thelarge number that 83.0% of thespecialists who did not respond.Analysis showed further The response of the and 65.5% of the generalpractitioners did not answer. and may indicate they see more general practitionersis significantly greater needs in general forrelated services thando the specialists. that 2,135 persons Despite these limitations,it is interesting to note by the 108 physicians in ten broad categories wereestimated able to benefit who responded to thequestion. TABLE 59-D

nature are not E. Which of the followingservices of a rehabilitative available in your community?

REGION REGION REGION REGION REGION TOTAL 1 2 3 14 5

Physical 11 18 Theraeist 12 10 11111 Speech 24 11 23 89 Therapist 19 12 19 83 Audiology 16 15 20 13

Occupational 40 29 111111111 160 Therapist 31 23

Psychologist 30 22 33 ..,27 11E1111 145 Psychiatric 3o 39 159 Social Worker 33 24 33 Medical 17 31 111 Social Worker 20 21 Vocational 26 24 27 117 Evaluation 21 19 Special Ed. 15 25 26 114 Teachers 25 38 191 Workshops 44 28 48

Half Way 42 223 House 50 33 Rehab. 41 205 Center 44 21 60 39 Treatment 22 48 38 37 185 Center 40

This question was includedto provide an inventoryof rehabilitation deficiency resources availablein the communities. It reveals a considerable

in services which arebasic and essential tocomprehensive rehabilitation.

Stated in percentages,we-find that statewide,20.0% of the respondent physi- communities, and cians do not have physicaltherapy services within their

need this hence, it can be assumed,readily accessible to patients who may

271 have such services basic service. In Region 5,53.3% of the physicians do not reported by 24.0% of thephysicians in available. The same situation was Occupational therapy wasreported regard to speech therapyand audiology. by 42.8%, psychology38.8%, as a communityrehabilitation service unavailable 29.7%, vocational evalua- Psychiatric social work42.5%, medical social work tion 31.2%, and specialeducation 30.5%. and rehabili- Facilities such as shelteredworkshops, halfway houses, available by approxi- tation and treatment centers wereindicated as being not mately 50.0% of therespondents.

TABLE 59-E

might be Do you have any patientswith emotional orsocial handicaps who F. indicated in more productivemembers of society ifthe above services as Question E, were madeavailable to them? If "yes," how many? Agency in Montana should: G. Do you feel that theVocational Rehabilitation (2) Maintain the status quo; (3) (1) Expand its services(operation); Reduce its services(operation); (4) No recommendation.

TOTAL REGION REGION 1 2

43 t 30 189 Yes 32 34 50 23 8 90 F No 23 14 22 1 28 How MA 44 61 63 64 22 178 Eand 32 224.---111 48 7 4 41 Maintain 15 12 3 2 0 12 G Reduce 4 1 No Recom- 15 27 20 13 95 te dations 20 8 6 48 No Response 15 9 10 The broadened definition of disability which includes social, emotional, and other conditions will have a substantial impact on program development in the coming years.An indication of physician identification and awareness of individuals having these problems, and their ability to benefit from services, was considered to be worthwhile, as was an assessment of the attitudes of the medical community toward the rehabilitation potential of this group.

Of the physicians, 189 indicated they have such patients, 90 indicated they did not. Of the physicians who stated they had such persons as patients,

283 persons, or an average of 1.5 such patients per physician were estimated.

Of the total sample of physicians then, 50.5% felt that rehabilitative services would be beneficial to the emotionally or socially handicapped person, but the number that was estimated was very low. Of equal interest was the opinion expressed by 24.1% of all respondents that they did not have such individuals in their patient loads.

The physicians responding to the survey expressed mixed feelings regarding expansion of the Vocational Rehabilitation agency in Montana. Of the respondents, 178 or 47.6% stated it should expand, 41 or 11.0% felt it should be maintained at the present level, 12 or 3.2% felt a reduction in program should be made, and 143 or 38.2% chose not to express a view. H. To what extent do you feel tha4 tho-e having the following social halidi- caps can be rehabilitated?

The definition of the criteria to be applied to an individual before

he can be considered "rehabilitated" is subject to interpretation and has

not generally been resolved in rehabilitation.Vocational rehabilitation, however, has been historically considered to have been accomplished when the

individual is placed in gainful employment.Despite the considerable latitude in definition of the term "rehabilitated," it was desired to have physicians rate certain social handicaps for rehabilitation potential.The following tables are presented as an indication of the rating of these conditions by degrees of potential with the numbers indicating the number of physicians so responding.

TABLE 59-F

ALCOHOLISM

CompletelyPartiallySeldom UncertainNo Response

Region 1 11 15 30 2 1

Region 2 10 16 20 1 4

Region 3 9 15 48 illeal 0

Region 4 11 14 31 24 3

Region 5 2 8 11111111 10 0

TOTAL 43 67 149 1 98 6 11

274 TABLE 59-G

DRUG ADDICTION

Completely Partially Seldom Never Uncertain No Response

Region 1 11 21 40 5 2

Region 2 10 11 15 24 2 4

Region 3 10 7 34 31 4 6

Region 4 14 10 15 39 3 4

Region 5, 3 8 14 18 1 1

TOTAL 48 43 99 132 15 17

TABLE 59-H

MENTAL ILLNESS

Completely Partially Seldom Never Uncertain No Response

Region 1 12 11 57 3 0 3

2 Region 2 9 2 44 9 0

Region 3 10 11 63 2 0 6

Region 4 10 9 54 - 6 1 5

Region 5 2 1 37 3 0 2

TOTAL 43 34 255 23 1 18

275 TABLE 59-1

MENTAL RETARDATION

Completely Partially i Seldom Never Uncertain No Response t..... Region 1 14 2 47 17 3 3

Region 2 10 0 1 32 19 2

Region3 10 0 51 21 Region 4 10 0 48 18 11. Region 5 0 31 06 2 ---- TOTAL 46 2 209

TABLE59 -J

DELINQUENCY

Completely Partially Seldom Never Uncertain 1;o Response

Region 1 14 18 34 11 1 8 Region 2 10 12 31 8 2 3

Region3 11 14 53 6 1 Region 4 13 19 40 8 0 5 2 Region5 3 13 24 2 1 25 TOTAL 51 76 182 35 5 TABLE 59-K

HABITUAL CRIMINALITY

Ccmpletely Partially Seldom never Uncertain No Response

Region 1 13 6 9 32 14 12

Region 2 14 5 9 29 6 3

Region 3 11 1 12 49 7 12

Region 4 13 3 16 31 , 15 7

Region 5 3 2 6 24 6 4

TOTAL 54 17 52 165 48 38

COMMENTS AND CONCLUSIONS:

Physicians play important roles in the process of rehabilitation.

They have a direct influence in the determination of which patients will receive the benefits of services that can be vital in total rehabilitation.

While referrals of individuals can come from any person or agency, it is imperative from the standpoint of the patient that the attending physician be aware of all the resources of rehabilitation and that he make prompt referrals and utilize these resources. It benomes incumbent upon all practitioners in medicine and rehabilitation to be cognizant of the role each must play if rehabilitation is to occur economically and expeditiously. The

Committee on Rehabilitation of the American Medical Association has eizphasized that the physician's understanding and leadership is essential if his patients are to receive all the benefits that total rehabilitation has tooffer.

