The Impact of Supported Employment for People with Significant Disabilities: Preliminary Findings from the National Supported Employment Consortium

Home , Supported employment

Edited by: Grant Revell, Katherine J. Inge, David Mank, and Paul Wehman

http://www.worksupport.com/Main/monograph.asp

Edited by: Grant Revell, Katherine J. Inge, David Mank, and Paul Wehman

Foreword

Introduction

CURRENT TRENDS AND FUTURE DIRECTIONS FOR SUPPORTED EMPLOYMENT

Supported Employment: Critical Issues and New Directions By: Paul Wehman & John Brocout

Paying For Success: Results-Based Approaches to Funding Supported Employment By: Jeanne Novak, David Mank, Grant Revell & Dan O'Brien

Supported Employment: It's Working in Alabama By: Valerie Brooke, Howard Green, Dan O'Brien, Byron White & Amy Armstrong

IMPROVING STATE LEVEL IMPLEMENTATION OF SE

Empirical Evidence of Systems Change in Supported Employment By: Martha McGaughey & David Mank

The Quality of Supported Employment Implementation Scale By: Gary R. Bond, Jeff Picone, Beth Mauer, Steve Fishbein & Randy Stout

A Profile of Vocational Rehabilitation Interagency Activity Improving Supported Employment for People with Disabilities By: Susan M. Foley, John Butterworth & Amy Heller

Interagency Agreements Encouraging Supported Employment for People with Disabilities: Preliminary Report on Exemplary Practices By: Susan M. Foley & Joseph Green

EVALUATING POLICY INITIATIVES INFLUENCING SUPPORTED EMPLOYMENT

The Cutting Edge: State Policy Innovation and Systems Change By: Martha McGaughey & David Mank

Initiatives Influencing the Emergence of Results-Based Funding of Supported Employment Services By: Jeanne Novak, David Mank, Grant Revell & Nancy Semaitis

IMPROVING SUPPORTED EMPLOYMENT SERVICES AND OUTCOMES

Vocational Outcomes for Persons with Severe Disabilities: Design and Implementation of Workplace Supports By: Katherine Inge, Wendy Strobel, Paul Wehman, Jennifer Todd & Pam Targett

Personal Assistance Services: A Vital Workplace Support By: J. Michael Barcus, Michael West, Ed Turner & Grant Revell

Rural Routes: Promising Supported Employment Practices in America's Frontier By: Cary Griffin

Workplace Supports: A View From Employers Who Have Hired Supported Employees By: Darlene Unger

Workplace Supports in Practice By: Pat Rogan, Becky Banks & Michelle Howard

Supproted Employment and Natural Supports: A Critique and Analysis By: Paul Wehman & John Bricout The Impact of Supported Employment for People with Significant Disabilities: Preliminary Findings from the National Supported Employment Consortium

Edited by: Grant Revell, Katherine J. Inge, David Mank, and Paul Wehman

FOREWORD- Supported Employment:

Toward Reducing the Impact of Disability

Paul Wehman

Almost two decades have passed since the initial published reports began to appear on supported employment as a means to help people with significant disabilities become competitively employed. During these past 20 years, we have learned a great deal about what works in supported employment and what does not (Mank, Cioffi & Yovanoff, 1997). We have also learned that there are many challenging implementation issues as well as persistent philosophical differences that have created major barriers to full implementation. We have seen greater amounts of deinstitutionalization (Hayden & Albery, 1994), the closing of state institutions (Stancliffe & Lakin, 1999), the down sizing of sheltered workshops, the selective reallocation of funds targeted from segregated programs to integrated programs and a more significant voice given to people with disabilities via the statutes, as well as advocacy movement (Wehmeyer & Lawrence, 1995). We have seen changes in the way that persons with mental retardation are classified by the American Association on Mental Retardation (Luckasson, Coulter, Polloway, Reiss, Schalock, Snell, Spitalnik, & Stark, 1992) with a movement away from intelligent quotient labels derived from tests and a movement towards a description of supports, both level and intensity, that are required by individuals with cognitive disabilities. In fact, the "hot" term for the 1980s was supports, and this terminology has only been strengthened through the new "hot term" of self-determination.The implicit power of supported employment, supported education, or supported living, when intertwined with the philosophical depth of self- determination and free choice, is a powerful means of marrying the programmatic strategy (supports) with the philosophical foundation (self-determination).

What have we learned over the past 20 years? Well, the most significant contribution generated through the evolution of supported employment and other programs that define themselves in a context of supports is the demystification of disability or, put another way, the reduction of the impact of disability. When one thinks of disability, one immediately thinks of terms such as handicapped, impairment, unable to do, less qualified. These are the thoughts and perceptions of too many people in society. The gift of supported employment is to reduce the impact of disability, even if it is only during the time frame that the individual goes to work. Once that individual departs the workplace, she may well be forced into a situation where she has to "put back on" her physical disability or mental retardation label. For example, consider the case of Roseanne, an individual with a significant physical and cognitive disability. Roseanne has very limited speech and requires personal assistant services throughout the day. When Roseanne is working, placing security scanners on CDs in Wal-Mart's electronics department, earning $7.20 an hour, receiving health benefits, and participating in the profit sharing plan; she does not have a disability label. Roseanne, through the eyes of her coworkers and management, is non disabled, because they are depending on her to complete her task. Once the end of her shift arrives; however, she is totally dependent on the local transit system serving people with physical disabilities. In fact, once Roseanne wheels out of the Wal- Mart, she must "put her label on" again and be dependent. The more that the concepts of supports can permeate not only the human service system, but communities and society as a whole, the more infused into the mainstream of daily life will individuals with disabilities become.

Many people who are reading this have been in the disability field for many years. Their respective jobs may be in special education, rehabilitation, advocacy services, administration, psychology, or occupational therapy. The specific field really doesn't matter. What does matter is that all of us are vulnerable to a disability or an injury at any point in time. Many of us experience permanent injury or chronic illness or disability or live with loved ones who do. Disability, particularly significant disability, is the great equalizer across gender, race, and socio- economic status. The quickest road to humility is to experience significant disability. The quickest road out of significant disability is to experience supports from family, friends, and competent professionals who know how to interact with people in a dignified and non- patriotnizing way.

When we review the progress made in supported employment over the last two decades, we must always return to our core values. It is these core values that have defined not only supported employment, but have created the substantial spill over effect of supports equaling re-duction of disability. No one is independent. We are all interdependent (Condeluci, 1991). The concept of true independence does not truly exist. We may all feel that we are completely independent at one time or another in our life, but invariably we will need others to help combat the physical, emotional, and intellectual disabilities that crowd into our lives. Understanding that we are all interdependent helps pave the way for understanding the role and impact of supports in designing systems that can help elevate people to a higher level.

The core values that have permeated supported employment are inclusion, consumer choice and involvement, a career path, parity in wage and hour benefits, parity in work style options and choices and the opportunity to be employed in the quickest most efficient manner possible as opposed to being subjected to extensive day program, nursing home or other segregated program activity. Much of this activity is well meant, but neither the data nor the philosophical perspectives of the people who are effected the most are consistent with this type of service delivery arrangement. The time is long over due to cease segregated program services and to expand competitive employment opportunities.

The U. S. economy desperately needs more workers. Only recently the Chief of the United States Federal Reserve, Allen Greenspan, (Barrons Financial Magazine, June 28th, 1999) reported his concern that the number of available workers in the U.S. market was dwindling to a dangerously low level. Once the number of available workers drops to an intolerable level, wages must increase significantly to coax workers to come to work at different businesses. This creates substantial inflationary pressures. In a tragic irony, we have hundreds of thousands of individuals with disabilities that could work. The pending Work Incentives Improvement Act (S 331) will hopefully open up many more doors into business and industry for people with disabilities who have not worked before. It will provide major new provisions to work such as the following:

Those who become ineligible for Social Security disability benefits on returning to work could continue their Medicare coverage.

Those with disabilities could buy Medicaid coverage even if they took jobs and earned income that would otherwise disqualify them.

States could allow workers with disabilities to buy Medicaid coverage, even if they lost their eligibility for cash benefits because their medical conditions improved.

A pilot program would be created under which states could provide Medicaid to workers not considered disabled but who have physical or mental impairments that are "reasonably expected" to become severe if they lack health care. This pilot is controversial, because it involves conditions such as multiple sclerosis or HIV that could lead to disabilities in the future.

It increases training and job search programs for those with disabilities and provides assurances that cash assistance would resume if persons become unemployed.

Even with these positive forces and the ADA, I suspect that much more will still need to be done. Systems change at a local and state level, alliances with business, person-centered planning and self-determination when combined with a "supports" philosophy and a strong economy will ultimately propel persons with disabilities into the labor force. As we enter the new millennium, we must set our sights much higher, building on the volumes of new knowledge established over the past two decades. INTRODUCTION

- The National Supported Employment Consortium

The National Supported Employment Consortium (SEC) for the com-petitive employment of people with significant disabilities is designed to critically evaluate supported employment programs nationally and to provide technical assistance on exemplary programs and practices to state and local agencies. The SEC was formed in response to the January 31, 1997 Request for Proposals issued by the Rehabilitation Services Administration (RSA) for a National Scope Project on supported employment to:

Determine what has been learned from community-based and statewide systems change projects supported by RSA and other agencies and organizations in recent years;

Identify and assess new exemplary supported employment models and practices that have emerged from these projects; and

Provide technical assistance to States and other provider agencies based on these new findings.

The SEC project comes at a critical point in the development of supported employment. Since 1985, the Rehabilitation Services Administration (RSA) has funded fifty-five, 3-5 year, grants to develop state systems for supported employment services along with several community-based demonstration projects. There are many indications that these grants helped supported employment become a popular and effective method for assisting individuals with significant disabilities achieve a competitive level of community integrated employment. There are, however, frequent disparities across states and communities in the quality, effectiveness, and accessibility of employment opportunities and support services for people with the most significant disabilities. Outcomes for supported employment participants range from career oriented positions reflecting personal choice and pay well above minimum wage to poor quality jobs on the fringe of the competitive labor market paying marginal wages. In truth, the vast majority of the population for whom supported employment was originally targeted remains chronically unemployed.

This disparity in employment outcomes and continued high unemployment among people with the most significant disabilities point to many important questions. What are the best practices in the areas of consumer self-determination, employer partnerships, and work place supports that encourage meaningful employment outcomes? What are the identifiable and replicable policies and practices of state systems that routinely demonstrate the ability to accommodate the employment service and support needs of a full range of people with significant disabilities? How can Personal Assistance Services at the work site be funded effectively to support those who need these services to achieve their competitive employment goals? What are the funding designs that strike an effective balance in addressing the interests and needs of supported employment service recepients, funders, and providers? How can the continued challenge of inconsistent funding and provision of extended employment services be met, and what steps are needed to effectively tap underutilized funding sources for supported employment services such as the Home and Community Based Medicaid Waiver?

The dual purpose of the National Supported Employment Consortium is to address these and related questions through a variety of evaluation studies and to disseminate widely the results of the studies and information on exemplary practices. The SEC is administered by the Virginia Commonwealth University Rehabilitation Research and Training Center on Workplace Supports. Its membership includes the Indiana University Institute on Disability and Community, the Boston Children's Hospital Institute for Community Inclusion, Transcen Incorporated, Indiana University/ Purdue University Indianapolis, and the University of Montana Rural Institute on Disabilities, along with a number of additional national experts. Since its inception October 1, 1997, the SEC has initiated a variety of evaluation studies, conducted a series of national training sessions and published a variety of newsletters on best practices, sponsored a Summer Institute where direct service staff received intensive training, initiated a web-based certificate course that provides interactive in-service training, worked hand-in-hand with rural communities to develop supported employment opportunities, and provided a wide variety of prescriptive technical assistance that matched national experts with state and community level requests for assistance.

The fifteen papers contained in this current monograph reflect the breadth and depth of the SEC's evaluation activities and its intent to frame results in a practical, best practice oriented viewpoint. The papers in the monograph address supported employment issues and practices in four areas. First, in the area of current trends and future directions, Paul Wehman and John Bricout identify and analyze the full range of employment supports needed by persons with the most significant disabilities. Jeanne Novak and her co-authors describe the national trend towards more results based funding of supported employment and provide numerous recommendations for agencies considering this funding approach. Valerie Brooke and her co- authors describe the implementation of a results based funding design in Alabama that incorporated intensive in-service training on quality supported employment services. Second, in the area of improving state level implementation, Martha McGaughey and David Mank analyze the evidence of systems change in supported employment to date and the factors influencing that change. Gary Bond and his research team describe the initial results of their research efforts targeted at designing a quality of supported employment implementation scale that will help generate more meaningful employment outcomes. Susan Foley and her co-authors evaluate state-level interagency collaborative efforts in supported employment with a focus on exemplary practices.

In the area of evaluating policy initiatives influencing supported employment, Martha McGaughey and David Mank describe the policy framework within which systems change takes place, and Jeanne Novak and her co-authors identify the many public initiatives that are influencing the move to more results based funding designs. Finally, in the critical area of improving supported employment services and outcomes, Katherine Inge and her co-authors evaluate the results of a demonstration project that assisted individuals with very significant physical disabilities work competitively. The paper offers a number of best practice recommendations. Ed Turner and his co-authors provide insight into the challenges faced in securing and directing Personal Assistance Services by individuals who need this support to work competitively. Cary Griffin evaluates the factors influencing the provision of supported employment in rural areas and provides numerous best practice recommendations for improving the quality and effectiveness of these services. Darlene Unger reports on the results of research on how employers view workplace supports. Pat Rogan and her co-authors describe a qualitative research effort to evaluate workplace supports in practice with emphasis on maximizing supports available at the job site, and Paul Wehman and John Bricout conclude the monograph by discussing the blending of practices identified as natural supports into a workplace supports model of supported employment services.

This first monograph published by the National Supported Employment Consortium describes the initial set of results from a wide variety of evaluation studies that are works in progress. The monograph's range of authors and topics reflects the comprehensive nature of the SEC evaluation effort. The SEC is designed to provide a steady flow of information on critical issues and best practices, and future dissemination efforts will continue to use a variety of written, web- based, and face-to-face methods to assure wide dissemination of information on SEC evaluation efforts.

The Editors Supported Employment: Critical Issues and New Directions

By: Paul Wehman & John Bricout

Within less than a decade, the national number of people participating in supported employment in the U.S. has increased ABSTRACT from 9,800 to over 140,000 (Wehman, Revell, Kregel, 1998). McGaughey and her colleagues (1994) indicate that approximately This paper chronicles the 18% of all persons with developmental disabilities in adult day pro- background, history, and grams participate in some integrated employment. Many thousands philosophy associated with supported employment. The more are working for the first time in countries all over the world. emphasis has been on growth These are individuals who historically were confined to adult activity of participation by people with centers, sheltered workshops, nursing homes, and institutions. disabilities into competitive Competitive employment was not likely to be in their futures as long employment for the first time. as they participated in segregated employment. The use of trained In addition to this important background, the concept of employment specialists, informed coworkers, mentors, and work supports is introduced. technological supports, together with enlightened legislation such A taxonomy of government as the Americans with Disabilities Act (ADA), have greatly enhanced supports, business supports, the employment possibilities for people with significant disabilities. and consumer supports is Unfortunately, hundreds of thousands of people with disabilities still presented and described in detail. Supported employment remain left behind in segregated centers. Many more are on waiting as a vehicle to help persons lists for employment despite the fact that people with significant with disabilities is more viable cognitive, physical, and behavioral challenges have demonstrated than ever; however, more their competence in the workplace. power is continuing to flow These employment successes are not episodic nor isolated, into the hands of people with disabilities and business. In- neither are they confined to any one region of the country or the creasingly, these two groups world. As Table 1 on the following page indicates, the growth of are becoming the primary supported employment as a real work option has emerged over the decision-makers of employ- less attractive alternatives of segregation. ment choices and outcomes. Despite encouraging signs of change, the bulk of day program resources still serves to maintain people with significant disabilities in segregated work centers. Even though many individuals with disabilities and their families want integrated employment opportunities, the vast majority have been unable to sufficiently mobilize their communities to make this happen. There are many reports that indicate that people with disabilities want to work, ranging from anecdotal case studies to national survey analyses such as the Louis Harris Poll conducted in the U.S. in 1998.

1 TABLE 1 -- TIMELINE OF SUPPORTED EMPLOYMENT GROWTH AND EMERGENCE

1960 - 1970 1970 - 1980 1980 - 1990 1990 - 2000

Domination of sheltered Placement into real National acceptance Consumer empower- workshops/ adult work/competitive em- and growth of sup- ment philosophies and activity centers/ state ployment occurs at ported employment via ADA emerge as primary institutions for mildly selected university several federal laws disability issues. and severely disabled. centers on a research/ with funding in U.S. demonstration basis. Supported employment Well over 1,000,000 Expansion into ALL growth continues inter- persons in 5,000 segre- Focus on those with severe disabilities. nationally. European gated day programs in mental retardation Union of Supported Em- U.S. alone. only. All 50 states in U.S. ployment/World Associ- offer programs with ation of SEP emerges as Emergence of applied Emergence of the term 3,000 programs offering major force. behavior analysis as im- job coach. SEP option. portant training tech- Efficacy of SEP chal- nology. Expanded use of term Expanded use of job lenged by well en- normalization in- coach model. trenched adult day creased deinstitutionali- centers. zation. Growth is 10,000 to 100,000 persons (still Community business and leaves close to one natural supports given million in day programs much greater emphasis. in U.S.).

Real, integrated work as an option is an quately marshal their collective efforts to increase issue on which most will increasingly agree. All work opportunities (Wehman & Kregel, 1995). parties involved benefit from supported or com- The adult service systems in the world are deeply petitive employment. Such employment provides entrenched, and have been for several decades the individual with a disability with a real job, (Albin, Rhodes & Mank, 1994). To change this benefits, and the dignity that arises from gainful way of providing services, particularly in times of employment. The employer gets a good worker reduced funding and a serious fiscal crunch, is and receives specialized support to train and extremely difficult. Hence, there is an over- maintain the individual. The family will be able whelming necessity to market the positive attri- to see their family member in a fully competent butes of supported employment for people with role in the workplace. Finally, taxpayers will significant disabilities on a community level. spend less money than they would to support Unfortunately, we in the supported em- the individual in a segregated day program year- ployment community, and even more broadly in and year-out. The question remains: Why do within the greater disability community, have not the vast majority of individuals with mental and told our story well. We have not communicated physical disabilities remain in segregated day the successes of this approach, nor the positive programs? impact that work has on the lives of people who The answer lies partly in the inability of have historically been disenfranchised and written advocates and people with disabilities to ade- off as incompetent.

2 Article 1 As an interested society, we must get past in supported employment did not work at the the notion that people with severe disabilities are minimum wage level of $4.25/hour. This is unable to work and do not want to work. The based on 18,000 vocational rehabilitation purpose of this paper to provide an overview of closures in supported employment, which is supported employment, while considering how below the overall national totals in supported interventions in the workplace might best be employment of 140,000 persons (Wehman categorized and implemented as we move into et al, 1998). Supported employment earnings the year 2000. have been reported to be $114/week, per client on an average basis (Wehman et al, 1998). While this constitutes an increase of several hundred percent over wages earned QUALITY EMPLOYMENT prior to entering the program, annual wages OUTCOMES ranging from $5000-$6000 are not consistent with the programs intent for individuals Quality employment outcomes include to pursue meaningful careers. In addition, competitive wages, good fringe benefits (including heavy reliance on part-time jobs results in indi- health insurance), long-term retention, flexibility viduals with disabilities receiving few fringe in work schedules and the opportunity to get on benefits (health care or paid vacation). Table a career track. For most individuals with signifi- 2, on the following page, provides a summary cant disabilities, this level of employment outcome of the 1993 vs.1995 supported employment has not consistently occurred in rehabilitation outcomes for people with disabilities. programs. However, achieving quality employ- A commitment to employment oppor- ment outcomes is the avowed purpose of pro- tunities implies that all individuals who can grams that embrace supported employment, tran- benefit from vocational rehabilitation should sition from school to work, assistive technology, have equal access to quality employment pro- and other rehabilitation approaches. grams that are able to respond to their prefer- While supported employment programs ences and needs. However, many excellent have produced employment outcomes for rehabilitation programs such as supported em- participants that are superior to those produced ployment only have resources to serve a small by segregated employment programs, when con- percentage of individuals who could benefit sidered in absolute terms (Rehabilitation Services from the supports and services offered through Administration, 1995), many supported employ- local provider agencies. Persons with severe ment programs still yield employment outcomes mental retardation and mental illness, cerebral that have fallen short of initial expectations. palsy, or autism remain under-represented in Needed improvements in areas such as earnings competitive employment programs in relation and fringe benefits, integration in the workplace, to their overall level of participation in adult employer attitudes, job retention and job satis- day programs (Snyder, Temple, & Crowell, faction remain as concerns in supported employ- 1996; Budde, Youngbauer & Snyder, 1997). ment program evaluation. Furthermore, the Individuals who are severely disabled, display limited number of hours worked (averaging 25 inappropriate behaviors, or are merely viewed hours per week) is a stumbling block to greater as too challenging or expensive to serve have prosperity (Wehman & Kregel, 1995). been historically excluded from supported The Rehabilitation Services Administra- employment programs in many areas tions data in 1995 indicated that 28% of persons (Wehman & Kregel, 1995). 3 TABLE 2 -- SUPPORTED EMPLOYMENT OUTCOMES IN THE U.S. FOR FISCAL YEARS 1993 AND 1995 (PRELIMINARY DATA) Data Element FY 95 FY93

Number of participants in 139,812 105,381 supported employment

Type of supported employ- Individual placement: 77.4% Individual placement: 79% ment model Group placement: 22.6% Group placement: 21%

Mean average hourly wage $4.70 $4.53

Mean average weekly wage $114.43 $107.10

Mean average hours worked 23.8 22.5 weekly

Number of S.E. providers 3,690 3,739

Primary disability mental retardation: 61.5% mental retardation: 70.3% mental illness: 26.0% mental illness: 19.3% physical disability: 9.6% physical disability: 7.2% other: 3.1% other: 3.0%

Level of mental retardation mild: 51.9% mild: 47.0% moderate: 37.7% moderate: 40.1% severe/profound: 10.3% severe/profound: 12.9%

Use of natural support not available increasing 74% staying the same: 7% decreasing: 0% dont know: 18.5%

Natural supports are the not available frequently: 3.7% predominant source of sometimes: 33.3% extended services rarely: 29.6% dont know: 33.3%

capitalizing on workplace potential on the other. MOVING SUPPORTED EMPLOY- Too often the rehabilitation needs of workers with MENT TO THE NEXT LEVEL disabilities are identified without simultaneously acknowledging the many potential work supports As we review the progress that has been available with the assistance of employers. made to date, there is some reason to feel en- Frequently, we have not looked closely enough couraged. People with significant disabilities are at the different types of work supports that are beginning to work more, to earn better wages, available to individuals with disabilities in the and to be more empowered (e.g., Blanck, 1998). workplace. The use of a paid job coach has At the same time, we have tended to approach been heavily relied upon by many providers the needs of workers with disabilities and of em- often with success. Yet, we need to broaden our ployers from mutually exclusive perspectives of perspectives further. Table 3, shown on the addressing perceived deficits on one side, and following page, presents four major categories

4 Article 1 of work supports and the subcategories within These supports can all be identified, them. These categories include supports that implemented and evaluated in the workplace are agency-mediated, business-mediated, gov- environment. However, they will be initiated ernment-mediated, and family/community- usually from different starting points and mediated. with different entities mediating resources and services. A literature review is provided as basis for designing this taxonomy. What follows is a short literature review and discuss- TABLE 3 -- TAXONOMY OF WORK ion of each category of work supports. SUPPORTS

I. Agency Mediated Supports AGENCY-MEDIATED SUPPORTS 1. Job Coach Assistance (e.g., special- Since most human services funding ized training) 2. Assistive Technology for rehabilitation flows through a single, com- 3. Compensatory Strategies (e.g., mon agency, the agency that provides sup- memory aids) ported employment services is an important 4. Counseling 5. Substance Abuse Services starting point for examining workplace 6. Medical Services supports. One of the services that may be 7. Specialized Transportation 8. Vocational Rehabilitation Counselor provided by such agencies is to coordinate services with other entities, be they employers, II. Business Mediated Supports government or providers of specialized services 1. Job Restructuring 2. Workplace Accommodations such as mental health treatment, vocational l environmental modifications rehabilitation, or education. Historically, the l assistive technology rehabilitation agency mediated the flow of l task modification l schedule modification supports. There are a number of different types 3. Coworker Mentoring of supports mediated by agencies that are l job task training and support l social support reported in the literature. These various types 4. Job Creation of supports are listed below. 5. Employee Assistance Programs 1. Job Coach Support. The majority 6. Employment Consultant (hired by business) of the work support literature has focused on the job coach (individual placement) model III. Government Mediated Supports of supported employment. This approach was 1. Social Security Work Incentives l Plan for Achieving Self-Support initially presented by Wehman (1981) and l Impairment Related Work Experience further articulated by Wehman and Kregel 2. Tax Credits l Work Opportunity Tax Credit (1989). Since then, Bond (in press) and l Disabled Access Credit Drake (1998) have significantly built on this l Tax Deduction to Remove Transporta- approach, focusing on persons with psychi- tion and Architectural Barriers. 3. Medicaid Waiver atric disabilities. The process is the same, regardless of the population of consumers: IV. Family and Community Mediated provide support services at the job site, rather Supports 1. Personal Care Attendant than treatment-centered support at a clinic 2. Peer Mentors or elsewhere. Many researchers have written 3. Family Members as Job Developers 4. Friends and Neighbors supporting the job coach/individual place- 5. Social Support Networks ment approach (e.g., Bond, Dietzen, McGrew

5 & Miller, 1995; Kregel, Wehman & Banks, support for social interaction with co-workers 1989; MacDonald-Wilson, Revell, Nguyen & (Park, Simon, Tappe, Wozniak, Johnson & Peterson, 1991; Shafer, Banks & Kregel, 1991; Gaylord-Ross, 1991). However, other empirical Sinnott-Oswald, Gliner, & Spencer, 1991; evidence suggests that workers with a severe cog- Wehman, Kregel, & Cifu, 1994; Wehman, nitive disability seeking social interaction may Kreutzer, West, Sherron, Zasler, Groah, Ston- benefit more from a different modality of support, nington, Burns, & Sale, 1990). In fact, the indi- a communications book of pictures to stimulate vidual placement/job coach model of supported conversations (Storey & ONeil 1996). employment appears to be the predominant 2. Compensatory Strategies. Compen- practice of vocational service agencies in the satory strategies represent one avenue of support field as well and has been viewed as something for overcoming the gap that sometimes occurs of a gold standardof services for many persons between worker abilities and environmental with severe disabilities (Kregel, Hernandez & demands. Compensatory strategies are plans, Hock, 1997). behaviors, or materials that help workers with The empirical research literature has disabilities compensate for functional impair- demonstrated repeatedly that persons with severe ments. Certainly, others in addition to the agency mental retardation can work with job coach alone can initiate compensatory strategies as support (e.g., Parent, Kregel, Metzler, & Twardzik, supports. In fact, the person with the disability 1992; Parent, et al., 1994; Revell, Wehman, will usually be a driving force in selecting a com- Kregel, West & Rayfield, 1994; Test, Hinson, pensatory strategy. The person with the disability Solow & Keul, 1993). Job coaches have pro- will often help the agency or job coach identify vided equally effective support for persons with what compensatory strategies or tasks makes the different disability labels, such as severe physical best sense, given the situation and available disabilities, traumatic brain injuries or psychiatric resources. disabilities (e.g., Danley, Rogers, McDonald- Examples for workers with cognitive disa- Wilson, & Anthony, 1994; Inge, Wehman, Kregel bilities include memory aids or strategies, addi- & Sherron-Targett,1996; Wehman, Kreutzer, tional time to complete tasks, verbal rehearsals, West, Sherron, Diambra, Fry, Groah, Sale, & checklists, and location markers (Adelman & Killiam, 1989; Wehman & Revell, 1996). Per- Vogel, 1993; Briel, 1996). For persons with sons with different disabilities will require a some- traumatic brain injury, compensatory strategies what different approach or emphasis on the part for cognitive remediation can be achieved using of the job coach (Fabian, Waterworth & Ripke, systematic task analysis (Giles & Shore, 1989; 1993). For instance, persons with a psychiatric Kreutzer, Wehman, Morton & Stonnington, disability may need less skills instruction and 1988; Kreutzer, Gordon and Wehman, 1989). supervision time than workers with a cognitive The job coach conducts an intensive analysis of disability, but they may also need more advocacy all job tasks until the constituent parts can be and encounter greater stigma and isolation identified and listed sequentially. Compensatory (Danley, et al., 1994; Drake, Becker, Xie & strategies are then developed on the basis of the Anthony, 1995). Workers with different levels of task analysis and the employees abilities disability may also require different support stra- (Kreutzer, et al., 1988; Kreutzer, et al., 1989). tegies. For example, there is empirical evidence Compensatory strategies can be developed that to suggest that for workers with a mild cognitive match the individuals presenting problems by disability, social skills training is a powerful integrating information from several sources in a

6 Article 1 graduated process of testing and modification workers with severe disabilities in a competitive (Briel, 1996). An evaluation of learning and workplace (Storey & Provost, 1996). This de- memory abilities is conducted, followed by a situ- vice consists of pictures bound together in a ational assessment and on-site job training feed- book or wallet and used to facilitate conver- back, with employee needs, preferences, and sations with non-disabled co-workers. Two concerns an ongoing part of the process (Briel, workers with severe disabilities were able to 1996). Similar supports are possible using increase their number of interactions with non- assistive technology. Assistive technology can disabled co-workers in some circumstances be considered specialized supports aiding the using a communications book (Storey & consumer in his or her adaptation to the environ- Provost, 1996). ment. Assistive technology complements the In the realm of high technology devices, supports provided by specialized professional an 18 inch long head pointer, together with services, such as mental health education and an angled control panel and touch-sensitive treatment, and other disability-specific services. screen enabled a worker with cerebral palsy 3. Assistive Technology. One of the to operate a copy machine as part of his job most influential definitions of assistive technology (Smith, 1992). Another copier innovation, is provided by the Technology-Related Assistance an attached computer and voice synthesizer, for Individuals with Disabilities Act of 1988 (PL allowed a worker with a visual impairment to 100-407) (Wallace, Flippo, Barcus, & Behrman, operate the equipment (Smith, 1992). A 1995). The Act can be paraphrased as stating robotic device to assist workers with severe that with respect to employment, assistive tech- motor impairments significantly reduced the nology are low and high technology devices, amount of time per work unit that an assistant services, and adaptations that enable some per- was needed, although at some loss of pro- sons with disabilities to participate in, contribute ductivity (Birch, Fengler, Gosine, Schroeder, to and interact in work life in much the same Schroeder & Johnson, 1996). High tech- fashion as non-disabled co-workers. Although nology devices must sometimes be adapted agency-mediated supports are the focus of this to real-life situations that require a coordina- section, it is important to note that government, tion of efforts among machine, supervisor, and more particularly the federal government, is worker and co-workers. a major funding source for assistive technology In fact, the effectiveness of high tech- (Parette & Van Biervliet, 1992). Supported em- nology devices may hinge more upon employment provider agencies play a pivotal role ployer needs and worker preferences than the in assistive technology, because job coaches have sophistication of the device (Lash & Licenziato, considerable input in the selection, procurement, 1995). It is encouraging in this light to note implementation and evaluation of devices used that at least one study has found that job as work supports. Some illustrative examples of coaches can provide effective assessments of these work supports follow. assistive technology needs (Behrmann & Assistive technology can be either low- or Schepis, 1994). Apparently job coaches can high technology. Several examples from both will serve as an effective link between worker and make the picture of assistive technology clearer. employer in identifying and implementing One example of a low technology is a support assistive technology. Other specialists in already alluded to briefly, a communications addition to the job coach may be involved in book. Such a book was used to help integrate the identification and implementation of assis-

7 tive technology. Examples include: rehabilitation from mental health providers in accordance with engineers, technology specialists, occupational his disability-related needs and goals. Simon therapists and physical therapists (Behrman & receives counseling and medication from a men- Schepis, 1994; Cooper, 1995; Leslie, 1995). tal health provider in order to manage his illness. However, the job coach is well-situated to provide These treatments will help him achieve success the necessary coordination between specialists in his employment goal. Simon has just landed and customers. his preferred job and his job coach has deter- 4. Specialized Agency Services. Indi- mined that co-worker aid is a critical work support viduals with disabilities can also benefit from for success in his new job. The mental health multidisciplinary expertise in their adaptation to services Simon receives will enable him to have the competitive workplace. This holds true for successful social interactions with co-workers after disability-related functional impairments as well he has received some additional social skill as for the design and implementation of assistive training from his job coach. The job coach is technology. Some combination of resources and able to successfully complete social skills training coordination of efforts, between the employment with Simon, because the mental health treatments service provider and disability-related service pro- he is receiving has increased Simons receptivity. vider is desirable (La Rocca, Kalb & Gregg, As this example suggests, it is not only 1996). Examples of specialized, disability-related the employee who benefits from the efforts of the service providers include psychological coun- specialized service provider, so too does the job seling (Rosseler, 1988), substance abuse pro- coach. When the specialized provider services grams, medical programs, mental health pro- are provided separately from vocational services grams (Rogers, Anthony & Danley, 1989), taxi they are called brokered services. Particularly or shuttle transportation (Griffin, 1994) and de- with respect to psychiatric disabilities, brokered velopmental disabilities programs (McGaughey, services have been found to produce less effective Kiernan, McNally & Gilmore,1995). Vocational employment outcomes and poorer customer rehabilitation providers may play the same role service than integrated services (Drake, et al. in mediating disability-related specialized services 1995). Ideally, integrated services are charac- as supported employment providers. Nonethe- terized by seamless customer-centered services less, their roles diverge, inasmuch as it is possible and resources, together with cross-training and/ for a supported employment provider to act as or education of vocational and specialized service the specialized service provider for a vocational staff (Bybee, Mowbray & McCrohan, 1995; rehabilitation service. For the moment, however, Drake, et al., 1995; Drake, McHugo, Becker & supported employment programs and vocational Anthony, 1996). Several authors have suggested rehabilitation services will be considered equally that the employer is also a critical rehabilitation vocational service providers, with other pro- resource ( Flexer, Goebel, Baer, Simmons, viders lending their specialized expertise on the Maryonyi, Shell, Steele & Sabousky, 1994; management and treatment of the disability in Rhodes, Sandow, Taliferro & Mank, 1993). Posi- question. A hypothetical example of the way tive employment outcomes have been attributed vocational and specialized providers influence to both employer collaboration in developing the employment outcomes of workers with disabil- work supports (Rhodes, et al., 1993), and sus- ities may bring these issues into sharper focus. tained positive relationships with employers In this example, Simon, a worker with a (Cook, Razzano, Straiton & Ross, 1994). What psychiatric disability, receives specialized services about employment resources that are primarily

8 Article 1 mediated by the employer? This will be the topic grams, practices, policies and procedures for of the discussion that follows on business-medi- disabled workers are realized. ated supports. 1. Workplace Accommodations. Accommodations such as assistive technology, BUSINESS-MEDIATED SUPPORTS job modification, environmental modification, Even though agencies have traditionally job restructuring and schedule modification initiated the work support process, an ever in- can often be achieved at a low cost. It is esti- creasing number of professionals are concluding mated that about eighty percent of accommo- that employers should also be initiating work sup- dations cost $100-$500, while half the ports (Hanley-Maxwell, & Millington, 1992; accommodations cost little or no money Harper, 1993; Sandow, Olson & Yan, 1993; (Johnson, 1992). Moreover, the federal gov- Test & Wood, 1996a). Businesses are a vital ernment offers businesses tax incentives to source of in-house work supports including cover part of the cost of removing barriers people (e.g., supervisors and co-workers), prac- (Johnson, 1992). The cost of job creation, tices (e.g., flexible scheduling), policies (e.g., another accommodation possibility, could be early return to work), and environmental supports justified by seasonal variations in product de- (e.g., accessible work spaces) (Fabian & mand, the labor pool, or unmet company Leucking, 1991; Rhodes, et al., 1993; Shoe- needs. At the same time, free accommoda- maker, Robin & Robin, 1992; Sowers, Kouwen- tions, such as schedule modification, or job hoven, Sousa & Milliken, 1997). Businesses restructuring may contain a hidden cost in can also lead collaborations with human service the burden or perceived inequity that they im- providers (Rhodes, et al., 1993). As Golden pose on co-workers, supervisors and employers (1995) notes, businesses can tap into govern- (Frierson, 1990). The need to have business ment-sponsored services such as those provided personnel buy-in to work supports and ac- under the Job Training Partnership Act, federal commodations hints at why these individuals employment-related funding such as the Disabled are themselves important work supports. Access Tax Credit, and non-profit funds such as 2. Co-Worker and Employer Sup- those provided by the Association for Retarded ports. Co-worker support has been identified Citizens wage reimbursement program. as critical to the work performance and job A wide variety of programs designed to satisfaction of all employees, disabled and meet the support needs of workers with disabilities non-disabled alike (Curl, Hall, Chisholm & have been sponsored by businesses. Businesses Rule, 1992; Fabian & Leucking, 1991). An have entered into partnerships to hire and provide important dimension of co-worker support is supports for workers with disabilities with public social integration, which has been linked to entities, non-profit organizations, insurance com- both social support (important to job satisfac- panies, and with other businesses (Akabas & tion) and mentoring (important to job perform- Gates, 1993; Minao, Nalvern & Hoff; Taylor, ance) (Curl, Cook, & Clemmons, 1996; 1994; Tilson, Luecking & West, 1996). Finally, Gaylord-Ross, Park, Johnson & Lee, 1995; businesses have also contracted with employment Storey & Provost, 1996). In addition to pro- consultants and Employee Assistance Programs viding social support and mentoring, co- to provide work supports (Kiernan & McGaughey, workers can provide formal training for workers 1992). In each of these instances business is with disabilities and have done so successfully the mediator through which work support pro- in a number of circumstances (Curl, et al.,

9 1996). Supervisors and employers provide train- It is not known to what degree employers have ing and mentoring support as part of their role, implemented or even adopted such a policy, although in the case of workers with disabilities, although a 1992 study in Michigan found a they may provide more varied, extensive and/or minority of respondents had either adopted and/ intensive training than for non-disabled workers. or implemented such a policy (Shoemaker, Robin Supervisors and/or employers also provide work & Robin, 1992). supports such as flexible scheduling, task However, there have been several busi- modifications, job restructuring and job sharing. ness-sponsored projects that have successfully Studies have indicated that employers do not implemented the model of in-house hiring and object to providing additional task-related support support for workers with disabilities ( Miano, for workers with disabilities (Adelman & Vogel, Nalven & Hoff, 1996; Rhodes, et al., 1993). 1993). However, employers have reported objec- These projects used the supported employment tions to providing additional support of a per- and/or natural supports models ( Miano, et al., sonal or emotional nature (Adelman & Vogel, 1996; Rhodes, et al., 1993). For instance, one 1993). Another source of supports is found in corporation sponsored a project team of profes- specialized in-house and contracted disability- sionals and employees who assessed the work- related programs and policies. place environment for the special needs of a 3. Employer-Sponsored Programs and group of deaf workers (Berkay, 1993). The Policies. Return to work policies, disability case recommendations of this team resulted in a num- management and rehabilitation have been iden- ber of adaptations and accommodations and tified as cost-saving procedures for employers inspired a model called the Assessment Center because of the high costs of disability claims Deaf Exercise Adaptation Model (Berkay, and replacement labor (Taylor, 1994). Disability 1993). The professionals in this team served as management programs are one response to the paid consultants for the corporation. high cost of worker disablement (Akabas & Businesses also use paid professionals with Gates, 1993). Such programs seek to identify expertise in the issues affecting workers with disa- and manage job-related stressors, along with bilities in Employee Assistance Programs (Hanley- workplace environmental limitations in order to Maxwell & Millington, 1992). Employee Assis- create a productive fit between the requirements tance Programs (EAP) can be either in-house or of the job and the worker (Akabas & Gates, 1993; contracted. In addition to serving employees Akabas, 1994). Supervisory support, job accom- with a disability directly, EAP can be designed to modations, supportive policies, training, evalua- serve the front line supervisor and co-workers tion, and prevention are integral components of who have family members with a disability a successful disability management program (Kiernan & McGaughey, 1992). Research indi- (Akabas, 1994). cates that EAP provide effective supports to em- In addition to internal policies about family ployees with disabilities (Kiernan & McGaughey, and/or medical leave, there are two federal 1992). It is thought that the ADA will encourage statutes of importance to employers of workers the growth of employee supports for workers with with disabilities: the Americans with Disabilities disabilities, such as the EAP (Kiernan & Act (ADA) and the Family and Medical Leave McGaughey, 1992). Once again, as in the in- Act of 1993 (Akabas, 1994). The ADA has re- stance of the job audits, tax incentives, program quired an early return to work policy of funding and workplace disability policies, federal employers (Shoemaker, Robin & Robin, 1992). statutes and initiatives loom large. Government

10 Article 1 is both a source and a mediator of work supports. goal, based on a individuals reasonable It is to the topic of government supports that the expectations to perform the work, and the viability of the plan for achieving it, based discussion turns next. on the steps necessary to achieve the goal.

GOVERNMENT-MEDIATED SUPPORTS l Unless there is evidence to the contrary, Government mediated supports are those the Social Security Administrations PASS policies and practices that enhance the likelihood Specialists will presume an occupational goal to be feasible, and the plan for that persons with disabilities will find and/or main- achieving it to be viable, if any of certain tain employment. Examples of government sup- state or private professionals in the field ports include selected Social Security policies, of vocational rehabilitation and employ- U.S. Department of Treasury tax policies, civil ment develops the PASS. If the PASS Spe- cialists cannot approve a PASS, he or she rights legislation, and other laws targeting specifi- will discuss the matter with the individual cally the employment of persons with disabilities. as well as with the plans preparer. Consider, for example, the Targeted Job Tax Credit (TJTC), a law passed by Congress l Instructions regarding the limit on occupa- and administered by the U. S. Department of tional goals will make it clear that this limit is not the strict entry level limit that Treasury for the purpose of enticing employers to many, both in and outside of SSA, per- hire persons with disabilities. Zivolich and his ceive it to be. The SSA policy stipulates colleagues (1995) studied the effects of the TJTC that, within the business, trade, or pro- and found it to be a useful support. Similarly, fession the individual has chosen, the occupational goal cannot exceed the the Social Security Administration (SSA) has imple- earliest point on the career path that mented a number of supports to help support would generate sufficient earnings to individuals with disabilities who want to work. enable the individual to pay for his or her Referrals to state vocational rehabilitation own living expenses, uncovered medical expenses, and work-related expenses. services, trial work periods, continuing eligibility for Medicare, deduction of impairment-related l Allowable expenses for major purchases work expenses from taxable earnings, and devel- will not be limited to down payments. opment of a Plan for Achieving Self-Support Funds set aside for installment payments (PASS) are all strategic elements of an effort to will be excluded to the extent that the expense remains related to and supportive support and promote the employment of indi- of an approved occupational goal, and viduals with disabilities. Some of these incentives earnings do not negate the need to con- or supports have been difficult for many bene- tinue the exclusion. ficiaries to access or understand (See General l Accounting Office report, April, 1996) and thus The PASS Specialist will play an earlier and expanded role in the PASS applica- many of these supports have been underutilized. tion or review, and he or she and the cus- Only recently has there been another tomer will be able to communicate directly effort to greatly improve the viability of the PASS with each other throughout the process. program. SSA (Colvin, 1998) provided a new set of guidelines to make PASS supports more Medicaid and Medicare reforms at the viable. They include: federal and state levels also have very significant impact on health benefits and employ- l PASS evaluations and notices will make a ment for persons with disabilities, as well as clear distinction between the feasibility of the the way in which Medicaid funds are dis-

11 tributed. For example, in 1997, the Congress regulations provide for accessibility, non-discrimi- amended the Medicaid statute in order to make nation, greater integration and participation in funds for supported employment available for workplaces, in community facilities, in the use Medicaid-eligible clients who were not previously of public transportation, and in telecommunica- institutionalized and who wish to enter supported tion use. As a consequence of the ADAs success employment. This is a major government support in bringing about some of these outcomes, young that may open up the door to supported employ- adults have been able to participate in a world ment for 150,000 new clients (NASMRDD, that is less discriminatory against people with August, 1997). The Home and Community disabilities. The ADA is a critical government- Based Waiver can be seen as a major govern- mediated social policy that brings necessary ment support adopted by states across the nation support to the enhancement of employment (West, Revell, Kregel, & Bricout, 1999) opportunities for persons with disabilities. In 1994, 135,000 individuals partici- Under Title I of the ADA, employers are pated in MR/DD waiver programs, a tripling of prohibited from discriminating against otherwise the number of participants since 1990. State qualified individuals with disabilities during re- and federal outlays for those programs totaled cruitment, hiring, evaluation, promotion, or any $3.5 billion in 1994. Twice as many people facet of employment. Employers are further re- with developmental disabilities participate in the quired to provide reasonable accommodations HCB waiver program as reside in public MR insti- to enable qualified individuals with disabilities tutions (West, et al., 1999). By 1995, the num- to successfully perform their jobs. Such accom- ber of individuals who participated in MR/DD modations are to be provided to the extent that HCB waiver programs had exceeded the number the employer does not sustain undue hardship. served in Intermediate Care Facilities for persons Reasonable accommodations may include such with mental retardation (ICF/MR) of all types things as restructuring jobs or work schedules, (West, et al., 1999). States are continually in- modifying equipment or providing assistive decreasing the number of services and supports vices, providing an interpreter or reading aids, they are offering in their programs, including or improving the overall accessibility of the work- supported employment. The number of people site. Employers in violation of this law face the participating in mental retardation or develop- same legal penalties as those found guilty of mental disability (MR/DD) Home and Community discrimination based on gender or race. Another Waiver Based (HCB) programs likely will grow piece of federal legislation providing critical sup- at annual rate of 10-15% for the next three-to- ports to workers with a disability is the Technol- five years (West, et al., 1999). ogy-Related Assistance for Individuals with Disa- But perhaps the most far-reaching govern- bilities Act Amendments of 1994 (P.L. 103-218), ment support can be found in the Americans also referred to as the Tech Act was signed with Disabilities Act, a law passed in 1990 that into law on March 9, 1994. This law provides provides a host of civil rights and protections for access to assistive technology services and devices persons with disabilities. For example, in Title I for individuals with disabilities of all ages. of the ADA, employment access is ensured There are numerous specific purposes of through nondiscrimination protections in the the Tech Act which are: workplace. This act was followed by a compre- l hensive set of regulations published exactly one to provide discretionary grants to states to assist them in developing and implementing year later (Federal Register, July 26, 1991). These a consumer-responsive, comprehensive,

12 Article 1 statewide program of technology-related informal care that ranges from general psycho- assistance for individuals with disabilities of social support to job-related skills training all ages. (Prosser, & Moss, 1996; Turner & Alston, l to fund programs of national significance 1994; Urbain, 1997). The ethnic group and related to assistive technology. culture to which the person with a disability belongs may have an impact in how strongly l to establish and expand alternative financing family influences consumer life choices and mechanisms to allow individuals with disabilities to purchase assistive technology de- decisions, with some groups and cultures em- vices and services. phasizing independence more than others (Parette, 1997; Turner & Alston, 1994). Indi- With the passage and reauthorization of vidual differences and context (e.g., employ- the 1994 Tech Act, Congress acknowledged the ment) may also influence the degree of inde- powerful role that assistive technology can play pendence from family a person with disabilities in maximizing the independence of individuals displays (Mowbray, Bybee, Harris & with disabilities. This law has the potential to McCrohan, 1995). However, family continues open many new opportunities for individuals with to be an important mediator of various work disabilities and their families to receive appropriate supports (Killiam, Petranek & Harding, 1996; assistive technology services. The Tech Act places Kutty, 1993; Parette, 1997; Prosser & Moss, the emphasis on being responsive to the needs 1996). For instance, family members have of consumers and their families. an important role to play in the selection and The state grants program under Title I of implementation of assistive technology devices the Act served a catalyst for statewide systems and services (Parette, 1997). Parents have change to increase access to appropriate assistive successfully managed a supported employment technology devices and services. These funds program for persons with severe disabilities were used to support systems change and advo- (Killiam, Petranek & Harding, 1996). Parents cacy activities to increase the availability of assis- trained by professionals have also been in- tive devices and services (Barcus, et al., 1995). volved in providing vocational services at community-based programs (Kutty, 1993). CONSUMER AND FAMILY- On the basis of experience from six pro- MEDIATED SUPPORTS jects nationwide, Urbain (1997) of the PACER In a consumer-driven system of human organization in Minneapolis formulated a services, persons with disabilities should be the comprehensive approach for parental involve- true customers of supported employment. Brooke ment in fostering natural supports in the sup- and her colleagues (1995) outline a series of ported employment process. She envisions steps and strategies for consumers and families parents as both facilitators and skills trainers. that help them take more power and responsibility For instance, as facilitators, parents can use for the supports they need. But as will soon their unique access to interpersonal networks, become evident, the literature on this topic is including relatives, neighbors, friends, business still developing. contacts and others to provide the job developer 1. Family Supports. Families play an with a broader range of employment possi- important role in the quality of life, adjustment bilities (Urbain, 1997). Parents can also act and health outcomes of persons with disabilities as skills trainers by actively encouraging (Kelly & Lambert, 1992). Families can provide successful work-related behaviors at home,