In summary, it appears that of the physicians responding to the survey, a significant number feel that the program is successful in fulfilling its

277 objective:.Of gmater zignificance, however,is the large number, 39.7, who felt unable to evaluate the program,and the vast majority who wish to be informed of action being takenby the agency.It is apparent that the agencies must take positive steps tostrengthen relationships with the medical profession, and could make anexcellent beginning by a programto keep physicians informed.

A strong, positive relationship appearsbetween those feeling the agencies do a good job and the use ofthe agency as expressed by referral of patients. It also appears general practitioners are morefamiliar with the agencies than are specialists,

As could be expected, a significantlylarger number,75.0%, of

general practitioners, as comparedto 53.9% of specialists hadcompleted medical forms to establish patienteligibility for VocationalRehabilita-

tion services.

A positive correlation was foundwith a Chi Square of58.8 obtained

on comparing QuestionB with Question C-1, which tends toindicate that

those physicians who have had moreexperience with the agency seem tohave

a more positiveattitude towards its success. Communications between physi-

cian and agency seem to constitute asignificant problem. The importance of

the physician's role in thedetermination of eligibility seemsunclear to many physicians, with45.5% indicating they were aware that theiropinions were a major determinate, versus42.5% who felt they were not.The exact

role of the physician must beclarified by the agency. General practitioners

seemed more cognizant of the valueof Vocational Rehabilitationservices than

did specialists, and seemed to identify moreclients who could benefit from

Vocational Rehabilitation services than didthe specialists.

278 The lack of availability ofservices was recognized as wouldbe expected, with the specialist groupfeeling more services were available than

situation, did the general practitioners.This probably reflects the actual It can as most specialists arein urban areas with moreancillary services. be seen that with20.0% reporting no physical therapy(a high of 53.3% in

Region 5), a substantial numberof injured and disabled do nothave a most identified as being basic therapeutic service. Other services likewise are in very short supply.

The three most neededrehabilitative services statewide wereindicated 2 to be as follows in descendingorder: physical therapy first, psychology second, and psychiatric socialwork third. Second choices were: occupational therapy first, psychiatricsocial work second, and arehabilitation center third. Third choices were rehabilitationcenter first, special education teacher second, and vocationalevaluation third.

The least neededservices3were social workfirst, psychologist second, and halfway house third. Second choices were: halfway house first, social work second, and psychiatricsocial work third. Third choices were rehabilitation center first, halfwayhouses second, and treatmentcenter third.

It is impossible to ascribe anysignificance to this rating schedule other than to give a grossindication of physician assessmentof service needs.

The interpretation of responsesto Question G must be madein recogni-

antagonistic to the program per- tion of the probabilitythat those physicians haps did not respond to thequestionnaire. However, a significant number appear to recognizethe merits of the program as a meansof reducing dependency

2See Survey Questionnaire,Appendix C.

3See Survey Questionnaire,Appendix C.

279 and assistini the ilidividual toward greaterself-realization and thus support

program expansion. Tables resulting from Question G must beinterpreted with

caution; however, it appears that, overall there isconsiderable pessimism as

to the rehabilitation potential of these groupswhich will receive increasing

attention from Vocational Rehabilitation.The attitude of physicians in this

regard is probably a reflection of society in general.

Comparison with physician referrals in other inter-mountainstates gives

some indication of the relationshipbetween physicians and the rehabilitation

agencies in Montana. In Montana, 5.9% of all referrals to DVR are madeby

physicians, in Idaho 9.1%, in Colorado7.4%, in Utah 9.5%, and in Wyoming5.2%.4

It would appear from the evidence that VocationalRehabilitation in

Montana must initiate a program to enhance effectiveworking relationships with the medical profession.

The physicians were given an opportunity to comment onthe program of

Vocational Rehabilitation. The following comments are grouped by subject matter

and were selected for presentation to give a cross-sectionof response:

Value of Vocational Rehabilitation IIImm11

"Vocational Rehabilitation has been very successful for those of my patients who were mentally and emotionally able toutil- ize the training they received."

"If able to rehabilitate certainly much more rational than to remain a constant drag on self andsociety."

"A very valuable service which should be available to more people and in more variety than now seems toexist."

"Should expand for necessary cases of severe or moderate handicapped, and not bother in minor illnesses that are not handicapping and clear usually."

rehabilitationServices Administration, Characteristics and Trends of Clients Rehabilitated in Fiscal Year 1963 71967, Table 18C, p. 22, Division of Statistics and Studies, United States Department of Health, Education, and Welfare, Social and Rehabilitation Series.

280 "This agency is very important."

Expand its services - on a very selective basis. Keep the goal of rehabilitation in mind.Don't just give financial aid to the needy."

Ned for Vocational Traininz

"Need vocational school in this state verymuch."

"Desperate need for on-the-job training or shortinstruction courses for specificjobs."

"Need broader job selection for rehabilitating people. Possibly the state is too small, too littleindustry, etc. to provide a good selection forretraining."

"We have several paraplegias now in the hospital whohave been through rehabilitation hospitals, but needfurther occupational training to become productive insociety."

"Expand only into getting people back to work.I am sure more types of job training are necessary.Many patients I have talked to do not care to learn watch repairand that was their only choice."

dam Criticism

"In the past Vocational Rehabilitation has been extremelylimited in -what it could offer patients - too manyended up as barbers. I feel that many of these patients who have nothad sufficient education could go on to some higher educationand possibly clerical work if they didn't have to worry aboutfinances during this period. They should get a subsistence that canfeed and clothe their families adequately during thisperiod of re- education."

"It should stop recruting people for the program who haveminor physical abnormalities and no actual handicap - manyof the people who come to me are in this category. Concentrate on those who really need it - rehabilitation of stroke casesand cardiac cases particularly."

"I believe that too much effort is wasted on minimallyhandicapped patients. I believe this is used as a crutch orgraft by some patients, and question the judgmentof the Vocational Rehabilitation Services in taking on the minimallyhandicapped patients." Program Criticism(cont.)

"One patient was sent for what I thought were verygood reasons - five childrento support - and because ofslow recovery from hepatitisplus emotional problems should have been rehabilitated.She was turned down. This will, in the end, cost the state moremoney."

"Expand services in light of the followingrecommendations: I feel that money is beingwasted in 'rehabilitating' illness of a trivial nature.For example, well-controlleddiabetics and idiopathic edemia of youngfemales.Since money is limited it should be used to help peoplewho have some potential and who have otherwiseseriously limiting handicaps so that they caneventually be self-supporting."

"Somewhat greater selectivity should be exercised astoo much money is spent on self-limitedproblems, not enough on special difficult rehabilitation cases; e.g.,two of my patients with loss of use of one eyereceived considerable help in going to college(I did not recommend them to the program). They both came from families well ableto finance their education.Another patient with paraplegia whohas exhausted his own resources was rejectedfor rehabilitation (he needs muscle transplants--joint fusion, andspecial equipment) because the projected cost for thispatient would have been too great."