13 such as timeliness, task completion and following disabilities, including many with mental retarda- instructions (Urbain, 1997). tion (Budde & Bachelder, 1986). Increasing the However, it is not easy to generalize about employability of persons with disabilities has the relationship of family support to actual em- always been one goal of independent living, ployment outcomes. In fact, the influence of within the broader goals of consumer decision- family support on employment outcomes appears making control and community participation to be uneven. Some investigators have found (Asher, et al., 1988; Asher, Asher, Hobbs & positive associations of family support to favorable Kelley, 1991), or as it is sometimes called total employment outcomes (see Kelley & Lambert, rehabilitation (Boland & Alonso, 1982). 1992; Siegel & Gaylord-Ross, 1991); others Personal attendants, also called personal have reported negative associations of family sup- care workers, are vital to successful independent port to favorable employment outcomes (e.g. living for many consumers (Atkins, Meyer & Smith, Mowbray, et al. 1995). Further research needs 1982). Personal attendants make it possible for to take place that clearly specifies the degree of persons with disabilities to live in their own resi- collaboration between family and supported em- dence and to work in the community (Budde & ployee, as well as specifying what constitutes Bachelder, 1986). Attendants help consumers family support, before any conclusions can be with domestic chores, personal hygiene and drawn on the influence of different kinds of family dress, cooking, and other daily living tasks (Asher, support on employment outcomes. It has already et al., 1991; Budde & Bachelder, 1986). The been suggested that the interpersonal supports services of the attendant can also be modified to available to individuals with disabilities extend include the role of advocate, advisor or coach beyond family to include co-workers, superviors (Budde & Bachelder, 1986). and mentors with a stake in their employment Personal care decisions are an important success. Peers and other friends and acquain- domain for consumer self-direction. That is, in tances may also have an important role to play making personal care decisions, and in directing in providing work supports for persons with their own personal care, persons with disabilities disabilities (Kelly & Lambert, 1992). have the opportunity to exert choice and control 2. Consumer, Friend and Peer Sup- in a critical area of their lives with direct conse- port. One important force in enhancing the quences for employment, as well as overall quality working potential and choices of persons with of life (Asher, et al., 1991). This consumer-driven disabilities is found in the independent living approach is known as the consumer model of movement. The independent living movement attendant care, in which the person with the for persons with disabilities grew out of a desire disability is responsible for the decision making to increase the autonomy and community partici- and administrative tasks, including attendant re- pation of persons with disabilities (Asher, Asher, cruitment, hiring, training and management Hobbs & Kelley, 1988). Independent living was (Asher, et al., 1988; Asher, et al., 1991). At the intended to provide a barrier-free, self-directed other end of the spectrum, the agency model environment and an alternative to institutionali- of attendant care locates all decisions and re- zation, medicalization and dependence (Boland sponsibilities in the agency (Asher, et al., 1988; & Alonso, 1982; Budde &Bachelder, 1986). Asher, et al., 1991). Both models are practiced Independent living was first conceived of as a to varying degrees in the community, allowing model for persons with severe physical disabilities, the consumer a continuum of choice-making but came to serve persons with a wide range of and control (Asher, et al., 1988; Asher, et al.,

14 Article 1 1991). A consumer focus would suggest that employment experience (Guay, 1994). On persons with disabilities have access to the atten- the job site, employees with disabilities may dant care model. This is because this model receive help from co-workers on the basis of maximizes individual decision-making and con- perceived friendship, rather than as a col- trol while providing needed support. lateral duty or shared obligation (Gaylord- Consumers with a psychiatric disability Ross, et al.,1995). Transportation is another and their peers have contributed directly to their work support that may be provided by friends own work adjustment through the model of psy- as well as family (Parent, et al, 1994). chosocial rehabilitation. In the psychosocial Admittedly, people with disabilities, rehabilitation model, consumers determine what their families, friends and community may not their goals are for functioning in the community always share the same perspective, or objec- and how they will achieve them (Peterson, Patrick tives. In the context of this discussion, the & Rissmeyer, 1990). This rehabilitation takes employment supports provided by each of place in psychosocial club-houses, facilities these parties is conceived as serving con- in which consumer members and professional sumer-centered goals and objectives. Re- staff work together to create an environment that gardless of the good intentions and consumer fosters the skills necessary to function successfully focus of others, individuals with disabilities in the community (Barker, 1994; Peterson, Patrick must still negotiate with their interpersonal & Rissmeyer, 1990). Prevocational skills and support systems. As members of family groups, even transitional employment may be offered work organizations, and a broader com- through such club-houses in addition to community, people with disabilities have to recon- munity support and social relationships (Peterson, cile competing tugs toward dependence and Patrick & Rissmeyer, 1990; Dougherty, 1994). independence, just as their non-disabled peers In a related vein, mutual peer support and self- must. The work and career goals they pursue help in a joint consumer-professional employ- are undertaken in a framework that requires ment project using a Self-help Employment both choice and compromise. What must Center enhanced the vocational rehabilitation not be compromised; however, is the ability of a group of individuals with serious psychiatric of the consumer to realize an employment disabilities (Kauffmann, 1995). situation that they find satisfying. The efforts Persons with disabilities have also suc- of family, friends, disabled peers, community, cessfully implemented and used a program of agency, business, and government must have self-directed personal services while employing the needs and aspirations of the individual personal assistants and others (Asher, et al., with a disability as their focus for this goal of 1991). Friends and family members may provide consumer satisfaction to be achieved. job leads or job networks through informal contacts (Wehman, Kregel, & Seyfarth, 1985). Community contacts and advocates can also provide job developers with critical referrals for per- KEY POINTS TO REMEMBER IN sons with disabilities (Nietupski, Verstegen, DESIGNING A SUPPORT Hamre-Nietupski & Tanty, 1993). In one demon- SYSTEM: CONCLUDING stration project, community members provided REMARKS various rehabilitation supports to persons with The use of community and workplace psychiatric disabilities, including limited pre- supports in the provision of supported employ-

15 ment services represents the state of the art of enjoy all of the same benefits as other employees what we know today in how best to support indi- of the company. Most importantly, they should viduals with severe disabilities in the competitive be able to choose these characteristics of their jobs of their choice. Empirically-based, inno- jobs, with the freedom to change their minds as vative support strategies and technologies, such their needs and preferences dictate. as those described previously, may better meet 3. The reliance on community and work- the needs of all individuals who would like to place supports is not an all-or-nothing, sink-or- work and receive assistance from supported em- swim approach, but rather one of the supportive ployment. However, as the field of supported features of the existing supported employment employment prepares to move to this next level, model. The job coach is responsible for imple- several critical caveats must be kept in mind. menting all of the services characteristic of the 1. The utilization of community and work- consumer assessment, job development, job-site place supports is not a panacea for correcting training, and ongoing, follow-along phases of all of the shortcomings observed in supported supported employment. However, the idiosyn- employment implementation. It will not fix all of cratic needs of individuals for different types of the inconsistencies in service delivery, the lack assistance, and for varying levels of support in of funding resources, the shortages of skilled job the employment process are respected and ad- coaches, the disincentives for conversion, the dressed by supported employment. The type of interagency turf issues, the large numbers of support an individual receives to meet each of persons on waiting lists for services, or the poor these needs, and the way it is provided can be quality outcomes reported for some supported decided by that person, using some of the strate- employment participants (e.g., low wages, inade- gies and supports outlined in this manuscript. quate integration, paucity of hours, lack of career For example, an individual with extensive advancement). What the new perspective on job-site training needs may choose to have a innovative strategies for support will do is to place co-worker teach one task, the job coach teach consumers in the drivers seat, allowing them to another, her parents arrange transportation, the direct their careers and truly choose the type and rehabilitation counselor purchase uniforms, a amount of assistance they would like to receive friend assist with managing her paycheck, and to achieve their career goals. the cafeteria personnel help with taking lunch 2. The basic premises on which supported and breaks. A supervisor could monitor her work employment was established have not changed, performance as a function of time spent in train- despite the expansion to include new service tech- ing. Meanwhile she might have the job coach nologies. People with disabilities want to work accompany her for social events on the job and in real jobs, and supported employment offers after work hours. Also outside work hours, a the means for achieving this goal. No support Social Security consultant might assist her with strategy or methodology, regardless of how good writing a Plan for Achieving Self-Support (PASS). it sounds, should compromise the values of em- 4. With the advent of new and creative ployment integration, participation and choice support technologies, the job coachs role is not upon which this vocational model was based. eliminated, but remains an essential element. It Individuals have the right to be employed by is evident that existing community and workplace community businesses where they can earn supports do not automatically meet the needs of comparable wages, work side-by-side with their individuals with severe disabilities. People were co-workers, receive adequate hours of work, and not working before the establishment of supported

16 Article 1 employment, and many more who could be the experience, ideas and feedback of the employed with proper supports are still unem- person with a disability, adequate and appro- ployed due to a lack of services. This situation priate work supports will not be developed does not mean that individuals cannot benefit and implemented. Moreover, the very notion from the assistance provided by different support of work support as something that enhances resources. Rather it suggests that help grounded the employment success of an individual with in practice experience, empirical research and a disability is meaningful only if it responds to first principles (e.g., consumer-focused) is needed the aspirations, abilities and enthusiasms of to marshall that assistance in a meaningful way the consumer, by whom success is measured. to meet particular support needs. The job coach Again, the focus is on the consumer as the is the one constant person who possesses the first and most basic mediator of work supports. skills to be able to identify and develop support The consumer focus is not a new focus, resources. It is the job coach who is most skilled rather it represents a salutory return to funda- at assisting consumers with accessing needed mental supported employment values and services, evaluating their effectiveness, and practices, which put the success and interests arranging alternative provisions as the need of the person with the disability first. Only with arises. the collection of empirical data and experi- As important as the job coach is to the ence, accumulated over time, has it become success of work supports, and as critical as the possible to determine which strategies and technologies and strategies of work supports are, supports help realize the promise of supported all of these hinge on the active participation, employment for consumer success, choice, and even leadership, of the consumer. Without and satisfaction.

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Wehman, P., Kreutzer, J., West, M., Sherron, P., Diambra, J., Fry, R., Groah, C., Sale, P., & Killam, S. (1989). Employment outcomes of persons following traumatic brain injury: Pre-injury, post-injury, and supported employment. Brain Injury, 3 (12), 397-412.

Wehman, P., Kreutzer, J., West, M., Sherron, P., Zasler, N., Groah, C., Stonnington, H., Burns, C., & Sale, P. (1990). Return to work for persons with traumatic brain injury: A supported employment approach. Archives of Physical Medicine and Rehabilitation, 71(13), 1047-1052.

Wehman, P., & Revell. W.G. (1996). Supported employment from 1989 to 1993: A national program that works. Focus on Autism and Other Developmental Disabilities, 11(4), 235-242.

Wehman, P., Revell, W. G. & Kregel, J. (1998). Supported employment: A decade of rapid growth and impact. American Rehabilitation, 24 (1), 31-43.

West, M., Kregel, J., Hernandez, A., and Hock T. (1997). Everybodys doing it: A national study of the use of natural supports in supported employment. Focus on Autism and Other Developmental Disabilities, 12 (3), 175-181, 192.

West, M., Revell, G., Kregel, J., & Bricout, J. (1997). The medicaid home and community-based waiver and supported employment. American Journal of Mental Retardation, 104 (1), 78-87.

Zivolich, J.S. & Aivilich, S. (1995). If not now, when?: The case against waiting for sheltered workshop change over. Journal of the Association for Persons with Severe Handicaps, 20, 311-312.

24 Paying for Success: Results-Based Approaches to Funding Supported Employment

By: Jeanne Novak, David Mank, Grant Revell, & Dan O’Brien

Societys increased emphasis on accountability in government ABSTRACT and expectations for results are changing the landscape for public funding of social programs in the United States. This move toward Increasingly, state Vocational greater accountability is evidenced by the emergence of the Govern- Rehabilitation and other agencies purchasing sup- ment Performance and Results Act of 1993, the National Performance ported employment services Review and the Government Accounting Standards Boards (GASB) are utilizing results-based Performance Measurement System. In a previous paper, Novak, funding methods. In this anal- Mank, Revell and Zemaitis (1999) describe these recent government ysis, issues and concerns related to the design and imple- initiatives, and how increasing emphasis on results may affect voca- mentation of results-based tional rehabilitation and funding of supported employment services. funding methods for sup- In addition, the paper reviews the underlying rationale for results- ported employment are dis- based funding of employment services for persons with disabilities cussed. Results-based funding is compared to traditional and compares it to more traditional, process-oriented funding meth- funding approaches, particu- ods. The purpose of this paper is to discuss the diversity of results- larly hourly fee-for-service, the based funding (RBF) approaches being used in supported employ- most commonly used supported employment funding ment, describe concerns that have emerged about these approaches, strategy. Examples are given and offer recommendations for effectively addressing these concerns. of the diversity of RBF ap- State Vocational Rehabilitation (VR) agencies purchase em- proaches currently being used ployment services from providers using a variety of purchase of service to fund supported employment services. The concerns (POS) arrangements such as cost reimbursement, slot-based, fee- that must be addressed if RBF for-service, and results-based funding. The distinguishing feature of is to reach its potential as a RBF is that a portion of a providers compensation is contingent funding strategy are analyzed, upon the achievement of specified outcome performance measures. and specific recommendations are given for structuring In contrast, more process-oriented traditional funding approaches, results-based funding mech- such as fee-for-service, base payment on units of service delivered anisms in a way that balances rather than specific outcomes achieved (Novak et al., 1999). the interests of the individual Supported employments emphasis on competitive employment with a disability in need of supported employment services, outcomes aligns well with the core principles of results-based funding. the community rehabilitation Emphasis on outcome accountability, data systems to track progress program potentially pro- towards defined goals, and primary attention to participant choice viding these services, and the funding agency paying for the are all notions congruent with supported employment and results- services. based funding. However, as the number and variety of specific results-based funding methods for supported employment being

25 implemented continue to grow, there are legiti- emphasis on valued outcomes; increased ac- mate questions being asked. For example, will countability for results; increased cost efficiency RBF make it more difficult to serve people with and effectiveness resulting from streamlined significant disabilities who are viewed as unlikely service delivery; and increased consumer choice to achieve successful employment outcome or and satisfaction. Each of these benefits will be have a need for extensive services to be success- discussed in turn. ful? Will RBF jeopardize high quality job matches Increased emphasis on valued out- in the interest of earning quick payments for comes. The goal of employment services is to securing job outcomes? Will career development deliver valued participant outcomes. Purchase lose emphasis? Will providers be discouraged of service arrangements in supported employment from pursuing creative job opportunities because have historically involved payment to provider of concerns that costs associated with prescriptive agencies for time spent in the employment pro- and intensive services and supports will not be cess. RBF presents a relatively new philosophy of covered by established outcome payments? provider compensation. A RBF approach com- In this paper, we address these questions pensates the provider when program participants and other issues related to the design and attain successful employment outcomes, rather implementation of results-based funding methods than reimbursing the provider for the amount of for supported employment. Results-based funding services it delivers. The ultimate measure of a is compared to traditional funding approaches, programs success is not the array or number of particularly hourly fee-for-service, the most com- services it provides but the extent to which it pro- monly used supported employment funding stra- duces results valued by those being served, the tegy (Revell, West, Cheng, 1998). Examples funding agency and society. are given of the diversity of RBF approaches Fee-for-service arrangements may have being used to fund supported employment ser- the unintended consequence of producing dis- vices. The concerns that must be addressed if incentives to consumer independence. At a basic RBF is to reach its potential as a funding strategy level, hourly billing tends to bear an inverse rela- are analyzed and specific recommendations are tionship to consumer independence: the more given for structuring results-based funding mech- independent the individual, the fewer units the anisms in a way that balances the interests of provider can bill. It may often be in the providers individuals needing supported employment best fiscal interest to emphasize billable hours services, the communitys rehabilitation program rather than working toward successful, long-term potentially providing these services, and the employment of the individual (OBrien & Cook, funding agency paying for the services. 1998). This creates a dilemma between the supported employment philosophy of decreasing dependence on the provider and the very real financial pressures to maintain billable hours. RBF THE CASE FOR RESULTS-BASED helps to resolve this inherent paradox by tying APPROACHES TO PURCHASING payment to successful employment outcomes. SUPPORTED EMPLOYMENT Increased accountability for results. SERVICES Recent government-wide initiatives have empha- Results-based funding strategies offer a sized a need for a fundamental shift in the system number of anticipated benefits over traditional of accountability in federal government from one funding strategies. These include: increased oriented around accountability for processes and

26 Article 2 inputs to one that measures performance and is based funding has the potential to de- accountable for results actually achieved (Gore, emphasize regulation, accounting, and micro- 1993, p. 17). Despite the successes of supported management of provider operations. Providers employment, it has operated in an environment will be granted greater flexibility in program in which accountability for following rules and administration in return for greater account- regulations has often taken precedence over ac- ability for program performance. Documen- countability for outcomes. In the early days of tation of time spent delivering services, a pri- supported employment, before the costs of mary reporting emphasis in a fee-based achieving outcomes (including the variability of system, is de-emphasized in RBF. Greater flexi- those costs) were known, it is not surprising that bility in service methods with less emphasis on funding was based on service delivery costs in- documentation and regulation should encour- curred by providers. RBF emerges at a time in age more cost efficient and effective service the history of supported employment when more delivery. data about outcomes and costs are available. Increased consumer choice and sat- The availability of historical cost data, combined isfaction. Results-based approaches to with efforts to improve employment outcomes for funding are expected to result in a stronger people with the most significant disabilities, make focus on participant outcomes and more effec- supported employment a likely point of discussion tive service delivery. In all likelihood, these fac- for results-based funding options. tors will lead to the achievement of more timely RBF provides incentives for provider outcomes for program participants, and hence, agencies and VR agencies to become more increased satisfaction with the system. It is im- outcome-oriented. Emphasizing agreed upon portant to note; however, that increased satis- results should increase accountability for aligning faction and choice are only possible if (1) there resources to achieve those results (Lessinger, is an individualized planning process in place 1971). While this may create added apprehen- that thoroughly involves the person with a sion when how to deliver outcomes is not disability and their circle of family and friends; specified, it can also foster creativity in service (2) the individual is supported to explore a design and provision. Gianakis (1996) notes range of job opportunities and career options; that the use of program outcome measures in and (3) the outcomes indicators defined by the resource allocation process encourages man- V.R. accurately measure the individuals satis- agers to focus on the results of programs and faction with the job, the services and supports increases their capacity to apply professional received, and the ongoing support plan. discretion in deciding how inputs will be used to These four anticipated benefits of results- achieve targeted results (p. 141). based funding provide the intriguing possibility Streamlined service delivery and im- of improving service quality and consumer sat- proved cost efficiency and effectiveness. One isfaction while at the same time increasing effi- promise of results-based funding is that there is ciency and cost effectiveness. RBF approaches less emphasis on bureaucracy. Osborne and hold the promise of increasing the satisfaction Gaebler (1992) define bureaucratic waste as of a variety of stakeholders, creating a win, people working hard at tasks that arent worth win, win situation for V.R., providers, and pro- doing, following regulations that should never gram participants. However, depending on the have been written, and filling out forms that perspective, historical context, and formal and should never have been printed (p. 23). Results- informal objectives of an individual funding

27 agency implementing results-based funding, service and results-based system components. different perceived benefits might take precedence Because the anticipated benefits, potential con- in the actual design of the RBF system. For ex- cerns, and recommendations addressed in this ample, a funding agency with a specific intent paper apply to all funding systems for supported to lower costs might weight its approach more employment that include an outcome-based heavily towards cost efficiencies to the possible component, we refer to any such system as a detriment of service effectiveness and consumer RBF system (even if the predominant component satisfaction. The diversity currently found in RBF of the funding system is fee-for-service or another of supported employment reflects the multiple non-results based approach). Therefore, a perspectives and objectives involved in their funding system designated results-based may implementation. The next section of this paper have (a) a results-based payment structure with explores this diversity found in current applica- no other payment mechanism included or (b) tions of RBF for purchasing supported employ- results-based component blended with other payment services. ment components (most likely fee-for-service). A useful framework for understanding the distinctions between funding systems is to look at the way in which funding mechanisms for supported DIVERSITY OF RESULTS-BASED employment services are developed. FUNDING APPROACHES Developing a funding agreement for the purchase of supported employment services in- Revell and his associates (1998) discuss volves three common elements: defining the spe- in detail the variety of funding designs used for cific services to be provided, defining the unit of the purchase of supported employment services. service, and establishing a cost for the service A results-based funding approach is defined as unit (Revell et al., 1998). The process for devel- any purchase-of-service arrangement that ties at oping the results-based component of a funding least a portion of a providers compensation to system, even with wide variety of existing RBF the achievement of outcome performance mea- applications, can be described in similar terms sures. Results-based funding designs link provider and involves the following steps. payments to pre-defined participant outcomes. For example, the provider may be reimbursed l Define the desired service outcomes. $1000 when the vocational assessment is completed, $2000 when the service recipient begins l Define the payment point(s) (i.e., benchmarks) for each service outcome, including criteria a job, and $3000 when this individual reaches for determining achievement of each bench- stabilization on the job. The provider receives mark. payment only if the service recipient successfully achieves a defined outcome. l Establish a fee for each payment point. A single funding system for supported employment may comprise one or more funding Table 1 on the following page illustrates RBF approaches (e.g., fee-for-service, slot-based, systems for supported employment developed in results-based). A system that incorporates more Oklahoma (OK), Massachusetts (MA), Kentucky than one funding approach is referred to as a (KY), and Rhode Island (RI). These state examples blended funding system. A blended system may represent the diverse range of RBF funding ap- include, for example, a combination of fee-for- proaches in use. The OK approach is strictly

28 Article 2

TABLE 1 -- DESIGNING A VR FUNDING SYSTEM FOR THE PURCHASE OF SUPPORTED EMPLOYMENT SERVICES: RESULTS-BASED FUNDING EXAMPLES 3. Establish Fee Per 1. Define Services or 2. Define Service Units or Service Unit or State Service Outcomes Payment Points Payment Point Oklahoma Assessment benchmark: Completion of Assessment 10% of bid (for DD benchmark: population) Placement Placement 15% of bid 4-week retention benchmark: 4-wk. retention 15% of bid 10-week retention benchmark: 10-wk. retention 15% of bid Stabilization benchmark: Stabilization 20% of bid Closure benchmark: Closure 25% of bid Massachusetts Assessment benchmark 1: Plan for Assessment $520 benchmark 2: Assessment Report $780

Placement benchmark 1: Career Plan $1,400 benchmark 2: Placement $1,400 benchmark 3: 30-day retention $700

Initial Employment Supports benchmark 1: 30-day retention $1,480 benchmark 2: Stabilization $2,220

Addi tional Support (or time increment: Hour variable hourly rate substitute for other service components) Kentucky Assessment time increment: Hour $30/hr. ($750 cap) Job Development time increment: Hour $30/hr. ($900 cap) Placement benchmark: Placement $3,000 Addi tional Support time increment: Hour $30/hr Rhode Island Assessment benchmark: Complement of $400 Assessment

Job Development & benchmark 1: Memo of Understanding $500 Placement benchmark 2: 1-month retention $800

Training & Ongoing Support time increment: Week $200/wk. (20 wk. cap)

Addi tional Support (beyond time increment: Hour $15/hr. other defined services)

NOTE: The table presents a summary of four state VR funding systems. It is not intended to provide a complete description of these systems. results-based; MA is predominantly results-based a two-year pilot in 1996 and is now a state- with an option for an hourly service component; wide funding option for community-based em- and KY and RI are blended fee-for-service and ployment services. Kentucky implemented its results-based system designs. Oklahoma began RBF system in 1995 and revised it to the current a series of expanding pilots in 1992 with full blended RBF and fee-based system in October, statewide implementation in January, 1997; the 1998. Rhode Island implemented its RBF sys- Massachusetts RBF system was implemented as tems statewide in 1991, and it is currently

29 being revised. The steps for designing RBF ap- systems have only one payment benchmark for proaches are described below using these and the assessment phase of supported employment. other illustrative state examples. The Social Security Administrations Alternate Define desired service outcomes. Sup- Participant Program utilizes a single point of pay- ported employment services commonly proceed ment for the employment services process. Pro- in several phases involving community-based viders are compensated when an eligible Social assessment, job development and job placement, Security Disability Income (SSDI) or Supplemental initial job site and related training leading to Security Income (SSI) recipient is working at the stabilization in employment, and ongoing support Substantial Gainful Activity (SGA) level after at at and away from the job site to facilitate retention least a 9 month continuous employment period. of employment. When designing a RBF system, A critical step in defining payment points a funding agency typically selects service out- is to identify the criteria that represents successful comes that correspond with these phases. For attainment of each benchmark. For example, example, the Oklahoma Department of Reha- Kentucky DVR requires the following criteria be bilitation Services (DRS) defines a specific set of met before a provider is reimbursed for the place- service outcomes in its vendor agreements. Under ment benchmark: 1) the supported employee is Oklahomas Milestones Payment System, the ser- employed for a minimum of 60 days in a job vice outcomes for persons with developmental consistent with the individuals work plan; 2) the disabilities include assessment and employment person is satisfied with the job; 3) a satisfactory service planning, placement, two job retention number of work hours is scheduled per week; outcomes, job stabilization, and case closure by and 4) extended services supports are in place. DRS. Other states have identified smaller sets of Payment is made after the 60-day minimum per- service outcomes. Rhode Islands system ties iod of employment only if all the four criteria are compensation to outcomes for assessment, job met (Kentucky Department of Vocational Reha- development, and job placement but does not bilitation, 1998). This type of clearly defined include outcome payments for stabilization and criteria can be built into the construction of a closure. Kentuckys system uses a results-based RBF approach to ensure protections around con- reimbursement mechanism for only one service sumer and employer satisfaction and the quality outcomesupported employment individual and stability of services. placement; all other reimbursements in the KY Establish a fee for each payment system are based on a fee-for-service model. point. The final step in development of a RBF Define payment points. Once service mechanism is to set a fee for each payment point. outcomes are defined, the next step is to define This step requires system designers to answer two the specific benchmarks and criteria that qualify questions. First, what process will be used to a provider for reimbursement. Each service out- determine the fee structure? In a RBF system, come may be reimbursed at one or more bench- fees may be established by the funding agency marks. For example, the assessment component (fixed statewide rates), or jointly determined by of the Massachusetts Community-Based Employ- the funder and provider agencies through ment Services (CBES) Initiative may be reimbursed negotiations or a formalized bidding process. at two bench-marks: providers may be reimbursed The Oklahoma Milestone Payment System $520 when a plan for assessment is submitted provides an example of a bidding process and $780 when the final assessment report is (OBrien & Cook, 1998). In Oklahoma, pro- completed. The Rhode Island and Oklahoma viders submit bids to DRS stating the average

30 Article 2 cost of serving each of a specified number of in- Upon acceptance of a bid proposal, payment dividuals within each defined level of support percentages are applied to the bid to determine need. For example, a provider may bid $6,000 the amount to be paid when an individual per successful outcome for regular supported em- achieves each milestone. For example, a pro- ployment and $8,000 for a consumer meeting vider assisting a consumer to complete Mile- the definition for Highly Challenged supported stone I, assessment, would be paid 10% per- employment. This bid includes not only provider cent of the approved bid. Another 20% of costs associated with serving individuals who the bid would be paid for reaching the 4- reach an employment outcome, but also costs week job retention milestone and meeting all historically associated with serving individuals quality indicators for that milestone. As pre- who do not reach 26 closure. DRS compares sented below in Table 2, the Oklahoma pay- provider bids with one another and with historical ment points and payment levels differ slightly costs of supported employment closures and then for individuals with developmental disabilities determines whether or not to accept the bids. and individuals with mental health diagnoses.

TABLE 2 -- OKLAHOMAS MILESTONE PAYMENT SYSTEM FOR SUPPORTED EMPLOYMENT Percentage (%) of Bid Paid at Each Milestones Milestone

Mental Health DD Consumers Consumers Assessment 10% 10%

Vocational Preparation 10% N/A

Placem ent 10% 15%

4-Week Retention 20% 15%

10-Week Retention N/A 15%

Stabilization 20% 20%

Closure 30% 25%

The second question RBF system designers amples of states with statewide fixed reimburse- must answer is: At what level will rate structures ment schedules. Rhode Island, for instance, be established? To answer this question, system has designed a system that includes a $400 designers must decide whether to establish fee fee for completion of the assessment, a $500 structures at the state level, provider level, level fee for submission of the Memorandum of of service recipient support need, or individual Understanding (which describes the individ- level. When payment points are fixed at the state ualized job search plan), and an $800 fee level, the funding agency assigns a rate for each for the one-month employment retention report benchmark to all vendors (Revell, et al., 1998). (S. Olson, personal communication, May 23, Kentucky, Rhode Island, and Tennessee are ex- 1999).

31 When rates are negotiated at the provider for person-specific reimbursement rates. Piloting level, factors such as provider cost information, of this system has not taken place at the time of regional cost variations, and disability groups this paper. Under the proposed system, a com- served are considered when setting benchmark prehensive assessment and employment needs rates (Revell, et al., 1998). When rates vary by worksheet would be completed for each program level of support need, the rate system is referred participant to determine the participants total to as a tiered system. Table 3 provides a estimated hours of service needs. Consumer hypothetical example of a three-tiered funding assessments are completed on a fee basis. The system with four payment points: assessment, estimated hours of service needs include time placement, stabilization, and closure. Each pro- required for tasks such as job development, co- gram participant is assigned to a Level of Support ordination of benefits, job skills training, and Need based on the anticipated number and employer advocacy. A personalized total budget intensity of employment supports required to figure would be determined by multiplying the secure and maintain employment. A tiered system anticipated hours of support needs by a provider- allows for providers to be reimbursed at higher specific hourly fee rate. Finally, the budget would rates for serving individuals expected to require be divided into set percentages to be paid upon more intensive support services. Tiered systems successful completion of established benchmarks, are one method to reduce the potential for results such as 15% for submission of the consumers based funding to emphasize the easier to serve, training plan, 35% after 5 working days of less costly individuals. Oklahomas Milestone employment, and 25% after 45 calendar days system is an example of the counter balancing of employment. A final payment of 25% would effect of a tiered payment system. Oklahoma be made when the consumer meets the criteria reports that the percentage (17%) of supported for job stabilization (J. Miller, personal com- employment consumers served who had reported munication, May 24, 1999). Massachusetts IQ scores below 40 remained consistent before CBES also has a mechanism for establishing fee and after conversion from hourly fee to the schedules on an individual basis. A distinct Milestones approach (OBrien & Cook, 1998). characteristic of the CBES system is that it does The final level at which rate structures may not represent a continuum of service; individuals be assigned is the individual level. The Penn- may choose to engage in just one or several of sylvania Office of Vocational Rehabilitation is the service components (e.g., assessment, place- engaged in the design of a RBF system that allows ment, initial employment supports). This allows

TABLE 3 -- RBF SYSTEM WITH A THREE-T IERED RATE STRUCTURE BASED ON INTENSITY OF SUPPORT NEEDS Level of Support Needs Payment Points Level I Level II Le vel III 1. A ssessm ent $500 $500 $1,000 2. Placement $500 $1,000 $1,000 3. Stabilization $1,000 $2,000 $3,000 4. Closure $1,000 $1,500 $2,000 TOTAL $3,000 $5,000 $7,000 32 Article 2 for greater flexibility and individualization of are currently being piloted and implemented services (C. Ghiloni, personal communication, with no two state RBF systems being identical. May 24, 1999). The Alabama Vocational Rehabilitation Incentive payments. In addition to sys- Agency used the Oklahoma Milestones ap- tem features determined during the three-step proach as a basis for its RBF system. However, design process, RBF systems may incorporate Alabamas replication pilot resulted in a num- results-based payments beyond the basic rate ber of adjustments to the Oklahoma approach structure. For example, the Delaware Division of in areas such as spacing and weighting of Vocational Rehabilitation supported employment payment points and the criteria defining out- funding system will pay a provider $250 for a comes. Alabama also deleted the Vocational status report when an individual reaches six Preparation service as an outcome for persons months of employment beyond V.R. case closure. with a primary mental health diagnosis, A second payment of $250 is made for a follow- choosing instead to have that as a separate up report when the employee reaches 12 months fee-based service available as needed. While of employment beyond case closure (M. most RBF states are still in the early years of McGarrity, personal communication, May 19, system implementation and are continuously 1999). The Iowa Division of Vocational Reha- refining their approaches, initial feedback has bilitation Services includes a payment incentive been generally positive in terms of reduction for high quality job placements (S. Tyler, personal of waiting lists, reduction in time before job communication, May 17, 1999). In this system, placement, increases in placements, and im- providers receive benchmark payments totaling proving successful outcome rates for parti- $2,000 for assisting program participants reach cipants in supported employment (Ghiloni, 90-day case closure. In addition, providers may Bickleman, Thomas, & van Gelder, 1998; receive up to an additional $3,000 for assisting OBrien & Cook, 1998). individuals to secure jobs that exceed minimum quality standards. To be eligible for an incentive payment, the individual must be employed at the customary wage at or above minimum wage. CONCERNS ABOUT RESULTS- The amount of the incentive payment is calcu- BASED FUNDING lated based on the following formula that includes APPROACHES hourly wage and hours worked per week: Results-based funding approaches that incentive payment = (actual wage/5.15) are not carefully designed and implemented X (actual hours/40) X $3,000 have the potential for creating unintended and adverse consequences. The relative inexact- For example, if an individual is working ness of job development methods, the need at the current minimum wage of $5.15 per hour to truly individualize services, and the variations for 20 hours per week, the provider would re- of job market and economic conditions make ceive an incentive payment of $1500 (incentive the process for achieving successful employ- pay-ment = (5.15/5.15) X (20/40) X $3000 ment outcomes something less than a science. = $1500). As such, precision in a funding system may As the preceding discussion illustrates, a miss the mark of improving outcomes and effi- wide variety of results-based funding approaches ciency unless practical concerns are taken into consideration in design and implementation. 33 Concerns about how results-base funding ap- who were the easiest to place (Osborne & proaches will addressed by discussing the Gaebler, 1992). Supported employment is following questions: already criticized for failing to meet the needs of persons with the most significant disabilities, in- 1. Will results-based funding create disincentives cluding individuals with multiple disabilities to serve people with the most significant (Mank, 1994; Wehman and Kregel, 1995). If disabilities? RBF systems fail to address this concern, sup- 2. Will RBF create incentives for providers to ported employment will continue to underserve serve individuals who appear to be easiest to the primary population for which it was intended. place or who have support needs the provider already knows how to address? Will results-based funding create disincentives to invest in good job matches 3. Will results-based funding create disincentives and creative job development? A good match to invest in good job matches and creative between a job and a persons interest and skills job development? often requires extensive job development and 4. Will the focus of results-based funding systems consideration of a number of possible jobs. RBF, be on valued outcomes? by definition, is focused on timely results. A poorly-designed RBF system could create a con- 5. Can results-based funding systems accommodate variations in service costs so that tingency wherein the provider, and in turn the providers receive adequate compensation (on individual with a disability, are less inclined to a program level) to continue to provide pursue creative job possibilities because of the quality services? extended time and cost associated with more 6. Will adequate attention be devoted to career thorough job development and job matching. development? Will the focus of results-based funding systems be on valued outcomes? Results- Will results-based funding create dis- based funding is premised on an agreed-upon incentives to serve people with the most sig- definition of valued results. Wage and hour nificant disabilities? Will RBF create incen- outcomes are easily measured. Integration can tives for providers to serve individuals who be measured to some extent. Satisfaction is more appear to be easiest to place or who have difficult to measure. What definition of valued support needs the provider already knows results will be emphasized? If wage and inte- how to address? One obvious concern about gration outcome indicators are chosen, because results-based funding is that it may create a they are easily measured, will they provide an disincentive to provide employment services for accurate and comprehensive picture of a sup- persons considered difficult to serve. Many people ported employment programs success? If satis- in government resist the idea of paying for results, faction on the part of the person with a disability because they have seen examples of it being is considered the most important outcome indi- done poorly. For instance, the Job Training cator, how will it be measured and what degree Partnership Act of 1982 (JTPA) mandated of wage and integration outcomes will still be performance-based contracts with service pro- expected? Results-based funding approaches viders. Original JTPA contracts were severely criti- must have the flexibility to address individual cized, because they rewarded providers based needs and preferences around these issues. solely on the number of trainees they placed. Can results-based funding systems This encouraged providers to serve only those accommodate variations in service costs so

34 Article 2 that providers receive adequate compensa- permanent job placements, thereby creating tion (on a program level) to continue to pro- a disincentive to support the career develop- vide quality services? There is little doubt that ment of individuals with disabilities? producing successful employment outcomes will These concerns about results-based require different services, along different time lines funding indicate that careful attention is and in different ways for different people. Can needed during the design phase to (1) creating RBF accommodate what is fundamentally an incentives for serving persons with more intense individually driven process? In RBF systems where and extended support needs, and (2) pro- costs are normed across a wide population, will moting good job matches and career develop- the needs of those individuals who substantially ment in a way that recognizes variation in com- exceed the norms be met? To ensure adequate munity, provider, and individual service cost financial support to the range of vendors pro- structures. These incentives do exist. The viding supported employment services to a diverse following discussion offers recommendations population, RBF approaches must be flexible for designing and implementing results-based enough to adjust to both the cost structure of the funding systems that are responsive to quality vendor and the level of need of the consumer. indicators of supported employment. Setting statewide rates has the potential to result in overpayment in low cost areas and under- payment in high cost areas such as metropolitan communities. Setting rates at the provider level RECOMMENDATION FOR DESIGN has the potential to be insensitive to cost variations AND IMPLEMENTATION among individual program participants. Can results-based funding mechanisms be designed The following set of recommendations in a way that recognizes, and even encourages, is not all-inclusive but is intended to define a the needed individualization of service intensity direction for promoting outcomes, account- and service duration that represents prescriptive ability, equal access, and fairness for all stake- supported employment services? Can these holders. The following recommendations may adjustments be made in a way that balances the aid policy makers and implementers to design need for simplicity in administration, flexibility in effective outcome-oriented systems for pur- application, and a concern for quality and indi- chasing supported employment services. vidualized services? Will adequate attention be devoted 1. Balance the interests of key stakeholders through collaboration. to career development? Another concern about results-based funding is the need for reha- 2. Emphasize cost effectiveness over cost bilitation to focus on career development. The efficiency. term career development suggests an ongoing 3. Insure that funding levels are working for series of jobs, opportunities for skill enhancement, providers of service. and job advancements over time. As such, it can be expected that a person will, and should, 4. Tie payments to the achievement of valued outcome performance measures to avoid change jobs over time. This calls for an in- exchanging quantity of quality. vestment in job development, placement, and job supports for multiple job positions. Will RBF 5. Emphasize individualization, flexibility, and approaches emphasize and reward more choice.

35 6. Avoid creating disincentives to serving people Alabama decided to move to a results-based with more significant disabilities. funding system similar to Oklahomas Milestone 7. Periodically review and refine the system. Payment System, an extensive stakeholder planning process was undertaken. Representa- Balance the interests of key stake- tion from the stakeholder-planning group in- holders through collaboration. The diversity cluded the three primary constituencies: con- of state approaches to results-based funding re- sumers, funders, and vendors. Three months of flects variations in how stakeholder interests are intensive planning in Alabama was followed by prioritized during the design phase. The chal- a pilot program and revisions by the group before lenge, of course, is to find a balance among the implementation. The Alabama experience sug- interests of individuals with disabilities, providers, gests a collaborative design and implementation and funding agencies. Service consumers seek process improves the quality of the final product a funding design that encourages self-advocacy and reduces resistance to change by increasing in planning and managing services and also understanding of the change process encourages access to supported employment for Emphasize cost effectiveness over cost the full range of persons with disabilities who efficiency. Osborne and Gaebler (1992) define need this service approach. Provider agencies efficiency as a measure of how much each unit seek to cover the true cost of providing services. of output costs. Effectiveness is a measure of the Funding agencies seek to purchase services from quality of that output: how well did it achieve providers that achieve desired participant the desired outcome? When we measure effi- outcomes in a cost efficient and effective manner. ciency, we know how much it is costing us to Clearly, each party has a valuable per- achieve a specified output. When we measure spective and must be accommodated to some effectiveness, we know whether our investment extent if the design is to work. Unbalanced was worthwhile (p. 351). The natural tension funding systems result in persons being excluded between efficiency and effectiveness should be from services, poor quality services that fail to welcomed and explored in results-based funding consistently achieve desired outcomes, and/or approaches. Clearly, the wrong thing can be inflated costs for services. For example, a funding done very efficiently. Both efficiency and effective- design that under funds (i.e., sets payment levels ness are important. Unfortunately, government that do not cover the actual costs associated agencies may be tempted to focus solely on con- with serving persons with more intensive support taining costs (efficiency) at the expense of striving needs) and provides no mechanism for a provider toward achievement of a programs ultimate goals to recoup costs for needed services will leave at a reasonable cost (cost effectiveness). certain individuals unserved or poorly served. Funding mechanisms are most likely to If there is to be a balance among the in- be effective if incentives encourage providers to terests of key stakeholders, the design and imple- place greater numbers of supported employment mentation of a RBF system should happen in participants in jobs. However, incentives should collaboration with those stakeholders (Theurer, not diminish emphasis on serving people with 1998). Halachmi and Bouckaert (1996) empha- more severe disabilities, consumer choice, excel- size this point by stating: Designing a system lent wage and benefit packages, or advance- that does justice and is fair to all stakeholders ment opportunities. We now have over a decade requires stakeholder participation in all stages of experience in funding supported employment of the systems development (p. 8). When services. We must ensure that funding levels truly

36 Article 2 reflect the real life costs associated with providing There are specific strategies that can quality supported employment services. be incorporated into the design of a RBF ap- Insure that funding levels are work- proach to help insure that the providers time able for providers of service. This recommen- investment at any one point in services to an dation closely relates to the need to balance the individual does not lag too far behind the op- interests of key stakeholders. Results-based portunity to cover the costs associated with funding strategies can be expected to create dif- that time investment. First, payment points ferent contingencies and perhaps greater uncer- should be weighted and spaced in such a way tainty than fee-for-service approaches. A critical that cash flow to the provider is reasonably factor in determining the effectiveness of RBF consistent with resource investment. RBF sys- methods will be their ability to balance the tems, by their very nature, create incentives to funding agencys desire to weight pay schedules achieve final outcomes (e.g., case closure). toward the final desired outcomes and the desire This usually results in the provider having an of the provider agency to maintain a steady cash ongoing deficit in payment earned in relation flow. For example, if 75 percent of funds are to costs incurred, until the final outcome is held back until an individual achieves a final achieved. The spacing and weighting of pay- outcome, provider agencies may find it difficult ments should be reasonable enough to keep to meet their ongoing financial commitments. this deficit from being a continued burden to This is particularly relevant to small specialty a provider. A second strategy is to use a proac- supported employment agencies that do not have tive approach to assessment and job planning. a multiple cost center funding flow. Several state The better the information used for the job systems address this issue by early payments for match, the better the chance for success. Third, assessment and job development. the design of the RBF system should accommo- RBF systems should insure that competent date costs associated with serving persons who providers of service are fairly compensated for fail to reach a particular benchmark. One way quality services so that they can cover their costs to do this is to incorporate the historical costs (and possibly even be rewarded for good perform- of serving participants who fail to meet a ance by turning a profit). A number of questions benchmark into the payment level determina- should be considered when constructing a RBF tion of that benchmark. Paying for success is system that can influence the balance of financial clearly the driving incentive of RBF; paying risks and rewards for providers. These include only for success ignores the information avail- the following: How will payment points within able through research on job retention patterns the fee schedule be distributed and weighted? in supported employment (McDonald-Wilson, Will providers be reimbursed for services leading Revell, Nugyen, & Peterson, 1991) and will to job replacement if the first job doesnt work underfund vendors. Fourth, clear policies are out? Will providers be able to cover or recoup needed regarding how the job replacement costs for providing services to consumers who needs of program participants will be ad- do not reach their employment objectives? What dressed within the RBF system. Some state fund- incentives will providers have to serve individuals ing agencies will only pay for each benchmark with more intensive support needs? Will VR one time for a particular program participant agencies be able to guarantee the availability of while other states will pay a benchmark more funds during a fiscal period or will providers be than once under certain circumstances. vulnerable to funding stoppages? Finally, the RBF system design should contain

37 incentives for providers to serve persons requiring employment that may go well beyond the easiest an intensity and duration of services beyond the measures of employment. The challenge to norm for a provider. The multiple payment tiers funding system designers is to link compensation discussed earlier are one such incentive. to outcome indicators that represent the substan- Tie payments to the achievement of tive benefits experienced by program participants. valued outcome performance measures to One way to address this issue is to include avoid exchanging quantity for quality. To measures of service quality in the payment mech- maximize effectiveness, results-based funding anism. Osborne and Gaebler (1992) suggest approaches should emphasize increasing the surveying consumer and employer satisfaction number of people who have quality jobs over with services. They also advise performance man- simply increasing the number of placements. agers to avoid incorporating too many or too While the traditional rehabilitation system has few quality indicators. The danger with too few not focused on outcome-oriented funding, it has indicators is the system will be distorted by overly emphasized person-specific definitions of what simplistic outcome criteria. An example is a VR constitutes quality employment. Ensuring the system that relies too heavily on Status 26 closures quality of services and outcomes is easier when as a primary measure of success and therefore services have clear and tangible results. Sup- pushes providers and VR counselors to terminate ported employment services have at least one services prematurely or to emphasize serving those clear and tangible resultemployment. However, individuals for whom the expectation for success many factors in addition to job placement rates in employment is higher. Too many quality indi- must be included when determining how suc- cators may result in complexity, confusion, and cessfully a vendor is providing vocational assis- poor compliance. tance to people with disabilities. Quality outcome The Kentucky and Oklahoma RBF sys- indicators such as wages and benefits, individual tems provide examples of efforts to incorporate a choice, opportunities for career advancement, balance of quality indicators. As stated earlier, and employment retention are also important. the Kentucky system makes reimbursement for The degree of success results-based the Placement benchmark contingent upon 60- funding experiences may be determined largely day employment retention, consumer satisfaction, by the extent to which valued supported employ- an established number of work hours per week, ment outcomes can be articulated and agreed and the availability of extended services support. upon in ways that work for all stakeholders. Oklahoma builds into each milestone up to five Relevant, understandable and agreed-upon per- quality indicators required for payment. For formance measures are difficult to articulate in example, the quality indicators for the Stabili- ways that keep a focus on performance but also zation payment for persons with developmental support the need to individualize services disabilities include a minimum of 17 weeks job (Fountain & Roob, 1994). Conceivably, very retention, fading of job coach support, documen- clear measures can be articulated (e.g. number tation of consumer and employer satisfaction, of people with disabilities served or placed in and the meeting of the consumers career plan jobs) that miss the mark on valued and substantive goals and desired work hours per week. benefits (i.e., positive quality-of-life changes). Emphasize individualization, flexi- While clarity of measures is clearly important in bility, and choice. Supported employment is a results-based funding system, the benchmarks centered on individualization of supports and defined must also meet a standard of successful outcomes. RBF system designers need to recog-

38 Article 2 nize the potential for reducing rather than en- challenged individuals attain the same hancing individualization. States have taken vari- milestones. Another potential solution is to ous approaches to ensuring individualization and include an add-on time-based reimbursement flexible service delivery. In the Massachusetts component in the funding design. Under the CBES system, for example, program participants Massachusetts CBES system, providers receive choose only those service components (e.g., an hourly rate supplement above and beyond assessment, placement, initial employment sup- benchmark payments when they provide extra- ports, additional support) necessary for employ- ordinary supports to highly challenged indi- ment success and may select different providers viduals. A third possibility is to create a single for various components. Pennsylvanias drafted payment track but require persons with more funding system, with its individually determined severe disabilities account for a predetermined budgets, is intended to encourage service flexi- percentage of a providers successful out- bility based on individual needs. States have also comes. Lastly, person-specific reimbursement found a number of ways to promote consumer rates, like those defined in Pennsylvania OVRs choice and control in RBF systems. Several states proposed system, have the potential to encour- attach person-specific outcome indicators to pay- age providers to serve people with more ment of the Placement benchmark. Delaware significant support needs. DVR, for example, reimburses providers for the Periodically review and refine the Placement benchmark only if the job placement system. It is difficult to identify and articulate meets criteria established by the program partici- program goals and to develop meaningful pant in conjunction with V.R. and the provider. measures of goal attainment (Kravchuk & Specific job match criteria include: type of jobs Schack, 1996). No measures are perfect. It is sought, acceptable geographic location, wage important to consider the extent to which out- and benefit requirements, and work schedule. come indicators are measuring what they are Avoid creating disincentives to serving intended to measure (Hatry, van Houten, people with more significant disabilities. A Plantz, & Greenway, 1996). Having some primary liability of RBF approaches is their poten- degree of flexibility in the system design will tial to reward service providers for serving people enable rapid and effective adaptation to feed- with lesser support needs. Providers could maxi- back. Because inexactness is to be expected, mize their earnings potential by serving only the it is important to establish a plan to evaluate most readily employable people at the expense and revise a system based on the experience of serving those with more significant support of using that system. Indeed, a number of states needs. When designing a RBF system, it is crucial have implemented RBF ideas by first creating to include some mechanism to minimize this pilot projects to study the process and improve problem. A basic premise of supported employ- it before attempting statewide implementation. ment is that it is designed to serve people with the most significant disabilities. One solution is to set different reimbursement rates for different populations. Oklahomas CONCLUSION tiered payment system accomplishes this by compensating service providers at a higher rate By making the funding and provision for assisting highly challenged individuals attain of supported employment services more each milestone than for assisting non-highly outcome-oriented, results-based funding

39 approaches have the potential to increase Voca- Groszyk (1995), Office of Management and tional Rehabilitations cost effectiveness and effi- Budget. Perfection is the enemy of the good. ciency. By focusing attention on employment Agencies should strive to do the best they can outcomes instead of the monitoring of service now. To delay until an elegant design or process processes, results-based funding provides many is put in place, or until all unknowns are ex- possible benefits over fee-for-service arrange- plained, simply means nothing will ever happen. ments. By emphasizing employment outcomes Experience to date with results-based funding of that are consistent with personal choice and work supported employment services indicates that goals, results-based funding systems can respond many of these concerns can be effectively ad- to the emerging voice of people with disabilities. dressed through a careful review of the RBF ex- RBF systems that align effectively with individual amples in place and the use of a design and empowerment through choice and control over implementation process that balances the interests employment services will help prepare state of the key stakeholders. Vocational Rehabilitation systems, program par- As discussed in this paper, there are num- ticipants, and vendors for the advent of the erous examples of results-based funding of sup- consumer-controlled voucher systems proposed ported employment services in place for which in the Work Incentives Improvement Act of 1999. states have reported improved service effective- The Act under consideration incorporates a num- ness and cost efficiencies. There are many inno- ber of RBF mechanisms. Title II of the proposed vative variations on existing approaches being legislation, the Ticket to Work, would give Social tested. States interested in moving to results- Security Administration (SSA) beneficiaries a based funding for supported employment services vocational voucher to purchase their own voca- have a number of examples and resources avail- tional services from the vendor or vendors of their able to them. The move to more results-based choice. approaches to funding supported employment Results-based funding approaches do services is consistent with the resounding call for elicit a number of concerns. Will disincentives to greater accountability in government programs. serving people with more significant disabilities The core accountability measure of supported be created? Will attention be diverted from crea- employment is a valued employment outcome tive job matches and creative job development responsive to the job interests and support needs in favor of expediency? Can the most appropriate of individuals with the most significant disabilities. outcomes be articulated and measured? Can By emphasizing outcome criteria that focus individual cost variations be accommodated? specifically on the job stability and job satisfac- Will career development be impeded? States tion of persons served, results-based funding seeking to improve outcomes in supported approaches can truly pay for success and help employment but hesitant to consider a move to the supported employment program fulfill its results-based funding because of these and other purpose. concerns are referred to the advice of Walter

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42 Supported Employment: Its Working in Alabama By: Valerie Brooke, Howard Green, Dan O’Brien, Byron White, & Amy Armstrong Despite the growing number of individuals with disabilities participating in competitive employment, there remains an alarming ABSTRACT high rate of underemployment and unemployment among this This paper examines the untapped labor source. These high unemployment rates continue changes that one southern for this countrys largest minority group in a time of record low state made to improve the national unemployment and in spite of repeated demonstrations of quality of employment ser- their ability to achieve gainful employment. Policy makers and people vices for individuals with with disabilities are demanding an answer to the question: Why significant disabilities. A arent more people with significant disabilities able to obtain and new supported employment payment system is shared maintain competitive employment? that compensates the em- Supported employment is a program specifically targeted to ployment service providers assist those individuals with the most significant disabilities to achieve based upon the outcomes community integrated competitive employment. Yet, some have achieved by the employee suggested that supported employment has underachieved its promise in competitive employment. and potential ( Wehman & Kregel, 1995; Mank, 1995) while others In addition a newly devel- have suggested that perhaps it may simply be a failed program. oped personnel training certificate program will be Most including researchers, rehabilitation service providers, and others shared that integrates the have concluded that this troubling incongruity between what we new payment system with know can be achieved and what in effect is occurring can be traced best practices in supported to a few significant implementation issues that are unique to supported employment using an em- employment. ployee-directed approach. One of the major issues confronting supported employment Participant training data implementation has been traced to the lack of trained personnel in and preliminary outcomes will demonstrate the sup- the field of community rehabilitation (Bowe, 1993; Mank, 1995). ported employment quality Perhaps the most critical part of any organization is its personnel. improvements. This is especially true when the goods or services provided by an organization are primarily the result of human interactions. Such is the case with organizations providing community employment services. The best mission statement, policies, procedures, and other organizational structures may be in place, but the organization will be ineffective without knowledgeable and dedicated staff who work well with individuals with disabilities, businesses, and the community at large. Vital to supported employment is the critical need for training across professionals assisting supported employment participants.