Physicians Informational Programs

This sampling of comments shows thatthere is an urgent need for closer liaison between the Rehabilitation agenciesand physicians. The medical profession should be better acquainted withthe program and its purposes. Nurses Survey

during November A survey of registerednurses inMontana was conducted

Planning office. The questionnaires and December of1967 by the Statewide of the MontanaNurses Associa- were sent bymail to 900 nurseswho are members total of 3,636 nursesin the state. tion and representedabout 25.0% of the with both publicand private In October the surveyquestions were pretested

nurses. (See Appendix forforms.) returned, which is54.8% of the 900 A total of493 questionnaires were

Partial analysis ofthe returns wasmade by sent out in thesingle mailing. University of Montanaat Missoula.Data the Department ofSociology of the

was compiledby county and byplanning region.

TABLE 6o

EMPLOYMENT CHARACTERISTICSOF 493 NURSES

Type of Practice ClassificationEmployment Status NrsgPub. FullPartNot Pri- Doc/ HospHomeHlthOther RNLPN NRTimeTimeEmp. NRvateDent ci- 8 4 40 5 14 11 Region 1 82 0 o 55111101 6 o 20 9 2 7 6 6o 4 22 Region 2118 0 1 83111111 2 24 26 14 12 9 67 Region 3140 0 0 85 33 18 17 3 7 3 52 7 10 Region 4 95 0 1 65111:11 7 1 0 4 6 41 0 1 Region 5 56 0 0 38111111111111 75 43 9 38 28 260 18 74 TOTAL 0 2 326 115

283 The greatest number of respondents were from Region 3, 28.4%; Region 2

was next, 24.1%; followed by Region4, 19.55;; Region 1, 16.6; and Region 5,

11.4%.

Of the nurses responding, 66.1% were working full time, 23.3% part

time, and 8.7% were unemployed. Most of the private nurses, 71.1%Iwere

working part time; 86.0% of the unemployed plan to return to nursing when

personal conditions permit.

Over half of the nurses, 52.715were employed in hospitals; 15.0% were

in public health; office and private categories total 13.4%; and 15.0% were

in other employment.

TABLE 60-A

A. How long have you been employed in your profession?

REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5

Less than 1 yr. 0 0 0 0 4

1 - 3 yrs. 10 12 9 4 46

4-6 yrs. 6 9 4 3 26

7 - 9 yrs. 2 11 7 3 28 10 - 12 yrs. 6 10 MIMI 1 46

More than 12 yrs. 75 101 60 45 336

No Response 3 i 2 1 1 0 7

TOTAL 82 119 140 96 56 493

An analysis of length of employment reveals that the most important characteristic of this group is that 68.2% of these nurses have been employed in their profession over 12 years; 24.5% have been with their present employers

284 over 12 years; and 53.6% have been employed in this state more than 12 years.

It would appear that a group with this experience in the health fields would

have considerable knowledge of rehabilitation and services available to the

disabled.

TABLE 60-B

B. Please state your highest level of education achieved.

REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5

High School 11 15 14 11 7 58 College less ; ': 70 67 51 37 268

BA Degree 20 19 28 18 8 Some Graduate Work 3 6 3 22 Masters Degee Ell 0 1 46 Equivalent 0 0 1 0 0 1

No Response 2 1 2 0 0 5

The level of education indicates that over half, 54.4%, of the respond-

ents have college or nurse's training but have less than a B.A. degree. This

category ranges from 66.1% of respondents in Region 5 to 47.91 in Region 3;

18.9% of the sample held at least a B.A. degree, and 9.3% hada Master's

degree. Many of the latter are teaching in the nursing field.When questioned

about their opportunities for up-dating professional skills, 85.7% said they were allowed time to attend educational activities, and 70.3% said they had in-service training programs. Of the respondents, 58.6% were natives of

Montana, probably most of them trained in this state.

285 TABLE 60-c

C. If you seldom or never refer disabled clients to the above agencies, please indicate why: (1) Ages below that accepted by DVR (currently 16 and over); (2) Ages above labor market potential; (3) No suitable referral system; (4) Not familiar with above agencies; (5) Disabili- ties encountered do not present barrier to employment; (6) Other.

D. If you have referred clients to above agencies, what is your estimate of success?

RESPONSE REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5

1 2 1 17 2 2 1111E11111111111111"1111 .1 25 17 112 C 1 INIE 12 i 10 11111=11 2 30 19 MEN NR 11113111111111111111 - iiiiIiii Good anill111111111.112111 0 Fair 111=111111111MINMEMEMIL11111111 7 42 2 D Poor 11101111111111011111 1 0 0 Don't know 7 17 1 12 NR 57 :4 . .9 Mill

In regard to why they had not made referrals, 58.8% of the respondents said they had not referred anyone to DVR in the past 12 months and64.1% had not referred anyone to DBS in the same period.Many who did not make referrals commented that this was the doctors' responsibility.A very high percentage,

29.2%, said they did not refer patients because they were unfamiliar with the agencies, and an additional 15.6% thought there was no suitable referral system; 23.2% gave the latter reason in Region 5.This is confirmation that communications and services are not adequate particularly in the eastern part of the state, and this response is generally consistent with what has been found in the other project studies.

286 When asked to judge program success,69.2% did not respond to the questions, and11.8% said they did not know about success ofrehabilitation of their patients. Of the remaining 19.1%,10.1% said that success was good and 8.5% said it was fair. The most favorable responses camefrom Public

Health nurses.

TABLE 60-D

services, which would be of benefit E. Assuming availability of the following to your clients: (1) Individual rehabilitation counseling. (2) Group counseling. (3) Psychological testing. (4) Vocational training. (5) Psychiatric treatment. (6) Job placement. (7) Other. what F. If you are aware of disabled peoplewho are not receiving services, do you believe are the reasons: (1) Lack of knowledge or informationof available services. (2) Cost of effort necessary to getservices. (3) Services inadequate or not availablewithin geographic area. (4) Apathy on part of client or family.

REGION REGION REGION REGION REGION TOTAL 1 2 3 4- 5 2 0 1 32 64 68 51 35 2 10 ; 2 1 11 ,- 25 3 itr- 477-- 29 -6 2 27 5 5.-- 27 17 5 3 11 ? 208 1 2 illiieliii 7 4 l5 7 F 2 11_ 11111E1111 30 11 25 39 27 50 2 1111011111

Nurses from all regionssaid that individual rehabilitationcounseling

Vocational training was the service whichwould most benefit theirpatients. and psychiatric treatment werelisted as the next most urgentneeds.

287 services were as Reasons given as to why thedisabled don't receive service was a reason follows: Lack of knowledge orinformation on available part of the given by 33.2% of the respondents;29.5% thought apathy on the most frequent patient or family was responsible.Inadequate services was the lack of services in reason given byRegion 5 nurses. This again reflects a that large area.

Nurse Comments

varied employment The nurses responding tothe survey had wide and

overview of many areasof concern to this experience. Their comments give an

profession.

Needs

"In our work with young menrejected at the Armed Forces Examination Station in Butte, wefound that few of them Many knew of any servicesavailable in theircommunities. of the defects for whichthe armed servicesrejected these Some men had been knownall through their school years. opinion had had maximum correction,but it is my personal either that we do not have necessaryhealth services available to young children or wehave not 'educated' the people to the value ofgood health."