43 These professionals would include the supported As discussed earlier, this lack of training employment service provider with responsibility extends into the business community with its on- for the direct delivery of the supported employment going levels of workforce reform. Employers are services, the state vocational rehabilitation (VR) caught between growing labor needs, changing counselors and managers responsible for guid- demographics, and fast-paced changes in ance and management of the supported employ- corporate structures. If an employer has never ment service, and employers who hire and retain hired or worked with an individual with a workers with significant disabilities. disability, it is natural that there might be some A large number of the professionals asso- questions and concerns such as productivity or ciated with the delivery of supported employment impact on co-worker morale (Brooke & Wehman, services are not fully equipped to perform their 1999). Professionals and individuals with disa- job. Many supported employment service pro- bilities must be able to anticipate these business viders come to their first rehabilitation job with concerns and be equipped to directly address little or no experience or training in the field their needs. (Everson 1989; Rusch, Trach, Winking, Tines, Personnel training is not the only issue and Johnson, 1988). This lack of training has that has plagued supported employment. Another resulted in excluding individuals with the most critical implementation issue confronting this significant disabilities from accessing employ- rehabilitation service relates to how the VR system ment, poor program marketing, inappropriate has historically compensated supported employ- job matches, ineffective job site training stra- ment providers for services that they render. Over tegies, and inadequate long terms supports. Addi- the last decade supported employment agencies tionally, many rehabilitation counselors graduate have been compensated by the VR system for from their university programs without any busi- providing services. These services are delivered ness courses or knowledge regarding the employ- without having to achieve any definable out- ment potential of individuals who stand to benefit comes, such as competitive employment or em- from supported employment services (Rubin & ployment of choice. This fee-for-services system Roessler, 1995). As a result, vocational rehabili- used in most VR agencies across the country is tation (VR) agencies hire staff who are: 1) intimi- designed to purchase services for VR clients, with dated by the business community and therefore significant disabilities, in the hope of obtaining unable to market their service to business cus- an employment goal. tomers; 2) unfamiliar with supported employment, Partly in responses to this payment system, resulting in inappropriate supported employment supported employment provider agencies develop referrals; and 3) inexperienced with business service plans that describe the range of services management techniques, resulting in poorly man- that will be delivered based upon an hourly price. aged contracts when services are purchased from These services are then purchased for a VR client a local supported employment vendor. Too often but are not tied to any tangible outcomes. As a these failures, on the part of those entrusted to result, supported employment provider agencies deliver the supported employment service, have may be paid for hours of job development services been misread and misunderstood as poor per- without having to actually find competitive em- formance by individuals with significant disa- ployment. Or in the case of job coaching ser- bilities or dismissed as simply a failure of the vices, an agency could be paid for hours of supported employment program. coaching services without having to assist a new

44 Article 3 employee in achieving stable employment. Man- grams such as welfare-to-work and managed agers in fee-for-service programs who need to care systems. Simply put, the Milestones system bill VR a certain number of hours each month to for payment pre-defines incremental outcomes keep their program solvent may make program- or milestones that must be achieved by the matic decisions based upon funding versus true customer, establishes an average cost per indi- employee need. This system of funding sends vidual to each milestone accomplishment, and the message to supported employment service reimburses the agency/organization based providers that VR will continue to purchase ser- upon the success of the outcome. Essentially, vices for an indefinite period (Novak, Mank, these Milestone accomplishments are the Revell, & OBrien 1999). In fact, when evalu- quality indicators of a successful supported ating the entire fee-for-service system, with its employment program. inherent lack of accountability for results, in light When staff associated with the Alabama of the tremendous personnel training issues facing Department of Rehabilitation Services (ADRS), the rehabilitation field, it is easy to see why those Supported Employment Systems Change pro- looking for simple solutions might question the ject went shopping for examples of true systems effectiveness of supported employment. change in the area of funding, it was inevitable This paper examines the changes that one that they would find this exemplary payment southern state made to improve the quality of model. Oklahomas Milestone payment system employment services for individuals with signifi- is recognized by the Council of State Govern- cant disabilities. A new supported employment ments, the Harvard Kennedy School of Govern- payment system will be shared that compensates ment, Duke Universities Sanford School of employment services providers based upon Management, the Ford Foundation, and the outcomes achieved by the new employee in Social Security Administration (OBrien & competitive employment. In addition, the authors Cook, 1998). At the direction of Lamona will show how the new supported employment Lucas, Commissioner of ADRS, Dan OBrien, payment system sparked the development of a one of the key originators of the Oklahoma successful certificate training program. Participant Milestones Payment System, was contacted to training data will be shared along with prelimi- facilitate the conversion from a fee-for-service nary outcomes that document an improvement based funding system to an outcome-based in the quality of supported employment services funding system. With the backing of the top for the state of Alabama. executives within ADRS, the organization change efforts quickly moved from are we going to change to how are we going to implement this change. This set a positive MILESTONES PAYMENT and forwarding looking tone for the newly SYSTEM established supported employment stakeholders group process, and avoided wasting The Milestone payment system, developed significant time arguing about the advisability by the Oklahoma Department of Rehabilitation of the change. The stakeholders group, con- Services, is a leading example of results based sisting of ADRS executives, rehabilitation coun- funding in the field of rehabilitation. This pay- selors and mangers, supported employment ment method is meeting with success and is inservice providers and job coaches, families, creasingly being adapted to other national pro- and individuals with disabilities, were then

45 faced with the clear and compelling question of ment service providers would be very concerned how to implement outcome-based funding in a about how they were going to be reimbursed given time frame that would result in a win/win and that in some cases, vendors might approach situation for all stakeholders. this process with real trepidation. Many vendors Building upon successes in Oklahoma, under the hourly fee-for-service arrangement the stakeholder group members established a simply measured staff performance based on two-phase pilot project aimed at increasing the process measures such as number of billable understanding of Milestones without hurting the hours generated. Under Milestones, there are operating cash flow of a supported employment no billable hours and the staff performance service provider or the individuals with significant measures were now focused on finding a job, disabilities seeking employment services. This job acquisition, and job retention. In fairness to hold harmless pilot phase allowed service pro- individuals with disabilities and to service providers and ADRS to operate a dual payment viders, ADRS arranged for personnel training of systems, giving both organizations an opportunity those who would be directly affected by the new to eliminate systems issues. Milestones system. The Table 1 below presents The phase-in process proved to be the the series of six meeting that led to the creation key to success for this organizational change of the final Milestones developed by stakeholders. effort. It was anticipated that supported employ-

TABLE 1 -- MILESTONE MEETINGS

Sequence Meeting Objective Outcome # 1 Learn mo re ab ou t th e O klah o ma exp erien ce fro m Dan Increase understanding of the O’Brien and a experienced supported employment Oklahoma M ilestone experience. provider from Oklahoma.

# 2 D e ve lo p in fo rma tio n ga th e rin g te a ms a ro un d ea c h o f the Team members gain specific five M ilestones to include: 1) assessment and career expertise around one of the five planning, 2) vocational preparation, 3) job development M ile ston es. and placement, 4) job site training and fading, and 5) job sta b iliza tio n .

#3 Share research materials and develop a draft definition of Individual team meeting to share each Milestone, along with outcome indicators to be used knowledge and create definitions by VR counselors to test quality of the service before for each of the 5 M ilestones. payment.

#4 Present draft definitions and corresponding quality Co mp re h e ns ive M ile stone s p ro - in d icators to all stakeh o lders fo r co m men t. duct developed for state-wide distribution. #5 Establish consensus on each of the five Milestone defi- Fin alize desig n for th e Milesto ne nitions, descriptions, quality indicators, and percent of system. to ta l b id to be p a id a t th e c o mp le tion o f e ac h M ile sto ne .

#6 Present provider and counselor suggestions for changes to Formalized system accepted by Milestones, based upon feedback from pilot groups. stakeholders and general public. Fo llo wed b y a pub lic m eetin g fo r a wid er stakeho lder audience.

46 Article 3 The hold harmless pilot was conducted the original design. The changes were made for a six month period, and a small group of based on provider and counselor feedback providers were selected for this pilot based on a from all of the pilot implementation phases. competitive bid process. Adjustments were made Changes were subject to approval by the stake- to the Milestone system based upon issues holder group before the Milestone system could confronting the group while changing over to be implemented. the new results-based system. Again using the competitive bid process, the second group of pilot programs were funded for a six month period. The final phase was the forced transition of all BEST PRACTICES IN remaining providers to Milestones following SUPPORTED EMPLOYMENT another hold harmless planning period. Table 2 on the following page presents the final set of Since the early 1990s, there has been Milestones for the Alabama supported employ- an increasing emphasis on the role of two ment programs. For each Milestone there is a major service customers: the potential new em- complete explanation of the outcomes to be ployee with a significant disability and the em- achieved, description of services to be delivered, ployer (Brooke, Inge, Armstrong, & Wehman, and documentation necessary for payment. 1995). It was critical to success for the new As noted in the first column of Table 2, Milestone payment system that all personnel providers are paid a percentage of their contract attending the training began to view supported for accomplishment of each Milestone. The employment participants in terms of their provider payment amount increases based upon abilities, strengths, and interests, rather than the longevity of employment for the new em- in terms of their disabilities. Once profes- ployee and results accomplished by the provider. sionals are able to make this important shift For example, ADRS agrees to pay a service in thinking, they are receptive to an employee- provider $6,500 for supported employment directed approach to the delivery of supported services; the provider would receive the following employment services. When using an em- payment for accomplishment of each Milestone. ployee-directed approach to supported employment, persons with significant disabilities l $975 for accomplishment of Milestone I: Determination of Need, are involved in all decisions regarding service approach and delivery. These decisions l $975 for accomplishment of Milestone II: include everything from the selection of the Hire, service provider to the identification of the strategies that will assist with career advance- l $1,300 for accomplishment of Milestone III: Job Retention, ment and ultimately facilitate long-term job satisfaction. l $1,300 for accomplishment of Milestone IV: This vision of long-term satisfaction is Stabilization, and equally important among employers. An em- l $1,950 for accomplishment of Milestone V: ployee-directed approach takes into considera- Closure. tion the employers wants, needs, and interests from the first marketing contact throughout It is important to note that the Milestones were the ongoing employment supports phases amended on three separate occasions following (Brooke, Revell, & Green, 1998). When sup- 47 TABLE 2 -- ALABAMA MILESTONES FOR SUPPORTED EMPLOYMENT

Outcomes & Percentage of Service Required Contract for Payment Description Documentation Milestone I (15%): Determination A minimum of two situational assess- Situational Assess- of Need ment completed in the community in an ments integrated work environment. Counselor Narrative Report A determination of the consumers reha- will have discretion to allow one if con- Vocational Profile bilitation needs has been made through an sumer and provider agree. A vocational Substitution Criteria assessment of the consumers abilities, profile may be substituted when situ- & Report if Appli- preferences, and functional limitations. ational assessments are determined to cable be impossible.

Milestone II (15%): Hire Job analysis and sequence of job Employment Report duties have been performed and forms Job Analysis Form Individual has been hired and has main- completed. The job in which the indi- Sequence of Job tained employment for three days in a vidual has been secured meets all Duties Form position that matches the vocational ob- federal and state supported employ- jective in the Individual Plan of Employ- ment guidelines and the new em- ment. ployee has begun work.

Milestone III (20%): Job Retention The purpose of the job retention Milestones Narrative phase is to provide intensive on and Progress Report The new employee has received the off site job supports which assist the Employment/Hours necessary support services in order to worker in adjusting to the demands of Verification Form perform job duties satisfactorily. the integrated work environment. Fading has occurred when the job coachs focus at the worksite is job maintenance.

Milestone IV (20%): Stabilization The purpose of this retention phase is Employer Evaluation to provide intensive on and off job site Form The employee is stable in employment as supports that assist the worker adjust Consumer Job Satis- measured by a satisfied employer, con- to the demands of the integrated work faction Form sumer, counselor, and service provider, environment leading toward Extended Services and the new employee has worked for at stabilization. Plan least 4 weeks at the IPE weekly hour goal. Milestones IV Prog- ress Report Employment/Hours Verification Form Employment Report Update

Milestone V (30%): Closure (Status 26) Closure will be determined to have Employment Evalu- been made when the case is ready for ation Form has been The outcome of the entire process is a closure by ADRS Counselor, and the submitted which in- worker who meets all required criteria supported employment provider has dicates acceptable and can be considered rehabilitated by submitted all required documentation. job performance. ADRS Counselor. The worker must have worked at last A Milestone IV Prog- 90 days beyond stabilization and re- ress Report ceived adequate training and support A Consumer Job Sat- after hire, as determined in the IPE. isfaction Form has Extended services must include at been submitted least two support contacts per month. which indicates consumer satisfaction.

48 Article 3 ported employment service providers are actively For example, the decision was made that in engaged in cultivating a strong open relationship order for a vendor to complete Milestone I between themselves, employees with significant and receive payment, the job coach would disabilities and the business community, they will have to conduct a minimum of two situational always be in a position to deliver a needed service assessments within a community-based inte- in a timely manner (Flippo, Gibson, & Brooke, grated work environment. Since situational 1997). assessments were new for the majority of the The following section will demonstrate job coaches and rehabilitation counselors, the how the elements described above were incor- training was designed to give the participants porated into a supported employment certificate classroom instruction, simulation experience, training program consisting of 48 contact hours. and homework assignments for practice and The unique features and benefits of this training feedback. Unlike traditional job coach design will be highlighted. Following this section training, the Alabama Supported Employment is a general discussion reviewing Alabamas Milestones Certificate Training curriculum had changes in policy, adaptations to implementation several unique features and benefits. These practices, and adjustments to program evaluation unique features include the following: in terms of national significance. l employee-directed approach to supported employment;

l interagency participation; UNIQUE FEATURES AND BENEFITS OF THE MILESTONE l community job analysis drills within local CERTIFICATE TRAINING businesses; PROGRAM l employer issues forum; Clearly, the need for qualified, well trained personnel was vital to the success of l job site training, support, and demon- Alabamas organizational change efforts. If the stration; Milestone system was to work, the vendors would l evening and home-based application have to ensure that their staff possessed the activities and practice; and compentencies necessary to provide quality supported employment services. In order for a pro- l follow-up day for technical assistance. vider to become a vendor under Milestones, all existing and new job coaches would have to Employee-Directed Approach for complete the Alabama Supported Employment Individuals with Significant Disabilities. Milestones Certificate training program designed The textbook used in the course was the VCU by Virginia Commonwealth Universitys Rehabili- Supported Employment Handbook for Job tation Research and Training Center. The cer- Coaches (Brooke, Inge, Armstrong & Wehman, tificate training agenda is shown in Table 3 on 1997). Each component of the curriculum the following page. stressed the need to involve the supported This curriculum, with its employee- employment participant with each aspect of directed approach was designed to enable parti- the employment service. Competency was cipants to reach a necessary level of competency achieved through a series of application to carry out reach of the Milestone requirements. activities demonstrating knowledge of how to

49 TABLE 3 -- TRAINING AGENDA

Learning Objectives Training Sequence DAY ONE Pre-class readings and completion of SE papers. 1. Describe the changes in SE over the past decade. ADRS history with Milestones. 2. Understand the various components of SE. Overview of a employee-directed 3. Able to describe the AL Milestone System. approach to SE. 4. Identify best practices in SE. Organizational marketing. 5. List functions of an employment specialist. Review homework assignment. 6. Describe difference between organizational marketing and job development. 7. Describe the components of a marketing plan and list at least 3 benefits.

DAY TWO Complete test. Review homework projects. 1. Become familiar with the customer profile. Discuss Customer Profile. 2. Develop a functional resume. Conduct Person-Centered Planning 3. Learn the difference between formal and informal exercise. assessments. Complete Situational Assessment 4. List the criterion for a situational assessment. Application activity. 5. Be able to conduct and complete a job analysis. Finish business contacts for job 6. Be able to address business concerns. analysis exercise. 7. Understand the requirements of Milestone 1 and 2. Conduct Milestone I and II activity. Review homework assignments .

DAY THREE Complete test. Review homework projects. 1. Learn to match job seekers to jobs. Present employer panel. 2. Become familiar with issues before customer starts to Demonstrate task analysis. work. Initiate job site training activities. 3. Be able to identify natural cues/supports. Demonstrate data collection 4. Complete a task analysis. demonstration. 5. Learn to design an instructional program. Complete compensatory strategies 6. Understand the need for and use of compensatory exercise. strategies. Conduct Milestone III activity. 7. Understand the requirements of Milestone III.

DAY FOUR Test Design a long-term plan of support. 1. Understand the need for keeping data. Watch assistive technology video and 2. Learn self management concepts. complete exercise. 3. Become familiar with job site modification. Complete Milestone IV & V activity. 4. Gain knowledge about assistive technology. Review fieldwork activities for follow- 5. Become familiar with fading strategies. up day. 6. Be able to develop a plan of long term support. Discuss directions for receiving 7. Understand the requirements of Milestone IV & V. technical assistance from VCU via the Inte rnet Complete evaluations.

Follow-up Day (4-6 weeks following initial training) Review long-term support article (Brooke, Revell & Green, 1998). 1. Be able to identify the importance of having a long-term Review situational assessment and job plan of support in place at closure. site training homework projects. 2. Demonstrate skills and ability to implement situational Play Milestone Jeopardy. assessments. Complete Milestone application 3. Gain knowledge of possible stalls and techniques to activity of quality indicators, overcome case load stalls. accomplishments and case load stalls. 4. Demonstrate knowledge of each of the five Milestones. Graduate.

50 Article 3 involve the new employee in achieving his or Employer Issues Forum. During each her career goal despite type or level of disability. Milestones training event, a local panel of Interagency Participation. Unlike a business representatives were invited to speak contract payment system where the rehabilitation to the group about their companies. Each counselor and job coach rarely meet or have business came prepared to share the qualities the opportunity to discuss employment issues or that it looks for when interviewing a perspec- concerns, the Milestone payment system is tive job candidate. The employer panel in- structured so the rehabilitation counselor is cluded several local employers and a repre- directly involved in the success or failure of each sentative from a supplemental staffing agency Milestone accomplishment. Therefore, in order who disseminated techniques on dealing with to ensure a smooth transition into this funding business in their efforts to secure jobs. Partici- design, it was requested that the rehabilitation pants used this opportunity to discuss a variety liaison counselors and supervisors attend the of employment issues including marketing certificate training program. This interagency procedures, job finding strategies, employment approach allowed both the providers and reha- fears and concerns, and business partnership bilitation staff to gain a better understanding of directions. The objective of this section was their respective work requirements while acquiring for participants to gain competence in pro- detailed knowledge of the Milestone components. cedures for identifying and meeting the em- It proved to be a direct benefit for both parties. ployers needs and thereby ensure successful Community Job Analysis Drills Within accomplishment with Milestone III, IV, & V. This Local Businesses. In order to match individuals training component gave participants confi- with significant disabilities to appropriate jobs in dence in approaching businesses. Members the community, the job coach needs to have a were reassured that employers are looking for rich knowledge base about specific businesses skilled and unskilled labor to meet their and the various jobs within a business. The more demands, and the vast majority of businesses direct knowledge a job coach and a job seeker are willing to work with rehabilitation agencies has about individual jobs and the duties in- and providers to meet their employment needs. volved, the easier it is to match people with ca- Job Site Training, Support, and reers of choice. When done correctly, this match Demonstration. For many rehabilitation process will yield satisfied employees and counselors and job coaches, this training was employers and lead to accomplishment of Mile- their first experience developing a sequence stone II. During the training, arrangements were of job duties, designing a task analysis, col- made by the instructors for participants to visit lecting probe data, and working with persons community businesses. Participants were divided with significant disabilities to design compen- into groups of 2 to 3 and were able to gain first satory strategies. This training component was hand experience of introducing themselves to a critical to ensure the new employee reached business and asking questions about specific job work stabilization and the accomplishment of duties associated with a position in order to Milestone III, IV, and V. Initially, training partici- complete a job analysis form. This experince was pants thought that this component was only rated as one of the best components of the designed for employees with cognitive disabil- training, because participants were able to gain ities, with providers serving persons with mental experience in an actual business setting as part illness being the most resistant. Upon comple- of a non-threatening educational experience. tion of the training, members were able to

51 articulate why the component was important these signs were limited to the rooms where the across disabilities, assess if learning was occuring, personnel training events occurred. Instructors and determine if employees reached stabilization. were able to assess an initial level of success Evening and Home-based Application through scores that were achieved by participants Activities and Practice. To ensure that partici- on their daily test. In addition, participants in pants were acquiring new knowledge, it was the certificate program rated the training ex- critical to the training design that evening work tremely high due to instructor knowledge level, was assigned, as well as home-based practice. interactivity of the design, and comprehensive Following a full day of instruction, participants scope of curriculum. The ADRS Executive were required to work in their community groups Leadership Team reported their gratification with (rehabilitation liaison counselor, manager, job the changes that were occurring as a direct result coach and program supervisor) and complete of the new Milestones payment method with its an application assignment. An intensive home- focus on accountability and outcomes. Im based assignment was built into the curriculum grateful to our staff who have so carefully docu- allowing job coaches and rehabilitation coun- mented our progress. At first we saw our agency selors to work together on a specific project. Par- cost escalating, then we realized that these ticipants were asked to establish at least two situ- projects were serving more people and achieving ational assessment sites in the community and a lot of outcomes. This is what rehabilitation is select several supported employment customers all about (personal communications Lamona for assessment. Job coaches were asked to devel- Lucas, Director of ADRS, 7/99). Jim Greene, op a task analysis and practice systematic instruc- with the ARC of Tuscaloosa, reports that as result tion with two customers in a business setting. of the Milestones training, his employment Technical Assistance and Follow-up specialists are spending more upfront time with Day. One month following the initial training, potential new employees prior to employment. all participants were required to reconvene, hand This is yielding better job matches with improved in home-based projects, and share implementa- employment outcomes for employees with tion issues and concerns. This allowed instructors significant disabilities (personal communica- an opportunity to work with individual groups tions, Jim Greene, Director of Supported who were experiencing community implementa- Employment,1999). Tuscaloosa ARC defined tion problems, review home-based projects, and improved employment outcomes as increased provide additional instruction in content areas hours of employment, higher wages, and lon- that needed developing. Those participants that gevity of employment. Several of the programs had completed all classroom instructional hours, serving individuals with psychiatric disabilities work assignments, test, and projects received a were initially very skeptical regarding developing certificate of completion of the Supported Employ- and conducting situational assessments. Most ment Milestone Certificate Program from ADRS. programs thought that the data collected within the day treatment center was sufficient and that employers would never permit them to use a place of business for assessment purposes. After SIGNS OF SUCCESS situational assessments were incorporated into homework exercises, the once apprehensive managers became the most vocal supporters of There are signs of supported employment this assessment technique. One new supporter success across the state of Alabama. Initially, 52 Article 3 was Kerry Weidenback, J.B.S. Mental Health that simply changing over to Milestones or Authority. I found situational assessments to simply providing another inservice workshop be established easily within a business, an efficient would not improve the overall system. In use of staff time, and they produced better infor- addition to the new funding system and the mation for job matching (personal communica- competency-based training, ADRS designated tion, Kerry Weidenback, Director of J.B.S. Mental a rehabilitation manger for supported employ- Health Authority,1999). Personal testimonials ment, with responsibility for program oversight from supported employment leaders along with and technical assistance. Newly trained reha- participant satisfaction and improved program bilitation counselors have been assigned as outcomes are signs that supported employment liaison counselors to specific supported em- is having an impact in the state of Alabama. ployment programs with management evaluating the overall system. These intensified efforts should prove to be successful for this state and the people served in supported SUMMARY employment. Clearly, supported employment services benefit individuals with disabilities in a variety Supported employment has always been of ways to include an opportunity to earn com- an extremely distinctive rehabilitation service with petitive wages and benefits that lead to in- its specific focus on individuals with the most creased independence, greater community in- significant disabilities, competitive employment clusion, removal from disability rolls, improved outcomes, use of job coaching services, and long self-esteem, and establishment of friends and term supports. The very features that comprise networks. Yet, in order for individuals with this unique rehabilitation service have required disabilities to become contributing members the service system to reexamine values, policies, of society, they must have equal access to the and procedures. ADRS is an excellent example supports and services that will assist them in of an organization that has reassessed its reha- achieving success. Supported employment bilitation service system and made a commitment can be that support. With proper implemen- to double its efforts in the area of supported tation, it will ensure that those individuals with employment. Leadership within ADRS clearly the most significant disabilities are able to understood the complexity of the issues facing participate in this nations labor force and are supported employment and knew from the onset included the fabric of their communities.

53 eferences: R Bowe, F.G. (1993). Statistics, politics, and employment of people with disabilities. Journal of Disability Policy Studies, 4 (2), 83-91.

Brooke, V. & Wehman, P. (Eds.) (1999). Tapping new talent for business: Employing people with disabilities. 1(1) (Newsletter). Richmond, VA. Virginia Commonwealth University Rehabilitation Research and Training Center on Workplace Supports.

Brooke, V., Inge, K., Armstrong, A. & Wehman, P. (Eds.) (1995). Supported employment handbook: A customer driven approach for persons with significant disabilities. Richmond, VA: Rehabilitation research and training Center on Supported Employment.

Brooke, V. Revell, G. & Green, J. H. (1998). Long-term supports using an employee-directed approach to supported employment. Journal of Rehabilitation, 64(2), 38-45.

Everson, J. (1991). Supported employment personnel: An assessment of their self-reported training needs, educational backgrounds, and previous employment experiences. Journal of Association for Persons with Severe Handicaps, 16(3), 140-145.

Flippo, K., Gibson, K., & Brooke, V. (1997). Job development: The path to careers. In Brooke, V., Inge, K., Armstrong, A. & Wehman, P. (Eds.). Supported employment handbook: A customer driven approach for persons with significant disabilities. Richmond, VA: Rehabilitation research and training Center on Supported Employment.

Mank, D. (1995). The underachievement of supported employment. A call for reinvestment. Journal of Disability Policy Studies, 5 (2), 1-24.

Novak, J., Mank, D., Revell, G., & OBrien, D. (1999). Paying for success: Results-based approach funding supported employment. In (Eds.) Revell, Inge, Mank, & Wehman. The impact of supported employment on people with significant disabilities: Preliminary findings of the national supported employment consortium. Richmond, VA: Virginia Commonwealth University Rehabilitation Research and Training Center on Workplace Supports.

OBrien, D. & Cook, B. (1998, December). The Oklahoma Milestone Payment System. {online}. Available: http://www.onenet.net/~home/milestone.

Rubin, S. E. & Roessler, T. R. (1995). Foundation of the Vocational Rehabilitation Process. Austin, Texas: Pro-Ed.

Rusch, F. R., Trach, J., Winking, D., Tines, J. & Johnson, J. (1988). Job coach and implementation issues in industry: The Illinois experience. In W.E. Kiermont, & R. L. Schaloch (Eds.), Economics, Industry and Disability: A Look Ahead (pp. 179-186). Baltimore, MD: Paul H. Brookes Publishing Co.

Wehman, P. & Kregel, J. (1995). At the crossroads: Supported employment ten years later. Journal of Association for Persons with Severe Handicaps, 20 (4) 286-299.

54 Empirical Evidence of Systems Change in Supported Employment

By: Martha McGaughey & David Mank

Supported employment emerged quietly in the late 1970s and early 1980s with scattered demonstration projects showing the ABSTRACT capabilities of people with severe disabilities to work in community jobs. This, coupled with growing dissatisfaction of segregated day Supported employment programs and sheltered workshops resulted in a nationwide initiative. emerged rapidly with the onset of federal incentives Now, practitioners and researchers have been demonstrating the for state systems change. benefits of supported employment for people with severe disabilities This expansion was influ- for over two decades. Clear and documented advantages include enced by policy initiatives and legislation, as well as higher wages and benefits, increased opportunities to interact with fiscal incentives. Nonethe- individuals without disabilities, improvement in participants adaptive less, states have imple- behavior skills, and greater employee satisfaction (e.g., Wehman mented supported employ- and Kregel, 1995; Mank, 1994). ment with variable success. This paper analyzes state In supported employment, individuals with disabilities typically outcomes in implementing receive job-related supports in order to obtain or maintain employ- supported employment with ment. Some of these supports may be provided by coworkers, family three goals: (1) to identify members or friends, and some are provided by professional staff. states who have excelled in implementing supported Although the technical knowledge was available as early as the late employment; (2) to examine 1970s and early 1980s to provide and/or stimulate effective, the relationship of eco- work-related supports for individuals with disabilities, the necessary nomic, socio-political and funding structures, administrative supports, trained personnel, and cultural factors to exemplary supported employment out- interagency linkages to establish local, state, and national networks comes; and, (3) to compare of supported employment were not in place until later in the 1980s. these relationships with A number of events occurred during the early 1980s that findings of other studies on state implementation of encouraged development of these linkages. The 1984 Develop- progressive public policy. mental Disabilities Act and the Education for all Handicapped Chil- This analysis suggets that dren Act of 1983 stressed the importance of employment in integrated the federal systems change work settings for individuals with severe disabilities and established strategies influenced the pace of implementation demonstration grant funding for transition from school to work. At across the states. States are the time of these new employment initiatives, special education legis- more likely to adopt a new lation had been in force for ten years. Students with disabilities and policy if it has been or is their families came to believe that their personal dreams of life in being adopted by another state and when motivated typical community environments might be able to come true upon by federal incentives. leaving school. Those dreams were likely to include a valued, community-based job, an apartment or house, the right to choose with

55 whom and how many people to live, hobbies, Services Administration (RSA) provided competi- and activities with friends and family members. tive grant funding for 10 states, with an additional Supported employment was first defined 17 states in 1986, to develop and/or provide as a legitimate VR service option in Title VI Part training, technical assistance, innovative funding C of the Rehabilitation Act Amendments of 1986 strategies and demonstration projects related to (PL 99-596). Supported employment has most supported employment for persons with severe recently been defined in the 1998 Rehabilitation disabilities. These grants continued through Act Amendments (PL 105-220) as: 1998, with all but two states participating. In addition, national scale technical assistance was . . . competitive work in integrated work established at Virginia Commonwealth University settings, or employment in integrated and the University of Oregon to provide and co- work settings in which individuals are working toward competitive work, con- ordinate national training and technical activities sistent with the strengths, resources, related to supported employment. priorities, concerns, abilities, capabilities, Inclusion of supported employment as a interests, and informed choice of the individuals . . . for individuals with the most separate, rehabilitation option in the Rehabilita- significant disabilities; (a) for whom tion Act and funding provided through Titles III competitive employment has not tradi- and VI established the initial legitimacy of this tionally occurred; or (b) for whom com- model within the state VR system and generated petitive employment has been interrupted or intermittent as a result of a significant potentially important resources for developing disability; and who, because of the nature supported employment service capacity and and severity of their disability, need inten- administrative networks within and across states. sive supported employment services. The Rehabilitation Act specified that RSA would provide funding for time-limited supported em- State Vocational Rehabilitation agencies ployment services. Follow-up or extended em- have the latitude to tap Title I monies (primary ployment supports were to be obtained from federal funding stream for state rehabilitation extended service funding agencies (e.g., state services) for supported employment services. As Departments of Mental Retardation/Develop- early as 1984, Virginia was funding supported mental Disabilities, Departments of Mental employment services through the other services Health, etc). Thus, the funding strategy de- as needed provision of Title I of the Rehabilitation manded coordination of service eligibility and Act (Hill & Revell, 1987). However, introduction service delivery procedures across state and local of supported employment into the state VR service organizations, both government and private. system seemed to call for a separate funding Prior to this time, federal funds had been source in order to demonstrate that individuals used for new policy adoption and systemic change with severe disabilities were, indeed, employable. in other human service areas (e.g., implementa- As such, a separate title, VIC, was established in tion of Title XIX Medicaid Act, federal welfare vocational rehabilitation specifically for supported and Social Security legislation, special education employment services. Up to this point, most state services mandated through Public Law 94-142). VR systems were still heavily invested in facility- (See McGaughey and Mank, 1999.) However, based or segregated services (Whitehead, 1989). this is the first time that such a large-scale federal Title III of the Rehabilitation Act allocates policy initiative had been financed toward em- funding for state and agency-level systems ployment for individuals with severe disabilities. change activities. In 1985, the Rehabilitation Logically, systems change in employment services

56 Article 4 follows deinstitutionalization, as supports for indi- States have had variable success in viduals with disabilities develop into more person- expanding supported employment. It is im- centered, more focused on inclusion, and in- portant to gain an understanding of why cer- creasingly shaped by individual preferences. tain states have been more successful than Broad-based systemic change is a chal- others in undertaking systemic change. How lenging goal to pursue. Since the beginning of have some states been able to achieve higher RSAs systems change initiative, research studies supported employment rates or serve a larger have documented consistent annual increases percentage of individuals with severe disabil- in the number of persons with disabilities working ities? A necessary first step to addressing these in supported employment across the United questions is to identify the factors or conditions States. This number has grown from a total of a related to positive supported employment out- few thousand in 1986 to more than 140,000 comes. The study presented relies on the theory in 1995 (Wehman, Revell, and Kregel, 1998). developed to explain the process of policy Other studies of employment outcomes for ex- innovation, adoption, and diffusion among tended service funding agencies confirm these the states (McGaughey and Mank, 1999). trends (McGaughey, Kiernan, Lynch, Schalock In many cases, state policy investigators and Morganstern, 1991; McGaughey, Kiernan, focused on the effects of federal mandates McNally, and Gilmore, 1995) and for special directed toward states, such as: legislative populations served by state VR agencies (Kiernan, acts, federal grants-in-aid, and other intergov- McGaughey, & Cooperman, 1991). ernmental transfer payments (e.g., Dye, In spite of impressive gains in the number 1969). Researchers began to study this pro- of individuals with disabilities working in sup- cess systematically during the Johnson admin- ported employment, several authors pointed to istration, when the federal governments shortfalls in the systems-change initiative. These expanded its involvement in state policy in- include: low percentages of persons with severe novation and adoption. According to Walker disabilities, funding disincentives, rate inequities, (1969), the main trend in intergovernmental entrenchment of some facility-based services, relations from 1964 to 1978 was an aggres- waiting lists of students leaving school, etc. sive national assertion of policy leadership (Mank, 1994; McGaughey, Kiernan, McNally, by the political and judicial branches of the Gilmore, & Keith, 1995; Wehman & Kregel, Federal government, even as the localities 1994; Wehman & Kregel, 1995). Disincentives and, the states were also experiencing the remain that hinder full systems change. Sup- most dramatic reformation in their two century ported employment remains as an additional history. Total government expenditures for do- service option rather than the prevailing service mestic purposes (excluding national defense option for people with severe disabilities. Fiscal and interest on the federal debt) rose from incentives continue to support the maintenance $119 billion in 1964 to $545 billion in 1978. of a parallel system of segregated employment Eyestone (1977) described the process of dif- and day services rather than conversion of fusion as a pattern of adopting policy innova- resources to integrated supported employment. tions. He noted that a states tendency True systems change to supported employment towards new policy adoption most likely de- will occurr when segregated services are an ex- pends upon a variety of factors, including its ception rather than the prevailing service for most intrinsic properties, state politics, emulation people with severe disabilities. of other states, and interaction effects.

57 Braddock and his associates (Braddock, the necessary related administrative struc- Hemp, Bachelder, & Fujiura, 1995; Braddock, tures and linkages, Hemp, Fujiura, Bachelder, & Mitchell, 1990; 2. to examine the relationship between eco- Braddock, Hemp, Parish, & Westrich, 1998) nomic, socio-political, and cultural factors have studied the relationship between economic and stronger supported employment outcomes, and and socio-political factors and state MR/DD agency spending. They have consistently re- 3. to compare these relationships with findings ported that political indicators (special interest from other studies of state innovation and group involvement, specifically state ARC mem- diffusion. bership, and protections offered through state civil rights legislation) are stronger predictors of Research to date suggests that systems state MR/DD spending than measures of state change is a complex process influenced by a wealth or population size. This finding is contrary wide range of factors. Conventional wisdom to results reported in many studies of state expen- might suggest the funding of five-year systems diture patterns, where more populous and wealthy change grants may account for systems change. states score higher on measures of policy innova- Clearly, this strategy delivered results as docu- tion (Klingman and Lammers, 1984; Walker, mented elsewhere (e.g., Wehman et al., 1998). 1969; Dye, 1990, etc.). According to Braddock Nonetheless, this factor is but one in a complex and his colleagues, MR/DD funding may be set of factors that must be considered in evaluating somewhat distinct from other categories of state systems change in supported employment in expenditure. It is likely that the presence and states. They include political factors, economic relative strength of disability-related advocacy factors, and demographic factors. Figure 1 below groups may counteract competing pressures on provides a vision of a conceptual framework for state coffers from other special interest groups. understanding a states environment. Previous research has documented a relationship between measures of state wealth (or personal income), taxation levels, urbanization FIGURE 1 -- STATE ENVIRONMENT measures, unemployment rates, state fiscal commitment, antidiscrimination employment legislation, and supported employment or competitive POLITICAL FACTORS: employment outcomes for persons with disa- l Political culture bilities. Other studies of supported employment l Liberalism outcomes have documented a great deal of vari- l Political Competition ability across states (West, Revell, and Wehman, l Grassroots Advocacy 1992; Wehman, Revell, and Kregel, 1998). ECONOMIC FACTORS: Research and analysis is needed to exam- l Employment Rate ine systems change activities and policies de- l SE Spending Ratio/Per Capita Income signed to understand systems change and en- l Federal Spending Ratio hance supported employment or convert facility- l Tax Ratio based resources. The goals of this study are DEMOGRAPHIC FACTORS: threefold : l State Population 1. to identify states that have excelled at estab- l Degree of Urbanization lishing supported employment services and l Degree of Industrialization

58 Article 4 MEASURES the earlier federal systems change grants may The data source used for this study was be those pioneer states that are consistently the National Longitudinal Study of Supported more receptive to new policy adoption, or Employment conducted by researchers at Virginia they may display stronger supported employ- Commonwealth University (VCU) from 1986 ment outcomes as a result of early participa- through 1997, with additional surveys planned tion in the systems change initiative (see (Wehman, Revell and Kregel, 1998). Data McGaughey and Mank, 1999). The time were collected from state Vocational Rehabili- period during which states received their sys- tation agencies and, in some instances, from tems change grant funding was coded as: 4 extended-service funding agencies. The state = states that received funding during more VR director was asked to appoint a respondent. than one grant cycle, 3 = the first group of When necessary, responses were clarified over 10 states, 2 = second group of 17 states, 1 the telephone by VCU staff. Each states data = remaining states to be funded, 0 = did profile was returned to the responding state office not receive a systems change grant. for final validation. For more information on the Several socio-political and demo- survey questions or methodology for this study, graphic characteristics also were examined refer to Wehman, et al., (1998). for their relationship to supported employment Outcome data used for this study include outcomes: state political preferences, the de- supported employment rates for 1988, 1990, gree of special interest group involvement, 1993, and 1995 (measured as the number of population size and density, and the degree supported employees per 100,000 of the states of urbanization. The policy liberalism factor population) as well as a summative measure of developed by Klingman and Lammers was the total number of supported employees reported chosen to measure state political preferences, for those four years. Several other variables were because it is based on a variety of regulatory examined for 1995 only: the percentage re- and expenditure-based policies across several ceiving extended employment services, percen- points in time. The final factor accounted for tage with severe mental retardation (of those with 61.5 percent of the variance in the following mental retardation), percentage with long-term variables: 1) Walker index of policy innova- mental illness, and wage and hour data. Two tiveness up to 1965 (Walker, 1969); 2) states were not included in the analyses due to McCrone-Cnudde scale of anti-discrimination missing data on the outcome measures. provisions as of 1961 (McCrone and Cnudde, Based on the review of factors reported to 1968); average monthly payment per recipient influence state patterns of adoption, economic of Aid to Families with Dependent Children indicators were analyzed to understand how they (AFDC) for 1965 (Social Security Adminis- were related to supported employment outcomes. tration, 1966); number of years since ratifi- For this study, the proportion of state wealth cation of the Equal Rights amendment for devoted to supported employment or state effort women as of 1978 (Boles, 1979); number was measured as spending on supported employ- of consumer-oriented provisions as of 1974 ment per 100,000/per capita income. It is likely (Sigelman and Smith, 1980); and percentage that supported employment outcomes also are of federal allotment to the state for Title XX related to states overall employment environment, social services programs spent by the state in which was measured as the percentage of the fiscal year 1976 (Whitney, 1975). Special population employed. States chosen to receive interest group involvement was measured as

59 state membership in the ARC (previously called reported a high percentage of change in enroll- the Association for Retarded Citizens) during FY ments from 1990 to 1995. It will be interesting 1997. Population size was measured as total to see whether state supported employment rolls state population reported in 1990, and popula- increase as rapidly during the period from 1995 tion density was based on total state population - 2000. Such increases may reflect the extent to in 1990/total square miles (U.S. Bureau of the which systems change has permeated other state Census, 1990). Finally, the percentage of the agencies, because state VR agencies must co- state population living in metropolitan areas in ordinate with other state agencies to develop 1990 was used to assess the degree of urbani- funding for extended services. zation (U.S. Bureau of the Census, 1990). Table 2 shows the state-by-state distribution for the percentage of employees with mental PROCEDURES illness and the percentage with severe mental A sub-sample of states (n=16, 32%) re- retardation (of the total number with mental reporting the highest number of persons in sup- tardation) for FY 1995. Again, there are fairly ported employment during 1988, 1990, 1993, substantial differences across states, although the 1995 was selected in order to examine charac- overall percentages served are quite small. Except teristics of the most effective states. Statistical for Oklahoma, Oregon, and Missouri, no states comparisons were conducted between the sub- reported more than 10% of their employees with sample and the remainder sample. Most analyses mental retardation as having severe or profound are based on 48 states (excluding two states due retardation. There also was substantial variation to missing data, except for the multivariate across states in the percentage of employees with analyses for which one additional state was also serious and persistent mental illness, ranging excluded due to missing data for one of the four from 2.6% in Utah to 58% in Idaho. years used to calculate the total served in sup- The 16 states with the highest supported ported employment.) employment rates for 1988, 1990, 1993, and 1995 are ranked in Table 3. In general, the same states appear across the years. However, differences that do exist may be related to the RESULTS rate of change from 1988 to 1995 (shown in Table 4), as a few states finally appeared on the 1995 list due to a high rate of change (e.g., Table 1 on the following page shows state Wyoming, Idaho, and Pennsylvania). As with the supported employment rates per 100,000 of the overall sample, the percentage change from state population for FY 1990 and FY 1995, 1988 and 1995 was correlated with higher sup- and the change from 1990 to 1995. Clearly ported employment rates in 1995. Thus, states there is substantial variability across states, with demonstrating the greatest change in supported the 1995 supported employment rate ranging employment services also reported the strongest from 13 to 165 per 100,000 persons. The num- results, either a high percentage of employees ber of persons in extended employment was sig- with disabilities overall or a high percentage with nificantly correlated with the supported employ- severe mental retardation or serious and persistent ment rate for 1995 and the rate of change from mental illness. 1990 to 1995. Hence, states that reported high The sub-sample state scores for the total supported employment rates for FY 1995 also served in supported employment during 1988,

60 Article 4

TABLE 1 -- PERCENTAGE IN SE PER 100,000 -- STATE POPULATION FOR FY 1990 & FY 1995 & CHANGE IN ENROLLMENT FROM FY 90 TO FY 95 (N = 48)

# in SE per 100,000 # in SE per 100,000 Change from State FY 1990 FY 1995 1990-1995 AK 106 111 5 AL 18 34 16 AR 15 20 5 AZ 24 34 7 CA 26 33 7 CO 57 106 49 CT 129 165 36 DE 128 17 -11 FL 33 34 1 GA 26 61 35 HI 25 14 -11 IA 7 15 8 ID 49 98 49 IL 18 24 6 IN 18 60 42 KS 25 55 30 KY 22 42 20 LA 13 32 19 MA 62 35 -27 MD 30 71 41 ME 24 92 67 MI 27 75 47 MN 123 232 109 MO 20 60 40 MS 29 13 -16 MT 42 100 58 NC 20 66 46 NE 12 49 37 NJ 15 23 8 NM 3 22 18 NV 6 31 24 NY 44 59 15 OH 9 66 57 OK 15 54 39 OR 65 80 15 PA 11 76 65 SC 37 38 1 SD 57 148 91 TN 8 39 31 TX 10 46 36 UT 24 49 25 VA 52 65 13 VT 100 129 29 WA 32 123 87 WI 60 103 43 WV 20 15 -5 WY 33 160 127 Mean 36 66 30 Sda 30 46 32 aStandard Deviation 61 TABLE 2 -- SELECTED OUTCOMES BY STATE -- FY 1995

% MR with % Long- % MR with State Severe MR Term State Severe MR % Long-Term (N = 48) (N(N=30) =30) MMI I (N(N=40) = 40) (N=(N=48) 48) (N = 30) MMI I (N(N=40) = 40) AK 1.4 36.6 MS NA NA AL NA NA MT NA NA AR .2 NA NC 2.1 36.4 AZ 2.0 8.1 NE 5.5 18.2 CA NA 16.5 NJ 3.8 NA CO .8 28.2 NM NA NA CT 8.5 41.2 NV NA NA DE NA 20.8 NY NA 34.6 FL .4 9.1 OH 3.5 12.5 GA .8 14.5 OK 20.6 15.7 HI .0 33.8 OR 20.4 15.0 IA 2.6 23.1 PA NA 30.7 ID .5 58.4 RI NA NA IL 6.5 24.4 SC NA 50.0 IN NA 23.1 SD 1.6 34.0 KS 3.2 36.4 TN 2.4 29.4 KY 2.0 24.4 TX 1.5 57.0 LA 5.7 24.4 UT 24.6 2.6 MA NA 32.4 VA 5.1 21.3 MD 4.0 27.1 VT NA NA ME NA 39.5 WA .2 31.4 MI 6.8 34.4 WI NA 25.8 MN NA 17.3 WV 2.4 13.3 MO 17.3 14.1 WY 1.5 20.4

Mean 1.5 28.4 SD 6.6 17.0

1990, 1993, and 1995 per 100,000 state pop- No states were represented from the south or ulation and their associated ranks are displayed southwest, an interesting finding considering the in Table 5. Minnesota obtained a much higher policy innovation and diffusion theories previously score and, consequently, served the largest rela- discussed (McGaughey and Mank, 1999). tive number of persons in supported employment Table 6 presents economic information compared with the other high-performing states. related to the sub-sample states for 1995, in- In fact, the cumulative supported employment cluding income, taxation, spending, and employ- rate reported in Minnesota was 33% greater than ment variables. Five states had average per- that of Connecticut, the state with the second capita income levels below the mean for 1995. highest rate. States with the strongest sup- State fiscal effort for supported employment was ported employment outcomes were located in based on the ratio of per-capita supported the northeast, northwest, and southeast coasts employment spending to per-capita income. or in the upper Midwest sections of the country. State wealth was included in the denominator,

62 Article 4

TABLE 3 -- STATES WITH HIGHEST SE RATESA FOR 1988, 1990, 1993, & 1995

1988 RANK 1990 STATE 1993 RANK 1995 STATE 1 MN 105 1 CT 129 1 MN 171 1 MN 232 2 VT 89 2 MN 123 2 VT 146 2 CT 165 3 CT 81 3 AK 106 3 AK 115 3 WY 161 4 RI 54 4 VT 101 4 WY 110 4 SD 148 5 WI 41 5 RI 75 5 CT 109 5 VT 129 6 MA 34 6 OR 66 6 ID 107 6 WA 124 7 CO 33 7 MA 36 7 WI 93 7 AK 111 8 WA 26b 8 WI 61 8 CO 91 8 CO 106 9 AK 26 9 SD 58 9 OR 88 9 WI 104 10 DE 26 10 CO 57 10 WA 77 10 MT 100 11 OR 23 11 VA 52 11 VA 70 11 ID 98 12 MD 22 12 ID 49 12 MI 55 12 ME 92 13 MT 20 13 NY 44 13 SD 53 13 RI 86 14 GA 17 14 MT 42 14 OH 52 14 OR 80 15 IA 16 15 SC 37 15 IN 52 15 PA 77 16 ID 15 16 WA 36 16 NC 50 16 MI 75

aSE Rates = Number in supported employment per 100,000 state population bRanks for ties based on value before rounding number

TABLE 4 -- STATES WITH GREATEST CHANGE IN SE RATES: 1988 - 1995

RANK STATE # CHANGE RANK STATE # CHANGE 1 WY 146 9 ME 81 2 SD 141 10 PA 75 3 MN 127 11 CO 74 4 WA 98 12 MI 68 5 AK 85 13 OH 65 6 CT 85 14 NC 64 7 ID 83 15 WI 63 8 MT 81 16 OR 57

63 because we were interested in measuring sup- TABLE 5 -- SIXTEEN STATES WITH THE ported employment funding as a proportion of HIGHEST CUMULATIVE SE RATES state resources. Most states obtained a ratio OVER FOUR YEARS -- 1988, 1990, close to or above the mean, but not all. Michi- 1993, & 1995- gan, South Dakota, and Montana all achieved aa Rank State Score notable employment outcomes with low spending 1 MN 632 to income ratios. State per-capita tax rates are 2 CT 485 shown in the next column. South Dakota, Colo- 3 VT 465 4 AK 358 rado, and Virginia had substantially lower tax 5 WY 318 burdens than other states. The sub-sample states 6 WI 297 employment rates are displayed in the last col- 7 CO 287 8 ID 270 umn. Except for New York and Rhode Island, 9 SD 266 all states reported employment rates above the 10 WA 264 11 OR 257 national average. A variety of socio-political 12 RI 256 characteristics of the sub-sample are revealed in 13 MT 209 Table 7 on the following page. State popula- 14 VA 201 15 MI 163 tion varied, from approximately 450 thousand 16 NY 157 to 18 million. State scores varied on the policy Mean: 97 liberalism but all states except Wyoming, South Standard Deviation: 40 Dakota, Vermont, and Virginia exceeded the

TABLE 6 -- SUB-SAMPLE RELATIONSHIP TO INCOME, TAXATION, SPENDING AND EMPLOYMENT VARIABLES

aa bb cc dd State PCINC Effort State Tax Rate % Employed

AK 22.5 35 22.5 68.5 CO 21.8 20 12.6 69.4 CT 28.2 48 20.6 68.5 ID 17.9 14 16.1 67.2 MI 22.0 02 16.6 62.7 MN 21.6 16 19.8 72.6 MT 17.2 03 14.5 64.8 NY 24.9 12 18.2 57.0 OR 20.2 21 14.2 65.1 RI 21.7 16 14.3 61.2 SD 18.1 04 9.4 69.4 VA 21.9 11 13.0 66.0 VT 19.5 31 14.8 67.7 WA 22.0 24 19.9 63.0 WI 20.3 18 17.2 69.7 WY 19.8 35 16.3 67.5 aAverage income for 1995 per 1,000 in population; bPer capita SE spending/per capita income * 100; cState tax rate per 10 in population; dPercentof noninstitutional civilian labor force employed 64 Article 4 national average, indicating a potential relation- displayed significantly higher proportion of ship between a states political preferences and supported employment funding to per-capita supported employment outcomes. The last col- income compared with other states (df=46, umn shows membership in the state ARC associa- t=3.6, p<.01), significantly higher numbers tion per 100,000 state population. For the sub- of persons in extended employment per sample, membership in the ARC fell both below 100,000 state population (df=46, t=7, and above the national mean. p<.001), significantly higher scores on the Three additional outcomes were examined policy liberalism index (df=44, t=3.6, for the sub-sample: extended employment rates p=.001), significantly higher overall state em- and the extent to which persons with long-term ployment rates (df=46, t=2.13, p<.05); and mental illness or severe/profound mental retarda- a significantly larger percentage of persons tion received supported employment services. with serious and persistent mental illness in The results are shown in Table 8. T-tests show supported employment (df=38, t=2.27, that the sub-sample of 16 states differed signifi- p<.05). cantly from the remaining states as follows: they

TABLE 7 -- SUB-SAMPLE CHARACTERISTICS ACROSS SELECTED SOCIO-POLITICAL VARIABLES

System Change Political Employment ARC aa bb cc dd State Population Grant Index Legislation Membership AK 550,043 3.0 Missing 4.0 45 CO 3,294,394 2.0 1.12 3.0 43 CT 3,287,116 2.0 1.45 4.0 19 ID 1,006,749 .00 .14 1.0 14 MI 9,295,297 3.0 1.10 4.0 52 MN 4,375,099 3.0 1.23 5.0 110 MT 799,065 1.0 .11 5.0 2 NY 17,990,455 4.0 1.86 5.0 19 OR 2,842,321 4.0 1.44 4.0 71 RI 1,003,464 .0 .87 4.0 162 SD 696,004 .0 -.58 4.0 75 VA 6,187,358 3.0 -.74 4.0 42 VT 562,758 2.0 -.35 5.0 00 WA 4,866,692 3.0 .58 5.0 24 WI 4,891,769 4.0 1.38 4.0 04 WY 453,588 1.0 -.08 4.0 127 Mean & Standard Deviation for all States (N = 48) 5,132,394 1.7 -.0006 3.8 54 5,507,672 1.3 1.02 1.7 49

a Higher score = Receipt of the earlier grants; b General Liberalism Index developed by Klingman and Lammers (1984); c Extent of coverage of state employment legislation affecting PWD, including states with criminal remedies; d ARC membership per 100,000. 65 TABLE 8 -- SUB-SAMPLE ACROSS SELECTED OUTCOMES

# w/Long-Term Of # w/MR Average Average Hours Average State Mental Illness % Severe Hourly Wage Per Week Weekly Wage

AK 37 1.4 NA 23 $115.00 CO 28 .8 $4.64 23 $104.40 CT 41 8.5 $4.29 23 $103.06 ID 58 .5 $4.50 20 $89.00 MI 34 6.8 $4.62 22 $102.37 MN 17 NA $4.05 NA NA MT NA NA NA NA NA NY 35 NA $5.10 25 $126.00 OR 15 20.4 $3.29 22 $61.74 RI 10 NA NA NA $123.00 SD 34 1.6 $4.24 24 $102.00 VA 21 5.1 NA NA $139.70 VT NA NA $5.43 NA $103.17 WA 31 .2 $5.58 19 $133.65 WI 26 NA $4.61 16 $73.53 WY 20 1.5 $4.55 24 $110.16

A Number in extended employment per 100,000 state population; b Number per 100,000 w/Long- Term Mental Illness; c % of MR population in SE with Severe or Profound MR

the state before it is adopted at the federal level DISCUSSION (Elazar, 1984). Elazar argued that the federal government is naturally the inventor of an innovative policy and suggests the implementation Studies of statewide policy innovation and process involves a shared commitment and redefi- diffusion have reported a number of trends nition of policy at state and national levels. associated with state-level systems change (Dye, 1969; Hanson, 1990; Klingman & Lammers, 1984; McGaughey & Mank, 1999). First, states are more likely to adopt a new policy if imple- PREDICTORS OF HIGHER RATES mented by another state, especially one which OF IMPLEMENTATION has similar economic, socio-political, and demographic characteristics (Walker, 1969). Second, A variety of factors were significant predic- states are more likely to engage in policy innovators of supported employment systems change tion when motivated by federal incentives, particu- outcomes in this study, including: economic larly those with a fiscal impact (Gray, 1973). indicators (employment rates, personal income, Third, most policy innovation originates within supported employment funding, and tax levels);

66 Article 4 socio-political measures (political preferences, ment outcomes. These 16 states also were anti-discrimination employment legislation, and more likely to adopt anti-discrimination em- the degree of liberalism); and demographic ployment legislation that contained broader factors (state population and population density). coverage and more complete remedies. The relationship of economic factors to supported employment outcomes are discussed first. State fiscal commitment to supported employment was the most significant predictor of SUSTAINING TRENDS supported employment rates, even greater than state wealth or the level of taxation. It is not sur- States that reported high supported prising that fiscal commitment was a significant employment rates for FY 1995 also reported predictor, but it is surprising that it had the greatest a high percentage of change in rates from impact among the economic indicators. 1990 to 1995. This may reflect the extent to It is also possible that the influx of federal which systems change has permeated other grants-in-aid into the state policy system could state agencies, since state VR agencies must have detrimental effects, such as influencing coordinate with other state agencies to states to substitute federal funds for state money develop funding for extended services. or to demand a higher level of public services States in the northeast, northwest, than they can afford (Dye, 1990). Formula southeast coast, and upper midwest showed grants that allocate resources based on specific the strongest supported employment outcomes. indicators tied to categorical programs (e.g., Southern states are more likely to have a tra- poverty rates used to distribute federal welfare ditionalistic political culture, one that is typi- monies) can reduce these effects somewhat. The cally less receptive to government programs. federal-state Vocational Rehabilitation system is Further research is needed to gain insight into based on a similar formula to ensure that states how southern states may have differed in their with fewer resource needs will receive less funding. development of supported employment or in Moreover, states are required to provide matching the reduction of sheltered services. One thing monies to receive federal allotments. Supported we do know is that states in the southern re- employment is somewhat unique in this context, gion had a lower fiscal commitment to sup- because states are expected to leverage long term ported employment (as a percentage of per- supports from state funds to sustain supported sonal income). It would be particularly inter- employment outcomes. Research related to the esting to examine any exceptions to these policy liberalism factor demonstrated that, al- trends in the south. It may well be that without though the type of policy being adopted mattered the stimulation of federal dollars (Titles III and little, progressive is a legitimate label for some VI), these states may have been less successful state policy trends (Klingman and Lammers, than they were in the change process. 1984). State political preferences (as concep- As indicated earlier, five states with tualized by Elazar, 1984) also are strong deter- higher outcomes had average per-capita in- minants of state policy innovation and systems come levels below the mean for 1995. Thus, change. Both Elazars typology and Klingman even with fewer resources, some states were and Lammers (1984) policy liberalism factor achieved impressive supported employment appeared to predict which states would appear outcomes. A few states achieved notable out- in the group with the strongest supported employ- comes with low spending to income ratios.

67 State employment rates may be an impor- as the consistent adoption and diffusion of new tant predictor of supported employment out- policies) that may be helpful. The high levels of comes, particularly for states with lower per-capita employment indicate greater economic growth, income levels and/or lower supported employ- even though state wealth was lower in certain ment funding to income ratios. In fact, South cases. Other potentially influential factors in- Dakota data may offer an intriguing example of clude state size and the extent of urbanization. this phenomenon, because a high cumulative Average wage levels may be lower in some states supported employment rate was achieved in spite due to the more rural nature of available employ- of the fact that South Dakotas fiscal commitment ment opportunities (farm labor, small retail and to supported employment was lower than other service establishments, etc.). The types of employ- states in the sub-sample. The percentage em- ment opportunities and their accompanying wage ployed also may help to explain high supported levels should be analyzed for this region as well employment outcomes in Minnesota (employment as for some of the other subsample states in order rate=72.6%) and Colorado and South Dakota to make effective comparisons regarding eco- (employment rates=69.4%). nomic growth and employment opportunities. State population varied widely among this Additional analyses is needed that includes sub-sample of states, from very rural to highly testing various multivariate models which may urbanized. As such, population is not a clear offer clarification regarding both the independent predictor of supported employment outcomes. and the relative effects of economic, socio- The period during which systems-change grant political, and demographic variables as predictors monies were received also varied across the of states cumulative supported employment rates. sub-sample, indicating that other factors may Research is needed to examine the rates of shel- be more influential. Most of the states in the sub- tered employment services in states with strong sample exceeded the national average on the supported employment outcomes and to com- policy liberalism factor. Higher scores on state pare significant determinants for both supported anti-discrimination employment legislation reflect employment and sheltered employment rates, broader coverage (mental and/or physical disa- especially in light of the focus on conversion of bility, pubic and/or private entities specified by sheltered workshops in some states (e.g., Texas). size) that is likely to have a greater impact, even Except for Oklahoma, Oregon, and for supported employment. Income differentials Missouri, no states reported more than 10% of appear to affect supported employment rates less their employees with mental retardation as having than political inclinations (e.g., liberalism scores), severe or profound retardation. There also was inclination toward use of federal funds, and substantial variation across states in the percent- employment and economic growth levels. age of employees with serious and persistent mental illness. What did states serving a large percentage of persons with severe mental retardation or long-term mental illness in supported em- STIMULATING SYSTEMS ployment do to achieve these outcomes? Did court-ordered deinstitutionalization influence the CHANGE IN ALL STATES populations served by these states? Were any Analysis of upper-Midwest states may pro- trade-offs made to achieve these outcomes (such vide insight into the process of systems change as fewer total persons in supported employment, as an overall phenomenon (defined in this study lower average wages, etc.)?

68 Article 4 The next stage of this research project will to provide supports and leadership, board include a survey of every state VR agency re- members to offer direction and vision, and garding systems change activities and the politi- family members and supported employees to cal context in states. Site visits will be made to develop openness to new possibilities. selected states that may offer especially relevant information related to the systems change process and new policy adoption. It will be particularly interesting to consider how policies related to CONCLUSION supported employment or to sheltered employment may vary across states and whether these differences help to explain variation in state out- Systems change is complex, and the comes that has not been clarified through bivari- implementation of supported employment ate and multivariate analyses. across states varies. The federal government Training and technical assistance dollars, has invested in systems change to supported as well as investment in creating high quality employment, and there is clearly evidence of demonstration projects, may be particularly im- progress across the USA. Initially our main portant when attempting to implement systemic question was: Did systems change strategies change because of the importance of addressing work for supported employment? This paper human resource issues during a period of such presents evidence that change has and extensive change. The new supported employ- continues to occur. However, this leads to ment eligibility and program requirements called questions that may be more important, to what for coordination and interagency collaboration extent has change occurred, and what predicts across various levels of services (provider to gov- greatest change? Some of the predictions of ernment, provider to families, government agency greater change (employment rate, tax limits, to government agency, etc.). Furthermore, sup- political context, etc.) are not in the control ported employment required all stakeholders to of implementors. Other factors associated with develop the flexibility to adjust to a more decen- greater change (state examples that can be tralized service model after having been more emulated, funding schemes, etc.) can be familiar with the security of a building as a place adjusted by state and federal collaboration. to go during the day. Operating effective sup- While there is evidence of change and factors ported employment services requires employment contributing to this change are emerging, it staff to develop new skills and a greater under- will be important to conduct a more indepth standing of employer needs, management staff analysis via surveys and case studies.

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71 72 The Quality of Supported Employment Implementation Scale By: Gary R. Bond, Jeff Picone, Beth Mauer, Steve Fishbein, & Randy Stout

ABSTRACT INTRODUCTION The authors describe a 33-item interviewer-rated checklist, the Quality of Supported Employment Implementation Scale (QSEIS), designed to measure Introduced in the 1980s (Wehman, implementation of supported employment (SE) pro- 1986), supported employment (SE) is an ap- grams for people with severe mental illness (SMI). proach to helping people with severe disabili- They used a 1.5-hour semi-structured interview with program directors in 32 SE programs in Kansas (KS) ties work in competitive employment positions. and New Jersey (NJ). Interviewers averaged 84% Although its principles are well described in the agreement in item ratings. The internal consistency for the total scale was low (Cronbachs alpha = .51), literature, its implementation has been variable but higher for four subscales: Teamwork (.74), Plan- throughout the U.S. In this project, the authors ning and Support (.60), Rapid Job Search (.74), and sought to develop a checklist that concretely Integration with Mental Health (.62). measures features of well-implemented SE pro- Substantial implementation of SE standards was grams. Although the current focus is on devel- found in these programs, with mean ratings ex- oping a scale applicable for programs serving ceeding 4.0 on a 5-point scale, for 18 of 33 items. Mean overall implementation was similar in both people with severe mental illness (SMI), the ulti- states, with somewhat different patterns, with NJ mate goal is to develop companion scales for rating higher on Planning and Support, and KS rating higher on Integration of Mental Health and Rapid other disability groups. Job Search. Scales to measure quality of supported employment implementation are of interest to The QSEIS total scale and 4 subscales were correlated with 9 indicators of employment outcomes, consumers, providers, and administrators. The obtained from a retrospective survey completed by recent Rehabilitation Act Amendments explicitly program directors in 24 of the programs. The total note the role of state VR agencies in helping QSEIS score was not significantly correlated with any of the outcome measures. Planning and Support consumers acquire information necessary to correlated positively with job tenure (r = .62), but make an informed choice about the specific ser- was not related to annual VR closure rate (r = -.15). Conversely, Rapid Job Search was negatively vices, including the providers of those services, correlated with job tenure (r = -.56), while positively that are needed to achieve the individuals voca- correlated with annual VR closure rate (r = .46). Thus tional goal. This information must include, at a different aspects of the supported employment approach may foster job acquisition and job retention. minimum, information relating to cost, accessi- The authors conclude that the QSEIS is a pragmatic bility, and duration of potential services, the con- tool for describing SE programs for people with SMI, sumer satisfaction with those services, the although more work on psychometric precision and predictive validity is needed. The survey provides qualifications of potential service providers, the norms by which other providers and other states can types of services offered by those providers, and compare their achievement of the principles of supported employment. the degree to which services are provided in 73 integrated settings (Public Law 105-220, 1998, of specific program procedures. McDonnell, 361.52 (b)). The reality is quite different; how- Nofs, Hardman, and Chambless (1989) devised ever. Despite this mandate, such information a 14-item checklist for monitoring a statewide typically is not available to consumers, nor do SE implementation. One contribution of this states have indicators of program quality by which study was that several items correlated with better they can describe supported employment services employment outcomes. Unfortunately, the items for consumers. Similarly, service providers request were not specific to SE, but instead reflected good guidance in the form of program standards to management practices (e.g., Written training achieve the goals articulated in supported em- programs are developed for each work assign- ployment legislation (e.g., diversifying employment.). A 28-item checklist of SE standards ment opportunities, improving wage outcomes, developed by Wood and Steere (1992) covers serving individuals with the most significant disa- many important dimensions of SE, but its response bility). Yet, self-assessment tools are not readily format appears to be vulnerable to socially desir- available to link program content to outcomes. able responses (Perkins, 1995). State agencies responsible for funding and moni- The IPS Fidelity Scale, a 15-item checklist toring of SE services also seek quality assessment assessing adherence to a specific SE model tools tied to performance to help identify program known as Individual Placement and Support improvement areas that can be addressed (Bond, Becker, Drake, & Vogler, 1997a), was through technical assistance. Thus, neither con- piloted in a sample of 27 programs that included sumers, service agencies, nor funding agencies a wide variety of vocational models. Both inter- have available at this time validated tools that rater reliability and internal consistency were ade- tie program content to valued employment out- quate. The scale discriminated sharply between comes in supported employment. IPS and the non-SE vocational programs. IPS Recently, several randomized controlled programs differed from other types of SE programs trials have suggested that SE is more effective on items measuring integration of SE with mental than traditional vocational rehabilitation stra- health services and on an item measuring zero tegies for people with SMI with respect to a range exclusion admission criteria. Subsequent work of competitive employment outcomes, including on the IPS scale with an expanded sample of 50 employment rates, total time worked, and sites yielded interrater reliability exceeding .93 earnings (Bond, Drake, Mueser, & Becker, and internal consistency of .87 (Bond, Vogler, 1997b). These findings heighten the importance Becker, & Drake, 1998). of defining the components of successful SE Vogler (1998) developed a 40-item scale programs so that they can be replicated else- to measure implementation of 24 SE programs where. Previous efforts to develop a method to in Indiana and Minnesota. Ratings were based assess critical SE program components have on both face-to-face interviews with staff during provided insight into the best strategies for site visits and telephone interviews. Agreement obtaining this information. In a national study between interviewers was very good, but overall of exemplary SE programs, Gervey, Parrish, and internal consistency for the scale was marginal Bond (1995) used a 49-item checklist to describe (Cronbachs alpha = .59). Vogler found no provider characteristics, funding, consumer eligi- systematic bias in the comparison of face-to-face bility, case management services, staffing, and ratings to telephone interviews. Correlations support services. The survey questions were gen- between ratings made from interviews with pro- erally factual and did not give a detailed picture gram supervisors and those with line staff were

74 Article 5 moderately high. However, ratings by follow- suggested a variety of additional items and along specialists (i.e., staff in the Indiana SE ser- descriptions of best practices (e.g., Ford, vice model who provide long-term support after 1995; Hoff, 1997; MacDonald & Roberts, consumers achieve successful VR closure status), 1998; Marrone, 1996; Matrix, 1992). Next, who were less informed about many aspects of draft versions of the implementation and em- the program organization and functioning, ployment outcome instruments described in this agreed poorly with ratings by other SE staff. Vogler report were developed and circulated to the found no relationship between the total score for advisory board for review and revision. The the SE implementation scale and employment instruments were piloted using 10 sites, the outcomes. She concluded that restriction of finding complied, and reviewed with the ad- range in the study sample limited internal consis- visory board. Based on this initial data analysis tency and correlations with outcome. and discussions with the advisory board, item The current study was aimed at devel- revisions and deletions were made and four oping a brief, self-explanatory checklist, suitable new items were added to the implementation for use in a telephone interview format, and ulti- checklist. The resultant checklists are a culmi- mately as an instrument completed by a program nation of this interactive process. Thus, the administrator or state planner, or as a self- instruments did not represent a single theoreti- evaluation by a study site. Concurrent with this cal perspective but were based instead on a effort, this investigators sought to develop a consensus process. method for collecting indicators of employment outcomes. The authors sought to determine STUDY SITES whether the checklist measuring program imple- State administrators from Kansas mentation would be well-received and usable in (Randy Stout) and New Jersey (Steve Fishbein) a statewide survey, whether it could be completed provided the research team with complete in a reliable fashion, whether the items constituted rosters of program directors for the SE programs an internally consistent scale, whether it aptly for people with SMI in their respective states. described services in the programs examined, Interviewing began first in NJ. Sites were sche- and finally, whether the ratings on the imple- duled according to time availability of program mentation checklist were associated with higher directors and interviewers. Of the 21 NJ sites, rates of employment outcomes. 20 (95%) participated, and one did not return calls. Of the 27 KS sites, 12 (44%) agreed to participate, with two programs refusing. The remaining sites had not been interviewed at METHODS the time of this report. Sample characteristics. There were no differences in longevity of programs between NATIONAL ADVISORY BOARD The current study was undertaken with KS (M = 5.07 years, SD = 3.18), and NJ (M the help of a national advisory board of experts = 6.71 years, SD = 3.08), number of employ- chosen for their knowledge and expertise in SE. ment specialists (full-time equivalents) devoted The point of departure included several existing to supported employment (KS: M = 2.88, SD SE scales, as described above. The advisory = 1.84; NJ: M = 3.34, SD = 1.26), number board was convened in a series of teleconfer- of active consumers (KS: M = 40.17, SD = ences at several stages of the process. The board 29.36; NJ: M = 42.85, SD = 17.94), or

75 number of consumers per staff member (KS: M collection were explained. Following the tele- = 16.67, SD = 8.45; NJ: M = 14.93, SD = phone interview, the Employment Outcomes 8.38). Programs were also comparable in the Form was faxed, and program directors were number of annual admissions (KS: M = 30.56, offered a $100 honorarium for the time required SD = 24.68; NJ: M = 27.46, SD = 11.31) to complete this form. and cases closed (KS: M = 15.00, SD = 9.60; NJ: M = 22.00, SD = 10.89). MEASURES QSEIS. The format and structure of the PROCEDURES QSEIS was borrowed from the IPS Fidelity Scale The research pilot was first presented to (Bond et al., 1997a). The QSEIS items are rated the study sites by the state administrators during on 5-point, behaviorally-anchored scales, where regularly-scheduled regional and statewide 5 represents full implementation, 4 represents meetings. The research team then contacted moderate implementation, with the remaining each SE program director (or, in a couple of in- scale points representing increasingly less ade- stances, another staff worker from the SE pro- quate implementation of the item in question. gram), to explain the project and determine the Behavioral anchors were developed through program directors willingness to participate in clinical judgment, trial-and-error, and prior norms the study. A convenient telephone interview time in the literature (e.g., Bond et al., 1997a; Vogler, was scheduled for those agreeing to participate. 1998). The QSEIS subscale structure (Vocational The QSEIS was administered during a Staffing, Organization, and Services) also was telephone interview, typically of about 1.5 hours borrowed from the IPS Fidelity Scale. Sample in duration. The first three authors served as the items are seen in Table 1 on page 78. interviewers. At least two interviewers were present during each interview (with one exception). l Vocational Staffing (6 items) -- is designed Altogether, 9 interviews were completed with 3 to assess the commitment of the program and agency to staffing SE programs at levels interviewers and 22 with 2 interviewers. appropriate for providing quality services. The QSEIS interview procedure began Examples of these items are: agency focus with a few orienting remarks followed by a semi- on SE, which assesses the ratio of agency structured interview that is scripted in the QSEIS staff devoted to SE versus other types of em- Interview Guide. The intent of the interview ques- ployment activities, and exclusive vocational focus, which rates the program on the amount tions was to be simple and direct, but minimize of time employment specialists spend on cueing socially desirable answers. Thus the ques- nonvocational activities. tions were worded neutrally as much as possible. For example, the QSEIS Interview Guide question l Organization (11 items) -- assesses the organizational features of the vocational pro- about consumer choice in job selection (versus gram and its relationship to mental health making job placement decisions primarily on the treatment services. Items include: attendance basis of job availability) asks, Do you have a at clinical treatment team meetings (by em- pool of jobs you use when placing consumers? ployment specialists), vocational unit (i.e., whether employment specialists work as a One interviewer was designated as the primary team), and team meetings (i.e., frequency interviewer, although the second interviewer oc- of meetings with SE supervisor). Other or- casionally added clarifying questions. ganization items assess the SE programs After the QSEIS interview was completed, policies toward and control of admissions, the procedures for the employment outcome data including screening policy, which gauges

76 Article 5 whether consumers are excluded on the basis gram (Bond, 1992). Moreover, higher place- of work readiness, and role of VR, which ment rates for programs with more staff, were rates the extent to which state vocational rehabilitation counselors determine who is expected by virtue of their greater capacity. accepted for services. Consequently, indicators that took program capacity into consideration were sought. Thus, l Services Subscale (16 items) -- examines for outcome indicators, scores were calculated the nuts and bolts of supported employ- for each site by dividing the absolute rates by ment specialists work. Representative items include length of vocational assessment, the number of FTE direct service staff in the SE rapid search for competitive employment, program. Four primary indicators were used: and types of follow-along supports provided. competitive employment rate (among current caseload), job tenure (rate of jobs held Role of VR, role of case manager, length for 6 months among currently employed con- of vocational assessment, and prevocational sumers), annual placement rate (i.e., new activities were not scored for the first 10 interviews, placements during last year), and annual VR because they were added after the initial pilot successful closure rate (i.e., rate of Status phase. Where appropriate, item means were 26 closures). Five secondary employment out- substituted for these missing scores. come measures for the current caseload were Employment Outcomes Form (EOF). also examined: full-time competitive em- Sites were offered 2 options for reporting employ- ployment rate (30 hours or more per week), ment and program outcomes. The EOF--Sum- rate of those not working on current case- mary Version asks sites to provide summary infor- load, average wages of those working, per- mation and is intended for sites already compiling centage of working consumers with fringe annual summaries for their own reporting pur- benefits, percentage of current jobs with poses. It includes 34 items on employment status reasonable accommodations. of current consumers (including job tenure, hours worked per week, job types, and wages and benefits) and 10 items on admission information, placement rates, and VR status of consumers over FINDINGS a recent 12-month period. The EOF--Con- sumer Version was designed for sites that did not routinely compile this type of summary informa- QSEIS tion. This version is a 24-item form completed Respondents indicated that interview for each consumer in the supported employment questions were easily understood and that the program. Respondents compiled information on length of the interview was not excessive. One all consumers on their caseload, person-by- issue encountered was that 7 (22%) respon- person. The individual data forms were then dents had limited contact with consumers. tabulated by the research team. In addition, all These respondents had difficulty answering sites were asked to complete information about questions concerning percentage of time in the current program staff, including months with specific activities; however, removing these 7 agency, education level, years of experience in respondents affected the overall results very the field, and current caseload size. little. There was anecdotal evidence that the No single indicator is adequate for sum- interviewers succeeded to some degree in marizing the performance of a vocational pro- avoiding socially desirable responses. Respon-

77 f e w s n c a o 90- sta SE Co scr be vie re fun Fir cat < 1 pr 4 71-90% 1 - 2 months 3 51-70% 2 or exclu- more sion criteria, but to still is intent most include SMI with clients 3 - 6 months Item Point Item 2 26-50% 7 months -1 year 1 < 25% of total staff totalof < 25% SE to devoted are criteria Screening have and extensive ex- of intent clear func- poorer cluding individuals. tioning is application job First typically > after1 year entry program TEMS QSEIS I : Ratio of : Ratio : Program does : Program Item ELECTED : The search for for search com- : The S OF

VSI - Agency focus on SE on focus - Agency VSI vocational vocational to staffdevoted solely staff all to devoted to SE services agency-run (including prevocational clubhouse, employment, workshop, sheltered employment, then is time Ifetc.). split, staff time. of % estimate -07 policyScreening eligibility exclusionary have not requirements relating topresumed job readiness, such as substance abuse, violent behavior, minimal mild functioning, intellectual compliance. treatment or symptoms, Note: requiringconsumers to under- an is not admission before SE stand criteria. exclusion competitive for search Rapid S5 employment petitive jobs occurs rapidly after entry program XAMPLES

Subscale 1 -- E Organization Vocational Staffing Services ABLE T

78 Article 5 dents sometimes referred to changes that they vocational, S5: Rapid search); Integration with were thinking of implementing, but the proposed Mental Health, consisting of 5 items (VS5: Ex- changes would have actually scored them lower clusive vocational focus, O1: Collocation, on the scale than their current practice (the basis O2: Attend treatment meetings, O3: Contact for our ratings). For example, some respondents with case managers, O11: Integration of mentioned plans to increase the use of standard- records). These subscales proved to have mar- ized assessment or to develop transitional employ- ginal to adequate internal consistency: Team- ment placements. work (.74), Planning and Support (.60), Rapid Job Search (.74), and Integration with Mental RELIABILITY OF THE QSEIS Health (.62). Also, the four subscales were Inter-interviewer agreement. The statistically independent, with correlations agreement between interviewers was moderately between subscales ranging from -.26 to +.25. high, as shown in Table 2 on the following page. At the item level, the average interrater correlation OVERALL DESCRIPTIVE FINDINGS was .80, while the percentage of exact agreement FOR QSEIS on item ratings ranged from 63% to 96%, with As shown in Table 2, all 33 items 10 items showing 90% or more agreement, 14 showed some variation, with mean item values items with 80% to 89% agreement, and 9 items ranging from 2.53 to 4.84 (on a 5-point less than 80%. scale). Although item ratings were skewed Internal consistency. Overall, internal toward the high end of the scale, all 5 rating consistency of the total scale was poor (Cron- scale points were used on at least some items. bachs alpha = .51). (Within the two state sub- The overall distribution of ratings was as follows: samples, Cronbachs alpha for the total scale 5 Full Implementation (57%), 4 Moder- was .19 for KS and .66 for NJ.) The internal ate Implementation (16%), 1 - 3 (27%). The consistency coefficients for the three a priori mean item rating across all QSEIS items was subscales of Staffing, Organization, and Services 4.09 (SD = 0.28). Mean ratings exceeded were all poor (less than .5). As shown in Table 4.0 on a 5-point scale for 18 of the 33 items. 2, item-total correlations varied widely, with 5 The last three items on the checklist (Peer sup- items negatively correlated and 6 other items port, Family involvement, and Assessing con- correlated less than .15. Deleting items with sumer satisfaction) were generally rated lower negative or low item-total correlations did not in both states. materially increase the internal consistency of Overall, both states showed similarly the total scale, suggesting that the QSEIS is multi- high ratings, suggesting moderate to full imple- dimensional. Exploratory factor analysis also mentation in most of the measured areas of proved fruitless. Four subscales were then defined SE. However, there were some differences at based on a conceptual grouping, as follows: the subscale and item levels in the two states, Teamwork, consisting of 3 items (VS6: Team as shown in Table 3 on page 81. NJ had size, O4: Vocational unit, O5: Team meetings); significantly higher implementation than KS Planning and Support, consisting of 6 items (S4: on Planning and Support, while KS had Benefits, S8: Career planning, S9: Support plan, significantly higher implementation than NJ S11: Length of follow along, S12: Multiple on Integration of Mental Health. The dif- jobs, S14: Peer support); Rapid Job Search, ference on Rapid Job Search approached sig- consisting of 3 items (S2: Assessment, S3: Pre- nificance, with KS higher than NJ.

79 TABLE 2

Agreement Between Raters Consensu Distribution of Item Label (mean s Rating Ratings Correlation pairwise) with QSEIS 1-3 4 5

Vocational Staffing VS1-Agency focus on SE 80% (.84) 3.69 (1.42) 13 5 14 .20 VS2-Staff capacity 88% (.95) 4.78 (0.490 1 5 26 -.13 VS3-Caseload size 90% (.87) 4.53 (0.62) 2 11 19 -.01 VS4-Vocational generalists 69% (.66) 3.94 (1.13) 11 8 13 .19 VS5-Exclusive voc. focus 94% (.95) 4.53 (0.67) 3 9 20 .10 VS6-Vocational team 91% (.97) 4.34 (1.21) 4 7 21 .47**

Organization O1-Co-location with MH 94% (.87) 4.38 (1.26) 4 5 23 .38* O2-Attend tx team meetings 88% (.96) 3.53 (1.44) 14 6 12 .25 O3-Contact with tx team 96% (.95) 4.56 (0.80) 4 5 23 .27 O4-Vocational unit 84% (.72) 4.28 (1.46) 5 3 24 .40* O5-Team meetings 92% (.89) 4.19 (1.40) 7 3 22 .38* O6-Information on SE 80% (.83) 3.97 (1.09) 14 3 15 .52** O7-Screening policy 71% (.56) 4.50 (0.80 6 4 22 .00 O8-Waiting list 84% (.96) 3.88 (1.54) 7 9 16 .19 O9-Role of VRa 94% (.87) 4.45 (1.10) 3 3 16 .22 O10-Role of case managera 80% (.81) 3.86 (1.52) 9 0 13 -.08 O11-Integration of records 67% (73) 3.34 (1.33) 19 4 9 .62**

Services S1-Community based 88% (.95) 3.97 (1.15) 9 9 14 .13 S2-Length of voc. assessment a 69% (.84) 3.36 (1.09) 13 5 4 .19 S3-Prevocational activitiesa 72% (.63) 3.86 (1.17) 8 5 9 -.02 S4-Benefits counseling 90% (-.07) 4.84 (0.51) 2 1 29 .37* S5-Rapid job search 94% (.92) 4.16 (0.81) 8 11 13 .06 S6-Individualized job search 94% (.72) 4.50 (0.92) 4 6 22 -.14 S7-Diversity of jobs 84% (.86) 4.78 (0.49) 1 5 26 .13 S8-Career-focused employment 80% (.61) 4.00 (1.34) 9 5 18 .56** S9-Job support plan 74% (.77) 4.03 (1.47) 8 4 20 .48** S10-Types of follow-along 86% (.53) 4.78 (0.55) 2 3 27 .41* S11-Length of follow-along 84% (.74) 4.34 (1.31) 7 0 25 .24 S12-Multiple jobs 88% (.61) 4.72 (0.52) 1 7 24 .00 S13-Assertive outreach 69% (.67) 3.88 (1.26) 10 9 13 .50** S14-Peer Support 76% (.93) 2.53 (1.61) 24 1 7 .25 S15-Family involvement 63% (.74) 2.97 (1.36) 22 3 7 .15 S16-Consumer satisfaction 80% (.80) 3.41 (1.62) 16 2 14 .35*

QSEIS Total 4.09 (0.28) - - - -

SUBSCALES Teamwork .51** Planning and Support .56*** Rapid Job Searcha .12 Integration with MH .54*** * p < .05, ** p < .01, *** p < .001 a n = 22, items not used for interviews 1-10 80 Article 5

TABLE 3 -- COMPARISON OF KANSAS AND NEW JERSEY ON QSEIS (N = 32)

Item Label Kansas (N = 12) New Jersey (N = 20) t Value Vocational Staffing VS1-Agency focus on SE 4.58 (0.90) 3.15 (1.42) 3.49** VS2-Staff capacity 4.75 (0.62) 4.80 (0.41) 0.28 VS3-Caseload size 4.50 (0.67) 4.55 (0.60) 0.22 VS4-Vocational generalists 3.92 (1.24) 3.95 (1.10) 0.08 VS5-Exclusive vocational focus 4.25 (0.75) 4.70 (0.57) 1.91 VS6-Vocational team 3.92 (1.44) 4.60 (0.99) 1.59

Organization O1-Co-location with MH 4.83 (0.39) 4.10 (1.52) 2.05* O2-Attend tx team meetings 4.50 (0.90) 2.95 (1.39 3.43** O3-Contact with tx team 4.92 (0.29) 4.35 (0.93) 2.52* O4-Vocational unit 3.58 (1.93) 4.70 (0.92) 1.88 O5-Team meetings 3.83 (1.64) 4.40 (1.23) 1.11 O6-Information on SE 4.00 (0.95) 3.95 (1.19) 0.12 O7-Screening policy 4.58 (0.67) 4.45 (0.89) 0.45 O8-Waiting list 4.17 (1.53) 3.70 (1.56) 0.83 O9-Role of VR* 4.22 (1.56) 4.62 (0.65) 0.71 O10-Role of case manager* 4.33 (1.41) 3.54 (1.56) 1.22 O11-Integration of records 3.67 (0.98) 3.15 (1.50) 1.06

Services S1-Community based 4.33 (0.98) 3.75 (1.21) 1.41 S2-Length of vocational assessmenta 3.89 (1.05) 3.00 (1.00) 2.01 S3-Prevocational activitiesa 4.11 (1.27) 3.69 (1.11) 0.82 S4-Benefits counseling 4.92 (0.29) 4.80 (0.62) 0.61 S5-Rapid job search 4.42 (0.51) 4.00 (0.92) 1.64 S6-Individualized job search 4.25 (1.29) 4.65 (0.59) 1.01 S7-Diversity of jobs 5.00 (0.00) 4.65 (0.59) 2.67* S8-Career-focused employment 3.50 (1.57) 4.30 (1.13) 1.55 S9-Job support plan 3.92 (1.44) 4.10 (1.52) 0.34 S10-Types of follow-along 4.75 (0.62) 4.80 (0.52) 0.24 S11-Length of follow-along 3.25 (1.66) 5.00 (0.00 3.66** S12-Multiple jobs 4.75 (0.45) 4.70 (0.57) 0.26 S13-Assertive outreach 3.58 (1.56) 4.05 (1.05) 0.92 S14-Peer support 1.42 (0.79) 3.20 (1.61) 4.18*** S15-Family involvement 2.50 (1.31) 3.25 (1.33) 1.55 S16-Consumer satisfaction 3.00 (1.71) 3.65 (1.57) 1.10

QSEIS Totalaa 3.99 (0.23) 4.16 (0.300 1.42

SUBSCALES Teamwork 3.78 (1.46) 4.57 (0.72) 1.75 Planning and Support 3.63 (0.69) 4.35 (0.57) 3.23** Rapid Job Searcha 4.15 (0.77) 3.49 (0.80) 1.94 Integration with MH 4.43 (0.31) 3.85 (0.81) 2.90**

* p < .05, ** p < .01, *** p < .001 a Ks (n = 9), NJ (n = 13). Item not used for site 1-10. 81 EMPLOYMENT OUTCOMES As shown in Table 5 on page 84, the Altogether, 24 (75%) sites returned Em- QSEIS total score had small and nonsignificant ployment Outcome Forms [10 (83%) KS sites correlations with all 9 employment outcome indi- and 14 (70%) NJ sites]; 2 had partly usable cators. Of the four post hoc subscales, Planning data and 22 were filled out completely. Nineteen and Support and Rapid Job Search had correla- sites (79%) opted for the summary version of the tional relationships with plausible theoretical inter- form, while 5 (21%) used the individual con- pretations. Planning and Support was positively sumer version. As shown in Table 4 on page the correlated with job tenure, consistent with the following page, KS and NJ generally did not view that systematic follow-along services lead differ on employment outcomes, with a competi- to better job retention. However, Planning and tive employment rate (per-FTE) among active Support contributed little to higher VR closure consumers of 7.0 (SD = 4.5) for KS and 7.0 rates, to judge from the slightly negative, nonsig- (SD = 2.9) for NJ. Overall, consumers averaged nificant correlation. Conversely, Rapid Job an hourly wage of $6.66 (SD = $1.01), and Search was significantly negatively correlated with 33% of those had fringe benefits. With regard job tenure, while correlating moderately (.46), to job tenure, NJ sites averaged a higher rate of although not significantly, with VR closure rate. current consumers employed for more than 6 Teamwork was negatively related to both place- months per FTE (M = 4.5, SD = 2.2) than did ment rate and to VR closure rate, while Integra- KS (M = 2.7, SD = 1.9), t = 2.09, p < .05. tion with Mental Health was not significantly cor- On the other hand, compared to NJ, KS sites related with any employment outcome indicator. averaged somewhat higher per-FTE annual rates for new job placements (12.4 vs. 8.7) and admissions (13.3 vs. 10.3). Together, these findings DISCUSSION are consistent with those from the QSEIS suggesting that NJ programs provide follow-along services for a longer time than do KS programs, This survey suggests how far supported while admitting new consumers at a slower rate. employment has evolved since its introduction into the psychiatric rehabilitation field more than CORRELATIONS BETWEEN THE QSEIS AND a decade ago (Mellen & Danley, 1987). Prior EMPLOYMENT OUTCOMES to its inception, state-of-the-art vocational services The next step was to explore the relation- for people with mental illness included club- ship between SE implementation measures and houses, transitional jobs, time-limited support and employment outcome indicators. From the prevocational skills training (Bond, 1992). From QSEIS, the total scale and the four post hoc the current perspective it is possible to forget that subscales were examined. In addition, correla- supported employment principles were revolu- tions between QSEIS items and employment out- tionary when they first appeared. Now, there comes were examined, but those correlations are few SE programs in either of these two states were generally nonsignificant and not reported. that do not exemplify many basic SE principles. With the large number of correlations and small Combined with results from surveys in other states sample size, this stage of analysis should be re- (Vogler, 1998), it appears that basic ideas for garded as exploratory. Both the actual size of SE are wide-spread among mental health centers. the correlations as well as the two-tailed signifi- Although both states had similar levels of cance level were examined. SE implementation, they differed somewhat in

82 Article 5

TABLE 4 -- EMPLOYMENT OUTCOMES (N = 24)

Total Annual Per-FTE Annual Rates Rates Measure n t Value Kansas New Jersey M (SD) % M (SD) M (SD) Admissions and Closures Admissions 23 29.0 (17.2) 13.3 (10.7) 10.3 (3.5) 0.80 Closures 24 19.8 (11.2) 7.3 (5.9) 8.4 (4.3) 0.52 Clients served 19 54.7 (30.3) 18.3 (10.0) 24.1 (11.0) 1.18 VR closure rate 21 9.7 (6.9) 4.6 (3.5) 3.1 (1.6) 1.23

Placements (most recent 12 month period) New job placements 23 26.7 (19.8) 12.4 (10.6) 8.7 (5.1) 1.02 Unduplicated count or 22 21.2 (16.9) 9.3 (7.4) 7.4 (5.2) 0.73 consumers in new Jobs ended 21 11.2 (10.3) 5.1 (4.7) 4.4 (3.4) 0.39 More than on placement 22 5.6 (5.9) 3.0 (3.1) 1.7 (1.3) 1.23 Current Status Clients not employed 24 18.3 (13.0) 7.3 (4.2) 6.5 (4.0) 0.45 Competitively employed 24 19.4 (11.9) 7.0 (4.5) 7.0 (2.9) 0.02

Wages and Benefits Wages 23 $6.73 $6.35 (0.84) $6.97 (1.18) 1.37 Employed with fringe 22 5.2 (6.9) 32% 33% 32% benefits Placements with job 21 12.0 (17.6) 32% 40% 26% accommodations

Job Tenure < 3 months 23 4.3 (4.3) 28% 2.2 (1.9) 1.3 (0.7) 1.37 3 - 6 months 23 4.7 (5.0) 21% 2.1 (1.9) 1.2 (0.8) 1.40 > 6 months 23 11.1 (7.3) 55% 2.7 (1.9) 4.5 (2.2) 2.09*

* p < .05 their emphases. These differences related partly SMI. It provides a common language for pro- to the influence of funding agencies (i.e., special grams to discuss their method of serving con- program initiatives in NJ and closure policies in sumers. If used with a semi-structured in- KS). The authors also speculate that the different terview given to a knowledgeable staff worker, patterns of implementation in the two states may it can be completed with good agreement be attributed partly to the challenges of providing between interviewers. However, the QSEIS SE services in predominantly urban and rural did not constitute a unitary scale. The post states. Further research will be necessary to deter- hoc subscales suggest that a multidimen- mine if geographical differences influence the sional approach will be more fruitful. practice of supported employment. The authors attribute the lack of internal consistency partly to a restriction of range PSYCHOMETRIC ISSUES among the sites interviewed. Studies of other The QSEIS constitutes a set of face-valid fidelity scales have also found low interitem items for describing SE programs for people with correlations in relatively homogeneous samples

83 TABLE 5 -- QSEIS AND SUBSCALE CORRELATIONS WITH OUTCOME (N = 23)

Planning Rapid Job QSEIS & Search Integratio Measure n Total Teamwork Support (n ))nn withw ith MH Competitively employment 24 .16 -.26 .34 -20 (16) .33 rate for current caseload

Ra te of jobs held fo r 6 23 .37 .25 .62*** -.56* (15 ) .21 months or more

New job placement rate 23 -.15 -.42* -.16 .33 (15) .27 during last year

VR closure rate for last year 21 -.05 -.52* -.15 .46 (13) .35

Full-time Competitive em- 22 .38 -.05 .14 .46 (14) .38 ployment rate (> 30 hrs.)