"I believe it would help if ourdoctors were more informed and interested and encouragedmore action fromthe R.N.'s. Cardiac, vascular and strokevictims seem to be the most frequent patients seen thatcould be helped." and "A program of activities fordaily living for patients families might enable thepatients to leave thehospital planned for the conven- sooner. Hospitals are not usually who ience of handicapped patients orthe ward personnel teach them to help themselves. If we had such a center, discharged patients could gothere with their familiesand would be stimulated tokeep up the motorfunctions they already have and to strivefor more," Needs (cont.)

therapy to "The V.A. sends patientswho need speech happens to other people Ninneapolis.I wonder what there is enough need who need thisservice and whether to warrant acommunity project?"

"I believe there is aneed for moreoccupational therapy and have to change for patients whohave been disabled, also for young their line of workdue to injury, and stay in wheel people with congenitaldefects who have to chairs." desperately needs "A large percentageof my caseload They could go to psychiatric evaluationand therapy. but both call for Helena or to aprivate psychiatrist families have." more moneythan my lower class rehabilitation to "Many low income personsneed special They be readied for ajob and itsresponsibilities. with no leg." need rehabilitation asbadly as the man

Vocational Rehabilitation

referrals "There is a lack of continuityin follow-ups of reports and communicationsof dispositions or progress personnel, and are nil -part of this isdue to lack of in frequency ofvisits to localareas." DVR, "Wherever I have had theopportunity to work with done a real finejob." they have been mosthelpful and have

"County public health nurses arefrequently frustrated The delay when they requestDVR services for apatient. criteria for in counselor contact,question of meeting major service, and feedback onwhat is the status are causes as Iinterpret them."

latmeglITI:L.Emalsa availability of "Most hospital personnel areunaware of feels referral systems to anyagency. Also the nurse services to patients. this is in the areaof physicians' use of these Perhaps publiceducation would increase agencies."

289 Informational Programs (cont.)

"Even professional people in Butte are not aware of all of the services we have available to us here. The state as a whole is horribly ignorant of the advantages our people have available to them."

"I feel most nurses are unaware in our area of any rehabilitation programs or services available as either patients are tot encouraged to seek the help while in thehospital but informed of it later, or available facilities are not known to either doctor or nurse. I have felt the need of rehabilitation with stroke patients and their families."

"I am not familiar with the services offered in Havre and I feel many people are in the same situation.Countless patients could profit if more nurses and physicians knew of the availability of such services."

"I do not work with patients but with nurses, and it is my opinion that most staff nurses do not know very much about referral or services available in their owncommunities."

COMMENTS:

Nurses do not often refer patients for rehabilitationservices unless

they are in a school setting or are in a Public HealthDepartment. The majority of respondent nurses are employed within hospitals wherethey work under the supervision and direction of the attendingphysician. The traditional working relationship of physician and nurse, ofnecessity, dictates that this be so and consequently this may be a reasonthat they do not make referrals to other agencies.The high percentage of response to this question in the "No suitable referral system,""Not familiar with DVR and DBS," and

"Other" categories tend to substantiate this.This situation becomes very obvious in relation to the responses given to the same questionby other professionals. Nurses by the nature of their employment and withthe greater opportunity for the prolonged patient contact that it affords, arein an

290 excellent position to increase patient awareness of rehabilitation programs, without inpinging upon the practices or ethics of the physician-nurse professional relationship.

291 Professional Personnel

The professional survey was intended to assess the characteristics of those persons engaged in rehabilitation and related activities and to ascer- tain certain broad aspects of the programs in which they function as they may relate to rehabilitation.Of equal interest was the determination of patterns of usage of rehabilitation services by these persons who togetherconstitute one of the major sources of identificationand referral of the disabled to the

Division of Vocational Rehabilitation and the Division of Blind Services.

Agency employee lists and lists of members of professional organizations were used as the basis of the survey. A total of 519 questionnaires were mailed with 378 returned, for a72.8% response to the single mailing.

This response may be considered indicative of the interest of these persons in rehabilitation as well as an expression of their desire to participatein activities which offer opportunities to advance the cause of the disabled individual in the state.

Questionnaires were mailed to all individuals identified as being employment counselors, probation officers, high school counselors,occupational therapists, speech therapists, physical therapists, psychologists,rehabilitation counselors, social workers, special education teachers, andadminis- trators in the service field. (See Appendix C for forms.) The forms were pretested in October of 1967 with all categories of professionalsrepresented.

The general mailing was made in November and December of1967. Partial analysis of the data was made by the Sociology Department of the Universityof

Montana at Missoula. Compilation was by county to allow analysis on a regional as well as on a statewide basis. In tabulating the returns,14 of the IBM cards were eliminatedbecause respondent professionals were notresiding in the state or becauseof

was numerically processing error.As it was determined that the response biased in favor of school personnel,the respondents were furtherseparated on the basis of schooland other professionals and were sotabulated and and 188 reported.Of the 364 respondents,176 (48.4%) were school personnel

(51.6%) were other professionals.

TABLE 61

PROFESSIONAL PERSONNEL SURVEY (NON SCHOOL RELATED)

REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5

Administration 10 13 10 11 7 51

Audiologist 1 1 1 1 1 5 Employment 4 5 7 1 24 Counselor 7 High School 2 2 2 1 10 Counselor Juvenile Proba- 4 4 4 18 tion Officer 3 3 Occupational Therapist 1 2 Physical 6 6 9 111111 1 111111111 - Psychologist 0 0 0 0 1 Rehab 1 18 2 1 5 7 3 Counselor Speech i 2 4 2 5 1 14 Therapist 1 43 Social Worker 7 10 9 7 10

2 27 Other 12 2 a 7

No Response 1 0 1 0 1

294 A total of 188 professionals othez thanschool personnel was tabulated.

Some respondents replied in more than oneemployment category which indicates the dual responsibilities some fulfill.A total of 250 job categories are represented by the 188 respondents. Three respondents did not specify a job category.

Of the group, 84.0% were employed full timeand only 6.0% were unemployed.One important deviation was in the occupationaltherapy group where 50.0% were unemployed and only16.7% were employed full time.

TABLE 61-A

A. How long have you been employed in yourprofession?

REGION REGION REGION REGICO REGION TOTAL 1 2- 4) 5

Less than 1 yr. 2 2 3 4 1 12

1 - 3 yrs. 13 22 10 , 9 3 57

28 4-6 yrs. 9 5 9 , 4 1

7 - 9 yrs. 7 2 3 5 4

lo - 12 yrs. 1 1 4 11 20 --,..--.- More than 12 yrs. 8 7 18 5 8 46

No Response 0 2 0 1 1111111111111

TOTAL 4o 41 47 39 188

The largest number of the respondentsstatewide have been employed between 1 and 3 years and the second largest groupfor 12 or more years.All personnel having experience of 12 or more yearsconstituted 24.5% of the group;

11.2% 30.3% had 1 to 3 years experience;14.9% had 4 to 6 years experience; had 7 to 9 years experience;and 10.6% had 10 to 12 yearsexperience.

295 Administrators have been employed in their profession for a median of 8.45 years and the employment counselors have been employed amedian of

2.8 years in their profession.The physical therapists have a median of

5.45 years in their careers.The social workers have a median of9.714 years and the "other" category has a median of 7.3 years.

The median length of employment for these professionals inMontana as a whole is 6.14 years.It appears that the employment counselors have fewer years in their profession than do any of the othercategories for which medians have been calculated. This trend is consistent among all the regions.

The social workers seem to have the most years of service whilethe administrators follow with a close second.

TABLE 61-B

B. Please state your highest level of education achieved.

t REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5

High School 0 1 0 1 4 College less than BA 4 5 6 6 0 23

BA Degree 16 17 14 9 75 Some Graduate Work 7 10 10 7 4 38 Masters De ee 6 8 9 8 6 37 Ph.D. or Enuivalent 6 0 3 0 10

No Response 0 0 0 0 1

Of the sample, 39.9% have Bachelorls degrees and19.7% have Master1s degrees. A further analysis of the questionnaires indicates that those in the categories of administration, audiology; and speech therapy seemto have

296 the most formal education.This is a reflection of the professional up-

grading which is occurring notably in the fields of audiology and speech

therapy. The certification standards of these professions will eventually

require a Master degree.This group also has the majority of those at the

Doctoral level.

TABLE 61-C

D. It you have referred clients to above agencies, what is your estimate of success?

RESPONSE REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5

1 11 14 36 6 6--, 2 5 2 1 1 11 3 0 5 2 2 3 12 r 0 3 0 9 5__ 3 7 ____6_ NR - - -

Good h. 22 Fair 10 2012 1111111111111111111 86 D Poor 11 12

oolt .I. -i 2 6 6 11111111E

The single reason cited most often for non-referral to DVR and DBS was age. The greatest significance seems to be that the majority do make referrals and that referral channels are open and are used. Few admit that non-referral is based upon their lack of familiarity with the agenc.j, this despite the number who indicate they wish more information. This might indicate that a rather cursory knowledge exists rather thana detailed understanding of DVR and DBS functioning. By professional groups, it is found that 25.0%

of the juvenile officers and 23.1% of the physical therapists indicate they

are not familiar with the above agencies. It is not unusual that this

exists among such a significant number of juvenile officers but is startling

when related to physical therapists who deal in one of the most basic thera-

pies and one that DVR particularly utilizes for the large number of orthopedic patients they serve.

During the preceding 12 months, 60.8% of those questioned had made referrals to DVR ana 35.2% had made referrals to DBS. Of those responding,

48.4% indicated that rehabilitationagency success was good. The range on this question was from 55.0% in Region 1 to 38.1% in Region 6; statewide

27.1% felt the agencies dida fair job; 6.9% indicated a poor rating; and

9.0% did not know how successful theywere.

298 TABLE 61-D

be of benefit E. Assuming availability of thefollowing services, which would to your clients: (1) Individual rehabilitation counseling. (2) Group counseling. (3) Psychological testing. (4) Vocational training. (5) Psychiatric treatment. (6) Job placement. (7) Parental or family counseling. (8) Other. services, what F. If you are aware of disabledpeople who are not receiving do you believe are the reasons: services. (1) Lack of knowledge orinformation of available (2) Cost of effort necessary to getservices. within geographic area. (3) Services inadequate or not available (4) Apathy on part of client orfamily.

REGION REGION REGION REGION REGION TOTAL 1 2 3 If 5 26 9c 31. Q 4 15....._ 25 1. 111 3 -----76 23 25 E 34 20 1.1 35 35 t 37 12 5 '21 22 21 15 25 15 32 fl17 35 32 21 22 1 121 17 7 7 0 0 ---,-.... ___ _ 22 18 . 2 5 33 112111111111111111111L1111 23 17 15 108- 11311M111111. 23 22 99

The services of a specialized naturethat are considered necessaryto

the disabled by the respondentsshow variations as would beexpected; however,

the critical need for vocationaltraining was cited as most neededin all regions, and rather uniformly soby this group of individuals. Surprisingly,

this group gave a higher priorityto vocational training thandid the school personnel, who might be consideredto be more cognizant of needsrelated to

education.

299 followinr ;Ire the rank orders ofthe services listed for this pwsi.ion. The servicP. are ranked by regionand for the state as a whole. tieion I Rion II Region III ..,,,....--- 1 VT 19.3% 1 VT 20.2% 1VT 19.3% 2JP 18.2% 2PFC 18.5% 2PFC 15.5% 3IRC 16.1% 3 JP 15,6% 3 JP 14.4% 13.0% 4IRC 15.0% 3IRC 14.4% 4 PTest 5 PFC 10.9% 5 PTr 12.1% 4PTest12.7% 5 PTr 10.9% 6 PTect11.6% 5 PTr 12.2% 6 GC 7.8% 7GC 5.2% 6 GC 7.7% 7 0 3.6% 90 1.7% 7 0 3.9%

F.egion IV Region V Montana 1 VT 19.8% 1VT 21.4% 1 VT 18.5% JP 15.5% 2 IRC 15.7% 2PFC 16.7% 2 3IRC 15.4% 2 PTest15.7% 2PTest16.7% 4 PFC 14.9% 2 JP 15.7% 3 IRC 15.7% 5 PTest13.5% 3 PFC 13.8% 4JP 13.9% PTr 11.3% 4PTr 9.4% 5 PTr 11.1% 6 GC 7.3% 6 GC 8.2% 6GC 7.4% 7 8 0 2.1% 6 0 0.0% 70 0.0%

"Individual rehabilitation counseling" isconsistently in third or

fourth place except that it issecond in the rank order forRegion IV. Job placement also ranks high as abasic need.

KEY: IRC Individual rehabilitation counseling GC Group counseling PTest Psychological testing VT Vocational training

PTr MD AND Psychiatric treatment

JP OM SS Job placement

PFC IND Parental or family counseling

0 OW /ND Other

The professionals seem tofeel that disabled do notreceive services

because of the client's lackof knowledge of servicesthat are available, as

well as a shortage or lackof needed services. A ratherlarge percentage be surprising feels that apathy is also asignificant factor which would not when related to the lack ofservices available to an individual. Obviously,

a high level ofmotivation cannot be maintained if theindividual cannot gain

access to what he needsto assist himself.

300 TABLE 62

SCHOOL PERSONNEL

Adminis- Employment High School Speech tration Counselor Counselor Therapist Other --- Region 1 11 0 22 2 14

Region 2 15 1 26 1 10

Region 3 5 0 15 1 15

Region 4 12 1 23 0 17

Region 5 4 0 21 2 13

TOTAL 2 107 6 66

The total number of school personnel is 176.Some or the respondents replied to more than one of the professional categories as indicated by the total number which shows up on the summary charts as 228 because of having positions of multiple responsibilities.

The breakdown for the school personnel sample is as follows: administration, 20.6%; employment counselor,0.9%; high school counselor, 46.9%; speech therapy, 2.6%; and other, 28.9%. Special education teachers compose the majority of the "other" response.