Ra te not wo rk ing for current 24 -.08 -.23 -.19 .34 (15) .03 caseload

Average wage of working 23 .01 .28 .12 -.30 (15) .11 consumers

Percentage of working con- 23 .24 -.29 -.00 .52* (16) .40 sumers w/fringe benefits

Percentage of working con- 21 .31 .29 .14 .18 (14) .36 sumers with accomoda- tions

(Vogler, 1998). Continued work is needed to higher employment rates. For example, the item establish both the factor structure and external concerning the inclusion of all clients without validity for the scale, both of which may be facili- pre-screening is an important SE value, but it tated by contrasting ratings for established pro- may lead to lower employment rates. A second grams with programs that do not subscribe to a factor concerned the difficulties in defining supported employment model. A larger study reliable and valid outcome indicators. Client sample is also needed to find a stable factor characteristics, such as severity of illness, lack of structure. job skills, and education level, are not captured Predictive validity has been found for by the employment indicators used in this report. implementation measures examined for other pro- Thus, any aggregate measures of employment gram models (e. g., McGrew Bond, Dietzen, & placement rates should be viewed cautiously, Salyers, 1994). Using the same reasoning, the because these measures do not tell us the severity researchers had hoped to find significant positive of disability of those helped to find employment. correlations between the implementation items The validity of any outcome measure also and factors and employment outcome indicators. depends on how the program defines the active In retrospect, this exploratory analysis failed to caseload on which outcome statistics are based. take into account several factors. One con- The authors speculate that the SE practices in cerned the specific content of some of the QSEIS KS, which involve transferring consumers to items, which one would not expect to predict mental health case managers once consumers

84 Article 5 achieve successful closure from the state voca- by SSA requires providers to assume substantial tional rehabilitation offices standpoint, may have risks without assurances of compensation. By understated the competitive employment rate for contrast, outcome-based funding designs in the active caseload. In other words, it is possible Oklahoma and Massachusetts provide for mul- that KS programs, by reporting the status of cur- tiple payment points for achievement of inter- rent consumers, did not fully represent the past mediate goals (OBrien & Cook, 1998). In successes of employed consumers who, because these two states, funding agencies have made of their transfer from SE caseloads to those of a good faith effort to fairly cost-out services case managers, were not counted in their employ- consistent with the population to be served ment summaries. In future applications, the Em- and the outcomes required. Even though this ployment Outcomes Form will be modified to financial risk-reward arrangement is more capture employment outcomes for consumers favorable for provider agencies, it has not who have been transferred. completely eliminated financial risk for providers. Determining equitable funding form- USING PERFORMANCE INDICATORS ulas poses a difficult challenge, particularly FOR FUNDING DECISIONS? when attempting to respond to individuals with One of the prime motivations for devel- complex employment issues. oping the QSEIS concerned a search for an The findings from the current study alternative to current trends in SE funding. suggest another problem with outcome-based Outcome-based funding refers to reimbursement funding. If the VR closure rate is used as the for program services based on actual outcomes. primary indicator of performance, then it will In the case of supported employment, outcome- not necessarily lead to desired outcomes with based funding refers to payment for successful regard to job tenure. As noted above, those case closures or other such employment indi- programs that more fully implemented items cators. For example, one such scheme, used by related to Planning and Support had better the Social Security Administration (SSA) in its job tenure, consistent with some studies sug- Alternate Participant Program, provides for a one- gesting the importance of long-term supports time payment to providers upon successful com- (McHugo, Drake, & Becker, 1998). However, pletion of 9 months of employment at a Sub- the Planning and Support subscale did not stantial Gainful Activity wage level. Versions of increase VR closure rates. In other words, outcome-based funding are now in practice in choice of employment outcome indicator is a some states, such as Massachusetts and Okla- critical decision that may shape the style of homa, with plans contemplated for other service employment services. Alternatively, by encour- systems, such as New York City (Pascaris, 1999). aging programs to examine their implementa- A basic question is whether rewarding agencies tion standards, it may be possible to achieve (or service systems) for increasing employment outcomes that optimize placement rates and rates among a target group actually leads to job tenure. We know, for example, that atten- better performance. tion to consumer preferences influences job In addition to these concerns about its tenure (Becker, Drake, Farabaugh, & Bond, effectiveness, experiences at the ground level with 1996); therefore, programs focusing on con- outcome-based funding designs suggest that sumer preferences should improve this out- such arrangements create uncertainty and stress come. It should be possible to attain this goal for provider agencies. The funding design used while emphasizing rapid job search strategies.

85 Tools such as a validated QSEIS could sible intervention, because the principle of close be helpful in supporting a continuous self-assess- integration of rehabilitation and treatment is part ment effort. However, progress in developing per- of the statewide model. formance indicators is crude at best. Indicators Using the QSEIS as a self-assessment described in this report should not be used to tool for individual agencies. The QSEIS might make reimbursement decisions. The researchers be used by providers to track SE implementation believe that funding schemes that incorporate over time. This use is of specific interest to newly- both implementation and outcome indicators will developed programs, who can benefit by having ultimately prove to be the most useful. a target to move toward. In the application of the QSEIS within individual agencies, SE pro- IMPLICATIONS FOR PRACTITIONERS grams may be more interested in comparisons Using the QSEIS for statewide moni- of their QSEIS ratings with their prior ratings than toring. One possible use of the QSEIS is to in comparisons to normative standards. Repeated provide comparative data to state planners re- use of implementation scales has been employed, garding implementation of supported employ- with some success, to monitor newly developed ment within their states. Examination of indi- case management programs (Bond, Fekete, & vidual items permits planners to decide whether Salyers, in press) and supported employment pro- a particular item fits with their objectives for the grams (McCarthy, Thompson, & Olson, 1998). state and if so, then to decide whether technical Using the QSEIS as an informational assistance might be desirable. To use the example tool for consumers. In principle, the QSEIS of New Jersey, the relatively low score for S3 should provide a basis for explaining how a pro- (Prevocational activities) was not of concern to gram operates in concrete terms that can be the state administrator, because the New Jersey understood by mental health consumers and their model endorses prevocational groups as a families. This function has not yet been field- method to engage consumers who are ambivalent tested, and it is likely that some of the terminology about beginning a job search. On the other needs to be simplified to make it more user- hand, the relatively low scores on O2 (Attending friendly for the lay public. If the mandate from treatment team meetings) did concern him, and Public Law 105-220 is implemented, then this did suggest an area for further inquiry and pos- effort is worth undertaking.

86 Article 5 eferences: R Becker, D. R., Drake, R. E., Farabaugh, A., & Bond, G. R. (1996). Job preferences of clients with severe psychiatric disorders participating in supported employment programs. Psychiatric Services, 47, 1223-1226.

Bond, G. R. (1992). Vocational rehabilitation. In R. P. Liberman (Ed.), Handbook of psychiatric rehabilitation (pp. 244-275). New York: Macmillan.

Bond, G. R., Becker, D. R., Drake, R. E., & Vogler, K. M. (1997a). A fidelity scale for the Individual Placement and Support model of supported employment. Rehabilitation Counseling Bulletin, 40, 265-284.

Bond, G. R., Drake, R. E., Mueser, K. T., & Becker, D. R. (1997b). An update on supported employment for people with severe mental illness. Psychiatric Services, 48, 335-346.

Bond, G. R., Fekete, D. M., & Salyers, M. P. (in press). ACT fidelity scale: A practical application in a statewide project. In K. M. Coughlin (Ed.), 1999 Behavioral outcomes and guidelines source- book. New York, NY: Faulkner & Gray.

Bond, G. R., Vogler, K. M., Becker, D. R., & Drake, R. E. (1998, August). Measurement of fidelity of implementation in supported employment programs. Paper presented at the Annual Convention of the American Psychological Association, San Francisco, CA.

Ford, L. H. (1995). Providing employment support for people with long-term mental illness. Baltimore: Paul H. Brookes.

Gervey, R., Parrish, A., & Bond, G. R. (1995). Survey of exemplary supported employment programs for persons with psychiatric disabilities. Journal of Vocational Rehabilitation, 5, 115- 125.

Hoff, D. (1997). Quality employment services: Will you know it when you see it? . Boston, MA: Institute for Community Inclusion, Childrens Hospital.

MacDonald, R., & Roberts, M. (1998). Supported employment quality service indicators : Boggs Center UAP and NJ APSE (Available from Melissa Roberts, UMDNJ, 1776 Raritan Road, Scotch Plains, NJ 07076).

Marrone, J. (1996). Managing employment with care: Better practices in employment for a state/county/provincial department of mental health to fund, support and monitor . Boston, MA: Institute for Community Inclusion, Childrens Hospital.

Matrix. (1992). Quality indicators for supported employment programs servicing persons with cognitive, psychiatric, and physical disabilities (Mid Atlantic Regional Information Exchange) . Philadelphia, PA: Matrix Research Institute.

McCarthy, D., Thompson, D., & Olson, S. (1998). Planning a statewide project to convert day treatment to supported employment. Psychiatric Rehabilitation Journal, 22(1), 30-33.

87 McDonnell, J., Nofs, D., Hardman, M., & Chambless, C. (1989). An analysis of the procedural components of supported employment programs associated with employment outcomes. Journal of Applied Behavior Analysis, 22, 417-428.

McGrew, J. H., Bond, G. R., Dietzen, L. L., & Salyers, M. P. (1994). Measuring the fidelity of implementation of a mental health program model. Journal of Consulting and Clinical Psychology, 62, 670-678.

McHugo, G. J., Drake, R. E., & Becker, D. R. (1998). The durability of supported employment effects. Psychiatric Rehabilitation Journal, 22(1), 55-61.

Mellen, V., & Danley, K. (1987). Special issue: Supported employment for persons with severe mental illness. Psychosocial Rehabilitation Journal, 9(2).

OBrien, D., & Cook, B. (1998). Oklahoma Milestone Payment System. [Online]. Available: (http:// www.onenet.net/~home/milestone ).

Perkins, D. V. (1995). Program evaluation report to Tri-County Center: Community Integration Initia- tion Establishment Grant . Muncie, IN: Ball State University.

Public Law 105-220. (1998). Workforce Investment Act of 1998, Title IV. .

Vogler, K. M. (1998). A fidelity study of the Indiana Supported Employment Model for individuals with severe mental illness. Unpublished dissertation, Indiana University-Purdue University Indianapolis, Indianapo- lis, IN.

Wehman, P. (1986). Supported competitive employment for persons with severe disabilities. Journal of Applied Rehabilitation Counseling, 17, 24-29.

Wood, R., & Steere, D. (1992). Evaluating quality in supported employment: The Standards of excellence for employment support services. Journal of Vocational Rehabilitation, 2, 35-45.

88 A Profile of Vocational Rehabilitation Interagency Activity Improving Supported Employment for People with Severe Disabilities By: Susan M. Foley, John Butterworth, & Amy Heller

Over the past 15 years, there have been substantial changes in the delivery and funding of day and employment ABSTRACT services for individuals with disabilities. Most notably, the introduction of supported employment has led to a dramatic in- The Institute for Community Inclusion (ICI) at Childrens Hospital in Boston crease in the number of individuals with severe disabilities in is conducting three companion studies integrated community employment. State Mental Retardation to investigate the extent of interagency and Developmental Disabilities (MR/DD) agencies report that activity among state agencies that the number of individuals supported in integrated employment deliver or fund employment services. This paper presents findings from the increased from 32,471 to 98,315 between FY 1988 and FY first study, completed in December 1996, and the percent of individuals with developmental disa- 1998, that examined the use of state bilities closed into integrated employment by Vocational Reha- level interagency agreements and their bilitation (VR) agencies increased from 74% in FY 1985 to impact upon supported employment. Interagency agreements were most 86% in FY 1995 (Butterworth, Gilmore, Kiernan & Schalock, frequent with state agencies that in press; Butterworth, Gilmore & Schalock, 1998). Similarly, specialized in or had substantial in- Wehman, Revell, and Kregel (1998) report national parti- volvement with disability services including the state mental health agency cipation in supported employment across disability groups in- (MH), the state mental retardation and creasing from 10,000 individuals in FY 1986 to almost developmental disabilities (MR/DD) 140,000 in FY 1995. agency, and the state department of Despite these promising changes, the implementation education (DOE). These agreements were also seen as having a more posi- of supported employment has not fully lived up to its expec- tive impact on employment opportun- tations. Early expectations for the initiative were that programs ities than agreements with other types would transfer resources and services from facility-based ser- of agencies. Agencies that typically vices to integrated employment. The National Survey of MR/ provide employment services to the general population were as likely or DD agencies found, in FY 1996, 77% of those served in all more likely to be participating in in- day and employment programs participated in sheltered em- formal interagency activity than written ployment or non-work programs. Data from state MR/DD state level interagency agreements. The agencies suggests that while the number of people in integrated impact of these agreements in encouraging supported employment varied by employment has increased, the number in facility-based or type of agency. The MH and MR/DD non-work programs has also increased (Butterworth et al., in agency agreements with the VR press). These results suggest that integrated employment ser- agency were rated as having the highest impact while the agreements vices, especially supported employment, are being viewed as between the One-Stop Career Centers an add-on service by community rehabilitation providers and the VR agency were rated as (CRPs). West, Revell, & Wehman, (1998) found 37% of CRPs having no impact: positive or negative. ran both facility-based services and supported employment

89 reported converting resources to integrated em- ment. During the Spring of 1999, the study will ployment. The remaining 63% maintained or interview key informants and explore the relation- increased their investment in facility-based ser- ship of an agreement to practice. The last study, vices. West et al. (1998) also found that sup- implemented in the Fall of 1999, is a survey of ported employment staff remained a minority, local VR administrators on interagency activity. on average only 11%, of an organizations total This brief report describes the first studys findings. staff. On a state level, there is considerable variability in supported employment rates. The percent of individuals served in integrated employment by MR/DD agencies, for example, METHOD varied from 4% to 60% in FY 1996 (Butterworth et al. in press). Sample: Supported employment prog- Identifying factors that differentiate state ram managers in the 50 states, and 4 territories level employment outcomes will contribute to including Puerto Rico, the District of Columbia, more effective systems level change. One factor the Virgin Islands, and the Pacific Islands were often emphasized in systems change is the role the sample. Program managers in the central of interagency collaboration and agreements in were personnel from the central office of the state focusing and maximizing resources. State agency VR agency. Forty-one of the 70 program man- collaboration in the delivery of supported employ- agers working for the commissions for the Blind ment services may lead to the expansion of these or the general VR agency responded. services (Nebraska Department of Education, Instruments: The survey was the FY 1997; Mississippi Department of Rehabilitation 1997 wave of a longitudinal data collection effort Services, 1997). Interagency agreements also begun in FY 1986 and lead by the Virginia may be a tool for systems change (Nebraska Commonwealth Universitys (VCU) Rehabilitation Department of Education, 1997) as well as a Research and Training Center (RRTC). The RRTC mechanism for local service delivery collabor- conducts an annual survey which collects infor- ation (Rogers, Anthony, & Danley, 1989). mation about the numbers of individuals served The Institute for Community Inclusion (ICI) in supported employment programs, numbers at Childrens Hospital in Boston is conducting served by types of supported employment models, three companion studies to investigate the extent numbers served by disability category and mental of interagency activity among state agencies that retardation level, wages, funding sources, author- deliver or fund employment services. The first ized providers, strategies, and types of rate struc- study, completed in December 1998, examines tures. Interagency agreement questions were de- the use of state level interagency agreements and veloped as a module which was included in the their impact upon supported employment. VR survey for the purpose of identifying the existence program managers at the central office were of interagency agreements and to gather nomi- asked to identify interagency agreements and nations for highly effective agreements. informal activity between the VR and other state Participants were asked about the pres- agencies. They were asked to nominate agree- ence of interagency activity between the VR ments that encouraged supported employment agency and fourteen other state agencies or pro- opportunities for people with significant disa- grams. Table 1 on the following page lists the bilities. The second study will analyze agreements state agencies and programs. Respondents were nominated as encouraging supported employ-

90 Article 6 asked to identify what type of interagency agreement was in existence and, if present, to what FINDINGS extent a state level written agreement influenced opportunities for supported employment. Two additional questions addressed other types of PRESENCE OF INTERAGENCY ACTIVITY interagency activity. Program managers were Table 1 below shows how many VR asked to identify any standing or ad hoc groups program managers reported interagency related to interagency activity, and whether or activity with the specified list of state agencies not the VR agency designated a staff liaison to or entities across three levels of activity. The other state agencies. levels of activity include: presence of a state Procedure: The survey was mailed to level written interagency agreement, presence respondents in the Spring of 1998 who were of a local level written interagency agreement, then contacted to confirm receipt of the survey. and presence of informal interagency activity. Follow-up phone calls reminded respondents to Respondents could report interagency activity return the survey, clarified any questions arising with an agency in one or all three categories. from the returned surveys, and requested copies Therefore, some respondents reported multiple of nominated interagency agreements. types of interagency activity per state agency.

TABLE 1 -- INTERAGENCY ACTIVITY BETWEEN VR STATE AGENCY AND OTHER STATE AGENCIES (N = 41)

STATE AGENCY OR ENTITY N1 NUMBER OF VR STATE AGENCIES2 STATES State Local Informal Agreement Agreement Activity

Block 1: Mental Health Agency 31 26 9 10 Mental Retardation Agency 28 23 7 13 Education and School-to-Work 26 22 8 9

Block 2: Welfare Agency 15 8 2 9 One-Stop Career Center 14 8 2 10 Employment and Training 14 8 2 8 Children Youth and Family 12 7 2 7 Social Security 15 6 0 10

Block 3: Corrections 9 5 0 4 Veterans Administration 5 5 0 3 Department of Public Health 7 3 1 3 Drug and Alcohol Programs 7 2 2 5 Health Care Centers/Hosp. 4 2 0 3

1Reporting any interagency activity, 37 states plus Puerto Rico, CT, NC, and TX have multiple VR agencies responding. 2These columns are not additive. Many VR agencies reported multiple levels of interagency activity.

91 The list of agencies or entities were sorted ported interagency activity between the VR and into three blocks. The first block includes agencies agencies or programs in the last block. Aside that have a high level of interagency activity with from Corrections, these agencies or programs VR across the three categories. The second block offer medical services to specialized populations. includes agencies that informal interagency activ- Seven of the forty-one respondents re- ity was reported more frequently or equally as ported no interagency agreements with any state formal written interagency activity. Overall, interagency and little, if no, informal interagency activ- agency activity was reported less often for this ity with any state agency. Four of these respon- group than for group one. The third block con- dents were from the state commissions for the sists of agencies with relatively little or no reported blind. Of the three others, one respondents state interagency activity with the VR system. has a highly consolidated service system. The The state mental health (MH) agency, VR agency, the MR/DD, the MH, and the welfare MR/DD agency, and the department of educa- program all operating under one state agency. tion (DOE) were the agencies reported to have the most state level and local written interagency IMPACT ON SUPPORTED EMPLOYMENT agreements, and informal interagency activity Respondents were asked to rate how with the VR system. These agencies provide ser- effective the state-level written interagency agree- vices to people with disabilities or, in the case of ment was in promoting integrated employment the DOE, have substantial involvement in the for people with severe disabilities. The possible disability services system. Formal written inter- choices ranged from strongly encourages to agency agreements are common between each strongly discourages supported employment. A of these agencies and the VR agency. score of 3 indicates no impact positive or nega- The next two blocks of agencies or pro- tive. Higher scores indicate more positive impact. grams include a wide range of services. Program Table 2 on the following page displays managers reported a few more interagency the state agencies by impact in descending order. agreements or activity in this grouping than in State MR/DD and State MH agency interagency the last. These agencies included the welfare agreements with the VR agency were reported to agency, One-Stop Career Centers, Employment have the strongest impact on integrated employ- and Training, Children, Youth, and Family Ser- ment for people with severe disabilities. Drug vices, and the local Social Security Administration. and alcohol programs is also listed in the top Most of these agencies or entities operate, fund, three, although this should be interpreted with or are involved in employment services programs caution. Only two respondents reported an inter- typically provided to job-seekers or people agency agreement with this state service. receiving TANF benefits. VR supported employ- Interagency agreements with the majority ment program managers reported more frequent of state agencies or programs have a slight impact informal activity than state level interagency on supported employment. In most instances, agreements for three out of five agencies in the few agreements exist between these agencies and block. Ten respondents reported informal inter- the state VR agency. Interagency agreements agency activity with the One-Stop Career Center between VR agencies and the One-Stop Career and eight reported state level written interagency Centers were rated as having no impact, positive agreement. This was true for the state welfare or negative, in improving integrated employment agency and the state or local office of the Social for people with severe disabilities. Security Administration. Few respondents re-

92 Article 6

TABLE 2 -- PERCEIVED IMPACT OF INTERAGENCY ACTIVITY: IMPACT OF INTER- AGENCY ACTIVITY UPON SUPPORTED EMPLOYMENT (N = 41 VR AGENCIES) N STATES PERCEIVED STATE AGENCY OR ENTITY REPORTING IMPACT RANK

Mental Retardation Agency 22 4.35 1

Mental Health Agency 25 4.08 2

Drug and Alcohol Programs 2 4.00 3

Children Youth and Family 7 3.86 4

Corrections 5 3.80 5

Secondary Education 4 3.67 6

Department of Public Health 3 3.67 6

Education (including School-to- 22 3.61 7 Work)

Employment and Training 8 3.57 8

Health Care Centers/Hospitals 2 3.50 9

Welfare 8 3.38 9

Social Security 6 3.33 10

One-Stop Career Center 8 3.00 11

Veterans Administration 5 3.00 11

137 states plus Puerto Rico, CT, NC, and TX have multiple VR agencies in the respondent pool including the Commissions for the Blind.

INTERAGENCY WORKING GROUPS VR STAFF DESIGNATED AS Of the 41 respondents, 26 reported the INTERAGENCY LIAISON presence of interagency working groups in which Eighteen respondents indicated that the the VR agency has a designated staff person VR agency has a staff person designated to present. Tables 3-5 on the following pages, list interagency work. Eleven of the 18 respondents the working groups, their function, and agencies are that designee. represented by state. The function of the working groups range from statewide service planning and policy setting to local service delivery. Several DISCUSSION & IMPLICATIONS working groups emphasize systems change in the area of employment or supported employment, in particular. Formal interagency activity defined as written interagency agreements is most frequent 93 TABLE 3 -- INTERAGENCY WORKING GROUPS: STATEWIDE GROUPS WITH POLICY FOCUS OR SYSTEMS CHANGE

STATE WORK GROUP FUNCTION REPRESENTATION BY

AZ Employment Related and Ex- Policy and quality CRPs, VR, multiple tended Employment outcomes agencies

DE MR/VR Work Groups State policy and VR, MR procedures

FL Work Group TA and policy VR, 20 state agencies

IL SEP Work Group Redesign day services VR, MH

KY Employment Initiatives SE expansion/conversion

MA Employment Services Advise executive office multiple state agencies

Action Counsel

Flexible Finance Interagency funding VR,MR/DD,MH, ED

NC ADVP - Adhoc Extended Services Rate MH, VR, CRP Setting

OK SSA Agreement Oversee Agreement PH, MH, VR

PA Employment Oversight Advisory for the ARC all SE funding agencies

MR Multiple Year Plan Develop SE Strategies VR, MH, MR, CRP

TX Interagency Work Group System Change Project VR, MH, MR/DD, ED, VR/B

VT State SE Team Systems Planning VR, MY, ED

1CRP = Community Rehabilitation Provider; DDC = Development Disabilities Council; ED = Education; MH = Mental Health; MR/DD = Mental Retardation and Developmental Disability; PH = Public Health; SE = Sup- ported Employment; VR = Vocational Rehabilitation; VR/B = Vocational Rehabilitation Commission for the Blind between the VR agency and the state agencies Supported employment program man- providing services to people with disabilities. agers at the state VR agency reported informal Agencies defined as partners in the Workforce interagency activity with a variety of agencies. Investment Act (WIA) of 1998 tend to have fewer In this survey, local level interagency activity is written interagency agreements with the VR likely to be under-reported as the respondents agency and relatively low impact on encouraging were central office personnel and may not be suppported employment opportunities. This is familiar with local collaboration. Regardless, particularly true for the agreements between the informal interagency activity is more frequent VR agency and the One-Stop Career Centers in among the workforce investment partners than the state. formal written agreements. One explanation 94 Article 6

TABLE 4 -- INTERAGENCY WORKING GROUPS: STATEWIDE GROUPS WITH RESTRUCTURING OR SERVICE FOCUS

STATE WORK GROUP FUNCTION AGENCIES REPRESENTED

ID Work Group Provide collaboration CRP, MR/DD, CAP

LA Transition Core Teams Coordinate systems VR, multi-service, ED

MD Interagency Transition SE implementation MH, SPED, MR/DD, VR, Gov

MS State Case Teams Youth with emotional/ AG, MH, HS, ED, PH, behavioral disabilities M/A, VR

NC Vocational Extended services VR, MH, MR/DD

Alternatives

Dual Diagnosis Enhance SE VR, MH

OK VR/DD Work Group General collaboration VR, MR/DD

UT New Futures SE Improve SE VR, Ed, MR/DD, MH

VT Core Transition Team Interagency Partner- MH, VR ship

WA SE Program Evaluate proviso VR, MR/DD, MH

Evaluation Activity DDA

WI Hi-Impact Cooperative Project VR, MR/DD

Transition Various models of SE VR, PI

Mental Health Various models of SE VR, DSL

CAP = Client Assistance program; DDA = Division of Data Analysis; DSL = Division of Supportive Living; ED = Education; Gov = Governors Office; HS = Human Services; M/A = Medicaid; MH = Mental Health; MR/DD = Mental Retardation and Developmental Disability; PH = Public Health; PI = Public Institutions; PWD = People with Disabilities; SE = Supported Employment; SPED = Special Education; VR = Vocational Rehabilitation for the low impact of formal written agreements importance of interagency agreements with with One-Stop Career Centers is that there is these two entities as defined in the WIA of less experience with interagency agreements 1998, this finding should be explored further between these two entities. Another explana- at a more local level. tion is that central office VR personnel may not Interagency agreements are one form be aware of local interagency agreements of interagency activity. Many states have between the local office of the state VR agency working groups whose members represent a and One-Stop Career Centers. Given the range of constituents with a vested interest in

95 TABLE 5 -- INTERAGENCY WORK GROUPS: LOCAL WORK GROUPS

STATE WORK GROUP FUNCTION AGENCIES REPRESENTED

CT Local Meetings Consumer/Agency VR, MR Relations

DE County SE Committees Oversight/Advisory VR, MH, MR

KY Local SE Teams Local level planning VR and other agencies

NH Alternative Funding Develop alternative Local disability funding agencies

WY Local Business Advisor Create SE job oppor- Public social service tunities agencies, private sector employers, VR

MH = Mental Health; MR = Mental Retardation and Developmental Disability; VR = Vocational Rehabilitation employment opportunities for people with disa- sible for oversight and planning of employment bilities. These groups function as statewide policy services. Existing working groups should consider and oversight bodies to locally based service their role in participating in or coordinating enhancement groups. The VR representative is activities with the WIA workforce boards. often the supported employment program man- Future research should address the range ager. Membership and partner agencies in the of interagency activity and determine which types workgroups are predominately disability specific are related to better employment outcomes. Re- agencies including the state MH agency and search activities should explore the particular the state MR/DD agency. Many groups also contextual and implementation factors of inter- included community rehabilitation providers, agency agreements that encourage supported advocacy groups, and employer groups. employment service delivery. What is the link Little is known about the impact of these between written agreements and local practice? groups upon increasing supported employment. What is the form of local interagency activity? Most target their activities toward improving Two current ICI studies will focus upon inter- employment services through policy and planning agency activity and local practice. One study or service delivery. It is likely that the working examines policy issues and employment service groups have significant impact upon employment delivery from the perspective of the MR/DD local outcomes for people with disabilities within their office administrator and case manager. The other state or locality. Interestingly, One-Stop Career study examines interagency collaboration from Centers, state welfare agencies, and employment the perspective of the VR agency local office and training service agencies are not frequent administrator. Information about the link between participants. This also may change given the re- various interagency activities and outcomes will quirements of the WIA which mandate the crea- provide multiple policy tools to advance employ- tion of state and local workforce boards respon- ment opportunities for people with disabilities.

96 Article 6 eferences: R Butterworth, J., Gilmore, D., Kiernan, W. E., & Schalock, R. (in press). Day and employment services in developmental disabilities: State and national trends. Washington, DC: American Association on Mental Retardation.

Butterworth, J., Gilmore, D., & Schalock, R. (1998). Rates of vocational rehabilitation system closure into competitive employment. Mental Retardation, 36(4), 336-337.

McDonald, B. (1998). Project UNITE: Final performance report. Mississippi: Department of Rehabilitation Services.

Nebraska Department of Vocational Rehabilitation. (1994). Supported employment systems change grant: Project report. Nebraska: Nebraska Department of Vocational Rehabilitation.

Rogers, E. S., Anthony, W. A., & Danley, K. S. (1989). The impact of interagency collaboration on system and client outcomes. Rehabilitation Counseling Bulletin,33(2), 100-109.

Wehman, P., Revell, G., & Kregel, J. (1997). Supported employment: A decade of rapid growth and impact. American Rehabilitation, 24(1), 31-43.

West, M., Revell, G., & Wehman, P. (1998). Conversion from segregated services to supported employment: A continuing challenge to the VR service system. Education and Training in Mental Retardation and Developmental Disabilities, 33(3), 239-247.

97 98 Interagency Agreements Encouraging Supported Employment for People with Disabilities: Preliminary Report on Exemplary Practices By: Susan M. Foley & Joseph Green

INTRODUCTION ABSTRACT

The Institute for Community The Institute for Community Inclusion (ICI) at Childrens Inclusion (ICI) at Childrens Hospital in Boston is conducting three companion studies to investi- Hospital in Boston is conducting three companion gate the extent of interagency activity among state agencies that studies to investigate the extent deliver or fund employment services. The first study, completed in of interagency activity among December 1998, examines the use of state level interagency state agencies that deliver or fund employment services. The agreements and their impact upon supported employment. Vocational purpose of the first study is to rehabilitation (VR) program managers at the central office were asked identify exemplary models and strategies used within inter- to identify interagency agreements and informal activity between agency agreements that im- the VR and other state agencies. They were asked to nominate agree- prove the delivery of supported ments that encouraged supported employment opportunities for employment services. This study examines the use of state people with significant disabilities. The second study will analyze level interagency agreements these and other agreements nominated as encouraging supported and their impact upon sup- employment. During the Spring of 1999, key informants will be in- ported employment. It also investigates the content, con- terviewed to explore the relationship of each agreement to employ- text, and impact of agreements ment outcomes and practice. The last study, implemented in the nominated by experts and key informants in the field of voca- Fall of 1999, is a survey of local VR administrators on interagency tional rehabilitation. This report activity at the local office level. presents the preliminary find- The first study found that interagency agreements were most ings of the qualitative study and provides a preliminary report frequent with state agencies that specialized in or had substantial on the nomination process involvement with disability services including the state mental health and the early phases of content agency (MH), the state mental retardation and developmental disa- analysis. It provides a list of agreements that have been bilities (MR/DD) agency, and the state department of education nominated as encouraging (DOE) (Foley, Butterworth, and Heller, 1999). These agreements supported employment opportunities for people with sig- were also seen as having a more positive impact on employment nificant disabilities and offers opportunities than agreements with other types of agencies. Foley, a method for categorizing Butterworth and Heller (1999) also found that agencies that typically agreements. During the next phase, the researchers will in- provide employment services to the general population were as likely terview key informants familiar or more likely to be participating in informal interagency activity with the development, pro- than written state level interagency agreements. The impact of these cesses, practice, and impact of each specific agreement. agreements in encouraging supported employment varied by type

99 of agency. The MH and MR/DD agency agree- 2. gathering nominations from organizations ments with the VR agency were rated as having and state agencies that are involved in interagency agreements; and, the highest impact while the agreements between the One-Stop Career Centers and the VR agency 3. validating the nomination through key in- were rated as having no impact, positive or nega- formant interviews and achievement of out- tive (Foley, Butterworth, and Heller, 1999). comes. A question emerges from this analysis: What factors of interagency agreements lead to The first two steps were implemented successful employment outcomes? Could these through three channels: factors be adopted or transferred to written agree- 1. an electronic mail (e-mail) solicitation; ments with other state agencies. The second study investigates the content, context, and impact of 2. telephone follow-up using a snowball tech- agreements nominated by experts and key inform- nique; and, ants of vocational rehabilitation. The purpose of 3. the FY 1997 Supported Employment Imple- this study is to identify exemplary models and mentation Survey administered by the Reha- strategies used in interagency agreements that bilitation and Research Training Center improve supported employment delivery. (RRTC) at Virginia Commonwealth University (VCU). This report summarizes the ongoing activities of the qualitative study and provides a pre- The e-mail nominations request was sent liminary report of the nomination process and to members of the Supported Employment Con- the early phases of content analysis. The intent sortium (SEC) who are nationally recognized is to provide a list of agreements that have been researchers active in employment and disability nominated as encouraging supported em- research. The inquiry asked members to identify ployment opportunities for people with significant best practice interagency agreements between disabilities and to offer a method for categorizing the VR agency and other agencies and to nomi- agreements. During the next phase, the re- nate other key informants. One nomination was searchers will interview key informants familiar received through this channel. with the development, process, practice, and im- Members of the SEC, state agency per- pact of each specific agreement. sonnel, researchers, and disability related organizations were contacted by telephone. Figure 1 on the following page displays a list of organizations contacted. This effort encompassed over METHOD thirty states and 93 respondents. Each person was asked to nominate interagency agreements NOMINATION PROCESS which increase supported employment oppor- The study used an expert opinion, inde- tunities for people with severe disabilities. Respon- pendent validation approach (Datta, 1993) in dents were also asked to provide contact informa- selecting interagency agreements. The approach tion of other individuals who would be able to has several steps including: provide a nomination. This approach had a snow ball effect as individuals furnished additional 1. gathering nominations from the literature and names of experts to contact. Fifteen nominations from researchers in the area of supported were received through this channel. employment;

100 Article 7

FIGURE 1: ORGANIZATIONS CONTACTED FOR NOMINATIONS

State Vocational Rehabilitation University and Research Programs Agencies -- Idaho Berkeley Planning Associates, Kansas California Louisiana University of Arkansas New Hampshire Human Services Research Institute New York University of Illinois Nevada Indiana University Rhode Island University of Iowa Virginia Matrix Research Institute Vermont University of Montana Wisconsin University of Oregon University of Vermont Other State Agencies or Entities Virginia Commonwealth University Governors Council on Disabilities, Alaska Employers and Providers Colorado Developmental Disabil- Marriot Foundation, Maryland ities Council Coordinated Employment Oppor- Iowa Department of Human tunities, Connecticut Services Dakota Works, South Dakota Minnesota Department of Human Transition and Community Employ- Services, Mental Health ment, Michigan Division Irene Ward and Associates, Ohio Massachusetts Department of Mental Health Disability Organizations Wisconsin Department of Independent Living Research Education Utilization Texas Department of Mental Arizona Bridge to Independent Living Health and Mental Retar- Valley Association for Independent dation Living, Texas Governors Council for People Rock Creek Foundation, Maryland with Disabilities, Utah Tasks Unlimited, Minnesota Virginia Department of Education New York Association of Psychiatric Rehabilitation Services

The third channel used a national survey portunities for people with severe disabilities. of VR program managers to gather nominations. Eleven nominations were received through this The FY 1997 Supported Employment Implemen- channel (Foley et al., 1999). tation Survey, administered by the RRTC at VCU, was mailed to 70 VR agencies including the com- INTERAGENCY AGREEMENTS missions for the blind in 50 states and territories. In total, 21 separate agreements were A topical module was inserted into the survey received from the three nomination streams. which included a request for nominations of inter- Table 1 on the following page lists the interagency agreements considered to be highly agency agreements and the channel through effective in increasing supported employment op- which they were nominated. Three agreements

101 TABLE 1 -- NOMINATED INTERAGENCY AGREEMENTS

State Title of Agreement1 Nomination

IN MOU between the Indiana Family and Social Services Telephone

Administration Division of MH and Disability, Aging, and Rehabilitation Services Survey

MN Interagency CA DES, Rehabilitation Services Branch Telephone

NC Paid Co-Worker Support, an Innovative Partnership Telephone

NY MOU regarding SE Telephone Survey

OK MOA between Department of Rehabilitation Services and the DD Division of the DHS E-mail

RI CA for the Delineation of Responsibilities for Individ- uals with Disabilities between the DHS and the DOE Telephone

CA for the Delineation of Responsibilities for Indivd- uals with DD and MI between the DHS and the Depart- ment of MH, MR, and Hospitals Telephone

SD CA Concerning SE Services Telephone

MOA between the DCS and VR Telephone

CA on Transition Services for Youth with Disabilities Telephone

Policy on Joint Funding Sources Telephone Survey

VT CA between DET and VR Telephone

CA between, VR, DDS and Vermont District Social Security Telephone

CA between DSW and VR Telephone

WA Extended Services Agreement with the VR Survey

WI MOA between the DCS and VR Telephone

Interagency CA/Contract for SE, DSL and VR Telephone

WV SE Partnership Survey

WY CA between the Wyoming VR and the Division of Behavioral Health/Wyoming State Hospital Survey

Independent Living Cooperative Agreement Survey

MOA between the Wyoming DOE and the VR Survey

1CA = Cooperative Agreement; DCS = Department of Community Services; DD = Developmental Disabili- ties; DDS = Disability Determination Services; DES = Department of Economic Security; DET = Depart- ment of Employment and Training; DHS = Department of Human Services; DOE = Department of Educa- tion; DSL = Department of Supported Living; DSW = Department of Social Welfare; MH = Mental Health; MI = Mental Illness; MR = Mental Retardation; MOA = Memorandum of Agreement; MOU = Memorandum of Understanding; SE = Supported Employment 102 Article 7 received multiple nominations. Most of the agree- eliminated. One was out of date, and two ments are between the VR agency and a state were understood to be agreements of required agency that operates disability services. interagency coordination for information sharing. PRELIMINARY CONTENT ANALYSIS Three categories of agreements ap- Content analysis of the agreements was peared: 1) consortia; 2) task-specific; and 3) subdivided into four tasks: 1) preliminary population-specific. Interagency agreements screening; 2) categorization; 3) content sum- with three or more state agency partners with mary; and 4) key informant interview. To date, substantive roles were considered consortia. the project has has completed the first two Those with a specific target population (i.e., tasks. The content summary and key informant people with severe psychiatric disability, tran- interview phase was scheduled for completion sition age youth with disabilities) that were not in late Spring 1999. The goal of the preliminary consortia were categorized as population screening was to determine if the interagency specific. These agreements listed multiple tasks agreements met basic criteria for inclusion in or goals to improve the service system for a the study. Agreements were screened for eligibility particular target group. Task-specific agree- according to the following criteria. ments may or may not have a particular target population specified but focused on a very l VR is one of the partners. narrow activity between two agencies (i.e., a one time transfer of dollars). Two agreements l The agreement addresses employment or related issues. from each were selected as representatives of that category. l The agreement focuses on or is relevant to people with disabilities.

l The agreement is active and in operation. FINDINGS & NEXT STEPS Two nominations were eliminated during the first screening. These nominations were not Table 2 on the following page lists the agreements but descriptions of a service delivered final six interagency agreements that will be by community rehabilitation providers. reviewed for content, context, and impact. The The goal of the categorization phase was two consortia are the Memorandum of Inter- to screen for exemplary practice potential and agency Understanding Regarding Supported develop a method for categorizing agreements Employment from New York and the Supported into types. The 19 eligible agreements ranged Employment Partnership Agreement from West from large multiagency systems change docu- Virginia. The New York agreement brings to- ments to agreements that resembled contracts gether four state agencies, the VR agency, for transfer of dollars for specific initiatives. Three Commission for the Blind and Visually Handi- researchers read the nineteen agreements and capped, MR/DD agency, and MH agency. rated independently whether the agreement was The intent of the agreement is to develop and likely to be a best practice or not. The team met enhance supported employment for persons to reach consensus. Only agreements that were with the most severe disabilities (The State rated as a potential best practice by at least two Department of Education, 1997, p.21). The researchers remained. Three of the nineteen were agreement delineates goals for interagency

103 TABLE 2 -- NOMINATED INTERAGENCY AGREEMENTS

Type State Title of Agreement

Task IN MOU between the Indiana Family and Social Services Administra- Specific tion Division of MH and Disability, Aging, and Rehabilitation Services

RI CA for the Delineation of Responsibilities for Individuals with Disabilities between the DHS and the DOE

Population MN Interagency CA DES, Rehabilitation Services Branch

OK MOA between Department of Rehabilitation Services and the DD Division of the DHS

Consortium NY MOU regarding SE

WV SE Partnership

1CA = Cooperative Agreement; DD = Developmental Disabilities; DES = Department of Economic Secu- rity; DHS = Department of Human Services; DOE = Department of Education; MH = Mental Health; MOA = Memorandum of Agreement; MOU = Memorandum of Understanding; SE = Supported Employment planning and coordination, eligibility, service de- The two task-specific agreements are the livery to consumers, program development and Memorandum of Understanding (MOU) for the coordination, and fiscal responsibilities. It re- Supported Employment Consultation and Train- sponds to a legislative mandate to improve inte- ing Program from Indiana and the Cooperative grated employment for people with disabilities Agreement (CA) for the Delineation of Respon- and is one piece of the Interagency Employment sibilities for Individuals with Disabilities Between Implementation Plan. The West Virginia agree- the Department of Human Services and the De- ment brings together seven state agencies or pro- partment of Education from Rhode Island. The grams to create the West Virginia Supported Indiana agreement is between the MH agency Employment Delivery System. and the VR agency. The intent of the agreement The seven agencies or programs include is for the MH agency to provide the state match VR, the MR/DD, the Office of Special Education portion for the Supported Employment Consulta- within the Department of Education, the Office tion and Training Program (SECT) which will of Employment Security and the Job Training Pro- assist providers to become eligible for establish- gram within the Bureau of Employment Programs, ment grants and to provide ongoing technical the Development Disabilities Planning Council, assistance to contracted providers (Division of the Governors Cabinet for Children and Mental Health, 1997, p. 1). The Rhode Island Families, and the Social Security Administration. agreement is between the VR agency and the The goal of the agreement is to define the roles Department of Education. The Department of of each of the partners and to encourage each Education provides matching funds to the VR partner to develop local interagency agreements agency with an overall goal of coordinating an (State of West Virginia, 1997). interagency approach to transition services

104 Article 7 maximum utilization of resources (Dept.of Re- habilitation Services, 1997, p.1). This agreement NEXT STEPS was the subject of a review by the Rehabilitation Research and Training Center on Employment and the National Supported Employment Con- Key informants from each of the sortium. It was recognized as an example of an agencies participating in the agreements will effective agreement between a VR agency and be interviewed indepth. A protocol developed the Home and Community Based (HCB) Waiver specifically for this study will be used to guide representatives (RRTC on Wokrplace Supports, the interviews with an open discussion en- 1998, http://www.worksupport.com/library/lp/ couraged. The first key informant is the central ssw/mar98.htm). The Minnesota agreement is office VR personnel most familiar with the between the MH agency and the VR agency. Its agreement. This individual will be asked to intent is to improve the quantity and quality of supply the name and contact information of rehabilitation and support services to persons with other VR staff with preference for a local admin- serious and persistent mental illness (SPMI) istrator. Personnel of other state agencies through: interagency systems planning and participating in the agreement will be recruited policy development, development of funding stra- in the same fashion. Qualitative data analysis tegies, service delivery and implementation, infor- techniques will be used to explore themes mation gathering and exchange, and training across the six agreements and to develop policy and technical assistance efforts (Rehabilitation and practice implications. Services Branch, 1998, p.1).

105 eferences:

R Datta, L. (1993) Best wishes and many happy returns: Some federal efforts in recognizing the best. Evaluation and Program Planning 16, 219-226.

Foley, S., Butterworth, J., Heller, A. (1999) A profile of vocational rehabilitation interagency activity improving supported employment for people with severe disabilities. In: G. Revell, K. Inge, D. Mank, & P. Wehman (Eds.) The impact of supported employment for people with significant disabilities: Preliminary findings from the National Supported Emlpoyment Consortium. Richmond, VA: Virginia Commonwealth University, Rehabilitation Research & Training Center on Workplace Supports.

Department of Rehabilitation Services (1997) Memorandum of agreement between the Department of Rehabilitation Services and the Developmental Disabilities Division of the Department of Human Services. Oklahoma: Department of Rehabilitation Services.

Division of Mental Health (1997) Memorandum of understanding on supported employment. Indianapolis, IN: Indiana Family and Social Services Administration.

Office on Rehabilitation Services (1995) Cooperative agreement for the delineation of responsibilities for individuals with disabilities between the Department of Human Services and the Department of Education. Rhode Island: Department of Human Services.

Rehabilitation and Training Center on Workplace Supports. (1998, March). Vocational rehabilitation and the Home and Community Based Services Medicaid Waiver. [Online] Available: http://www.worksupport.com/library/lp/ssw/mar98.htm.

Rehabilitation Services Branch (1997) Interagency cooperative agreement with Department of Human Services-Mental Health Division and Department of Economic Security-Rehabilitation Services Branch. Minnesota: Department of Economic Security.

State Department of Education (1997) Annual status report: Integrated employment . Albany, NY: The University of the State of New York.

State of West Virginia (1997) West Virginia supported employment partnership agreement. West Virginia: Division of Rehabilitation Services.

106 The Cutting Edge: State Policy Innovation and Systems Change

By: Martha McGaughey & David Mank

Broad-based systemic change in social services is, if anything, a challenging goal to pursue. Social change for people with disa- ABSTRACT bilities in the last several decades has included an expanding emphasis on civil rights and inclusion in every part of community life. One The adoption and expansion of the fronts in broad systems change for people with disabilities of supported employment has has been in employment. For people with severe disabilities, the evolved steadily, if unevenly, across the United States. This traditional opportunities for employment have been primarily in expansion was initiated in the segregated settings rather than typical community businesses. In- context of systems change innovations in the 1970s and early 1980s led to the supported centives offered by the federal employment initiative aimed at systemic change from segregated government beginning in employment to integrated employment for people with severe disa- 1985. While unique in rehabilitation, the concept of bilities. Since then, supported employment has expanded to a world- systems change in the imple- wide initiative (Wehman, Revell, and Kregel, 1998). Since the mentation of progressive beginning of RSAs supported employment initiative in 1985, public policy has been used research studies have documented consistent annual increases in on a number of social issues the number of individuals with disabilities working across the United for a number of decades. This States. This number has grown from a total of a few thousand in analysis describes the factors that influence state implemen- 1985 to 140,000 in 1995 (Wehman, Revell, and Kregel, 1998). tation of public policy, dis- This represents a fourteen fold increase in supported employment cusses the political cultures for people with severe disabilities. Studies of employment outcomes that vary across states and the reported by extended service funding agencies mirror these trends disability policy orientations (e.g., McGaughey, Kiernan, McNally, & Gilmore, 1993). The that affect disability policy implementation. These ele- implementation of supported employment; however, has been ments are discussed in the uneven at best. Some rehabilitation programs have made dramatic context of the emergence and gains in supporting people with severe disabilities in community expansion of supported em- jobs. Others have failed to make significant change. Some states ployment. This paper con- have rapidly expanded integrated supported employment; other states cludes that while there is vari- have not. As a result, while supported employment has grown with ation in implementation from state to state, systems change some rapidity, the clear majority of people with severe disabilities strategies for supported em- are without the opportunity for a job in the community with indi- ployment have had a positive vidualized supports. impact. Beginning in 1985 when the Rehabilitation Services Adminis- tration first funded 10 states with systems change grants, the federal government made funds available to states for the specific purpose

107 of systems change to supported employment for the 1960s when the federal government ex- people with severe disabilities. By 1993, nearly panded its policy-making role in relation to the every state had invested to some extent in the states. According to Walker (1984), the main notion of systems change to supported employ- trend in intergovernmental relations from 1964 ment (Mank, 1994). While every state made this to 1978 was an aggressive national assertion of investment, the outcomes in terms of growth policy leadership by both the legislative and judi- varied widely from state to state. cial branches of the Federal government, even It is important to gain an understanding as the localities and, most notably, the states of why some states have been more successful were experiencing the most dramatic reformation than others in undertaking and achieving systemic in their 220-year history (through various forms change. How have certain states been able to of policy experimentation) (p. 132). Total gov- achieve higher rates of supported employment ernmental expenditures for domestic purposes or to increase the percentage of individuals with (excluding national defense and interest on the severe disabilities? Why have some states been federal debt) rose from $119 billion in 1964 to successful in expanding supported employment $545 billion in 1978. In constant dollars, this beyond developmental disabilities and now serve amounts to nearly doubling the resources that people with mental illness and brain injuries? were invested. Moreover, the federal contribution Why do some states have a higher rate of serving to state and local expenditures grew from 15.4 people with more severe disabilities? percent in FY 1964 to 26.5 percent in 1978. One of the first and necessary steps to (McGaughey, Kiernan, McNally, & Gilmore, addressing these questions is to identify conditions 1993). Despite this national scale investment, that facilitate state policy innovation and systems it is also clear that implementation of social policy change. While the focus of this paper is on sys- change varies widely from state to state. tems change in supported employment, it is im- In the conclusion to their study, Klingman portant to note that a focus on systems change and Lammers (1964) raised some critical issues is not unique to supported employment or reha- related to state policy trends and noted contextual bilitation issues. For rehabilitation in general and differences from state to state and region to supported employment in particular, this systems region. The snowbelt states had enjoyed relatively change focus was quite unique. However, broad high levels of wealth (personal income) and systems change in social services has been and economic growth (corporate profits, tax revenue) is pursued on a number of social issues. that helped sustain their tendency toward ex- pansive implementation of policy change in the public sector. By 1984, economic decline and population loss in this region made it questionable INFLUENCE ON STATE whether the cultural and political forces would INNOVATIONS be sufficient to maintain the existing expenditure This analysis relies on theory developed levels. Conversely, economic growth in the Sun- to explain the process of policy innovation, belt states increased demand for public sector adoption, and diffusion among states and serves services to the point that the ruling elites in to define a context for better understanding sys- these states began to respond to the need for tems change in supported employment (see Table public and social services. 1 on the following page). Investigators initially Although total federal domestic spending began to study this process systematically during increased between 1981 and 1990, the Reagan

108 Article 8

TABLE 1 -- KEY INFLUENCES ON SOCIAL POLICY ADOPTION BY STATES

Key Influences Source

State Wealth Klingman & Lammers (1964)

Economic growth and economic cycles Dye (1990); Klingman & Lammers

Industrialization and urbanization Walker (1969)

Federal incentives to states (e.g., grants-in-aid) Welch & Thompson (1984)

State policy liberalism in a particular area Gray (1974); Menzel & Feller

General state social policy liberalismKlingman & Lammers (1984); Light (1978); Savage (1978)

Interstate communication among policy-making Walker (1969)

Adoption of a policy by other (particularly similar) states Walker (1969)

Political culture (moralistic, individualistic, or Elazar (1984) traditionalistic) administration reduced the proportion of state (1973). Walker (1969) conducted an im- and local spending provided by federal aid, drop- portant study where he hypothesized that a ping almost to its 1964 level (from 26.5% to typical diffusion pattern involved a pioneer 16.8% of total outlays). Most states continued state adopting a new course, followed by other to struggle with economic and budgetary prob- pioneer states, and then by states that tend to lems during this peiod. Several states experienced emulate those early innovators. He defined incredible economic growth, only to tumble into an innovation as a program or policy that is recession (e.g., California and Massachusetts). new to the states adopting it, no matter how Specifically related to disability services, the pro- old the program may be or how many other portional reduction in federal aid, economic re- states may have adopted it. Walker (1969) cessions, and court orders requiring states to developed an innovation score for each state upgrade state-run institutions and/or to expand by adding the percentage of time that elapsed the capacity of community-based services for per- between the first adoption and its own accep- sons with disabilities all placed competing pres- tance of the program and found that state sures on state coffers. Dye (1990) maintained measures of industrialization, urbanization, that economic cycles, not political factors, predict and wealth were significantly correlated with welfare spending and legislation. State econ- the innovation score. This suggests that systems omies typically experience cycles of fiscal austerity change is related at least in part to the state as well as stages of economic growth. In fact, context. the peaks and valleys accentuate the cyclical According to Walkers findings (1969), nature of this process. the pioneering states with the highest inno- Two of the early authors to examine the vation scores adopted new programs about process of adopting new programs within and as quickly during the early part of this century across states were Walker (1969) and Gray as they did during the 1960s. The diffusion

109 time for all states decreased; however, primarily planning, agriculture and civil rights) from because the slower states responded more several time periods with varying levels of fiscal quickly. Walker (1969) attributed this to ex- incentives. They found that federally-sponsored panded federal grants-in-aid and to increased policies (especially fiscal ones) diffused signifi- communication among policy-making officials. cantly faster than state-sponsored incentives. The The average diffusion time decreased from more initial rate of adoption was influenced by whether than 60 years before 1900 to less than 30 years the policy used positive incentives (rather than during the post-New Deal period. Still, the likeli- penalties of some sort), whereas adoption by the hood of a state adopting a new program was slower states was influenced by whether there higher if another state had already undertaken it was a federal incentive of any sort. Still, federal and, even higher, if that state was viewed as involvement and the type of policy explained only having similar characteristics. Welch and a very small percentage of the variance in states Thompson (1984) cautioned; however, that diffusion rates (Adjusted R 2 =.03-.18). As Eye- We should not minimize the impact of federal stone (1976) observed, a state adopts or rejects grants-in-aid. That the federal government a policy due to a complex web of factors, of chooses to deal with a problem through federal which the federal incentive is only one. grants and incentives to states rather than through Gray (1974) examined factors hypoth- a direct federal program indicates that support esized to reflect liberalism or progressivism in for the policy is limited (Monypenny, 1960; Lowi, the states, including measures of state welfare 1969). The adoption of a social initiative or a spending, education expenditures, and civil- federal grant program may often be a political rights legislation. She concluded that progressiv- compromise, which reflects a failure by most ism is not a one-dimensional factor underlying states to adopt the policy prior to federal action, all policy, but rather, that most states are pro- and which also indicates a lack of total commit- gressive in some area. For example, states that ment to the program by the federal government. ranked high on welfare-spending measures did Under such conditions, it is not surprising that not rank consistently high on education spending policy diffusion takes as long as it does (pp.727- measures. State anti-discrimination legislation 728). Such a statement seems true for supported was the only area for which a consistent pro- employment given the conflicting policy priorities gressivism factor appeared to exist. at the time of its creation and at the present time By 1984, there was still a lack of consensus (e.g., Mank, 1994, Wehman & Kregel, 1995). on whether some states were consistently more Supported employment also may be somewhat progressive on a range of policy issues. Some unique in light of this, because its implementation researchers agreed with Gray (1974) that innova- calls for a mix of funding from both state and tion was specific to particular policy areas and federal sources. That is, the responsibility for time periods (Menzel & Feller, 1977), whereas implementation must be shared rather than others reported more consistency in state policy residing with either the federal government or innovativeness across issue areas over time (Light, state governments. This sharing of responsibility 1978; Savage, 1978). Klingman and Lammers might be a benefit, a hindrance, or both, de- (1984) entered this debate by studying the rela- pending on the context. tionship between political factors, legislative vari- Welch and Thompson (1984) studied ables and state policy adoption patterns. The seven, major domestic state-policy areas (educa- investigators developed a general policy liberal- tion, health, welfare, environmental regulation, ism factor for each state from state scores on six

110 Article 8 variables hypothesized to reflect a more liberal tributing resources. However, government was stance (these variables are discussed later). generally perceived to be an appropriate entity to contract for or to provide employment training, along with other private-sector organizations or businesses. The individualistic politi- STATES POLITICAL cal perspective places a high value on indi- CULTURE DIFFERENCES vidual freedom, choice, and personal responsibility. It might be characterized as the Horatio Elazar (1984) developed a topology of Alger Perspective: given the right oppor- three, distinct political cultures based on each tunity, every citizen has the potential for great states prevailing values and beliefs regarding success in the United States. These groups the distribution of resources among disadvan- emigrated from non-Puritan England and the taged groups and whether government was the interior northern European countries into the appropriate entity for addressing these issues. middle Atlantic states: New York, New Jersey, According to Elazar (1984), these three political Pennsylvania, Delaware, and Maryland. They cultures were spread from east to west, along moved west into the central parts of Ohio, traditional migration routes. In this analysis, Indiana, and Missouri, and on into Nebraska, states have cultural identities but may be influ- South Dakota, and Oregon. enced by more than one of these perspectives. In the traditionalistic political culture, Puritans and Yankees in New England established those at the top of the social class structure a moralistic political culture most likely trace- (the elites in this language system) were ex- able to their status as immigrants seeking religious pected to take a dominant political role. The freedom. Government involvement in income traditionalistic political culture started redistribution tended to be viewed as necessary primarily in southern states. Those who settled and appropriate. The moralistic political cul- in the south were often seeking individual op- ture can be characterized as the most liberal portunities similar to their northern neighbors. of the three cultures, with respect to government However, because the plantation-centered intervention. Of these three political cultures, agricultural system was based on slavery, it the moralistic culture can be characterized as provided an environment for an American-style the most liberal, containing the most tolerance traditionalistic political culture in which land- for government intervention into social welfare owners controlled both resources and the issues. This political culture was imported into political system. There tended to be little recep- New York and northern Ohio and on into tiveness to the idea of government assuming Michigan, Wisconsin, and Minnesota. Pilgrims a major role in social welfare policy. Rather, and Yankees were joined in these states by older institutions like the church and family Scandinavians with compatible political views. were considered the primary sources of assis- Groups adhering to an individualistic tance with poverty and related social problems. political perspective were united more by their Elazar (1984) described the initial mi- search for individual opportunity in America. gration of traditionalistic political culture: Policies that addressed the needs of disadvan- Virginias people dominated in the settlement taged groups generally emphasized removing of Kentucky; North Carolinas influence was barriers to opportunity (e.g., employment-training heavy in Tennessee; and settlers from all four and literacy programs, etc.) rather than redis- states covered the southern parts of Ohio and

111 Illinois and most of Indiana and Missouri (Elazar, tation toward redistribution is strong, liberal eligi- 1984; p.133). The traditionalistic political bility benefit policies are likely. High costs and culture was spread through Texas, Oklahoma, negative orientation toward redistribution are (where it mixed with the individualistic per- likely to yield more conservative policies. Mixed spective) across New Mexico, Arizona, and into results can be predicted where costs are high southern and central California (where it over- and orientations are favorable, or where costs lapped with the moralistic political culture). are low but orientations are unfavorable toward Elazars theory (1984) helps explain the exis- redistribution (p. 331). This suggests that the tence of outlier states that differ from their re- nature of federal incentives to states is important. gional neighbors, depending on migration routes Although conventional wisdom suggests taken and whether characteristics from more than that federal aid would have the most influence one culture were combined. In some cases, mi- on states with fewer resources, Hanson (1984) gration patterns were interrupted by mountain found this is not necessarily true. Southern states ranges or other geographic barriers, isolating with fewer resources were less likely to use federal specific groups from the mainstream (e.g., the funds to expand their array of Medicaid-funded Scotch-Irish communities in Appalachia). In services and more likely to transfer fiscal respon- sum, political culture, like all culture, is dynamic. sibility from the state to the federal level. In con- Changes occur internally within particular cul- trast, wealthier states were more likely to expand tural groups, movement occurs from group to the range of optional services and the number group, cultures borrow from one another, and of eligible participants than they would have with- both cultural erosion and culture syntheses take out federal funding. Hanson ultimately con- place over time (Elazar, 1984, p. 134). cluded that federal assistance may therefore be a necessary, but insufficient, condition for establishing a uniform health care program for the nations poor (p. 335). THE INFLUENCE OF Dye (1990) maintained that intergovern- FEDERAL RESOURCES mental transfers led some states to substitute federal monies for state resources instead of ex- Hanson (1984) analyzed expenditure mea- panding the eligibility criteria or the range of sures, political culture characteristics, and polit- optional services offered (substitution effects), ical competition variables as potential explan- whereas other states end up buying more public atory factors in a study of state Medicaid program services than they would have without the supple- differences. He noted that resource constraints mental federal dollars (inflated demand for may not be a major issue for programs when public services). The federal government can intergovernmental transfers are made according require states to contribute a percentage of the to progressive schedules. Because the redistri- total as matching funds to discourage this trend bution impact of state Medicaid policies depends (e.g., federal-state Vocational Rehabilitation on the eligibility criteria established and the range funding) or it has the option of establishing truly of services offered, Hanson included a variable redistributive funding formulas based on demo- to control for interaction between the cost of a graphic and economic characteristics (e.g., pov- states Medicaid policies and its cultural orienta- erty rates, number of recipients of Aid to Families tion toward redistributive policies. Where the with Dependent Children, etc.). Furthermore, cost to state government is small, and the orien- the more stipulations federal government places

112 Article 8

TABLE 2 -- EVOLUTION OF DISABILITY POLICY ORIENTATION

Dominant Policy Examples Orientation Protectionist Model The English Poor Relief System, initiated around the turn of the 17th Century, (1600 to 1900) required each parish to levy a tax to provide for the unemployable poor (Scheerenberger, 1983)

Large residential institutions were founded in the late 1800s to segregate, protect, and care for individuals with disabilities.

Medical Model The federal-state Vocational Rehabilitation Program was originally established in (1900 to 1970) 1920 to treat the pathology of individuals with disabilities so that they could return to work.

During the first half of the twentieth century, 30 states passed legislation per- mitting the sterilization of individuals considered to be morons or feeble-minded to prevent them from reproducing their kind (Scheerenberger, 1983).

Socio-political Model The Rehabilitation Act of 1973 prohibited discrimination against individuals with (1970 to present) disabilities under any program or activity receiving federal financial assistance and the American with Disabilities Act of 1990 extended this prohibition to the private sector.

The Education of the Handicapped Act of 1975 (now referred as the Individuals with Disabilities Education Act) mandated that a free and appropriate public education must be provided to all children with disabilities.

on grant funding, the less likely that it will be moving from a protectionist framework into a substituted for programs currently supported with medical/rehabilitation, psycho-social model state monies. However, this does not appear to and then into a socio-political and economic be the accepted trend, the deinstitutionalization framework (see Table 2). From the charity- and subsequent decentralization of services for protectionist perspective, disability was viewed persons with disabilities during the 1980s and as a misfortune that required protection and 1990s has been accompanied by expanded care, often in the form of segregation. This state fiscal decision-making authority in the form viewpoint provided the rationale for the devel- of federal block grants with few requirements and opment of a wide range of services for in- other more open-ended transfer payments. dividuals with disabilities, starting with the English Poor Relief system in the 1600s and developing into state-run residential institutions by the end of the nineteenth century. POLICY ORIENTATION The federal-state Vocational Rehabilitation sys- INFLUENCES tem was established during the late 1920s to provide medical and rehabilitation services to ODay (1998) has conceptualized and World War I veterans so they could be rehabili- described the evolution of disability policy as tated for employment. 113 The federal/state VR partnership was firmly based on a right to education. Court cases based on a medical-rehabilitation model that related to disability policy proliferated when ad- served as a legitimate reference point for state ministrative or legislative solutions failed (ODay, VR services and moved the framework for disa- 1998). Public and private entities were sued by bility policy from protection to rehabilitation. individuals with disabilities for housing discrimi- Rather than being viewed as objects of charity, nation, the right to integrated, community-based individuals with disabilities were perceived as services, and the right to an education. Although needing professional intervention and care. judicial intervention was not the preferable solu- Barriers to employment were viewed to exist within tion, it opened the door for a rights-based, socio- the individual, such as lack of education and political concept of disability. skills. The Americans with Disabilities Act (1990) Conflicts in the underlying principles of was the crowning piece of federal civil-rights the medical/rehabilitation model versus the socio- legislation affecting individuals with disabilities. political framework of disability lead to policy The Act was founded on principles of civil rights conflicts, programmatic barriers and increased and equality, productivity and individual respon- unemployment for persons with disabilities sibility, community integration and inclusion, (ODay, 1998). There are clearly different values community accessibility, and consumer choice. inherent in each approach. A medical model The ADA extended anti-discrimination and physi- assumes that the individual can be cured or fixed cal and communications accessibility coverage in some fashion. A socio-political framework to all public and private entities with 16 or more assumes that supports for people will improve employees. As a civil rights act, the ADA takes quality of life without expecting that a person a very different approach to shaping disability will be cured of anything. This conflict in perspec- services and attitudes than federal mandate and tive continues to exist in disability services. federal incentive approaches. The Rehabilitation Act of 1973 was Braddock, Hemp, Parish, and Westrich modeled after the Civil Rights Act of 1964 and (1998) have studied the relationship between prohibited discrimination based on disability in economic indicators, socio-political factors and the same manner that the Civil Rights Act pro- state MR/DD agency spending. They have con- hibited discrimination based on gender or race. sistently reported that political variables (e.g., Not only did the Rehabilitation Act of 1973 priori- size of disability advocacy group membership tize services to those with severe disabilities, but and state civil rights legislation) are stronger pre- also it prohibited employment discrimination and dictors of state MR/DD spending than measures required physical and communications accessi- of state wealth or state population. This finding bility by all public and private entities receiving is contrary to results documented in many other federal funding. state expenditure studies, where state wealth is Other disability-policy legislation based typically the strongest predictor. More populous on a socio-political, civil rights model was passed and wealthy states also score consistently higher during this period. For example, the Air Carriers on policy innovation and diffusion measures Access Act (1973) addressed physical accessi- (Dye, 1990; Klingman & Lammers, 1984; bility, the Fair Housing Act (1980) offered protec- Walker, 1969). According to Braddock and his tion from housing discrimination., P.L. 94-142 colleagues, MR/DD funding appears to be (1974) authorized special education services for affected by different factors other than state tens of thousands of children with disabilities expenditure categories.

114 Article 8 Disability advocacy activities helped to taxation, urbanization, unemployment, state over-ride the influence of economic factors and fiscal commitment, anti-discrimination employ- other competing pressures (especially competing ment legislation and supported employment special interest groups) on state budgets. Disa- or competitive employment outcomes for per- bility may be one area where this is politically sons with disabilities (e.g., Braddock, Hemp, feasible, as most citizens do not view individuals Parrish & Westrich 1998). Other studies of with severe disabilities as taking advantage of supported employment outcomes over time the welfare system. Furthermore, it would seem have documented a great deal of variability supported employment funding would be one of across states (Wehman, Revell, & Kregel, the most acceptable publicly-funded programs, 1998). as it offers a potential for return on investment by Further research is needed to examine increased tax contributions from workers with systems change activities and policies designed disabilities and reductions in Supplemental Secur- to enhance supported employment and/or ity Insurance (SSI) and Social Security Disability convert facility-based resources. Three goals Insurance (SSDI). From a political perspective, it of research seem especially needed: 1) to is interesting to note supported employment identify states that have excelled at establishing began and expanded rapidly in the mid to late supported employment services and the neces- 1980s during the Reagan administration. sary related administrative structures and link- New work incentive provisions now pro- ages, 2) to examine the relationship between vide a context wherein there may become an in- economic, socio-political and cultural factors centive to work even if a person receives other and stronger supported employment outcomes, social benefits rather than simply a loss of other and 3) to compare these relationships with benefits when working. This could have a positive findings from other studies of state innovation effect on the implementation of supported em- and diffusion. Overall, such investigation and ployment. Amendments to the Home and Com- analysis should assess the extent to which the munity-based Waiver legislation (Medicaid, Title systems change initiative in supported employ- XIX) removed the requirement that individuals ment has actually resulted in the continued must have been previously institutionalized before implementation of supported employment and, they could be eligible for supported employment of course, in systems change. services under the Title XIX Waiver program. These legislative changes offer the potential for greatly expanding the number of individuals with severe disabilities in supported employment, and CONCLUSION for the work incentives provisions, for expanding the number of individuals with any type of disability in employment. Outside of the ADA, there There are a number of points that is probably no more important piece of federal should be considered in the context of the im- legislation related to employment and disability plementation of the national supported em- than the federal work incentives provisions. They ployment initiative. First, the notion of inte- are likely to create a lasting impact on employ- grated employment for all persons with disa- ment for individuals with disabilities. bilities, including those with the most severe Previous research has documented a re- disabilities, grew out of a small number of lationship between measures of state wealth, exemplary programs that demonstrated that is

115 was clearly possible for people with severe disa- the ideas for statewide implementation were not bilities to work successfully in integrated settings unique to nor limited to states with a federal in- (e.g., Bellamy, Rhodes, Mank, & Albin, 1988; centive grant. Indeed, some states without systems Wehman, 1980). change grants began aggressive implementation Second, these innovations were viewed without federal funds. This suggests that providing by state and federal governments as improve- an incentive to some states, but insuring that the ments over the segregated day services and ideas for implementation were available across sheltered employment programs that were avail- states, actually facilitated cross state implemen- able. Third, the federal government then created tation beyond the stated scope of a given state incentives (albeit fiscally small incentives) for systems change grant. states to expand supported employment and The complexity of this broad emphasis on specifically offered funding for systems change systems change must also be considered in the to supported employment. It is important to point context of political, social, cultural and economic out that the actual amount of money offered was issues across states. Perhaps an unstated assump- the same for each state (initially about $500,000 tion in systems change to supported employment per year for five years) rather than based on popu- has been that the strategies and possibilities for lation. Fourth, some states adopted a policy of change were very similar from state to state and expanding supported employment much earlier that offering an incentive from the federal govern- than other states. Fifth, early adoption of sup- ment would result in similar change within each ported employment is not necessarily the same state. The ideas and information discussed in as more complete implementation of supported this paper suggest that the implementation of employment. systems change is much more complex than that. An important question in systems change is The purpose of this paper has been to the extent to which a federal incentive (in this provide an analysis of the context for the systems case, funding for systems change to supported change initiative in supported employment. As employment) is associated with more rapid or noted earlier, while the idea of systems change more complete systems change. How this ques- as a strategy was unique for employment services tion is asked makes a difference. One relevant for people with severe disabilities, it is not a unique question is whether or not the federal incentive approach in social services in the United States. resulted in more rapid or more thorough imple- Indeed, it has been used and analyzed related mentation within a state (compared to states that to a number of social policy issues. did not initially have access to this incentive). Economics, political culture, cultural identity, Another question is the extent to which funding taxation policy, and more provide the context of some states influenced the national, cross-state understanding. In order to better understand the implementation of supported employment. While status and the future of supported employment, implementation of supported employment was these factors must be considered. presumably enhanced by access to federal funds,

116 Article 8 eferences: R Bellamy, G. T., Rhodes, L. E., Mank, D. M., & Albin, J. M. (1988). Strategies for change in facility-based programs. In G. T. Bellamy, L. E. Rhodes, D. M. Mank, & J. M. Albin (Eds.), Supported employment: A community implementation guide (pp. 139-159). Baltimore: Paul H. Brookes Publishing Company.

Braddock, D., Hemp, R., Bachelder, L., & Fujiura, G. (1995). The state of the states in developmental disabilities (4th ed.). Washington, DC: American Association on Mental Retardation.

Dye, T. R. (1990). American federalism. Lexington, MA: D.C. Heath & Company.

Elazar, D. J. (1984). American federalism: A view from the states (3 rd ed.). New York: Harper- Row.

Eyestone, R. (1977). Confusion, diffusion, and innovation. American Political Science Review, 71 (2), 441-447.

Gray, V. (1973). Innovation in the states: A diffusion study. American Political Science Review, 67 (4),1174-1185.

Gray, V. (1974). Expenditures and innovation as dimensions of progressivism: A note on the American states. American Journal of Political Science, 17, 693-699.

Hanson, R. L. (1984). Medicaid and the politics of redistribution. American Journal of Political Science, 28 (2), 313-339.

Klingman, D., & Lammers, W. W. (1984). The general policy liberalism factor in American state politics. American Journal of Political Science, 28 (3), 598- 610.

Light, A. R. (1978). Intergovernmental sources of innovation in state administration. American Politics Quarterly, 6 (April), 146-166.

Lowi, T. J. (1969). The end of liberalism. New York: Norton.

Monypenny, P. (1960). Federal grants-in-aid to state governments: A political analysis. National Tax Journal, 13 (March), 1-6.

Mank, D. (1994). The underachievement of supported employment: A call for reinvestment. Journal of Disability Policy Studies, 5 (2),1-24.

McGaughey, M. J., Kiernan, W. E., McNally, L. C., & Gilmore, D. S. (1993). National perspectives on integrated employment: State MR/DD agency trends. Boston: Childrens Hospital, Training and Research Institute for People with Disabilities.

Menzel, D. C. & Feller, I. (1977). Leadership and interaction patterns in the diffusion of innovations among the American states. Western Political Quarterly, 30, 528-536.

ODay, B. (1998). Restrained labor: An exploratory study of unemployment among people with disabilities. Waltham, MA: Brandeis University. Unpublished doctoral dissertation.

117 Savage, R. (1978). Policy innovativeness as a trait of American states. The Journal of Politics, 40 (1), 212-224.

Scheerenberger, R. C. (1983). A history of mental retardation. Baltimore, MD: Paul H. Brookes Publishing Company.

Walker, J. L. (1969). The diffusion of innovations among the American states. The American Political Science Review, 63 (3), 880-899.

Walker, J. L. (1984). Comment: Problems in research on the diffusion of policy innovations. The American Political Science Review, 67 (4), 1186-1191.

Wehman, P., & Kregel, J. (1995). At the crossroads: Supported employment a decade later. Journal of the Association for Persons with Severe Handicaps, 20 (4), 286-299.

Wehman, P., Revell, W. G., & Kregel, J. (1998). Supported employment: A decade of rapid growth and impact. American Rehabilitation, 24 (1), 31-43.

Welch, S., & Thompson, K. (1980). The impact of federal incentives on state policy innovation, American Journal of Political Science, 24 (4), 715-729.

118 Initiatives Influencing the Emergence of Results- Based Funding of Supported Employment Services

By: Jeanne Novak, David Mank, Grant Revell, & Nancy Zemaitis

The Rehabilitation Act Amendments of 1986 added supported employment as a program option of the federal-state Vocational ABSTRACT Rehabilitation (VR) program for the specific purpose of assisting individuals with significant disabilities to work successfully in com- An increasing number of state petitive employment. By providing individualized and ongoing sup- VR agencies are using results- ports, supported employment made community-integrated, competitive based funding strategies to employment opportunities available to individuals with disabilities purchase supported employment services from community who historically had not worked competitively or had worked only rehabilitation providers. In this intermittently. Before supported employment, the service options article, results-based funding is available to this population were largely limited to segregated settings discussed within the context of such as sheltered workshops, work activity programs, and nonwork- the evolution of supported employment funding practices. oriented day treatment programs (Wehman, Kregel, & Shafer, 1989). Results-based funding meth- Supported employment has made significant advances over ods are presented as an altern- the past 13 years of implementation. The 139,000 persons reported ative to traditional purchase of working in supported employment during Fiscal Year (FY) 1995 service agreements that make represent a fourteen-fold increase from service levels in FY 1986; provider compensation contingent upon the provision of ser- the number of supported employment provider agencies has grown vices rather than the achieve- from 324 in FY 1986 to approximately 3,700 in FY 1995 (Wehman, ment of valued results. This Revell, & Kregel, 1998). The impact of supported employment services article describes recent gov- is particularly apparent within the Vocational Rehabilitation system. ernment-wide initiatives to improve accountability for res- In FY 1995, state Vocational Rehabilitation counselors successfully ults that are influencing the assisted 18,142 individuals in obtaining community integrated em- operation of state VR pro- ployment through supported employment; this figure represents a grams. It also addresses con- 30% increase from the FY 1994 total. The number of individuals cerns about outcomes and with successful employment outcomes through VR in FY 1995 more consumer satisfaction within the VR program that are than doubled those in sheltered employment (Brooke, Revell, & Green, leading state VR agencies to 1998). By expanding the service delivery options and improving consider results-based funding the employment outcomes for people with significant disabilities, approaches. supported employment has played a major role in strengthening the consumer informed choice and self-determination provisions of the 1998 Amendments to the Rehabilitation Act. Core tenets of supported employment are contained in this legislations emphasis on competitive employment in integrated settings and the presumption that individuals with the most significant disabilities can be successful in

119 employment if provided with appropriate services examined the effectiveness of various methods and supports (Inge, 1998). VR agencies use to purchase supported employ- Despite all of supported employments ment services from providers. The purpose of the successes, people with the most significant disa- present paper is to further examine one particular bilities continue to face numerous barriers to funding strategy that is increasingly being used achieving competitive employment outcomes. by state VR agencies to encourage accountability For example, state Mental Retardation/Develop- for outcomes,results-based funding. Within Voca- mental Disabilities agencies reported that ap- tional Rehabilitation, results-based funding (RBF) proximately 450,000 individuals were enrolled refers to a funding design wherein the VR agency in day/work services in FY 1996 as compared compensates providers based on the delivery of to 92,000 in supported employment. The num- specified employment outcomes. Following a brief ber in day/work services grew by 21,000 from overview of the history of supported employment FY 95 to FY 96 as compared to a growth of funding, we will explore the reasons behind the only 7,000 in supported employment over the current trend toward results-based strategies for same period (Braddock, Hemp, Parish, & purchasing supported employment services. Westrick, 1998). The challenges still facing supported employment are well documented (Mank, 1994; Wehman & Kregel, 1995). There are concerns about the quality of employment outcomes THE EVOLUTION OF SUPPORTED in relation to service costs. To improve the record EMPLOYMENT FUNDING of success for supported employment, funding STRATEGIES agents and service providers must recognize their The initiation of supported employment accountability for assisting individuals with the in the mid-1980s required a significant redesign most significant disabilities achieve valued em- of state agency funding arrangements with pro- ployment outcomes. The continued predomi- vider programs. Supported employment systems nance of day/work services and the high unem- were created by combining the time-limited fea- ployment rate for people with disabilities who tures of VR with the long-term supports typically want to work (N.O.D., 1998) an unemploy- funded by state developmental disabilities and ment rate seemingly unaffected by our robust mental health agencies. Supported employment national economy suggest a need for greater represented a dramatic departure from traditional accountability in the use of public funds for the services for state VR agencies and long-term sup- delivery of employment services. port agencies for people with significant disa- A primary means by which accountability bilities. Not only were service features of the two can be accomplished is through the ongoing systems combined, in addition, widely different evaluation of outcomes and program effectiveness funding approaches in the two systems were used (see Bond, Drake, Mueser, & Becker, 1997; in the interest of supporting people with significant Mank, 1994; Wehman et al, 1995; Wehman disabilities in community jobs. VR agencies made et al., 1998). By examining the extent to which the transition to funding extensive jobsite sup- goals are being achieved and understanding the ports for a population of individuals with greater relative success of various approaches to support needs than previously served. Long-term achieving these goals, the quality of supported services agencies, which historically funded nonemployment services can be improved. Revell, work or segregated work opportunities, were now West and Cheng (1998), for example, have funding job-related services in integrated settings. 120 Article 9 State agencies such as Vocational Reha- paid $30 for each hour of job development, bilitation, Mental Retardation/Developmental job coaching, or any related employment sup- Disabilities, and Mental Health use a variety of port service it provides to an eligible supported purchase of service (POS) methods to obtain em- employment program participant. ployment services from provider agencies. Most Hour-based POS agreements have POS methods have common elements: (1) de- several advantages over earlier POS methods. fined services; (2) a purchasable unit for each The supported employment participant has service (e.g., day, hour, specific outcome); and available the degree of service intensity pre- (3) a unit cost for each defined service (Revell et scriptively needed for job success. The provider al., 1998). Prior to the advent of supported em- of services can customize services based on ployment, most work-related POS agreements individual support needs, because it is reim- were used to purchase facility-based services bursed for each hour of service provided to such as work adjustment and sheltered employ- an individual. The funding agency has access ment (Hill & Revell, 1987). The purchasable units to individualized information on the specific for services were typically days of service or con- services being provided and the impact of funds tracted slots that did not differentiate the charges being spent. For these reasons, the hour-based based on the type, number, or intensity of the fee-for-service approach has evolved as the services received by participants. In contrast to predominant POS method for funding services facility-based services, supported employment in- leading to individual job placements in sup- volves professional job coaches providing discrete ported employment. and individualized services to people with disabil- Despite its continued prevalence, there ities in community job situations. Funding agents are growing concerns with perceived break- concluded that POS alternatives were needed downs in the benefits obtained from the hourly that provided individualized program information unit of service approach in comparison to its based on the specific units of services received costs. These are two key perceived breakdowns. by each supported employment customer. First, the hourly approach does not readily en- As the number of supported employment courage quality assessment and quality control provider agencies grew nationally, hour-based by service providers, because hours of services POS agreements gained in popularity (Wehman are paid for without regard to the success of et al., 1998). A recent national survey of state those services. Second, there are limited incen- employment funding agencies reported 45 tives to encourage participant movement examples of an hourly rate for supported employ- toward valued employment outcomes. Like the ment in FY 1995 (Wehman, et al., 1998). The funding approaches before it, the hour-based original intent of the hour-based POS approach POS approach emphasizes the provision of was to respond proactively to the service needs services and time spent providing those services of people with significant disabilities for whom rather than emphasizing what happens as a there was little experience in providing support result of those services (Oklahoma Department in competitive settings. Using this approach, the of Rehabilitation Services, 1997). provider agency can be compensated for the There is currently a move from process- costs involved in implementing an individualized oriented approaches to funding supported em- service plan regardless of whether that plan in- ployment services to more results-based ap- volves 100 hours of services or 250 hours of proaches. Strategies are emerging that com- service. For example, a provider agency may be pensate providers for the outcomes of services

121 rather than the process of service delivery. These Schack, 1996; Osborne & Gaebler, 1992; strategies are based on both the general concern Wedel & Colston, 1988). The remainder of this that public funds ought to pay for valued out- paper discusses the forces behind the current comes and the specific concerns that individuals trend toward RBF approaches, highlighting forces receiving employment services would benefit from at the federal level and forces within the federal- a greater emphasis on outcomes within the state vocational rehabilitation system. VR funding funding system. The principal intent of RBF ap- strategies will also be discussed within a systems proaches is to pay for meaningful and mea- framework and the nature and rationale of surable employment outcomes at a defined cost. results-based compensation systems examined. Results-based funding may be viewed as a logical next step in the evolution of supported employment funding practices. Now that the costs of providing services can be more accurately esti- FORCES PROMOTING THE T REND mated and many of the variables that influence TOWARD RBF APPROACHES costs have been identified, funding agencies are better equipped to reimburse providers based on The movement toward results-based ap- outcomes. proaches or funding supported employment A variety of results-based approaches to services can be attributed to forces within the funding supported employment are being tested broader context of federal government reform and implemented nationally. In a survey con- and vocational rehabilitation. When considering ducted by Wehman et al. (1998), state VR the impetus for change within state VR agencies, agencies were asked what funding methods they it is important to take into account the influence utilized in FY 1995 to purchase employment of the federal government of which they are a services from providers. Twenty state VR agencies part (Ginsberg, 1994). Recent government-wide reported paying providers based on a results- initiatives to improve performance measurement based funding approach. For example, a VR and accountability are influencing the operation agency may reimburse a provider when an em- of state VR programs. Concerns about outcomes ployee successfully completes key service steps and consumer satisfaction are leading state VR such as assessment, obtaining employment, and agencies to consider results-based funding continued job maintenance for a specific time approaches. The ultimate goals of reform federal period. There are multiple variations of compen- and VR agency levels of government are to im- sation strategies in place and being tested by prove their efficiency, quality, and effectiveness. state VR agencies. Numerous examples are RECENT INITIATIVES TO IMPROVE described in the companion report prepared by GOVERNMENT PERFORMANCE Novak, Mank, Revell, and OBrien (1999). The American government system has long The shift to greater accountability and been criticized for bureaucratic excesses and pre- results-based funding is not unique to supported sumed ineffectiveness. As funding for federal employment or rehabilitation. While it is still programs has become more and more scarce, somewhat novel in rehabilitation, this shift is a programs are being closely scrutinized and are part of a much broader shift by society and gov- under pressure to justify their value (Groszyk, ernment to emphasize accountability in the use 1995; Martin & Kettner, 1996). Public cynicism of public tax funds (Else, Groze, Hornby, Mirr & about the performance of government is growing. Wheelock, 1992; Gore, 1993a; Kravchuk & Taxpayers no longer appear willing to pay for

122 Article 9 effort, they want to see results (King, 1995). The (e.g., supported employment providers) federal government has responded to such criti- accountable to government agencies who fund cisms by implementing a number of reform initia- them (e.g., VR). tives on improving how government operates. National Performance Review Three of the most notable initiatives are the A second prominent initiative that Government Performance and Results Act, the emerged soon after passage of GPRA was the National Performance Review, and the Govern- National Performance Review (NPR; Gore, mental Accounting Standards Boards Perform- 1993a). The NPR, headed by Vice President ance Measurement Project. Al Gore, is a wide-ranging endeavor to make Government Performance and Results Act the government work better and cost less. With the passage of the Government Per- Several parts of the NPR are directly related to formance and Results Act (GPRA) of 1993, the performance, including a commitment to aid issue of performance measurement became a in the implementation of the Government Per- high priority within government agencies formance and Results Act of 1993. A NPR in- (Kravchuk & Schack, 1996). Taxpayers no longer vestigation of how federal agencies measure seem satisfied with information about how many their performance found that most agencies clients were signed up for a service, how many are measuring the wrong things. The investiga- forms were filed, or how much money was spent; tion revealed that federal agencies are mea- they now want to know, What did our money suring the resources that go into their pro- accomplish? (Gore, 1995; King, 1995; grams, inputs, instead of the results of their Theurer, 1998). GPRA requires federal agencies programs, outcomes (Gore, 1995). to define long-term goals, set specific annual The National Performance Review is performance targets, and report annually on per- largely the federal governments implementa- formance relative to agreed upon targets. Annual tion of the precepts contained in Osborne and performance plans, which are required govern- Gaeblers 1992 book, Reinventing Govern- ment wide beginning with fiscal year 1999, must ment. The book, which focuses on improving include measurable goals and performance how federal, state, and local governments indicators. When federal agencies begin sub- operate, is having a substantial influence on mitting their annual reports, the first is due in public management practice (Martin & Kettner, March of 2000, the President, Congress, and 1996). The authors describe a new form of the public will have a clearer picture of how well government emerging in the public sector federal agencies are performing (Groszyk, (Osborne & Gaebler, 1992). This new form 1995). In the United States, this emphasis on of government is intended to be less bureau- how well agencies are actually accomplishing cratic and utilize resources in more efficient their program purpose and objectives is referred and effective ways than traditional government. to as Managing for Results. The reinventing government movement empha- Demonstrations of the usefulness of out- sizes systematic measurement and use of come information have been cited at all levels performance data in the public sector. In fact, of government (Olsen, 1997). Performance mea- an entire chapter of the book is devoted to surement has shown to improve accountability principles for creating a results-oriented gov- and program performance. Performance informa- ernment (i.e., government that funds outcomes tion has demonstrated to play a significant role rather than inputs). These authors lay out seven in holding non-governmental service deliverers simple yet eloquent statements about the

123 philosophy behind measuring performance and standards to include the reporting of performance funding outcomes: measures (Osborne & Gaebler, 1992). The GASB proposed reporting standards are intended 1. What gets measured gets done. to provide a more complete picture of the performance of governmental agencies than tradi- 2. If you dont measure results, you cant tell success from failure. tional reporting standards (Fountain & Roob, 1994; GASB, 1994). These standards would 3. If you cant see success, you cant re- require state and local governments to report ward it. annually on what the GASB calls service efforts 4. If you cant reward success, youre and accomplishments (SEA). SEA reports provide probably rewarding failure. information about (a) the resources that went into government programs; (b) the services they 5. If you cant see success, you cant provided; (c) whether those services achieved the learn from it. established objectives; and (d) what effects the 6. If you cant recognize failure, you cant services had upon service recipients and others. correct it. An increasing number of government agencies 7. If you can demonstrate results, you are experimenting with SEA measures (GASB, can win public support. (Osborne & 1994), and the GASB has recently been awarded Gaebler, 1992) a three-year grant to research and develop performance-reporting techniques to be used by In 1995, Vice President Gore declared state and local governments (American Institute that the combination of the Government Perform- of Public Accountants, 1998). ance and Results Act and the reinvention initi- While compatible with GPRA and the atives emphasis on results has enabled federal National Performance Review, SEA reporting pro- agencies to begin serving people better with lower vides more guidance and greater specificity than costs to the public. The NPR recently changed these federal initiatives and may ultimately sub- its name to the National Partnership for Rein- sume them (Martin & Kettner, 1996). Together, venting Government (Laurent, 1998). Along these three public sector initiatives highlight the with this new name came a broader vision, one central role that outcome accountability and per- which not only seeks to make government oper- formance measurement are beginning to play in ate more efficiently but also promises to get results the administration of public sector programs. This that are valued by Americans. trend will likely continue and intensify over the GASBs Performance Measurement Project next several years. As state and local government The federal initiative with the greatest agencies become responsible for reporting more potential impact on government accountability performance information to the federal govern- and performance measurement comes from the ment, it will be necessary for them to collect such Governmental Accounting Standards Board performance information from their private non- (GASB) (Martin & Kettner, 1996). GASBs mission profit and for-profit grantees and contractors. With is to set the accounting standards followed by increased access to provider performance infor- state and local governments. In response to mation, VR agencies will have expanded capacity growing frustration from taxpayers who are de- to use performance information to assist con- manding to know what they are getting for their sumers in making decisions about service pro- money, the GASB is redefining its accounting viders and resource allocation.

124 Article 9 IMPETUS FOR CHANGE WITHIN THE The streamlining initiative is an ongoing pro- STATE-FEDERAL VR PROGRAM cess of self-evaluation and continuous im- Advocates have long highlighted sup- provement developed in response to an iden- ported employments emphasis on outcomes as tified need to improve the efficiency and effec- evidenced by improvements in wages and com- tiveness of the state-federal VR program. In munity integration realized by those who obtain line with the larger reinvention movement to employment through supported employment pro- make government more customer-driven and grams (McCaughrin, Ellis, Rusch, & Heal, results-oriented (Osborne & Gaebler, 1992), 1993). While many individuals with the most the streamlining initiative endeavors to make significant disabilities have become employed the VR system more responsive to the persons with the assistance of supported employment ser- it serves and to enhance the employment out- vices, people with disabilities, state VR programs, comes of individuals with disabilities. Stream- and service providers continue to voice concerns lining efforts are directed at identifying and about acceptable outcomes. People with disa- revamping policies and practices that impede bilities and advocates point to the need for better the rehabilitation process and outcomes (RSA paying jobs, more hours, and a greater variety & CSAVR, 1996). of employment settings. A common sentiment A performance-based monitoring sys- by people with disabilities is, We are receiving tem is being developed and implemented to countless employment services, but what we complement streamlining activities (Schroeder, really want are jobs. Vocational rehabilitation 1997). This initiative is similar to examples of agencies express concern about the high cost of performance-based emphases in welfare to supported employment relative to other VR pro- work, early intervention, and home healthcare. grams, the temporary nature of many jobs, and The system includes standards and indicators the lack of emphasis on including people with for measuring VR state agency performance. the most significant disabilities. Service providers As state VR agencies become more immersed express concern about reimbursement rates not in streamlining and performance measurement meeting true costs (Revell, West, & Cheng, activities, they will likely seek similar acc- 1998), difficulty in maintaining capacity to de- ountability for results from supported employ- liver high quality services, and excessive document service providers. One way to increase mentation requirements. In fact, while supported provider accountability is to tie compensation employment has successfully assisted many to service results rather than to traditional individuals with the most significant disabilities process requirements. achieve competitive employment, considerable concern with regard to quality outcomes is expressed from many perspectives. The federal-state VR program has recently POS ARRANGEMENTS taken several steps to enhance its accountability USED TO DATE and effectiveness. In February of 1996 the Reha- bilitation Services Administration (RSA) and the A useful framework for comparing the Council of State Administrators of Vocational POS agreements used to purchase SE services Rehabilitation (CSAVR) entered into an agreement is a systems model. A systems approach has to streamline the public vocational rehabilitation long been used to analyze the nature of hu- service delivery system (RSA & CSAVR, 1996). man service delivery (Kettner & Martin, 1993,

125 Martin & Kettner, 1996; Rosenberg & Brody, l Outputs are the products of service delivery 1974). Figure 1 shows the interrelated elements (Rosenberg & Brody, 1974). Outputs are often defined as service volumes (e.g., # of that constitute a human service delivery system. hours of job coaching provided) and service Using the systems framework, it is possible completions (e.g., number of individuals who to articulate four types of performance in human completed community-based assessments; Kettner & Martin, 1993, Martin & Kettner, service delivery: inputs, process, outputs, and 1996). outcomes. l Outcomes are the benefits individuals reap l Inputs are resources that a program uses to during or after participating in program achieve its objectives (Gore, 1993b). Inputs activities (Hatry, van Houten, Plantz & can be thought of as the raw materials (e.g., Greenwood, 1996). They reflect a change program participants, staff, facilities, funding) in the quality of life of program participants that go into a human services program (Kettner & Martin, 1987; Martin & Kettner, (Martin & Kettner, 1996). 1996; Rosenberg & Brody, 1974). More specifically, outcomes refer to the impact l Process is the actual provision of services services have on program participants as (Rosenberg & Brody, 1974). It encompasses they relate to established objectives. This all activities necessary to reach service objec- impact may be a change in what partici- tives. In supported employment provider de- pants know or can do; how they behave; or livery systems, process may include activities their condition, status, quality of life or other such as transactions between staff and attributes. Put simply, outcomes are the program participants, communications with actual results or accomplishments attributed employers and potential employers, and to a service program. negotiations with the funding source.

FIGURE 1 -- COMPONENTS OF A HUMAN SERVICES SYSTEMS MODEL

INPUTSPROCESS OUTPUTS OUTCOMES

Table 1 on the following page represents to outcome performance expectations but rather a systems framework for understanding VR pur- to the resources allocated to the program. This chase of service agreements with supported em- type of funding mechanism, in which providers ployment provider agencies. As the table illus- are reimbursed for the costs they incur regardless trates, VR agencies can make compensation con- of the volume of service provided or the results tingent on inputs, process, outputs, or outcomes. achieved, can be described as input-based. Alter- Grants, slot-based agreements, and fee- nately, VR funding systems that compensate pro- for-service arrangements are examples of pay- viders for having a given number of program ment methods focused on service provision. For slots filled are most accurately identified as example, when VR awards a grant to a provider process-based funding structures. When a VR agency, the providers compensation is not linked agency has a slot-based agreement with a service

126 Article 9

TABLE 1 -- SYSTEM COMPONENTS OF SUPPORTED EMPLOYMENT SERVICE DELIVERY PROGRAMS AND CORRESPONDING VR FUNDING METHODS

Human Services Contracts or Component Definition Example(s) Agreements Inputs Resources that go into a Staff, facilities, employee hours, Grants program program participants

Process Program activities Job development and job coaching Slot-based activities

Outputs Service products Completion of 30 hours of job Fee-for-Service coaching per month

Outcomes Benefits of a particular service Knowledge gained via completion of Results-based Intermediate in a series of services assessment

Ultimate Long-term qualify-of-life Desired, stable employment Results-based changes

provider, the service provider is paid for the num- The human services field has been criti- ber of individuals with disabilities receiving em- cized for responding to the demand for ac- ployment services for a defined unit of time, typi- countability by emphasizing the process of ser- cally a day, week, month, or year; (Revell, et al., vice provision (Else, 1992). To measure per- 1998). Finally, when a service provider receives formance in terms of process is, in reality, payment for units of service actually delivered merely to specify and monitor service inputs, (e.g., one hour of job development), it is being outputs, and delivery standards. Kettner and compensated for service outputs. Supported em- Martin (1993) refer to this perspective on ployment fee-for-service arangements would be accountability as the triumph of process over classified as output-based funding arrangements. results (p. 62). Implicit in funding mechanisms While it is possible to make distinctions that tie payment to inputs, process, or outputs between input-, process-, and output-based is the assumption that if individuals are re- funding mechanisms, more important to the pre- ceiving services, they will attain meaningful sent discussion is the distinction between these results. While receiving services is an obvious three funding approaches (as a group) and prerequisite for reaching targeted outcomes, outcome-contingent, or results-based, funding funding mechanisms that compensate providers approaches. This distinction is in line with the solely for service provision neither guarantee Government Performance and Results Act, the desired results nor address outcomes directly. National Performance Review, and Govern- VR purchase of service approaches have mental Accounting Standards Boards emphasis not escaped this criticism. They too have on measuring and reporting service results rather predominantly funded provider agencies to than service efforts (Fountain & Roob, 1994; deliver services (process) designed to turn Gore, 1993a; Groszyk, 1995). program participants (inputs) into individuals

127 who have received services (outputs) in the hope chase-of-service agreement that ties at least a that this will improve the participants quality of portion of a providers compensation to the life (outcomes). Frequently, provider program achievement of outcome performance measures. descriptions focus on the plan for service provision The defining characteristic of VR results-based (such as assessment, job development, job funding is payment for the valued accomplish- coaching) without defining a service outcome ments of service recipients. (e.g., chosen employment). Furthermore, it is Central to results-based funding is the not unusual for provider compensation to be de- notion of outcomes. Some human services pro- livered independent of the achievement of out- grams are viewed as having various levels of comes. This has led to situations in which pro- outcomes, with intermediate outcomes leading gram participants undergo a multitude of to longer-term ones (Hatry et al., 1996; Kettner assessments and countless hours of job develop- & Martin, 1987). Supported employment pro- ment without ever finding a job. And, if employ- grams, offer a series of services (e.g., vocational ment is secured, they may spend many months, assessment, job development, job coaching, or even years, receiving job coaching services long-term employment supports) and for each without making measurable progress toward service there is an expected outcome. For assess- more stable employment. Apparently, an under- ment, it may be increased understanding of job lying assumption of these funding mechanisms preferences, abilities, and support needs; for job is that services may be provided indefinitely with- development, securing a job position that out a reduction in service intensity or costs. Of matches these preferences, abilities, and needs; course, it may be difficult to discern when more for job coaching, improved social integration extensive services and long term supports will be and work skills, etc. Each of these, however, needed and when an emphasis on outcomes would be classified as an intermediate outcome; will result in a more permanent outcome with they represent movement toward a desirable lesser expense over time. quality-of-life change. The principal measure of successful employment services is integrated, competitive employment with opportunities for career advancement. This ultimate outcome may NATURE OF RESULTS-BASED be measured in terms of length of employment retention, program participant and employer satis- FUNDING MECHANISMS faction, and compensation package, just to name The increased emphasis on accountability a few. Attainment of intermediate and ultimate for results has led to a relatively new class of outcomes is intended to produce overall positive funding approaches in rehabilitation that make quality-of-life changes in program participants. compensation contingent upon the outcomes of Some outcomes preclude direct measure- service provision. Provider compensation is now ment (Hatry et al., 1996). In such cases, it is linked to affirmative answers to the following necessary to identify measurable yet meaningful questions: Does the program work? What is the approximations of the targeted outcome. In mea- program accomplishing? Is the program chang- suring successful employment, various indicators ing peoples lives for the better? Are program of an outcome may be used to capture multiple participants satisfied with the services they are aspects of the outcome. The challenge is to receiving and the results of those services? A choose indicators that most directly and efficiently results-based funding arrangement is any pur- represent the outcome of interest.

128 Article 9 ported employment will tend to have moderate CONCLUSION and mild disabilities, that wages will tend to average less than $500 per month, and that these individuals will work about 22 hours a While somewhat new in the arena of sup- week and realize moderate social integration ported employment, the notion of results-based benefits (e.g., Mank, Cioffi, and Yovanoff, funding and greater accountability for social ser- 1997). These outcomes, while an improve- vices has been in development for over a decade. ment over the past, have been largely stagnate From the viewpoint of the taxpayer and the gov- for at least the last five to eight years. At the ernment, results-based funding ideas are at- same time, we know that people with disabil- tractive, because money and results are clearly ities and advocates are calling for better jobs, linked. From the perspective of the recipient of at better pay rates, in a greater variety of work services, there is presumably a benefit of greater settings, and for career development opportun- clarity of expectations because expected service ities. If we continue to use the structures and results are known when service delivery begins. the strategies we have used to date, it may be From the perspective of the provider of service, unreasonable to expect better outcomes in the the basic notion may be attractive because of future. the reduced emphasis on process, regulations, Results-based funding offers one and service definitions. The notion might be method for rethinking the structure and the troublesome for providers of services if the ex- strategies of supported employment to create pected results seem unreasonably high given the a new level of employment and social out- payment level and structure. Regardless of the comes. We know that purchase of service ar- perspectives involved, results-based funding rangements have historically emphasized the approaches will be further discussed and devel- process of service delivery. The question at oped because of their potential benefit in rehabili- hand is: To what extent can a shift to RBF (by tation and supported employment and because emphasizing results) create incentives for this movement is a part of a broader societal funding agents and providers to produce better and government emphasis on results. employment outcomes and create a new level Another reason for discussion and devel- of expectation for supported employment? opment of results-based funding approaches for Vocational Rehabilitation results-based supported employment is the relative predicta- funding approaches are emerging in a variety bility of supported employment outcomes within of forms in states across the USA. From these and across states. Supported employment has experiences, questions have arisen that need repeatedly and reliably demonstrated that it to be answered: How exactly are these ap- produces economic and social outcomes far in proaches working in the real world? How excess of the outcomes of nonemployment similar and how different are the strategies that programs and segregated employment programs are currently being used? What are the results for people with significant disabilities (eg., in terms of quality jobs for people in supported McCaughrin, et al., 1993; McGaughey, employment? How do these results compare Kiernan, McNally, & Gilmore, 1993; Wehman, to traditional funding mechanisms? What et al., 1998) However, after 13 years of imple- system features seem to work best? What con- mentation, the outcomes are now largely static cerns do various stakeholders have? These (Mank, 1994). We know that people in sup- and other questions are important to consider

129 whether you are a person with a disability, a made use of traditional funding mechanisms to supported employment provider, or a funding pay for those services. Results-based funding ap- agent. proaches will necessarily rely on the basic ser- Supported employment began as a service vice methodologies that are already developed method aimed at creating integrated, competitive and used daily by supported employment pro- employment opportunities for people with signifi- grams; this change is about how the money cant disabilities. In large part, it was a new way works. And of course, money changes every- of delivering individualized services to people that thing.