301 TABLE 62-A

profession? A. How Jong have youbeen employed in your

REGION TOTAL REGION REGION REGION REGION 4 5 1 1 2 3

18 5 Less than 1 yr. 3 MIME= 7 5 32 1 - 3 s. 6 11111111111 26 5 5 6 4-6 yrs. 5 6 4 29 7 - 9 s. 6 6 o 17 1 0 4 3 10 - 12 yrs. 5 5 8 17 7 54 More than 12 yrs. 11 U

26 43 30 TOTAL 36 41

of 12 or more years School personnel havingemployment experience consistent throughoutthe constitute 30.7% of the group,and this is rather Region 4. Administra- regions with a rangeof 23.3% in Region5 to 39.5% in 57.5% of them having over12 years. tors have considerableexperience with experience;14.8% had 4 to 6 years; Of the total group,18.2% had 1 to 3 years experience. 16.5% had 7 to 9 years; and9.7% had 10 to 12 years TABLE 62-B

B. Please state your highest level of education achieved.

REGION REGION REGION REGION REGION TOTAL 1 2 3 11 5

High School 1 0 0 0 0 1 College less 1 0 0 3 than BA 0 6 16 BA Degree 1 3 3 Some Graduate 13 46 Work 7 10 7 9 Masters Degree 24 26 15 24 17 Ph.D. or Eouivalent 2 0 1 1 0 4 61111P ANEMIC=

In the sample, 60.2% of the school personnel haveMaster/s Degrees.

Within the administrator's category, 91.5% haveMaster's L-grees. A total of

26.1% of the remainder have some graduate work and only 9.1% have just a

)5. Bachelors Degree. Range by region for the Master egrees of the total group is68.6% in Region 1 and 53.1% in Region 5. Remaining statewide categories are "college less than a BA" 1.7%; "highschool" G.6%; and "Ph.D. or equivalent" 2.3%. TABLE 62-C

C. If you seldom or never refer disabled clientsto the above agencies, Please indicate why: (1) Ages below that accepted by DVR (currently 16 and over); (2) Ages above labor market potential; (3) No suitable referral system; (4) Not familiar with above agencies; (5) Disabili- ties encountered do not present barrier toemployment; (6) Other.

D. If you have referred clients to above agencies,what is your estimate of success?

RESPONSE REGION REGION REGION REGION REGION TOTAL 1 2 3 4 5

4 22 I ; 2 1 0 0 0 1 3 --4-----rn 1 13 -Tr- C 4 0 1 ---'r C7 5 3 5 12 30 5 r 29 . 7 , _ - _ i : 1111111111I 52 00. :L7 a3 6 lo _6 a 2 4 8 2 7__ D 'o 2 4 x't know 4 0 4 56 6 4 6 29

The highest number of respondents,46.7%, indicates they do not refer cases because of"age below DVR acceptance," which would be expectedof the school population. The categories of "disabilities encountereddo not present a barrier toemployment" are related to the same cause. The combined number indicating "no suitable referral system" or"not familiar with the agencies" indicates additional contact work by theVocational Rehabilitation agencies is needed. Referrals to DVR in the prior 12 months weremade by 48.7% of the respondents and to DBS by10.5%.

Of the respondents,29.5% felt that the success of the DVR and DBS could be classified as"good." The reports of good success ranged from47.2% in Region 1 to 20.00 in Region 5.

304 It seems that the respondents from Region 1 were moresatisfied with

the program than were the respondents from the other regions.

TABLE 62-D

E. Assuming availability of the following services, which would be ofbenefit to your clients: (1) Individual rehabilitation counseling. (2) Group counseling. (3) Psychological testing. (4) Vocational training. (5) Psychiatric treatment. (6) Job placement. (7) Parental or family counseling. (8) Other.

F. If you are aware of disabled people who are not receiving services, what do you believe are the reasons: (1) Lack of knowledge or information of available services. (2) Cost of effort necessary to get services. (3) Services inadequate or not available within geographic area. (4) Apathy on part of client or family.

REGION REGION J REGION REGION REGIONTOTAL

1 2 3 Li. 5 8 1 16 22 9...... -- 23 8 16 . 4

lo 26 lo _i 8 ..,, , E 11111 28 2* 8 28 5 15 20 5 10 : .r 19 1 19 22 10 ..

34 36 23 26 , 21 iho 7 , 3 4 1 12 0 ...,_ 1 23 35 22 23 1 121 1 "Er... 2 5 33 o IIIII 22 31 23 17 15 108 WI 22 22 23 22 10 99

Parental or family counseling and vocational training were considered by educators to be the most needed of specialized services.

305 The following are the rank orders of services listed from the services thought tobe most useful.

Region I Region II Re.on III

1 PFC 26.2% 1PFC 21.3% 1 PFC 26.7% 2 VT 21.5% 2 VT 17.2% 2 JP 22.1% 3 JP 13.6% 3 PTest15.4% 3 VT 20.9 .; 4IRC 12.3% 4IRC 13.0% 4IRC 10.5% 5 PTr 11.5% 5 Ph. 11.8% 5 GC 7.0% 6PTest 7.7% 6GC 9.5% 6 Ph. 5.8% 7GC 6.2% 6 JP 9.5% 7PTest 3.5% 8 0 0.0% 70 2.4% 70 3.5%

Region IV Region V Montana

1 VT 20.3% 1PFC 23.3% 1PFC 22.8% 2 PFC 18.8% 2VT 22.2% 2 VT 20.1% 3 IRC 16.7% 3 IRC 12.2% 3 JP 14.0% 4 JP 15.9% 4 GC 11.1% 4IRC 13.2% 5 GC 10.9% 4JP 11.1% 5 PTest 9.5% 6 PTest 7.3% 5 PTest10.0% 5 PTr 9.5% 6PTr 7.3% 6PTr 8.9% 6 GC 9.0% 70 2.9% 70 1.1% 70 2.0%

KEY: IRC--Individual Rehabilitation Counseling GC--Group Counseling PTest Psychological Testing VT Vocational Training PTr--Psychiatric Treatment JP -- Job Placement PFC--Parental or Family Counseling 0 Other

Concerning reasons that some disabled are not receiving services,33.5% of the respondents answered that lack of knowledge regarding services was a deterrent and 29.9% felt inadequate or unavailable services within the area was a significant reason.Family or client apathy was identified by27.4% as the primary reason.

306 COMMENTS AND CONCLUSIONS:

Of all the school personnel responding, 91.2% are full time employees

as compared to 84.2% full time employees for the other professionals. Only

50.0% of the registered occupational therapists responding are employed full

time. This may be indicative of the lack of understanding and appreciation

of the contribution of occupational therapy to the rehabilitation process by

not only physicians but administrators of hospitals and facilities, as well

as by related professionals. This assumption gains support when it is found

that the desire for more information on occupation therapy ranked third after

the DVR and psychiatric social work when respondents were asked if they would

like information on specific fields.

The survey did not identify with any significance the reasons for

unemployment, primarily because of the low number of respondents who are

unemployed. It could be assumed that non-employed professionals would not be motivated to return the questionnaire.

Natives of Montana account for 57.4% of all respondents, and in general

it can be said that those reporting the highest academic qualifications are non-natives.

Most respondents felt they have average client or student loads according to the standards of their profession; however, 10.0 considered them to be excessive. Over 80.0% of all respondents indicated they were allowed time off to attend professional meetings. Only 46.5% of the school people reported they had in-service training programs as compared to 64.0% of the other professionals. Other comparative results show that in terms of length of employment, 30.7% of the school people, versus 24.5% of the

307 other professionals, have been employed 12 or more years in theirprofessions;

18.5% of the school people, versus 30.3% of the other professionals, had 1 to 3

years; 14.8% of school, versus14.9% of other professionals, had 4 to 6 years;

16.5% of school, versus 11.2% of other professionals, had 7 to 9 years; and

9.7% of school, versus 10.6% of other professionals, had 10 to 12 years.