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133 134 Vocational Outcomes for Individuals with Significant Physical Disabilities: Design and Implementation of Workplace Supports By: Katherine J. Inge, Wendy Strobel, Paul Wehman, Jennifer Todd, & Pam Targett

Despite the protection from laws such as the Americans with ABSTRACT Disabilities Act (Wehman, 1992), individuals with physical disabilities continue to have a limited presence in the nations workforce. People Individuals with significant disa- who experience spinal cord injuries, cerebral palsy, or other physical bilities still face multiple barriers disabilities usually are very challenged by work entry or reentry. Health to accessing paid community employment. The national un- issues, transportation, social security disincentives, and personal care employment data for persons needs all have been documented as impediments to employment for with disabilities clearly reveals this group of unserved individuals (Wehman, Wilson, Targett, West, that many are not achieving Bricout, & McKinley, in press). employment at the rate of their A closer look at some of these issues and how they effect the non-disabled peers. This paper reports the findings of probability of work outcomes demonstrates many reasons that competi- one program that provided tive employment has remained an elusive goal for large numbers of supported employment ser- persons with physical disabilities. For instance, the physical capacity vices to individuals with signifi- and ability to move within the workplace and perform tasks is one cant physical disabilities. Spe- major challenge facing rehabilitation specialists who work with these cifically, the workplace supports that were developed and individuals to find appropriate job matches ( Inge, Wehman, Kregel implemented for a group of and Targett, 1996; Inge, Wehman, Strobel, Powell, & Todd, 1998). individuals with spinal cord in- At the same time, managing travel arrangements and reducing mobility jury, cerebral palsy, and other barriers becomes a major barrier to be removed, since transportation significant physical disabilities can be notoriously unreliable (Wehman et al., in press). will be described. Another issue is the disincentives associated with work for many people who are dependent on Social Security Disability Income (SSDI), Supplemental Security Income (SSI), and Medicare or Medi- caid funding for health benefits. These programs place varying levels of restriction on ones ability to work without losing benefits. Not sur- prisingly, when Congress held hearings on the barriers to employment, many beneficiaries reported that they were afraid to work for fear of losing medical and cash benefits. It has been estimated that 4.8 million people will receive SSDI benefits in 1999, and another 4.3 million will receive SSI (Croser, 1999). With the many health care needs associated with physical disabilities as well as assistive technology needs, the prospect of trying out a new job and subsequently losing benefits is not an

135 enticing thing to do. In addition, if an individual training reinforces and strengthens them (Inge, with a significant disability has been living in a 1997; Sowers, 1995). Together this package nursing home, the fact that most of the money of supports can facilitate employment for a group earned must be returned for care is not a moti- of individuals who have not achieved success at vator for attempting to become more indepen- the rate of their able-bodied peers. dent. For instance in Virginia, individuals who Therefore, it is the purpose of this paper reside in intermediate care facilities such as to describe how workplace supports were devel- nursing homes can keep a maximum of $196 oped and implemented for a group of individuals per month of their earnings. Any amount beyond with spinal cord injury, cerebral palsy, and other this must go to their care. In addition, individuals significant physical disabilities. The majority had residing in an ICF cannot benefit from social never worked or had not worked for a significant security work incentives such as having a Plan period of time due to the challenges associated for Achieving Self-Support (PASS) or Impairment with their disabilities as well as the other barriers Related Work Expense (IRWE). Therefore it is not previously discussed. This paper chronicles how surprising that many do not become employed. interventions were made and outcomes achieved. These are only some of the barriers to competitive employment for persons with significant physical disabilities. Clearly, there are other impediments such as the need to overcome the METHOD attitudinal barriers of employers and rehabilitation service providers. Employers may have diffi- This program took place at a major uni- culty understanding how a person with limited versity research center that provides research, physical abilities can perform the essential func- training, and demonstration services for people tions of a job. Service providers often focus on with significant disabilities. The project was funded the persons disabilities rather than abilities. Fo- by grant support and was designed for the pur- cusing on a persons limitations and disabilities pose of targeting those individuals with significant can result in an inability to match the persons physical disabilities for work entry or reentry who interests and talents to a potential job in the had been unable to gain employment on their community. own. In order to identify potential participants, In order for this group of unserved indi- the project staff communicated with local reha- viduals to be successful in joining the nations bilitation counselors, the administrator and social workforce, a number of supports must be imple- workers for a large nursing home (ICF) for people mented. Supported employment allows for the with physical disabilities, family members, and needed intervention and support that can be physicians from local rehabilitation hospitals. tailored to each consumer. More specifically, a Ultimately, twenty-one individuals were placed persons abilities and interests are highlighted into employment for whom cumulative support during the assessment process (Parent, Unger, & needs and work outcomes were tracked. This Inge, 1997), allowing the job coach to use these report should be considered interim as the pro- identified interests and abilities for career develop- gram is continuous and ongoing with additional ment and job matching (Brooke, Inge, Armstrong, persons being referred to the program. Tables 1 & Wehman, 1997). Assistive technology can and 2 on the following page, provide a demo- then enhance the consumers abilities ( Inge, et graphic profile of the participants including where al., 1996; Inge, et al., 1998); while job-site they lived and the nature of their disabilities. 136 Article 10

TABLE 1 -- SUMMARY OF PARTICIPANT TABLE 2 -- SUMMARUY OF PHYSICAL DEMOGRAPHICS CHARACTERISTICS IMPACTING WORKPLACE SUPPORT NEEDS Characteristics Percent Characteristics n % Sex male 62% Upper Extremity Mobility female 38% Age Significant involvement both upper 13 61.9% 17-25 14% extremities 26-35 29% Moderate Involvement in both 3 14.3% 36-45 48% upper extremities 46-55 9% Mild involvement 2 9.5% Primary Disability Full mobil ity of upper extremities 3 14.3% Cerebral Palsy 43% Spinal Cord Injury 38% Ambulation Traumatic Brain Injury 14% Other Developmental Disability 5% Manual Wheelchair 7 33.3% Power Wheelchair 13 62.0% Education Motorized Scooter 1 4.7% High School Graduate 19% Certificate of Completion 14% Communicat ion Nine to 11 years 33% Eight years of less 34% Significant speech involvement 6 28.5% Residence Moderate speech involvement 2 9.5% ICF - Nursing Home 48% No communication support needs 13 62.0% Home with Family Members 14% Supervised Apartment 19% Chronic Health Issues Independent Living 19% Prior Employment History Interfere with Work 4 19% None 52% Unemployed since acquiring 38% Transportati on disability 10% Intermittent/minimal work Specialized bus services 21 100% history

Forty-three percent of the participants had people with significant disabilities while only a primary disability of cerebral palsy; 38% spinal 1/3 resided in inclusive environments. cord injury; 14% traumatic brain injury; and 5% Criteria for acceptance into the project other developmental disability. Of the 21 individ- was that the individual must experience a sig- uals who became employed, 48% lived in an nificant physical disability and be chronically ICF nursing home for people with significant unemployed. As such, 52% of the group had physical disabilities who had intensive daily living never been employed; 38% had not been em- support needs. Another 19% lived in a supervised ployed since acquiring their disabilities; and apartment complex designed for people with the remaining 10% had an intermittent/limited disabilities. The remainder resided in the com- work history. All were users of manual wheel- munity, with 14% living at home with family mem- chairs or powered mobility devices. The major- bers and 19% residing independently in a home ity, 76%, had significant and/or moderate or apartment of their own. Essentially, 2/3s of motor involvement in both upper extremities. the participants lived in segregated settings for Only 14.3% had full mobility in their upper

137 extremities with another 9.5% having mild in- degree in severe disabilities and a Ph.D. in volvement. All required personal assistance ser- education. She had 20 years experience working vices in dressing and preparing for work; 76.2% with individuals with severe disabilities, ten of needed some assistance on the job; and 23.8% which also included experience managing sup- required intensive personal assistance in the work- ported employment demonstration projects for place. No one in the group was independent in persons with severe cognitive disabilities. The staff travel skills; all required specialized transporta- also had access to a rehabilitation engineer who tion services to travel in the community. Thirty- was employed by the State Office of the Depart- eight percent had significant to moderate speech ment of Rehabilitative Services. He had 10 years involvement making it difficult for them to com- experience as a rehabilitation engineer in the municate with unfamiliar people. Finally, 19% state system. These individuals served as consul- had some type of chronic health issue such as tants to the employment specialists for assistive pressure sores, chronic urinary tract infections, technology identification, selection, and fabrica- and chronic pain that interfered with working. tion. The rehabilitation engineer also provided hands on assistance in the workplace for fabri- PROJECT STAFF cation of devices. Finally, the project director Staff directly responsible for assisting the had 10 years experience supervising supported project participants in identifying and obtaining employment programs for individuals with trau- employment were three employment specialists, matic brain injury, mental retardation, and other the project principal investigator, project director, developmental disabilities. She served as coordi- and a rehabilitation engineer. Of the three em- nator for the projects job development activities. ployment specialists, one worked on the project The job coaches were responsible for for a period of 2 years. This individual had 5 directly assisting the customers with disabilities, years experience working as a job coach with employers, and coworkers in the workplace individuals who had severe cognitive disabilities, related to all job site needs. Initially, the employ- but he had minimal experience with those having ment specialists received training on assistive physical disabilities. This individual had a high technology devices and services. This included school diploma. When he resigned to take an- attending a day-long assistive technology work- other position, this job coach was replaced with shop and a half-day individualized workshop pre- a young woman who had a masters degree in sented specifically for them by an individual with rehabilitation counseling She had just completed more than 15 years experience fabricating de- her degree work and had no experience as a vices for individuals with severe disabilities. In job coach. The other two employment specialists addition, the rehabilitation engineer, the project both had undergraduate degrees in psychology principal investigator and director provided on- with one having 3 years experience and the other going consultation and technical assistance to 2 years experience training individuals with cog- the employment specialists on assistive technology nitive disabilities. None of these employment application. More information will be discussed specialists had any prior training in evaluating on this aspect of the project later in this paper. or selecting assistive technology (AT) devices or providing training and technical assistance to ASSESSMENT customers in the workplace on AT application. Assessment for individuals with significant The project principal investigator was a physical disabilities has focused on the identifi- registered occupational therapist with a masters cation of assistive technology services and devices

138 Article 10 which facilitate the persons function or overcome other person involved in their lives who could environmental barriers to participation. Typically, assist them in identifying career goals. Most this evaluation has taken place in clinical settings. of the project participants identified parents, In light of the fact that many assistive technology siblings, staff from their residential facilities, devices are abandoned when using a clinical rehabilitation counselors, as well as profes- approach (Phillips & Zhano,1993; Stineman, sionals such as social workers and occu- 1998), the goal of this program was to conduct pational therapists who had been important an evaluation of each customers needs within in the past. There were no limitations placed real-life environments related to specific em- on the number of participants. Size of the ployment goals. Therefore, the assessment pro- meetings varied from project customer to cus- cess included identification of the individuals tomer, with as few as two attendees at one career goals, an environmental analysis of the meeting to as many as 20 at another. The consumers functional capacity, an assessment only criteria was that the individuals invited of current assistive technology applications that had to be approved by the person whose em- could be applied to the individuals identified ployment interests and dreams were being career goals, and finally assessment of the cus- identified. tomers potential support needs within the work- The PATH meeting provided a forum place. This functional approach to evaluation for everyone to brainstorm and share their ideas has been referred to as a customer profile and expertise in order to formulate a blueprint (Brooke, Inge, Wehman, & Armstrong, 1997; for assisting the customer in making his or Inge et al., 1996). her employment dream a reality. The purpose Customer Profile. A customer profile of the PATH meeting was to find out what the was completed for each individual (focus person) individual would like to do remembering that who was referred to the project. The first step in- she or he may not be able to articulate specific volved using a person-centered approach, specifi- careers, offer suggestions of jobs in that interest cally the PATH process, which was developed by area, and determine possible supports that Pearpoint, OBrien, and Forest (1993) to assist would be necessary in order to pursue these the individual, family members, advocates, and interests. In all instances, each person was support professionals in developing a vision for able to identify at least some direction for con- the focus persons future. Inservice training on tinued activities that eventually led to job person-centered planning was provided for all development and employment opportunities. project staff by a skilled facilitator who had been Several individuals participated in situational trained by Pearpoint and Forest. assessments (Moon, Inge, Wehman, Brooke, PATH was used to assist customers in & Barcus, 1990) to further define their career determining career/employment dreams and goals. These opportunities were individualized goals, as well as to set a course for the accom- to each participants needs, and everyone did plishment of these goals. The process incorpor- not participate in the same support activities. ated a two hour meeting during which individuals, While the PATH meetings set the stage who were familiar and important to the focus for individualized customer directed activities, person, were invited to assist in identifying a they were also used to mark milestones towards career path. When setting up these initial employment for each individual. All partici- meetings, customers were asked to identify pants received their PATH graphic to be posted friends, family members, professionals, and any in a location of their choice. As items on the

139 diagram were completed or achieved, the indi- This mouthstick was later used when she began viduals checked off their accomplishments. her job as a receptionist at a small business devel- Assessing Functional Capacity. In ad- opment agency. Another talked about using a dition to PATH meetings, the employment spe- headpointer to type simple letters on a typewriter cialists for the project spent individualized time to a friend in Michigan during her PATH meeting. with each participant to discuss his or her plans This device now serves her at work for data entry. for employment. These informal observation and If the individual was not using any assistive interview sessions provided a wealth of informa- technology devices, project staff did not immedi- tion to include 1) assistive technology devices ately refer the person for a traditional assistive being used by the customers; 2) personal care technology evaluation. The intent at this point support needs; 3) perceived barriers that had was to identify currently used devices rather than prevented employment in the community; 4) per- randomly select and train on devices that might sonal interests; and 5) physical abilities. These not transfer to a job not yet located. Job specific meetings took place in a setting of the customers assistive technology assessment and selection choice and involved doing an activity selected occurred after the individuals job had been by the customer. Some of the selected activities selected and the customer was an employee of included going out to dinner, going shopping, the business. and attending a community event. The selected activity also provided insight into each persons JOB DEVELOPMENT interests and abilities. For instance, the employ- Job development was completed using a ment specialist was able to evaluate if the indi- customer-specific approach. Each individual vidual could select an activity of interest, set up was assisted by an employment specialist in loan appointment to get to the location, and use cating a job using the information generated by his or her wheelchair independently. Since many the customer profile. More specifically, the pro- of the customers selected shopping as an activity, gram used informational interviewing that the employment specialist was able to assess generated an opportunity to conduct a job analy- many and varied functional skills such as money sis of potential positions. This led to job restruc- use, reading, personal care, and choice making. turing and the development of employment pro- After a customer had completed a PATH, parti- posals that ultimately resulted in the employment cipated in a functional activity, and had an op- of project customers with disabilities. Each of portunity to meet and talk with the three employ- these components will be discussed below. ment specialists, the customer selected the job Informational Interviewing. Since all coach that he or she preferred to assist with the of the customers served by this program had sig- employment search and training components. nificant physical disabilities, they most likely Assistive Technology Assessment. Each would be unable to fill existing job openings. In customer was asked to describe the technology an effort to match the needs of the businesses that he or she was currently using to complete with the skills and abilities of the customers, the functional activities during the PATH meeting, employment specialists focused on the hidden as well as to demonstrate the use of technology job market or on restructuring existing positions. while participating in the behavioral/functional The goal of the initial contact was to get an ap- observations and informal interviews. For in- pointment with an employer in order to obtain stance, one project customer demonstrated using information on the business and to identify a mouthstick to access the telephone in her room. potential needs that could be met by a customer

140 Article 10 with a significant physical disability. Strategies a position, the job coaches focused on ways for obtaining an appointment with a business the company could save money, time, or in- included an introductory letter, a telephone call, crease productivity by hiring a project customer. or a cold call. In general, the employment By addressing the employers bottom line, specialists were slightly less successful in gaining the employment specialist focused on the pro- access to an appointment when a letter of intro- spective benefits to the company rather than duction was mailed vs. telephone or cold calls. on the persons disability. Also, by targeting Regardless of the strategy used, they were succ- specific tasks that were not being done, or not essful in scheduling an appointment in 36% of getting done in a timely manner, positions were the total contacts made. The type and number developed to meet the employers needs. This of contacts made during the course of the pro- approach to job restructuring seemed to gram are outlined in Table 3 below. eliminate the problem of accepting jobs with Before the meeting, the employment existing production standards that proved dif- specialist did initial research on the company to ficult to impossible for the customers with physi- determine what services or products were pro- cal disabilities to meet. vided, who the customer base was, and what The employment specialists were careful types of positions might be available. In general, to consider restructuring jobs where customers employers were asked to schedule approximately could reasonably complete the job duties with 20 minutes for an initial meeting. Questions accommodations. Therefore, a working knowl- during this meeting focused on potential benefits edge of available assistive technology devices to the company (e.g., What tasks require em- allowed the employment specialist to see possi- ployee overtime? What is not getting done in bilities for people when talking with an em- your business? What would make things easier ployer. When in doubt, they referred to the for you or your employees?) rehabilitation engineer and other project staff Job Restructuring. During the informa- to determine if technology could be fabricated tional interviews, the employment specialists or purchased to bridge the gap between the obtained information about possible areas for customers abilities and the restructured job job restructuring within a company. When in- requirements. Accepting a position for which quiring about possible opportunities to restructure no technology exists or where there are no

TABLE 3 -- INITIAL EMPLOYER CONTACTS

Number of % of Contact Employers Number of # % of Contacts Resulting Appointments Method Contacted Appointments Jobs in an Appointment Resulting in Jobs

Letters 144 37 2 25.7% 5.4%

Cold Calls 232 85 2 36.6% 2.4% Visits

Telephone 1890 697 19 36.9% 2.7%

TOTALS 2266 819 25 36.1% 3.1%

141 ideas for possible device fabrication only dooms The employment proposal allowed the employ- the person with a disability to failure. ment specialist to highlight the prospective em- Once tasks were identified with an employees skills, the job duties that he or she would ployer, the specifics of the restructured position perform, and how the individual with a disability were negotiated. Many times, the process was could complete the essential functions of the job an informal conversation where the employers with support of the employment specialist and questions about how a person would complete assistive technology. This allowed the employ- a specific task were addressed. After the initial ment specialist to answer the employers questions negotiation was completed, the customer with a or concerns about the restructured position or disability interviewed for the position. potential employees. The proposal also high- Employment Proposals for Restruc- lighted the customers skills, not their lack of tured Positions. In other instances, a more struc- experience or education. Figure 1 below is an tured approach was taken that included the example of an employment proposal developed development of a formal employment proposal. for a large business in the Richmond, VA area.

FIGURE 1 -- EMPLOYMENT PROPOSAL FOR PART-TIME BINDER ASSEMBLY POSITION

RATIONALE: Ensure timely response to customer requests for information by hiring a person who will perform the following tasks: l Assemble Commercial and Industrial Binders l Pull Orders for Literature l Respond to literature orders within 14 days of request l Enter completed orders into computer

PROPOSED EMPLOYEE: T.L. is an enthusiastic person who is interested in performing the job duties listed above. He has gained experience in information dissemination through a volunteer experience at a local library. T.L. is extremely motivated to work and offers strong attention to detail which will ensure that your customers will receive prompt and courteous service.

HOW: With the introduction of a few accommodations. T.L. will be able to perform the job duties outlined above. In order to ensure that he will have access to the information needed to fill orders, frequently used literature will be placed on a lazy susan filing system at his desk. Information that is needed less frequently will be placed on the shelves behind his desk. An electric hole punch will be obtained, at a cost of $80, to enable T.L. to prepare literature for the binders. All accommodations will be approved by the office service coordinator to ensure that they will not interfere with the operations of the department.

CONDITIONS: T. will provide these services for $4.75 an hour, for 5 hours week. If hired, T.L. will be an employee of ______. An employment specialist from Project Access will : l identify needed technology l assist T.L. in learning his job tasks l ensure that assigned job duties are completed to your satisfaction until the appropriate technology is in place l be available on an ongoing basis after the initial training phase for any issues that may arise.

142 Article 10 The initial contact for this company was the job used here as an example of an employ- a letter of introduction that was mailed to the ment proposal evolved over an eleven week company president May 24, 1996 followed by period. Each customer became an employee a series of phone calls and meetings. On June of the business and was hired at minimum 4, the Human Resources (HR) Manager called wage or better. None of the customers received the project staff to express an interest in hiring a less than minimum wage, and all placements person with a disability, and a meeting was were individual supported employment place- scheduled for June 17. During the initial meeting, ments. Please refer to Table 4 on the following project staff explained the services available, page for a summary of job titles, wages, as focusing on the benefits of such assistance with well as total wages earned by the individuals the identification and selection of assistive tech- served by this program. nology, on-going support for the employee with a disability, training opportunities, as well as how JOB SITE TRAINING AND ASSISTIVE TECHNOLOGY the program could save the company money. All of the project participants received The following questions were posed to determine supported employment services beyond initial where there might be opportunities to save money job development and placement to ensure by restructuring a position: Whats not getting long-term employment success. Services pro- done or getting put off? What tasks would in- vided after employment included assistance crease company productivity? Are you paying with arranging and using specialized transpor- overtime, and if so for what job tasks? tation services; identification, fabrication, and The HR Manager asked the Office Services purchase of assistive technology devices; in- staff to consider these questions, and a backlog struction and support for learning job tasks; of orders for promotional binders was identified as well as developing workplace skills such as as a potential job for restructuring. The manager interacting and responding to coworkers and and staff determined that if a person was hired employers. Job site interventions were de- to respond exclusively to requests for information, signed to provide as much support as each the company could provide more timely service person with a disability needed and desired to customers and thereby increase business. A during the initial stages of employment. These second meeting was scheduled on July 11, during supports were gradually withdrawn as provided which time the project staff discussed the restruc- by the employment specialist and transferred tured position with the Office Services Coordi- to the coworkers and supervisors of the work- nator and the HR manager. An employment place as the customers became comfortable proposal was used to outline the primary func- and satisfied in their work settings. tions of the position along with suggested accom- Assistive technology application. modations. An interview was scheduled for Job matching and placement occurred before August 8 with the applicant, the employment technology was purchased or fabricated. specialist, the Office Services Coordinator, and During the initial days on the job, the employ- the Office Services Manager. The individual was ment specialist completed tasks that the cus- offered the position on August 28, 1998 and a tomer could not while the technology was September 5 start date was established. being identified and purchased. The employ- In most of the project case studies, job ment specialist acted as the coordinator of restructuring and employment proposals evolved all AT workplace supports. As such, he or she over a period of weeks and months. For example,

143 TABLE 4 -- LENGTH OF EMPLOYMENT AND CUMULATIVE WAGES

# Months Wage Total Wages Customer Job(s) Worked per hour Earned M.S. Da ta Entry - VA Commonwealth 32 6.04 $7,731 University T.L. Clerk Assistant - Alpha Laval 30 5.25 $7,560 Manufacturing J.S. Receptionist - Small Business 29 5.50 $12,760 Development Center L.M. Box Folder - Pizza Hut 29 5.15 $5,376

C.G. Frame Finisher - Ben Franklin 25 5.25 $4,914 Frame Shop T.F. Telemarketing - National Wheel- 23 5.15 $23,056 chair Sports 6.50

S.T. Mail Room Clerk - First Union 22 7.50 $17,089 Customer Service - VCU Student 6.27 One-Card M.W. Computer Kiosk Technician - 21 8.00 $15,680 VCU R.W. Cashier - Borders Books and 19 6.25 $11,500 Music

J.W. Internet Technician - VCU 16 8.00 $15,360

L.F. Dispatcher - VA Overland 15 5.75 $9,919

A.F. Billing Assistant - Thurbers 14 5.15 $4,326

J.S. Da ta Entry - Aram ark 5.25 $4,200 J.S. Substance Abuse Lecturer 15 5.50 $1,500

B.C. Cloths Processor - Wal-mart 95.15$1,644 Prep work - Pizza Hut 4.75 S.G. Customer Service - YMCA 9 5.15 $1,112

S.C. Stock Clerk Assistant 85.00$3,193 Da ta Entry - VCU 6.04 L.R. Food Prep - Pizza Hut 7 5.15 $1,154

D.T. Data Entry - Aram ark 4 5.25 $1,680 D.S. Customer Service - GTE Wireless 3 7.75 $1,860

S.M. Sales Associate - Willies Records 3 6.00 $1,080 & Tapes N = 21 N = 25 Mean: 15.66 5.87 Mean: $7,271 Months

144 Article 10 was responsible for 1) assisting the customer in individuals served by this project worked an identifying funding sources for technology; 2) average of 15.66 months, and each earned determining which professional could provide an average of $7,271 in wages. Customers services and devices; and 3) training and tech- were hired by both small and large businesses nical assistance on the use of devices to the con- to do a variety of tasks to include data entry, sumer, employers, and co-workers in the work- customer service, clerical assistance, as well place. Staff held weekly meetings to include the as food prep. principal investigator, project director, and em- The average amount of time expended ployment specialists. Each case was discussed in development of a position at a large business using a brainstorming approach to problem was 12.4 weeks. The range was 1 week to solving to determine any special accommodation 42 weeks. The average amount of time for needs. Strategies for bridging the gap between development of positions in small business was the customers abilities and the requirements of 3.29 weeks, with a range of 2 days to 10 the job were suggested and tried in the workplace. weeks. The average length of time expended Initially, the employment specialists relied in pre-placement activities per customer was heavily on the rehabilitation engineer for most 47.6 hours. Post placement intervention hours of the low as well as high technology solutions. from placement to stabilization per customer However, as the project evolved, they began to averaged 75.3 hours. Pre-placement activities successfully identify and apply many of the included the development of the customer needed low technology devices. The rehabilita- profile as well as job development and place- tion engineer continued to provide all of the sup- ment activities. Post-placement activities port fabricating devices needed to fill needs for included job site training, assistive technology which no commercial products were available. identification and support, as well as ongoing Project staff and the consulting rehabilita- follow-up and support for job maintenance. tion engineer conducted job site evaluations of This data is summarized in Table 5 below. the customers technology needs in the workplace. In only one instance did a customer receive an evaluation in a setting other than the job site. In that example, the customer required TABLE 5 -- MEAN SUPPORT NEEDS an adaptive keyboard for data input. Instead of PER CUSTOMER bringing multiple devices to the job-site, the customer was evaluated on keyboard use in an oc- Mean Initial Mean Second placement Placement cupational therapists clinic where devices were n = 21n = 4 available. Once the choices were narrowed to Pre-placement Inter- 47.6 hours 82.4 hours a specific option, that device was brought to the venti on Hours workplace for evaluation prior to purchase. Post-placement Inter- 75.3 hours 61.4 hours venti on Hours to Stabilization RESULTS Weeks to Stabi li zation 8.1 weeks 6 weeks Weeks Employed 51.9 weeks 42.8 weeks

Intervention Hours per 1.6 hours 2.3 hours A total of 28 customers were served by Week for Extended this program with 25 job placements made. The Services

145 The assistive technology support needs of the project customers varied from individual to TABLE 6 -- COMPARISON OF PROJECT individual; however, the majority of the supports ACCESS ACCOMMODATION COSTS were considered low technology in nature. A TO NATIONAL DATA total of 100 accommodations were put into place Job by project staff across 23 jobs with a total cost of Accommodation Project $11,235. The average cost per accommodation Accommodation Network (JAN) Access CostsData Findings was only $112.35. The most expensive assistive technology device was a computer with voice- No cost 19% 7% activated software which was actually donated Between $1 and 50% 88% to the job site by the state vocational rehabilitation $500 agency. The job site where this was needed was Between $501 and 12% 5% not required to make the accommodation, since $1,000 there were fewer than 15 employees hired by Between $1,001 7% 0% and $2,000 the company. The least expensive device was an eraser on the end of a head-pointer, which Between $2,001 9% 0% and $5,000 costs only a few cents. In several instances, assistive technology Greater than 3% 0% $5,000 was rented for the customer while funding was arranged. For instance, a customer needed to * Please note: Items in this category include have a power wheelchair for mobility. This was surplus equipment that was rented by the project while her case manger donated for use by project customers. worked out arrangements for Medicaid to fund the power chair. The cost for this technology was not figured into the total cost for project ac- However, recognizing these limitations, several conclusions still may be drawn and a number of commodations, since it was provided by the ICF unique issues and concerns raised. where the customer resided. Table 6 compares First, people with significant physical disa- the costs of the technology purchased and fabri- bilities clearly benefit from supported employment cated for the programs customers to the national services. The individuals served were chronically data from the Job Accommodation Network. unemployed due to a variety of reasons. The approach used provided the necessary advocacy, intervention, and long term support required to DISCUSSION facilitate positive employment outcomes for both the individuals and their employers. Furthermore, the customers reported an enhancement in their This paper has described the efforts of one quality of life. Businesses also benefitted as evi- program that provided supported employment denced by the high retention rate among partici- opportunities to individuals with significant phys- pants. This leads to a reduction in employer ical disabilities. The results of the program are costs associated with turnover, like recruitment limited by the small number of participants and and training. Overall both parties benefitted the time frame. A longer time period and addi- for a variety of reasons. tional illustrations of success are needed to Second, with the exception of time ex- demonstrate the full effectiveness of this approach. pended in job development, the types of services 146 Article 10 described here, appear to be cost effective. The The clear message is that supported majority of pre and post employment interventions employment programs must become more did not incur exorbitant costs. Additional data, efficient in selling their services to meet busi- collected over time, may reveal that costs will nesses existing needs. Job restructuring must continue to decrease. Regardless, it is important be presented as a way for businesses to save for us as a society to recognize the significance money by eliminating the need for overtime, of affording all Americans with the right to work, as well as a way to complete job tasks not including individuals with the most severe dis- typically accomplished to ultimately make the abilities, even if this means providing intensive company more effective and efficient in serving services and the long term supports, despite the its customers. The employers emphasized the additional costs. need to view hiring individuals with disabilities Five of the challenges that were faced by from a job restructuring approach rather than the project are of critical importance: 1) the devel- the notion of creating jobs. Job creation is opment and utilization of effective marketing and perceived as increasing costs rather than job development practices; 2) the development increasing company efficiency. and utilization of functional assessment pro- However, relations hip building takes cedures; 3) the utilization of effective assistive time, as does obtaining the necessary infor- technology supports; 4) the utilization of an effec- mation about a company in order to sell sup- tive media campaign to battle negative percep- ported employment services. In essence, the tions; and 5) the development of long term and employment specialists had to establish a col- responsive funding. laborative relations hip with the businesses they dealt with by explaining how a person with a MEETING BUSINESS NEEDS significant physical disability could perform The employer contact data presented the essential functions of a job. This was ac- earlier in this paper points to a very real barrier complished one business and one employer related to employers viewing individuals with at a time. Clearly, in order to make a significant physical disabilities as qualified applicants. impact on the unemployment rate of people Specifically, project employment specialists made with significant disabilities, rehabilitation per- 819 appointments that ultimately resulted in only sonnel, advocates, and family members must 25 jobs. Late in the first year of the program, disseminate more efficiently and effectively staff held an employer focus group in an attempt knowledge of what an individual with disa- to address some of the barriers they were facing bilities can do with carefully prescribed sup- in identifying jobs for customers. Ten employers ports. representing small to large businesses in the Richmond metropolitan area attended. One pre- ASSESSMENT vailing theme that emerged was that the em- Individuals who have very limited or ployers did not view individuals with significant no work experience will have a difficult time physical disabilities as qualified applicants for expressing their job preferences, strengths, and existing positions within their companies. The support needs. Limited information exists on employers raised numerous questions concerning how to determine the vocational interest, abil- production standards, the cost of accommoda- ities and support needs of people with signifi- tions, and the individuals perceived inability to cant physical disabilities. These individuals perform essential job functions as they existed. and program staff need to have access to a

147 variety of creative and functional approaches like engineering services to ensure greater and quicker the ones described in this paper to assist with access to technology and adaptive equipment. developing a personal vocational profile that will Also, there may be some uncertainty about provide a direction for career development. This who should pay for the AT and other accommo- project used a combination of approaches very dations. Some of the individuals who went to successfully to include PATH, functional assess- work did not qualify for existing positions, and ments, community behavioral observations, as jobs were restructured to create work from mar- well as situational assessments. Supported em- ginal duties of other existing jobs. In this pro- ployment staff will need training on how to effec- gram, most costs were not significant, and a cost tively implement these approaches in order to sharing approach was used. Other accommoda- assist their customers with making appropriate tions that businesses made at no cost to them career decisions. included redesigning the immediate work environment to reduce excessive movement and ACCESS TO TECHNOLOGY allowing modified or flexible work schedules. AND SUPPORTS Many employers appeared more readily agree- Once employed, this group of individuals able to interview applicants when notified that was very successful in achieving independence the AT would be primarily funded by an outside within the workplace. The fact that the majority resource, and the employment specialist would of the technology identified and put into place be available to assist with: was obtained commercially and was of low cost is evidence that individuals can be supported a) identifying and arranging for the purchase successfully with minimal costs to the businesses. of AT; and In addition, the technology applications were b) the employment specialist guaranteed that orchestrated successfully by employment spe- the work would be done to the required cialists with the support of a rehabilitation engi- standards while the new employee was waiting for the AT, learning the job, or how neer rather than by using a more traditional and to use the AT. costly approach to assessment and implementation. Money was not expended on devices that Some individuals needed assistance with ultimately were not used in the workplace, which activities of daily living at work, such as eating addressed the problem of technology abandon- or going to the restroom or coworker support to ment often cited as a problem in the literature. perform certain parts of the job that the person While it was not unusual for assistive tech- could not accomplish alone. Service providers nology to be either: a) owned by the individual and job seekers with significant physical disa- with a disability, b) ready made and available bilities need to consider how these issues will be for purchase, or c) created by the service staff, addressed, prior to accepting a job offer. In sometimes items were needed that required more some cases a simple change in scheduling may complex fabrication skills. While a vocational eliminate the need for the person to eat a full rehabilitation engineer was readily available to meal, take medication, or go to the restroom at this project, many community programs do not the workplace. In our project, coworkers were have access to such personnel due to staffing or more than willing to assist with eating, drinking, a back-log of service requests. State vocational and the completion of work related tasks but rehabilitation agencies and providers need to were less likely, and in some cases resistant, to find ways to expand and enhance rehabilitation assist with toileting needs. The vast majority of 148 Article 10 individuals served by this project choose to limit ensure the funding is being used as intended, fluid intake, schedule work for limited hours, and for people with the most severe disabilities. wear protective clothing or catheters to deal with Furthermore, opportunities to use blended their personal hygiene needs. Clearly, the use of funding and other resources should be personal assistance services and natural supports examined like on the job training funds paired within the workplace must be developed further. with job coach training services. Also, when individuals need this type CHANGING PUBLIC PERCEPTION of service option it is critical that funding not This projects observations revealed that be restricted to the point where adequate sup- the general public, business personnel, people port cannot be provided. Many individuals with disabilities and vocational rehabilitation pro- will require extensive and extended support. fessionals need to embrace a stronger and more A lack of funding for long term support severely powerful conviction that every person should have limits those who can take advantage of sup- the opportunity to work when give the proper ported employment. Not only does the lack work place supports. All of the individuals who of funds restrict access to service, it also deter- participated in this project made a meaningful mines whether or not supported employment contribution to a business and society. As more is available at all. States who have been suc- people with significant disabilities go to work, cessful in developing innovative and creative positive changes should occur in the attitudes of ways to fund long term supports need to share others related to the ability of people with severe this with others. disabilities. A more aggressive national media In closing, this demonstration program campaign is needed that highlights the idea that revealed that individuals with the most severe disability does not mean inability. Such a cam- physical disabilities can work when provided paign could promote the value that people with with effective supports. As we move toward disabilities should work while combating existing the Year 2000, the United States economy is stereotypes and myths. booming with jobs that do not require physical competence. This report of individuals with ADEQUATE FUNDING significant physical disabilities working is Funding for supported employment ser- heartening, because with the right supports vices remains a serious problem, even though tens of thousands more who are at home, in research has revealed financial benefit cost ratios nursing homes, day activity centers, or sheltered related to this option. The current mechanisms workshops could be competitively employed. of funding severely limit access to supported em- All the participants of this project earned at ployment for people with the most significant least minimum wage, were employees of the disabilities. State vocational programs are en- company where they worked, and became couraged to review the characteristics of the per- independent of an employment specialists sons being served by supported employment, to daily intervention.

149 eferences: R Brooke, V., Inge, K.J., Armstrong, A., & Wehman, P. (1997). Supported employment handbook: A customer-driven approach for persons with significant disabilities. Richmond: Virginia Commonwealth University, Rehabilitation Research and Training Center on Supported Employment.

Croser, M.D. (1999, March/April). Every little bit helps. AAMR News & Notes, p. 2.

Inge, K.J. (1997). Job-site training. In V. Brooke, K.J. Inge, A. Armstrong, & P. Wehman (Eds.). Supported employment handbook: A customer-driven approach for persons with significant disabilities (pp. 159-204). Richmond: Virginia Commonwealth University, Rehabilitation Research and Training Center on Supported Employment.

Inge, K.J., Wehman, P., Kregel, J., & Targett, P.S. (1996). Vocational rehabilitation for persons with spinal cord injuries and other severe physical disabilities. American Rehabilitation, 22(4), 2-12.

Inge, K. J., Wehman, P., Strobel, W., Powell, D., & Todd, J. (1998). Supported employment and assistive technology for persons with spinal cord injury: Three illustrations of successful work supports. Journal of Vocational Rehabilitation, 10(2), 141-152.

Moon, M.S., Inge, K.J., Wehman, P., Brooke, V., & Barcus, J.M. (1990). Helping persons with severe retardation get and keep employment: Supported employment strategies and outcomes. Baltimore, MD: Paul Brookes Publishing Company.

Parent, W., Unger, D., & Inge, K.J. (1997). Customer profile. In V. Brooke, K.J. Inge, A. Armstrong, & P. Wehman (Eds.). Supported employment handbook: A customer-driven approach for persons with significant disabilities (pp. 46-97). Richmond: Virginia Commonwealth University, Rehabilitation Research and Training Center on Supported Employment.

Pearpoint, J., OBrien, J., & Forest, M. (1993). PATH a workbook for planning positive possible futures: Planning alternative tomorrows with hope for schools, organizations, businesses, families. Toronto, Canada: Inclusion Press.

Sowers, J.A. (1995). Adaptive environments in the workplace. In K. Flippo, K.J. Inge, & J.M. Barcus (Eds.). Assistive technology: A resource for school, work, and community (pp. 167-186). Baltimore, MD: Paul H. Brookes Publishing Co.

Wehman, P. (Ed.). (1992). The ADA mandate for social change. Baltimore, MD: Paul Brookes Publishing Co.

Wehman, P., Wilson, K., Targett, P., West, M., Bricout, J., & McKinley, W. (in press). Removing transportation barriers for persons with spinal cord injuries: An ongoing challenge to community reintegration. Journal of Vocational Rehabilitation.

150 Personal Assistance Services: A Vital Workplace Support

By: Ed Turner, J. Michael Barcus, Michael West, & Grant Revell

Great disability rights leaders and self advocates like Ed Roberts and Judy Huemann have proven the value of customer-directed ABSTRACT personal assistant services (PAS) through their work in the independent living movement and at the World Institute on Disability (WID). These This article reports findings two pioneers demonstrated the value and cost effectiveness of from focus groups and survey research on experiences and customer-directed PAS in enabling people with significant disabilities issues related to the use of to live in the community. Their work was documented in the research personal assistance for per- monograph Attending to America (Litvak, Zukas, & Huemann 1987). sons with disabilities in work This document has become a blue print for establishing the customer- settings. These findings directed PAS model systems being developed in a number of states. underscore the need for con- These model systems are enabling thousands of individuals with sumer control and self-advocacy in planning and ar-rang- significant disabilities to live and work in the community. ing workplace personal assis- PAS is broadly defined by Nosek (1991) as assistance from tance. another person with activities of daily living to compensate for a functional limitation (p. 2). Activities of daily living (ADLs) include such activities as personal hygiene, meal preparation, housekeeping and household chores, and community mobility. In the words of Litvak et al (1987), these are tasks that individuals would normally do for themselves if they did not have a disability (p. 1). PAS allows people with severe physical or health impairments to participate more fully in community settings and activities, including employment (West, Mast, Cosel, & Cosel, 1996). Shortly after the passage of the Americans with Disabilities Act (ADA), the Presidents Committee on Employment of People with Disabilities (PCEPD, 1998) wrote:

In the workplace, PAS is provided as a reasonable accommodation to enable an employee to perform the functions of a job. The employers responsibility for providing reasonable accommodations begins when the employee reaches the job site and concludes when the work day ends. PAS in the workplace does not include skilled medical care.

The Job Accommodation Network (JAN) developed a list of possible tasks that could be done by personal assistants in the work-

151 l place. Work-related PAS might include filing, facility where the staff seem to not understand retrieving work materials that are out of reach, her desire to be on time for work. Another indi- or providing travel assistance for an employee vidual in the same project had great difficulty in with a mobility impairment; helping an employee finding a personal assistant to assist him with with a cognitive disability with planning or meals while at work. Both individuals worked decision making; reading hand-written mail to with a mentor to develop self-advocacy skills to an employee with a visual impairment; or en- resolve their problems. In a research study suring that a sign language interpreter is present conducted by the VCU-RRTC to determine factors during staff meetings to accommodate an em- which impact self-determination, respondents ployee with a hearing impairment. Each person said that being able to manage their personal with a disability has different needs and may assistant was important to their independence require a unique combination of PAS. (West, Barcus, Brooke, & Rayfield, 1995). These Many customers with disabilities have experiences led to the VCU-RRTC conducting gained the skills necessary to manage their own investigations aimed at determining how best to personal assistant by attending PAS training use PAS in the workplace. programs offered by Centers for Independent Living (CILs). CILs have done an excellent job of training their participants about how to recruit, hire, and manage a personal assistant in the METHODOLOGY home environment. CILs consider self-advocacy a very important part of their PAS management training because it is essential to successfully There were two distinct phases of this re- directing a persons personal assistant. search: two focus groups to define the issues The Rehabilitation Research and Training related to PAS in the workplace, and a survey of Center at Virginia Commonwealth University CIL personnel related to access to PAS in the (VCU-RRTC) has long recognized PAS as a valu- workplace for their customers. These two phases able support in enabling people with significant will be discussed separately. disabilities to live in the community. The VCU- RRTC shares the belief that PAS services are most FOCUS GROUP RESEARCH effective when they are directed by people who Sample: The two focus groups consisted use them. When people with disabilities are able of a total of nine individuals with significant to self-direct PAS, they can utilize these services physical disabilities who were employed, four CIL when needed without being dependent on a employees, and one personal assistant. The home health care provider. groups also utilized a recorder who has significant These beliefs have been reinforced by disabilities, two facilitators, and two assistants. years of interaction with people with disabilities The first group included individuals who through demonstration projects, self-determina- had little or no experience at managing their tion research studies, and by employing people own care. Many lived in a residential care facility. with significant disabilities. In one of its recent The remainder of the group resided in the com- projects, a participant who is now employed at munity. the VCU- RRTC expressed her concerns regularly The other group was conducted at the at not being dressed on time to meet her ride to 1998 National Council on Independent Living work. This individual lives in a residential care (NCIL) Conference held in Washington, D.C.

152 Article 11 This group included employees from CILs who The final version of the survey contained six utilized PAS in the workplace themselves or CIL items related to experiences with obtaining PAS managers who provided such services to their in the workplace for the agencys customers, employees as a reasonable accommodation. use of public and private rehabilitation The input obtained from the second focus group agencies to obtain PAS in the workplace, and lead to the development of a list of tasks that are issues related to PAS on the job such as training required to be done by personal assistants in the or providers, and customer supervision. Each workplace. See Table 1 below. survey item included a menu of choices and Procedure: One focus group was con- space to provide additional information or ducted in the Richmond, VA area, and one at comments. the annual meeting of the National Council on Sample and Procedure: The sample Independent Living (NCIL). Congruent with stan- for the survey was drawn from two lists main- dard focus group procedures (Krueger, 1994), tained by The Independent Living Center Re- the two groups were homogenous, including one search and Training Center in Houston, TX which primarily consisted of customers and one and the National Council on Independent primarily consisted of service providers. The ques- Living (NICIL). The survey was mailed to all tions posed to the groups were related to the 400 CILs on the two lists after cross matching need for personal assistance on the job and dif- to eliminate duplicates. Included in the mail- ficulties in obtaining PAS for workplace support. ing was a letter requesting that the most appropriate staff member complete and return the SURVEY RESEARCH PHASE survey. A follow-up reminder letter was mailed Survey Development: The survey instru- after 1 month to encourage return of the instrument was developed following the focus groups ment. A total of eighty completed and usable and addressed the issues by the participants. An surveys were returned for a 20% return rate. initial draft of the survey was piloted, and modi- These representatives were from independent fications were subsequently made to the items. living centers in the United States and Canada.

TABLE 1 -- DUTIES OF PERSONAL ASSISTANTS

PERSONAL DUTIES JOB FUNCTION DUTIES

l Assist with grooming tasks l Make telephone calls l Assist with getting beverages l Assist with filing l Assist with food l Take dictation l Assist with toileting l Voice interpretation l Assist with transportation l Assist with making copies l Travel on business trips l Enter data l Assist with dressing and grooming l Take notes in meetings tasks while on business trips l Read documents l Get and open mail l Keep work-space organized l Travel on business trips

153 of methods used to recruit potential personal RESULTS assistants who could perform support in the workplace (as seen below in Table 2). Another outcome of the focus groups and of the survey FOCUS GROUPS was to come up with a definition of PAS in the The focus group held in Richmond agreed workplace that can be understood by employees they were more concerned about obtaining PAS with disabilities, personal assistants, and em- at home than in the workplace. They believed ployers. This definition is: that PAS could be obtained through coworkers, health care providers, and the VR system. Also Personal assistance services in identified was the need for employees with signifi- the workplace are services cant disabilities to receive training on how to provided to an employee with a manage their personal assistants in the workplace. disability by a personal assistant to enable the employee to One of the most important outcomes from perform the essential duties of a the NCIL group was the wide variety of needs job more efficiently. expressed by its members. These ranged from assistance in getting a cup of coffee to having This definition can be clearly understood by em- sophisticated computer skills in order to support ployees with disabilities, personal assistants in a researcher at WID. Other information obtained the workplace, and potential employers or their from the NCIL focus group led to a laundry list human resource managers.