Master's Degrees were held by 60.2% of school people and19.7% of other

Professionals. Of the latter group, 39.9% held B.A.'s and9.1% of school

people were in this category.

Most respondents were unable to evaluate results of rehabilitation

services for those they had referred. However, 22.4% of the school people

and 36.4% of other professionals considered results good. Just 3.1% of the

school personnel and 3.7% of others considered results poor. In general,

Region 1 professionals considered results very good, while Region 5reported more poor results than any other section.

When asked what services would benefit their clients most, school personnel ranked parental or family counseling first and vocationaltraining

second. Other professionals ranked vocational training first in allregions and job placement second.

Lack of knowledge of available services was given by the professional group as the biggest single reason for somedisabled not receiving services.

Inadequate services or apathy on the part of the client or family werealso cited as deterrents.

In general, the respondents in Region 5 were less aware of rehabilitation activities and reported less rehabilitation work in progress than the rest of the state.

308 Comments were solicited from those responding tothe survey and the following were selected as indicative of problemsidentified:

Rehabilitation Needs

"I feel our greatest need in Montana is an in-patient rehabilitation center where severe disabilities can be treated with training for physical, social,and vocational rehabilitation."

"Montana needs a centralized Rehabilitation Center to serve all Montana; a completeservice."

uWe are much in need or some kind of sheltered work shop, or some program whereby these boys andgirls can learn a trade to copewith the society in which they live."

"I feel there is a great need for vocational training for those physically handicapped over16."

"I believe there is much need for child guidance and family counseling centers in thearea."

"Most of my work is with older special education students. Many of these come back to us even after school years for counseling. I have also been asked to help the American Legion:in rehabilitatingseveral veterans who have been transferred to localnursing homes. I am most happy to do this but need help on occupational and recreational therapy."

"We need special education for our educable mentally retarded.We need vocational schools available within geographic area - our limited area schools make it necessary for students to getpost-graduate training out of state."

"The 'hard core' unemployed (disabled) need concentrated effort; first for testing as to their capability(physical and mental), second, job placement services(including motivation). Presently the counselor does not have the time needed for these cases."

309 Rehabilitation Needs (cont.)

"The greatest need that is presently not met for students is adequate mental health facilities."

"The need is very great for vocational schools in Eastern Montana; also psychiatric help is hard to obtainhere."

"In my position, retardation and lack of vocational training are the greatest problems."

Vocational Rehabilitation

"It appears that Vocational Rehabilitation needs to place a greater effort on helping to locate ajob for some of their trainees once they have completed their training. Vocational Rehabilitation's plan for the person seems to be somewhat weak in this area. There is no sense training a person for an occupation unless you canplace him on the job upon his completing his training."

"Working relationships with Vocational Rehabilitation office have been excellent and cooperation has been very good."

"As a public welfare agency, we refer whom we can to DVR and DBS, but circumstances such as small children in the home, non-cooperating doctors, and lack of clients with I.Q.'s from 70 to 100 make referral a waste of time.Of those clients we have referred, we have had immediate response and action from DO and are greatlypleased."

"Services of Vocational Rehabilitation usually require a person to support himself while intraining, which require- ment makes it impossible for applicant to take advantage of training."

"I feel more people should become acquainted with the services of Vocational Rehabilitation."

"Montana needs more vocational counselors to cover this part of the state.We are serviced from Billings, 140 miles away, once a year (in the town ofWilsall)."

"Mr. of the DVR has been very helpful. I do feel his caseload is ridiculously high."

310 CLOSED CASELOAD STUDY

closed after A study of Division ofVocational Rehabilitation cases, 1966-67, was conducted by services but not rehabilitated,in the fiscal year The study in- two former Division ofVocational Rehabilitationcounselors. made) and Status 28 cluded Status 30(closed before a rehabilitation plan was form (closed after a rehabilitation plan wasdrawn up). A questionnaire of case file in- (see appendix) was filled out foreach client on the basis Six formation. A total of 152 casesclosed during the period werestudied.

146 whose cases were reviewed. of the clients died duringthe period, leaving closed during Cases in Status 30 and28 constituted 19.8% of the total cases the year by the Divisionof Vocational Rehabilitaion. closed without being In regard to generalcharacteristics, the clients rehabilitated did not differsignificantly from those closed asrehabilitated. 69.6% of those Of the group studied,72.6% were male, compared to rehabilitated in the same period.

There were 72.6% living inurban areas and the balanceof 27.4% were

rehabilitated group are avail- in rural areas. No comparable figures on the able as DVR does not maintainstatewide records of thistype.

The median age was31.48 in comparison to therehabilitated group

average of 31.

Orthopedic disabilities were mostprevalent, with28.8% of the non-

rehabilitated being in this group,compared to 36.7% of therehabilitated

mentally re- group. By contrast,17.8% of the non-rehabilitated group were disabled. Heart tarded as compared to4.9% of those rehabilitated who were so compared with and circulatory conditions werereported in 10.9% of the group

10.5% of those rehabilitated.

311 and 9.1% were identi- There were 10,3c4 reportedto have mental illness fied in this category asrehabilitated. give some insightinto The following judgmentsof the case reviewers

146 cases. Individual case mobility the characteristicsand needs of these from the caseloadprior to rehabili- was the major reasonfor removing clients presumably most of them tation.Of these,32.2% moved to other locations, Division of VocationalRehabilitation. beyond the jurisdictionof the Montana judged too severe torehabilitate. In 13% of the cases,the disability was decision to close the casebased However, in just4.1% of all cases was the emphasizes the importanceof non-medical on medicalevidence, which further factors as determinantsof vocationalrehabilitation services. and by far Significant related problems werestudied in each case,

the part of theclient, 17.1%, the most prevalent waslack of interest on

and on the part ofthe family,13.0%. 6.2% of the cases.With the Age was given as asignificant factor in this is an areawhich will number of senior citizensincreasing constantly, Vocational Rehabilitationand re- require more attentionby the Division of 6.2%, and lack of clientfinances, lated agencies. Multiple disabilities, factors to failureto 5.5%, were also considered assignificant contributing considered a factor in8.2% achieve rehabilitation. Antisocial behavior was other than medicalservices, if these of the cases, whichindicates a need for

problems are to bedealt with. that rehabilitationcould In 39.7% of the cases,the reviewers judged

funds had been available. have resulted ifunlimited services and properly serve thosewho could Additional services deemednecessary to

special medicalsupervision, have been successfullyrehabilitated included

312 maintenance, social casework, family counseling, and vocational training.

Suitable vocational training was mentioned most often. A total of 30.8% of those needing additional services were in this category.

The reviewers agreed with the counselors' judgment in closing the clients in almost all cases, given the circumstances which prevailed at closing.Percentage of the reviewers' agreement with the counselors ultimate decision was 97.3%. This may be an indication of similarity of counselor-reviewer bias, or it may indicate a high degree of accuracy of judgment on the part of the counselor when the case was closed.The auestion becomes academic however when in-depth studies are conducted with all needed services and facilities available.

Actual cost to the Division of Vocational Rehabilitation was under

$2400 per client in 63% of the cases. This means that many cases received no service beyond the authorized physical examination and manyeither moved or effected other changes prior to extensive service.Another 9.6% were closed prior to the Division of Vocational Rehabilitation spending $50.00.

Expenditures in excess of $1,000.00 were made in 6.8% of cases. Most cases closed in this category were participants in a special project at Boulder, serving severely retarded clients.This factor also accounts for the three to one ratio of mentally retarded cases to other disabilities referred to previously.

In 56.8% of the cases involved, agencies other than the Division of

Vocational Rehabilitation expended funds.Of those receiving aid from other agencies, 25.3% were assisted by the Department of Public Welfare, while 58.9% did not identify the agency that had expended funds.

313 Of tho:,:e rehabilitated during the year,18% had referred themselves to the agency, and 15.6'0 were referred by other individuals(not agencies).

For the non-rehabilitated group, only 9% referred themselveswhile 23.7% were referred by other individuals. This would indicate that there was more motivation to succeed on the part of those who were interested enoughto initiate contact with DVR without intervention of a third party.

The study did indicate that success in rehabilitation could be substantially improved if Montana could provide many of the specializedservices that are available elsewhere.

TABLE 63 NON-REHABILITATED CLIENT CHARACTERISTICS CLOSED CASELOAD STUDY BY SEX

Non-Rehabilitants Rehabilitated Cases Sex NumberPercent NumberPercent Male 104 72.6% 429 69.6% 30.4% Female l 4o 27.4% 187

TOTAL 146 100.0% 616 100.0%

TABLE 64 RESIDENCE Non-Rehabilitants Number Percent Urban 106 72.6%

Rural 35',..'r 23.9%

lank 6 3.4%

...... TOTAL 146 100.0%

314 It is significant that according to the 1960 census, the proportion

of urban and rural residence in the state is almost evenly divided; 50.2% of

the state population was listed as urban at that time.* As it appears here,

the urban class far outnumbers the rural class.

What this means is that many rural residents are not adequately served

by this program or at least they do not get involved as readily as urban

residents. It seems unlikely that rural occunations would be as much 2ess

hazardous as the caseload study ratio might suggest.

TART.F65

AGE AT CLOSURE

A.e Number Percent of Total

60 & Over 2 1.4% 50 - 59 21 14.4%

40-49 20 13.7%

30 - 39 33 22.6% 20 - 29 47 32.2%

16- 19 17 11.6% Under 16 1 .7%

Unknown 3 2.1%

Blank 2 1.4%

TOTAL 146 100.0%

The median age for this group is 31.48. The median age for the whole state as of the 1960 census reports was 27.4 years. This shows that the age distribution for the closed caseload study is a bit older than the population as a whole. The majority of rehabilitated cases of the agency is in the34

*Urban residence as used by the 1960 census included all incorporated Places of 2,500 or above. It also includes all densely settled urban fringes, whether incorporated or unincorporated, of urbanized areas.

315 or younger age group,4=il of 616; 85 were in the 35 to 44 age group; 97 in the 45 to 64 age group; and only 3 were65 or over.

TABLELG

NUMBER OF DEPENDENT S PER CLIENT NON-REHABILITANTS

Dependents Number of Cases Percent of Total 1 13 8.9%

2 9 6.2%

3 - 4 10 6.8%

5 - 6 8 5.5%

Over 6 5 3.4%

Unknown 33 22.6%

Blank 68 46.6%

TOTAL 146 00.0%

The rehabilitants during this period had dependents as follows: 343 had none; 68 had 1 dependent; 129 had 2 or 3; and76 had 4 or more dependents.

The median number of dependents was 3.

TABLE 67

EDUCATIONAL LEVEL

Years Completed Number of Cases Percent of Total

Under 6th 10 6.8%

6-8 26 17.8%

9 - 11 26 17.8%

H.S. Diploma 39 26.7% Some College 4 2.7% ...- 2 Yrs. College 4 2.7%

B .A. 0 -

Unknown 33 22.6%

Blank 4 2.7%

TOTAL 146 100.0%

316 The median numner of school years evercompleted for the whole state

according to the 1960 census reports was11.6 years. Thus the group con-

sidered here may be slightly but notsignificantly below the presentstate median.

TABLE 68

DISABILITY CATEGORY

Number of all Number of Primary Disability Conditions Percent Conditions Rehabil- itated by DVR(1)

Orthopedic 45 30.8% 217 Arthritis 13 8.9% 17 Visual Impairments 11 7.5% 31

Amputations 5 3)4 35 Hearing Impairments 13 8.9% 41 Cardiac, Heart & Stroke 14 9.6% 67

TB & Other Respiratory 8 5.5% 12

Epilepsy 10 6.8% 16

Speech Impairments 13 1 8.9% 7 Diabetes 2 1.4% 13 Alcoholism 14 9.4 Drug Addiction 0 0.0% 0 Mental Illness 25 17.1% 29 Mental Retardation 26 17.8% 30

Delinquency 8 5.5% NA Habitual Criminal 1 .7% NA Other 82 56.2% 92

TOTAL 290 616

As can be noted, there was a preponderanceof "orthopedic" and "other"

disability conditions in the non-rehabilitated group.The total of 290 indicates

(1)Source: Form R301 fy 1966-67, Montana Division ofVocational Rehabilitation.

317 the high pre?alence of multipledisabilities in the group studied."Mental

Illness" and "Mental Retardation" are also freauentdisabilities in the group. A directcomparison with those closed as rehabilitatedby DVR in the

1966-67 fiscal year is not possible due to thereporting practice of that agency which indicatesonly a primary disability. However, the number of

Persons rehabilitated byprimary disability is presented forinformational

Purposes.It is known that many of therehabilitated group also have multiple disabilities.

TABLE69

REASONS NOT SERVICED TO SUCCESSFULCONCLUSION

Reviewer II Reason Reviewer I Number Percent NumberPercent

32.2% Client Moved 47 32.2% 47 - Client Deceased 6 - 6 Disability too Severe 17 11.6% 19 13.0% Multiple Disability 11 7.5% 2 1.4% 2.7% Disability Combined With Age 11 7.5% 4

Client or Family too Migratory 1 .7% - - Not Financially Able to Assist 2 1.4% - -

Alcoholism 10 6.8% 5 3.4%

Antisocial Behavior 4 2.7% 1 .7% Lack of Interest on Part of Family 1 .7% 1 .7% 1.9% Other 8 5.5% 16

TOTAL NUMBER 118 101

The six deceased members of thesample were not i.cluded in thetotal

and thus no percentages could becomputed for them.

The "Client Moved" category seems to be the mostimportant as a reason

for not completing services.

318 with Age,""Disability The "MultipleDisability," "Di ability Combined Assist" categories, aside from too Severe," and"Not Financially Able to inadequate financial resources medical considerations,have relationship to nature.If more needed to support the necessaryfacilities of a specialized counseling, and medical services were availablein the form of financial,

help, these people mayhave been rehabilitated. Behavior" while The categories related to"Alcoholism" and "Antisocial

which need additional not the largest in numberdefinitely point to areas

attention.

TABLE 70