TABLE 2 -- METHODS FOR LOCATING PERSONAL ASSISTANCE SERVICES

l Advertise in local newspapers.

l Advertise by word-of-mouth.

l Tell friends you are looking.

l Advertise in the local high schools, colleges, and universities.

l Look in the Yellowpages of your local phonebook for home care services.

l Check with local colleges about a business intern who may be interested in serving as a personal assistant and learn about the business at the same time.

l Call a local Center for Independent Living and see if they maintain a registry of personal assistants.

l Tell your co-workers that you are seeking a personal assistant.

l Check with local churches or community service clubs.

l Check out the want-ads in the local newspaper.

l Check with schools that are training students for the health care profession who might be interested in obtaining practical experience.

l Advertise in a business newsletter. 154 Article 11 SURVEYS Sixteen of the respondents (20.0%) Of the 80 CIL representatives responding indicated that their CIL had attempted to locate to the survey, 25 (31.6%) indicated that they work-related PAS through home health care had assisted a consumer in obtaining personal agencies. Overwhelmingly, the comments pro- assistance services (PAS) for the workplace. Of vided centered on restrictions on funding to those who had not, the overwhelming majority home-based services. (39, 78.0%) indicated that the primary reason l they had not assisted a consumer in obtaining We have found that home health care agencies cant provide PAS via Medi- PAS was that the need had not yet arisen. The care or Medicaid if the consumer is only other primary reason given by more than working and not home-bound two respondents was that the CIL was unable to l We have been specifically told that locate a funding source (8 respondents, 16%). home services are limited to the con- Of the 80 respondents, 20 (25%) indi- fines of the home; PAS at work is the cated that they or their customers had worked employers responsibility. with vocational service providers (i.e., VR, em- l Only available dollars are to fund ployment support programs, private rehabilitation, home support. No money for job etc.) to incorporate PAS on the job. The majority supports. of comments given to this item were related to limited to resources to fund PAS and difficulty in l Agencies that provide home health care in our area do not provide services working with the agencies. For example: outside of the home because Medicare/ Medicaid do not pay for such services. l No funding for PAs in tennessee beyond $16,000 that is currently in use by 15 l Agencies insist that they are not people statewide. allowed to provide personal assistance services at the job site. l It was failry cumbersome...it appeared to us that other organizations doubted the consumers ability to perform job duties. A number of PAS-related issues were in the survey. Respondents were requested to l It was a positive experience in that we indicate if any of the four issues were substan- were finally able to secure the services. However, it was a challenge to work with tially different or more problematic when ap- Social Services, Home Health Services, plied to work settings as opposed to home- and Social Security. based PAS. The responses to this item are shown in Table 3 on the following page. It is l [VR] will only provide PAS while the consumer is in vocational training, but once notable that less than one-third of the respon- the consumer is employed, their PAS dents viewed any of these PAS-related activities funded through [VR] is stopped. as substantially different when applied to the l The Personal Assistance Program has a workplace. lengthy waiting list due to funding Respondents were given the opportunity to make additional comments related to PAS l The individual services contract program services. Most of the comments reiterated the provides financial assistance to consumers for PAS on the job; however, the consumer difficulty in locating PAS funds or providers. must meet the MR/DD eligibility to receive Some of the more salient comments are listed the [service]. on the following page:

155 l Most individuals with disabilities and many Rehabilitation Counselors are not aware of PAS funded services through Title DISCUSSION I. Our local office (VR) has not funded this service. The findings of this study underscore the l Living in a rural area, sometimes it is barriers to employment faced by individuals with hard to find individuals to work for you. significant personal assistance needs. Less than l Sometimes the consumer has problems one-third of the CIL representatives who re- being the employer. They become friends sponded to the survey indicated that they had with their PA and then struggle on how to experience in locating PAS for work-related needs. direct them. The comments provided by the focus groups and l I think the primary reason we have not the survey respondents indicate that PAS is a criti- been requested to provide assistance [at cal support for workplace functioning. Yet, to a work] is because PAS services in general are so limited. They are only available large extent, PAS needs are not being addressed now to provide the bare minimum daily by public and private sources. assistance for consumers. The VCU-RRTC has long recognized PAS as a valuable support in enabling people with l PAS is a critical need in our state. Many people live in nursing homes due to NO significant disabilities to live in the community. choice. It would be crucial for the em- From prior experiences, staff at the VCU-RRTC ployer to assume responsibility for PAS on are convinced that employees with a disability the job, independent of income. This is who have the ability to recruit, hire, and manage not required by the ADA and will be a difficult sell to employers. their own personal assistant in their workplace will be more successful in their chosen careers. l Most individuals with severe disabilities Having this knowledge and ability can mean are in such low-paying jobs, they will never be able to hire a personal assistant if they the difference between maintaining or losing em- needed one. ployment opportunities. The need for individuals with disabilities to be very knowledgeable and resourceful in acquiring and managing PAS in the workplace TABLE 3 - RESPONDENTS INDICATING is reinforced by the current tendency of PAS PAS ISSUES ARE SUBSTANTIALLY funding sources to emphasize home as compared DIFFERENT AT WORK to work-based assistance. For example, the Massachusetts Health Care Plan incorporates ISSUES NO. % PAS for people with disabilities who are employed (Ghiloni, 1999). Coverage is provided through PAS Training Programs 20 5.0% two programs. The first is the MassHealth Stan- dard Plan for people who are disabled according Recruitment Strategies 24 30.0% to Social Security Administration (SSA) standards and whose family income is no more than 133% Training/supervision 26 32.5% of the Federal poverty level. The Alternative Cover- provided by customers age Plan is offered through the CommonHealth program, which is available to adults with disa- Other areas 15 18.8% bilities and children who are not eligible for the

156 Article 11 MassHealth Standard Plan, usually because their result in PAS services being delivered as unob- family income exceeds income limits. There are trusively and efficiently as possible within the eligibility guidelines for the Standard Plan for individuals work schedule and overall job working adults (age 18-64) involving the require- environment. Readily available training re- ment of 40 hours or more a month of employment sources and mentoring support are needed to (with the option to pay a one-time deductible for support development of self-direction and self- individuals working less than 40 hours a month advocacy skills among PAS recipients to ad- or not working at all). The CommonHealth pro- dress both home-based and work-based PAS gram bases monthly premiums and deductibles issues and problems. on family income, although there is not a set It is important for rehabilitation per- cap on income or asset limit (Ghiloni, 1999). sonnel and potential employers to have a better Eligibility for PAS through MassHealth understanding of PAS as a workplace support. requires that the person with a disability be In order for PAS in the workplace to be bene- evaluated by a designated agency, which at times ficial, its potential positive impact must be is an independent living center. An individuals understood. Employees with disabilities must PAS needs are evaluated by a registered nurse, have the skills to find the most appropriate who then forwards the assessment report to the personal assistant who can best support them state Department of Medical Assistance. Once on the job. Personal assistants must be trained approved, all personal assistance funded through on how to provide the necessary support in MassHealth must be home-based. There is no the most unobtrusive manner. Employers must coverage through MassHealth for worksite-based recognize that an employee with a disability, PAS, because it is viewed as a reasonable accom- with the support of a personal assistant, can modation to be provided by the employer. There both increase productivity and add diversity are examples in Massachusetts of persons in sup- to the workforce. ported employment utilizing PAS through the Self-advocacy is a key component of MassHealth program, but these services are the PAS in the workplace. Knowing how to limited to assisting individuals in getting ready use self-advocacy skills is essential for em- for work and preparing items that might be ployees in managing their personal assistant needed during the day. and in relating to employers and immediate The PAS coverage in MassHealth is of sub- supervisors. Employees with disabilities should stantial value. One example is an individual develop skills needed to recruit, hire, and who pays a monthly premium of $204 but re- manage personal assistants to perform the ceives $1,400 in PAS a month (Ghiloni, 1999). duties in the workplace. Some of the activities However, because it restricts PAS to home-based will include writing recruitment ads, writing services, the Massachusetts program does show contracts, learning dispute resolution tech- the importance of PAS recipients being knowl- niques, and also learning to use self-advocacy edgeable and capable of self-direction in ob- as a management tool. taining needed services. The individual with a Personal assistants should understand disability must have the skills, knowledge, and how to provide essential support to the person confidence needed to potentially negotiate with who hired them to work in a job setting. Train- an employer to first gain agreement that PAS is a ing protocols for personal assistants should reasonable accommodation, and then make the stress the differences between providing support arrangements and conduct the training that will in a business environment from a home envir-

157 onment. The training should include methods sentatives introduced a bill, that if passed, would on ways to remain unobtrusive while providing establish the long awaited program. Unfor- the level of support needed by the employee. tunately, the last session of Congress ended In the early 90s, WID held a conference without passage of that bill. Therefore, advocates of PAS Stakeholders to come up with a plan to must reunite and fight harder to have the bill develop a national PAS program. Conference reintroduced. participants established a set of values that would Additionally, the time is ripe for Congress drive PAS services provided through a national to rectify the discrepancies in the Social Security program. These values are: Disability system in its treatment of individuals based on disability group identification. For the 1. No medical supervision is required. vast majority of individuals with disabilities, the income level for determining engagement in 2. The services provided include personal maintenance and hygiene including catheteriza- Substantial Gainful Activity (SGA), and therefore tion, mobility, and household assistance. ineligible for benefits, is $700, effective July 1, 1999. Seven hundred dollars is insufficient in- 3. The maximum service limit should exceed come to live independently, especially if one must 20 hours per week. pay for personal assistance. In contrast, the level 4. Service is available 24 hours a day, seven of SGA for wage earners who are blind is currently days a week. $1,110 and has automatic annual cost of living adjustments. 5. The income limit for eligibility is greater than As a matter of equity and common sense 150% of the poverty level. Further, individuals who are severely disabled whose income in public policy, the differences in SGA for blind exceeds that established for eligibility should recipients and all other recipients should be re- be allowed to buy into an insurance policy moved. At present, few individuals who receive that would provide attendant care. Marital disability benefits attempt work, and almost none status and consequent financial circum- earn enough to become financially independent stances should not govern access to personal care assistance. (U.S. Government Accounting Office, July 1995; February, 1996). If an SGA of $1,110 is suffi- 6. Individual providers can be utilized by the cient to encourage blind recipients to attempt consumer. work, then it would be sufficient for recipients 7. The consumer hires and fires the assistant. with other disabilities as well, especially for those who must hire personal assistants in order to 8. The consumer pays the assistant. work. Applying the SGA level for blind recipients to all others would enable those with large work- 9. The consumer trains the assistant. related expenses, such as the need for personal 10.The consumer participates in deciding on assistants or assistive technology, to access those the number of hours and type of service he/ services independently. she requires. Until that time, more individuals with personal assistance needs who are Social Se- For years, the plan to establish a national curity Disability recipients should be made aware program went unfulfilled. Finally, after consider- of available work incentives, most notably the able pressure from disability organizations like Plan for Achieving Self-Support (PASS). A PASS ADAPT, the Speaker of the U.S. House of Repre- can be written to shelter income for the purpose

158 Article 11 of hiring a personal assistant. Using a PASS for mean being able to recruit, hire and supervise this purpose would allow the worker with a disa- a personal assistant who will provide the level bility to increase his or her earnings enough to of support needed to maximize their efficiency. be able to hire a personal assistant, while still For personal assistants, it will expand employ- retaining eligibility for health care assistance ment opportunities in more exciting work envi- under Medicare or Medicaid (West, Wehman, & ronments. For employers and human resource Revell, 1996). personnel, it will provide opportunities to As customer-directed PAS moves into the diversify their workforce and increase the employment arena, there is little doubt that it productivity of employees with disabilities. will have a positive impact on all concerned. Utilizing PAS in the workplace can be a win- For employees with significant disabilities, it will win situation for everyone.

159 eferences: R Ghiloni, C. (1999). Massachusetts Health Care Plan [online]. Available: http:// www.vcu.edu/rrtcweb/sec.

Litvak, S., Zukas, H., & Heumann, J.E. (1987). Attending to America: Personal assistance for independent living: A survey of attendant service programs in the United States for people of all ages with disabilities. Berkeley, CA: World Institute on Disability.

Nosek, M.A. (1991). Personal assistance services: A review of the literature and analysis of policy implications. Journal of Disability Policy Studies, 2(2), 1-17.

Presidents Committee on Employment of People with Disabilities (1998). Personal assistance services in the workplace [on-line]. Available: http://www50.pcepd.gov/pcepd/pubs/ek97/ personal.htm.

U.S. General Accounting Office (1995, July). Supplemental Security Income: Growth and changes in recipient population call for reexamining program. Gaithersburg, MD: Author.

U.S. General Accounting Office (1996, February). PASS program: SSA work incentive for disabled beneficiaries poorly managed. Gaithersburg, MD:

West, M., Barcus, M., Brooke, V., & Rayfield, R.G. (1995). An exploratory analysis of self- determination of persons with disabilities. Journal of Vocational Rehabilitation, 5, 357-364.

West, M., Mast, M., Cosel, R., & Cosel, M. (1996). Applications for youth with orthopedic and other health impairments. In P. Wehman (Ed.), Life beyond the classroom: Transition strategies for young people with disabilities (2nd ed.) (pp. 419-443). Baltimore: Paul H. Brookes Publishing Co.

West, M., Wehman, P., & Revell, R.G. (1996). Use of Social Security Work Incentives by supported employment agencies and consumers: Findings from a national survey. Journal of Vocational Rehabilitation, 7, 117-123.

160 Rural Routes: Promising Supported Employment Practices in Americas Frontier

By: Cary Griffin

Today, it may be safe to say that rural is a state of mind rather than a geographic place. In the past, rural conjured up a ABSTRACT clear picture in ones mind: a farm, a small schoolhouse, a few white churches, small towns with tree-lined streets connected via This article provides an over- Elm or Main Street to a small and pragmmatic town center, and view of the conceptualization businesses based on agricultural products of the surrounding county. of rural and sets the stage for a discussion of best practices, While there remain many places fitting this description, the bucolic new opportunities, and tradi- ideal has changed substantially. tional barriers to facilitating Many rural areas have become bedroom communities to employment for individuals large adjacent cities, bringing antiseptic housing developments, with significant disabilities re- highways, and strip malls to once productive fields. Rural, in many siding in these areas. Critical areas for exploration in this cases, has become the safety valve for urbanites facing inner city article include: job creation, decay, high housing prices, and crime. The predominance of the job carving, the natural evolu- automobile, instead of mass transit, makes high speed access to tion of self-employment from distant communities possible for middle class Americans, while the supported employment, re- poor in rural communities remain isolated. Where the small town source ownership and job market competitiveness, once stood as the nexus of human interaction, in many cases today choice and self-determination, it exists as a resting place and haven from work life. It is no longer staff development, civic en- the economic foundation nor the natural tonic of the citizenry gagement, and rural transpor- (Oldenburg, 1997; Federal Reserve Bank of Kansas City, 1996; tation. A number of inventive Taylor & Wacker, 1997; Rifkin, 1995). and consumer-director options are discussed. With that said, there remains a tremendous amount of the United States that exists unaffected by the development frenzy of the ubiquitous metroplex. These are the areas of concern for this paper. The other issues are critical, but the impact is on a much smaller scale in rural communities surrounding Billings, Montana, or Sioux Falls, South Dakota, than in those places within commuting distance from Denver, Colorado, or Austin, Texas. In remote parts of this country, the economic boom of late appears less dramatic, and in many cases has breezed by without a trace. Farming and ranching communities on the eastern plains of Wyoming, Montana, and Colorado, for instance, continue to see a decline in population and economic health. Montanas strong 1980s economy now struggles with the highest per capita number of children living in poverty and

161 the 46th lowest per capita income rate in the used it to satisfy the socio-economic phenomenon country (Billings, 1998; Number of Jobless, of single and double working parent households. 1998). Waiting for harried parents to formulate a desire Regardless of the current economic status for a high speed oven would have taken forever, of local economies, employment development is if it ever happened. Expecting employers and still possible. People consistently go to work in communities to recognize the talents of people the morning; hiring continues; and there is much with disabilities is equally futile. Success in rural work to be done. While many rural areas do not employment development comes from creating appear to be the direct beneficiaries of the growth the need for employers to hire or for customers economy, the decrease in interest rates, the avail- to buy from entrepreneurs with disabilities. ability of low interest loans and venture capital, liberalized lending rules, increases nationwide in entrepreneurship, improved telecommunica- tions infrastructure, and government downsizing DEFINING RURAL make it easier to create jobs. The subtle, but important, shift in thinking and activity from job hunting to creation is critical. Rural may be a state of mind or be Job development and placement are culturally defined, but that does not mean there traditionally rooted in reactive strategy. That is, are not formal descriptors for such areas. The people with disabilities (and organizations that United States Census Bureau (1995) contends assist them) prospect for what exists in the that rural is technically any community with marketplace. Historically, job development 2,500 or fewer people. Using this definition, techniques relied on testing that predicted em- there are 61,685,330 rural residents spread out ployability in certain trades or occupations. When over 75% of the land mass of the nation. This no surplus of those identified jobs existed, the definition oversimplifies rural. Rural thereby person with a disability often went unemployed. includes communities and areas adjacent to Today, best practice suggests that approaching major metropolitan areas that may be small, but a job match using an environmental validity benefit from their proximity to the services and strategy makes more sense. In other words, activities of the neighboring city. Some rural looking at a persons desires and gifts makes practitioners debate the true ruralness of more sense than trying to fit a person into a par- adjacent communities and argue for the more ticular occupation. And, if the desired occupation strict frontier definition offered by the Census does not exist, working to create that job becomes Bureau (Montana University Affiliated Rural In- a logical step in this proactive process. stitute on Disability, 1998). Frontier areas are In rural areas, it is often necessary to iden- described as those with population densities of tify or reveal a need, then present a solution to fewer than 6 people per square mile. Only satisfying that need. Small business grows histori- 2,447,630 people live in frontier counties, and cally through filling needs that others have not 15% of these residents have disabilities (McNeil, filled and by creating needs that can profit indi- 1993). Frontier communities exemplify the re- viduals. This is the essence of inventiveness, which moteness and isolation of truly rural Americans. is a primary requirement for success in rural em- Regardless of definition, rural communities have ployment. After all, no one needed a microwave the highest rates of poverty in the United States oven until someone identified the technology and (Rojewski, 1992). Providing quality employment

162 Article 12 support in remote communities is often hampered (but certainly not impossible) by a lack of trans- TABLE 1 portation options, a limited array of jobs, the uncertain availability of venture capital, the paucity of community rehabilitation options, and Consumer Choice and Self-Determi- nation -- Typically, this involves the use limited access to current information on best- of Person-Centered Planning that offers full practices. access to information and provides support Regardless of the definitions, rural sup- for choice making (Griffin & Hammis, 1996). ported employment is as challenging in its way Functional Assessment of Skills and De- as urban supported employment is challenging sires in Real Workplaces -- Experiencing in its way. Both environments suffer unique bar- a host of possible work environments to riers. And both environments present tremendous afford the worker a comparative assessment opportunities for community engagement and of possible jobs and co-workers. employment discovery. Thoughtful and Formal (i.e. written) Job Analysis -- A detailed study of the whos, whats, whens, and wheres of particular worksites (McLoughlin Garner, & Callahan, SUPPORTED EMPLOYMENT 1987) MODELS Thoughtful and Formal (i.e. written) Job Match -- An examination of goodness of Service delivery models are important for fit, as well as training supports necessary for providing structure and benchmarks for the initial employment success (Moon, Inge, Wehman, development and incubation of community em- Brooke, & Barcus, 1990). ployment, regardless of environment. However, Skillful Utilization of Systematic Instruc- strict adherence to any model in the face of tion -- Strategic use of behavioral and unique circumstances, such as those presented planful teaching techniques on the job (Inge in remote areas, may limit effectiveness. For & Tilson, 1997). supported employment techniques to work, they Tactful Acknowledgment of Worksite must be flexible and pragmatic. What should Culture -- Understanding the rites and not be compromised are the critical elements of rituals of unique worksites and minimizing any high performance employment process. the disruption of the environment (Griffin & Table 1 lists the components of a high perform- Sherron, In Press) ance employment process. Planful Identification and Facil-itation Just as in urban areas, when shortcuts of Natural Supports -- Assessing the are taken, problems occur. A pervasive myth in interactions of co-workers, the availability rural communities is that everyone knows every- of cues, and the use of typically utilized methods and tools in a particular work envi- body else, thereby making communication and ronment (Callahan & Garner, 1997; Griffin, working relationships easier and more casual 1992; Nisbet & Hagner, 1988). than in anonymous city environments. This myth is further manifested in the belief that formal Customer Friendly and Respectful Con- sultation Services -- Supporting both the processes are restrictive and unacceptable in employer and the employee in making the environments where people feel a cultural job a success. obligation to the folklore of informality. The fact

163 is that business people do not do business on a representing them. If job developers (and this handshake. They are used to complex contracts includes everyone in a community rehabilitation and agreements. So, using a formal job match program, every VR employee, etc.) take action process, structured on-the-job experience, and to become known as credible and giving mem- systematic instructional techniques (with close bers of their communities, the job development attention to honoring the work place culture and process gains the respect of employers. utilizing natural support methodologies) will not One promising technique for growing alienate or frighten employers; it could reassure jobs involves nurturing community relationships them of your professionalism. and networks by establishing Active Employment Councils (AECs) or Business Leadership Networks (BLNs). These councils meet monthly and members are required to bring at least one employ- GROWING JOBS ment lead or contact. One or two consumers are asked if they have an interest in exploring employment in the contacts business. This Typically, job development is constrained contact is then called and given the name of the by the reactive methods traditionally employed council member who suggested calling, and an in the field. Even today, many job developers appointment to discuss employment opportunities are taught to review the labor market and test is made. Sometimes contacts are suppliers to people with disabilities to see if they fit within the the council members business and, a natural current economic environment. In areas of high business relationship already exists that can be commercial activity, this approach may work well leveraged into job development. Often, too, enough to reinforce its premise. But in typical the council members find that they have jobs markets (and especially in depressed markets), available in their own companies and can help this reactive approach to job development just minimize the red tape and other roadblocks labels people with severe disabilities as unem- inherent in job hunting. Because business and ployable. In rural areas (and urban, too), people consumers participate in the council, employ- get jobs through various networks of associa- ment outcomes are the absolute priority for all tion, and by being competitive in the workplace. council activity; mutually beneficial and respectful relationships form that create a force for job EMPLOYER AND CONSUMER CONTROL development in the community (Griffin & Sherron, OF THE JOB DISCOVERY PROCESS in press; Hammis & Griffin, 1998). The power of networks for the job seeker Critical lessons are being learned through cannot be overstated. Without the representation such councils that seem to have universal ap- of respected other, the job seeker is just another plicability to all communities. Table 2 on the name on an application. In interviews, job seekers following page outlines these lessons. may be just another applicant, except that they Staff at the Rural Institute at the University also have a disability. Job developers and job of Montana develop and create jobs in rather seekers alike must create networks that include remote sections of the country. Often, no formal people who influence those who hire. Typically, jobs exist. The strategy is to look for products or people use references such as their former bosses services that are needed and either create a or professors, but many people with severe consumer-run business enterprise or assist busi- disabilities have no one of community standing ness to expand through the use of formal partner-

164 Article 12 help identify local entrepreneurs and com- TABLE 2 -- LESSONS LEARNED FROM panies that are willing to incubate partnerships CREATING BUSINESS LEADERSHIP and businesses within businesses, and individ- NETWORKS ual members bring their priceless expertise and 1. Job developers must be known by the advice concerning local market conditions. business community. At the heart of these councils is Peer Marketing, having an employer influence 2. Job seekers must actively and visibly create business and personal relation- other employers to hire individuals with disa- ships within their communities. bilities. Peer Marketing is much more powerful and effective than human service represen- 3. Job developers and seekers must become tatives acting as sole job developers. Employ- active participants within their Cham- bers of Commerce, service, clubs, and ment development benefits from creative pro- city/county governments. They should fessional rehabilitation expertise, but there is use these resources to assist with job a major role to be played by having business development efforts. folks work face-to-face with both people with 4. Dont overlook Public Sector employment disabilities in need of employment and with opportunities. Government jobs exist in peers in the business world. Hiring people with even the smallest of communities. Wash- ington State, which has a large rural pop- disabilities is, unfortunately, still viewed as a ulation, has a state government initiative business risk. Hearing of successful employ- to hire people with severe disabilities. ment from both business and workers with 5. Employers understand their workforce disabilities provides powerful support to em- and production needs. Use them to assist ployers who have not yet hired. Human service in job restructuring and on-site training. roles seem most appropriate in the context of Provide consultation on instructional support and effective teaching/super- getting these constituents together and provision strategies. viding technical and strategic support until a quality employment relationship is solid. 6. Create consumer-run enterprises by filling a need in communities where no formal jobs exist. Or, assist businesses ex- JOB CARVING/JOB CREATION pand through the use of formal partner- Job carving is the process of breaking ship agreements. down jobs into their key components and reas- signing those pieces in more efficient or understandable ways. This strategy is a creative ex- ship agreements. Recent business start-ups in- tension of job development that results in job clude a small engine repair business, run as a restructuring or job creation (i.e., typical work sole proprietorship but located within another duties are reassigned to one or more workers fix-it shop in Plains, Montana; and a stuffed or a new job is created to address efficiency animal concession at a Nature Center in Red needs). While full-time employment is certainly Lodge, Montana (the Nature Center receives 10% a reasonable outcome, job carving is often on all sales in exchange for housing the business used with individuals in transition from school- run by a young entrepreneur with significant disa- to-work or supported employment who, for a bilities.) The possibilities are limitless (Hammis variety of reasons (including physical disability, & Griffin, 1998). Active Employment Councils psychiatric illness, medical fragility, available

165 supports, and choice) may not be in the market for full-time employment (Griffin & Sherron, in TABLE 3 -- RURAL JOB CARVING press). Care must be taken not to create jobs EXAMPLES that devalue people with disabilities by physically separating them from other workers or by having Clerical Assistant -- Duties include photo- copying, formatting and copying computer them perform tasks that are considered bother- disks, answering phones, assembling docu- some, dangerous, or unpleasant. ments. Job carving entails analyzing work duties Mail Delivery -- Duties include mail, parcel, of specific jobs and identifying specific tasks that and message delivery for rural county govern- could be assigned to employees with severe disa- ment offices. bilities who have a proficiency for these tasks Pet Groomer -- Duties include washing dogs, and who want to perform these jobs. Job carving general animal care. can be a useful tactic for helping individuals Bank Teller Assistant -- Duties include gain experience in paid situations and for helping sorting documents, operating coin counter equipment, paper shredding. employers reach a new comfort level with employees with disabilities. Taxidermist Assistant -- Duties include salting hides, preparation work. Monday - Many variables influence job carving. For Friday, 20 hours per week. instance, the marketing approach in job carving Seamstress -- Duties include guiding material is deliberate and businesslike. Job developers through computerized sewing machine, quality should approach potential employers as diag- control, packaging. nosticians, ready to determine needs and offer Car Wash Attendant -- Duties include solutions to productivity challenges. Another cleaning wash bays, refilling soap and liquid variable is consumer employment objectives. No wax reservoirs, emptying vacuum cleaner bags, policing the grounds. job development effort can take place without a thorough understanding of the type of work that Grocers Assistant -- Duties include facing cans on shelves, arranging produce, unloading is suitable and acceptable to a particular delivery trucks, light cleaning, recycling individual. shipping boxes. In some remote communities, it may be Gas Station Attendant -- Duties include necessary to carve positions in several businesses pumping gasoline, washing windshields, for a person to be able to earn a livable wage. checking oil and fluid levels, washing and detailing vehicles. In such cases, transportation issues may arise that challenge the problem-solving skills of the Farm Hand -- Duties include moving cattle, clearing irrigation ditches, feeding cattle, most inventive employment specialists, con- bucking bales, assorted tasks performed in sumers, and employers. Always consider trans- partnership with the manager. portation a key element in any job match. Before recommending a job to a person, access must be attainable; otherwise, the job is simply not a good match. A person must be able to get to SUPPORTED SELF-EMPLOYMENT, work before he/she accepts the job; otherwise, BUSINESS PARTNERSHIPS, the person is at risk of failure and the employment AND OWNERSHIP relationship is jeopardized. Table 3 provides examples of rural job carving. Moving supported employment into the next century requires new options and new tools

166 Article 12 for employment specialists. Significant barriers become part owner of a small portion of the seem to be in our beliefs and expectations. The business. The owners knowledge of the busi- business world has been and is ready to do business world came into play again, as he ad- ness. Employers are interested in hiring em- vised, amended, and assisted in creating an ployees who own substantial employment related entirely new proposal for a sole proprietorship resources, forming limited partnerships, and for the young man, based on a $28.00 per supporting sole proprietorships with people of hour rate for the new small business, and a similar interests and dreams. 25% consignment fee for use of space at his Small business is the fastest growing seg- garage and also a method for sharing of ment of the business sector today (Friedman, customers and work loads. The Business Plan 1996). All of the options in the business world and PASS were approved, and an absolute are possible for people with disabilities. Acting no from a potential employer was turned on this belief makes it possible to achieve em- into a mutually profitable sole proprietorship ployment. For instance, in a small rural town in and partnership. Again, the business world Montana, a challenging person having multiple demonstrated it is possible to achieve employ- and significant disabilities shared his work ment even in an economically depressed com- dreams. The place he identified for his work munity of 1,500 people. dream was a local Nature Center. On a tour, he demonstrated the interest and relationships IMPORT SUBSTITUTION he had already developed. When attempting to Discussion of entrepreneurial ap- develop a job, objections were heard from the proaches in rural communities must include manager, including lack of funding for new the concept of Import Substitution. This practice employees. The manager agreed to any volunteer is being used around the world in developing help, but had no money for new employees. nations and many rural communities. Quite Acting on the belief that it is possible to simply, Import Substitution is a process that create employment for anyone, a business plan identifies goods and services that a local for a sole proprietorship was developed and given economy purchases from an outside source, to the Nature Center manager. The proposal and then creates the mechanism for providing was to operate a retail sales business at the those goods and services locally (Hong, 1993; Nature Center, and in return the Center would Marston, 1997). Job developers can use this receive 10% of the profits. The manager reviewed practice to create employment but should be and assisted in refining the plan and submitted cautious not to fall into the trap of having the it to the Board of Directors for approval. The market need drive the employment opportun- business is owned by the person with a disability. ities of people with disabilities. The job seeker By following the process for job creation, a busi- needs to remain at the center of job creation. ness outcome was created. Using proper person-centered tech- Another example involves a young man niques, the person with a disability established in a rural town, where an employer was asked an employment direction. In one case, a to develop an entry level mechanic assistant posi- young woman being served in a local institu- tion. The employer did not have adequate cash tion for people with developmental disabilities flow to hire him, but utilizing funds from a Social explained that she wanted to work in an office Security Plan for Achieving Self Support (PASS), environment performing clerical duties. Further a limited partnership proposal was written to exploration and job tryout indicated that she

167 enjoyed paper shredding. The job developer others used their sales experience and local visited a small clinic in the community, as well connections with people of influence. Most as 2 banks. He discovered that they needed people served in supported employment have confidential document destruction, and also little or no competitive employment experience, found several other businesses (accounting firms, formal education, and few typical relationships doctors offices) that also needed this type of in the community. Knowing that employment is assistance. All these businesses; however, con- secured by having respected others speak on tracted out their services to a large city service your behalf and by having recognized skills and shipped their work there monthly. None of instead of deficits and needs, there is little wonder the businesses generated enough work indi- that people with disabilities remain the nations vidually to justify the expense of hiring someone most heavily unemployed and underemployed and purchasing the equipment. minority group. The job developer was able to convince Employment is based on competition. the local businesses to shred their paper locally. Applicants use their connections, skills, and assets He enlisted the local Vocational Rehabilitation to sell themselves to the employer. The basic office to purchase a small but powerful portable arrangement is that the employee agrees to be paper shredder for the job seeker. She then con- exploited by the employer in return for wages. tracted with each of 4 businesses and visited The employer maintains employment as long as their offices one day a week for 2 to 4 hours to the revenue generated by the employee is greater shred their sensitive documents. The cost to the than the amount expended to retain the em- businesses was reduced, and the service was more ployee. In this basic capitalist model, workers secure and confidential, because the young with severe disabilities, who have no positive woman could not read. reputation, no apparent exploitable skills, or who Other examples of Import Substitution are seen as poor investments, stand little chance include a recent business start-up plan for a of being hired (Hammis & Griffin, 1998). Native American-run appliance store on an To change this circumstance, it makes Indian Reservation and a custom embroidered sense to augment an applicants profile by clothing retail store (Hammis, 1998). These were helping him or her attain skills training. This is established by beginning with consumers desire not readiness. Employment-specific education to work in a particular location and perform jobs includes activities such as learning computer they liked, then identifying the related products programs or small engine repair or learning to and services the community previously purchased use tools or equipment of value to the employer from a distance as part of the business plan and that the employee can use in performing the job. job match. And while these particular examples Training may also include using personal trans- represent small business developments, there are portation that makes the person more reliable many jobs that are out-sourced in rural com- than other applicants. munities that clever employment specialists could These items require cash. Creative rural carve back in to existing companies. service providers can set aside a percentage of their revenues to provide these critical elements. RESOURCE OWNERSHIP These are commonsense expenditures for organi- In the above examples, the employees zations whose missions are community employ- utilized a variety of resources to become success- ment. Still, some expenses are too great, so ful. One used a paper shredding machine, the supplemental funding could be provided through

168 Article 12 the local Vocational Rehabilitation or Job Training and high tech assistive technology for work Partnership Act (JTPA) counselor. One of the and education. Each person involved owns most underutilized but lucrative sources of funds the resources purchased through the PASS. is the Social Security Plan for Achieving Self PASS provides a very personalized and custom- Support (PASS). ized incentive to ownership and community PASS is a part of the original supplemental employment. A successful PASS simultane- security (SSI) statute of the Social Security Act ously educates and combats the fears of losing and is designed to increase a persons earning Social Security benefits prior to earning a potential. PASS and other related Social Security reasonable wage and securing health cover- Work Incentives, such as Impairment Related age in the community. Work Expenses (IRWE), Blind Work Expenses PASS as a resource is utilized extensively (BWE) Subsidy, and Trial Work Period, acknowl- in the Rocky Mountain West. At this time, edge the fact that for people who are classified Montana, Wyoming, and Colorado are by Social Security as Blind or Disabled, achieving leaders in the use of PASS Plans (Social Security self support may be a gradual and ongoing pro- Administration, 1998). In rural communities, cess. A PASS allows a person to have multiple resources such as Social Security Work Incen- jobs along a career path while placing set-aside tives cannot be ignored; they are essential to funds into the hands of the person with a disability consumer choice, power, and control in em- and increasing his/her resource ownership and ployment matters. And with training in SSA decision-making responsibilities. A PASS results Work Incentives available through a number in a flexible type of written guide for ones future of quality sources, there is no excuse for them and personal agreement voucher between SSA not being employed whenever possible to and the person with the PASS. support job development and retention. Rural Institute staff have written, developed and managed over 500 approved PASS plans, typically generating $1,000 to $5,000 per year in voucher type resources for individuals with CHOICE & SELF- disabilities. The average single PASS covers 3 DETERMINATION years, with the option of unlimited revisions along a career path. Of the plans written to date, the The new watch-words of rehabilitation resources identified by people with disabilities, are Choice and Self-Determination. As with their family, advocates, or employers to be pur- any radical shift away from tradition, incremen- chased with PASS have included: new and used talism threatens these concepts. Choice and vehicles; computerized sewing machines; com- Self-Determination are rooted in person- puterized embroidery equipment; livestock; per- centered planning techniques of the 1980s. sonal assistants and care attendants; college Enlightened vigilance is required to guard tuition; laptop computers; motorized wheelchairs; against diluting these approaches to support. paid taxi and alternative transportation; per- There is mounting evidence that person- sonally chosen therapy not covered by Medicare/ centered planning has become tremendously Medicaid; mechanics tools; business clothing; bastardized and ineffective due to shortcuts and dental improvements; augmentative communi- misuse. True person-centered planning can cation devices; paid co-worker support at work; guarantee the individual power in planning long term one-to-one tutoring; a variety of low his/her own life and provide supports that make

169 it possible to advocate for outcomes in systems service vouchers to numerous people residing in that do not traditionally respond quickly or uni- remote communities. In such areas, service de- quely to those served. Across the country, person- livery is either not available or the choice of pro- centered techniques are being employed within viders is severely limited. By offering vouchers, service system environments, with service system customer service improved, consumers could personnel, and within the framework of system remain in their home communities, and typical service arrays. At least one software package is citizens and family members were enlisted to available to speed the development of the person- support the employment and rehabilitation goals centered planning process. In other words, the of the individual (B. Grimme, personal communi- language of rehabilitation may have changed: cation, June 6, 1998). talk of constructing maps fills conference In Oregon, a relatively rural state, a re- rooms. But the mapping process is only a small cently funded project assists families of transition piece of person-centered planning. Its strength age children. The Family Management Grants lies in the commitment of those attending the (FMG) is part of Oregon Transition Project and meetings in making certain that things change provides families with up to $3,000 to implement for and with the person. The real strength and their childs employment plan. Fifty families have promise of person-centered planning is gone in received financial assistance in purchasing job many organizations. The power of person- development and coaching, resulting in 40 indi- centered planning is that it challenges people to viduals gaining community employment at better radically change from a model of control and than minimum wage (Toews, 1998). In continuum to a model of support and invention. Montana, four rural communities are coming Once person-centered planning becomes man- together through a series of structured town dated and/or practiced at the convenience of meetings and Active Employment Councils to state or local rehabilitation or school programs, develop supported employment for individuals its power is forever vanquished. with psychiatric disabilities. The project is funded There are places, however where Choice through the national Substance Abuse and Men- and Self-Determination are driving change. The tal Health Services Administration (SAMHSA) and Choice Access Project, funded by the Rehabilita- is designed to build community consensus on tion Services Administration and operated by the ways to solve the unemployment problem for United Cerebral Palsy Association national people with mental illness. Currently, the rate of employment projects office, is working in several joblessness for people with psychiatric disabilities rural communities. The project offers individuals is greater than any other disability group. By with severe and multiple disabilities vouchers for recognizing the hopes and aspirations of con- work experience, job coaching, job development, sumers, then identifying the strengths of the and related supports. In Montana, one young community, the project will create employment. man of transition age has secured a variety of A variety of partners is being enlisted to focus on work experiences and summer employment sup- community building. These partners include: port that would not have been available through consumers, Vocational Rehabilitation, the local the high school in his small community of fewer affiliates of the Alliance for the Mentally Ill, the than 1,000 people (E. Condon, personal com- Coalition of Montanans Concerned with Disa- munication, December 23, 1998). bility, Montana Community Partners (the Man- In South Dakota, the state Vocational aged Care Organization), the state Mental Rehabilitation agency leads the nation in granting Health Division, the regional Mental Health

170 Article 12 Centers, local businesses, families, and civic sions often in full view of the community and entities (Griffin, 1998). business. We expect them to be directed by There are many local, state, and national consumers, and we expect serious outcomes initiatives to guarantee Choice and Self-Deter- such as home ownership and employment. mination. The best recognize that communities Certainly they are not solely responsible for are capable of solving their own problems once these outcomes, but front line staff are major they know they exist. Rural communities, where contributors to success. local pride and control are topics of daily conver- This level of responsibility and stress, sation, are fertile ground for experimentation. In coupled with meager or outdated training, many rural communities, little formal infrastruc- leads naturally to high turnover on the front ture exists to serve people with serious disabilities, line. Turnover rates vary from coast to coast, thereby allowing local solutions to flourish, but 80% annual staff replacement for a CRP unhampered by bureaucratic infrastructure. providing vocational and residential services is very common. In fact, it is this high turnover rate that is often blamed for the unmanage- able cycle of resignations and hirings. CRPs RURAL STAFF RECRUITMENT are continually forced to reinvest in recruitment AND TRAINING and basic training rather than increasing salaries, providing better management support One of the most critical issues facing rural of staff, offering advanced training, and Community Rehabilitation Programs (CRPs) is the increasing support resources used to achieve recruitment, training, and retention of quality front community outcomes. The reasons CRPs uni- line staff. The role of direct line staff in CRPs has versally give for not using PASS Plans (a sig- evolved dramatically. Twenty years ago, all that nificant source of consumer-directed revenue was expected of front line staff was to help folks for achieving career goals) is that management get through the day safely and make certain the is often too busy putting out fires, and front contract work in the workshop got done. That line staff also do not have the time to learn was pretty much the extent of many job descrip- how to use this Social Security Work Incentive. tions. In my own career, I saw that evolution. I The same reason is true for effective partnering went from working in a group home, to starting with Vocational Rehabilitation, the use of a supported living program, to taking over as Assistive Technology, and the creation of busi- director of the adult vocational program. Within ness collaborations that lead to employer- six months, my duties and responsibilities had initiated jobs. changed drastically. My salary also improved. Turnover saps the potential of CRPs, Today, a front line staff person has fewer and, therefore, seriously undermines the opportunities for advancement, because the potential of talented staff and consumers who systems are more bureaucratized, professional- rely on these agencies to support them in non- ized, and complicated. The pay at the front segregated environments. Couple this with lines is relatively the same as it was twenty years Non-Value Added activities in the CRP daily ago, which is slightly better than minimum wage. routine, and outcomes become very difficult Also, with the move to community integration, to achieve (Griffin, 1999). the demands on front line staff have increased. Non-Value Added activities do not Now, direct support staff work and make deci- directly relate to achieving essential consumer

171 outcomes, such as home ownership and real Establishing front line staff as an organiza- jobs. The types of Non-Value Added activities tions most valuable investment, after consumers, are many and varied, and are found in most dramatically changes corporate culture. Such a social service systems. They include such items change requires an investment mind set. Exit as staff meetings that perpetuate inactivity, certifi- interview data reveal that many front line staff cations of quality that do not have a direct and leave for three primary reasons: 1) low pay; 2) obvious influence on consumer community out- frustration with managements lack of focus and comes, standardized or norm-referenced testing support for outcomes; and 3) restricted autonomy and evaluation, readiness or prevocational or power in decision making. training, various day activity classes performed One of the first steps in accomplishing in artificial environments, and cost-response be- such dramatic change is identifying the necessary havior approaches emphasizing behavior change front line Core Competencies. A competency is instead of finding ecological validity. If CRPs a set of skills and attributes that influences job focused on providing just what the consumer performance. Because competencies are based needed to be supported in community environ- on skills, they can be measured and improved ments, many of these wasteful accouterments of through training and practice. Personalities do rehabilitation would be eliminated. Small, rural not appear to change through training. So, new CRPs are plagued by insufficient economies of hires should not only exhibit critical competency scale. If efficient means are not employed, potential, but also have personality traits that resources for experimentation and invention are support an organizational culture focused on out- quickly squandered just doing what has always comes and quality customer service. Achieving been done. Functional approaches, such as this match of skills and personality takes much on-the-job experience and situational assessment more work than simply hiring warm bodies; it is save significant resources, can generate funds a long-term investment-based strategy to achieve from partners such as Vocational Rehabilitation, consumer-desired outcomes. A supported em- give front line staff and consumers real world ployment specialist might need to exhibit compe- experience and success, and build adaptive tency in: negotiation; image, marketing and corporate cultures focused on outcomes achieved public relations; customer service; systematic in- through systematically defined and implemented struction; self-management; communication; and operational processes. problem-solving. Eliminating or significantly reducing front Training in these skills is available through line turnover and increasing consumer outcomes turnover savings and by partnering with local requires organizations to immediately quit doing universities and businesses. Further, good recruit- things that do not work. Telling the truth about ment entices people away from other businesses our efforts is job one. For over 50 years, the that have already trained these staff in many promise of community rehabilitation has gone related and complementary skills. The key here unfulfilled. Today, approximately 1,000,000 is that the CRP must compete on salary as well people with developmental disabilities are served as working conditions, work autonomy, and in sheltered workshops and segregated day pro- clarity of outcome expectations. It is true that grams. Despite the promise that an adult service front line staff leave for income reasons as much system would train and place people in the com- as for other reasons. It is not the only reason, munity, only slightly more than 15% of consumers but it is essential that staff be able to feed and have achieved community employment. house themselves. By re-investing the savings

172 Article 12 from organizational re-engineering, salaries can be significantly improved, and training can be CIVIC ENTREPRENEURSHIP high quality. Table 4 below lists the basic steps AND LEADERSHIP: THE for initiating a Save the Front Line program. CHANGING ROLE OF THE HUMAN SERVICE SECTOR A major challenge for rehabilitation TABLE 4 -- SAVE THE FRONT LINE programs in any community is projecting a PROGRAM STEPS positive image of individuals with disabilities. 1. Analyze organizational outcomes data in Years of paternalism and public misinformation relation to the baseline that all people with about the specialness and inability of people disabilities should live, work, and recreate with severe disabilities must be overcome in in typical community settings. order for employment reform to occur. The 2. Account for all staff time and effort over establishment of segregated programs for (i.e. approximately a 2-month period. group homes, special schools, workshops) 3. Compare the work thats being done to the conveyed the message to the public that people work that needs to be done. Many rehabili- with disabilities were the systems problem; tation personnel are not actively engaged in outcome related work most of the day. that the community was not prepared or properly trained to deal with such folks; that 4. Calculate unproductive personnel time in theyd rather be with their own kind anyway. terms of salaries, benefits, and if possible, in terms of lost opportunities and billables. In many small towns, the citizenry took pride in fund raising efforts that established local 5. Calculate the cost of personnel turnover throughout the agency in terms of over- programs that were state-of-the-art. The time pay for coverage, lost billables, change to a philosophy of integration and in- advertising, interviewing, orientation and clusion devalues these community efforts. With- training time. out a planful approach to community re-entry, 6. If possible, calculate the stress to con- the best efforts of employment specialists may sumers, staff, and managers turnover be met with resistence. causes. Consider the impact of a crisis orientation when scrambling to find staff Staff training, as mentioned above, is and the inconsistency of customer service one critical element in linking the community to community employers. and the rehabilitation effort. Staff must know 7. Create a competency-driven staff recruit- the agencys mission, proper conflict management profile that finds and retains the best ment approaches, respectful language, and staff possible. efficacious worksite training approaches to 8. Develop an equitable salary scale that overcome years of systems-driven stereotyping. makes agencies competitive with business. The role of the CRP, its leaders, consumers, 9. Change the organizations rhythm to one families, and Board changes to that of net- of continuous communication, refinement, work builder and link to the public sector and invention, and quality. the opportunities available in the private sector. 10. Think future development and capacity Attention is turned to creating an environment building. Do not fall victim to the myth that where the community recognizes people with rehabilitation is doomed to forever pay people less than they are worth, and that disabilities as citizens who should no longer people with disabilities deserve less than be denied the rights of housing and economic the absolute best. self-sufficiency. 173 The steps in achieving this are familiar. when money is available to purchase transpor- They demand a strong effort on behalf of the tation, often there is simply none available at CRP in becoming contributors to community any price. Rural Americans make up 27% of the building, using staff expertise to help solve com- U.S. population, but only 5% of federal transpor- munity challenges, and a fundamental change tation funds are allocated to rural communities. from reliance upon a specialized system to re- Where transportation is available, it is typically framing disability issues as community issues. unreliable, because over half the vehicles are Unemployment, for instance, is not a disability beyond their useable life, and fully 60% of mass issue, its a community issue that needs community transit in rural areas is not wheelchair accessible action. The CRP can bring light to the high (Bernier & Seekins, 1996). Add to this the cost local unemployment rate of people with disabil- of transportation for a population that lives in ities. When this has been done, in places such poverty, as well as the challenges of geography as Greeley, Colorado, the community has taken and weather, and isolation remains as the pre- action through its Active Employment Council dominant factor in frontier communities. (Griffin & Sherron, in press). In Missoula, As mentioned earlier, one approach to Montana, the need for small business start-up transportation is to make sure the job analysis loans for entrepreneurs with severe disabilities process includes a studied examination of access led to increased access to existing loan funds resources. A job that one cannot get to is simply and technical assistance especially relevant to not a good job. Transportation is another issue borrowers who also received Social Security and that supports the role of the civic entrepreneur. needed to protect portions of their benefits pack- Transportation in remote areas is everybodys age. The loan funds were accessed through problem and benefits from community-wide local business development sources and with a solutions. loan guarantee/risk pool funded by City Council. One example of rural problem solving Efforts to bring the public and private occurred in southern Colorado in the early sectors together are incubated by civic entrepre- 1980s. The CRP played a leading role in forming neurs, which include CRPs. The civic entrepre- a transportation cooperative in Colorados re- neur leverages or augments existing resources in mote and poor San Luis Valley. Several human the community, such as low-interest/high risk loan service organizations pooled their vehicles and funds, transportation, medical care, etc., without formed a new corporation to provide both fixed creating a separate but equal resource for route and door-to-door services. This CRP also citizens with disabilities. Even in the most remote utilized private citizens for transportation from communities, resources exist to address many remote to hub communities. Service consumers problems that are not unique to people with where matched with commuters from nearby disabilities (Henton, Melville, & Walesh, 1997). areas. The commuter transported the individual to and from work and received payment from the CRP to underwrite the drivers costs. This approach has been replicated with success in TRANSPORTATION rural Michigan, Kansas, Montana, and South Dakota (Bernier & Seekins, 1996). Finally, the use of vouchers is a promising A commonly shared challenge to employ- practice as self-determination approaches to ment and health care services in rural areas is rehabilitation gain favorable (M. Callahan, per- the lack of accessible transportation. And, even 174 Article 12 sonal communication, May 23, 1998; Bernier funded in the 1980s and 1990s show that & Seekins, 1996). The use of Social Security little effort was directed at engaging the com- Work Incentives, such as PASS and the pending munities as problem solvers and addressing Ticket to Independence, to underwrite commuting the challenges faced by remote CRPs and and private transportation costs is a potential consumers. solution (Griffin, Flaherty, Hammis, & Shelley, The agenda for the next decade cer- 1998). As portability money allotted for service tainly must include a reformulating of our efforts delivery becomes a reality, more options will arise. at community employment. States must take a lead role in offering incentives to CRPs for assisting people in attaining and retaining community employment. States must start CONCLUSION granting personal service vouchers, especially in rural areas, to create consumer-control of outcomes and to spark competition where The challenges of the rural population none now exists. States must set some com- are many. Isolation due to a paucity of accessi- munity employment outcomes expectations ble transportation, waiting lists for services, highly where none now exist. Training must change competitive markets for low-paying and repetitive for vocational counselors and staff to include jobs, underpaid and overworked front-line CRP emphasis on rural issues, the work abilities of staff, and continued stereotyping of people with people with even the most significant disabil- severe disabilities all contribute to making rural ities, and the role of self-employment and supported employment one of the toughest chal- micro-enterprise. Programs must de-empha- lenges communities face at the turn of this century. size predictive validity via vocational testing After many years of federal systems change and instead, make a commitment to funding projects, training programs, increased funding supports that augment community success. rates, and a growing civic awareness of the em- Finally, and perhaps most difficult of ployment rights of people with disabilities, the all, professionals and consumers alike must prospects of finding a good job remains difficult. face the community and engage the populace. A brief review of state developmental Years of separation and isolation have pro- disability plans reveals that few states currently duced a fear of the greater community. Our provide financial incentives for assisting people neighbors share many of the same hopes and with severe disabilities into community employ- concerns that we in the public sector and disa- ment. Rural programs with limited economies bility community share. Engaging employers, of scale face greater risks, because their financial townspeople, and city governments is a crucial status is typically more tentative than larger urban step in addressing community and employment programs. Therefore, experimentation is some- access. A fundamental shift in thinking will times limited for fear of fiscally jeopardizing the change our view of the community from a program. A review of final reports of rural state Pandoras Box to that of a resource rich Supported Employment Systems Change projects Treasure Chest.

175 FIGURE 1 -- SUMMARY CHART: IMPROVING SUPPORTED EMPLOYMENT IN RURAL AREAS

Best Practice Practice Examples Contact Information Employer Business Leader-ship Carol Dunlop, Presidents Committee on Employment Involvement Networks of People with Disabilities (202) 376-6200 [email protected]

Consumer Control: Business Enterprise State Vocational Rehabilitation Agency in your state; Consumer Run Pro-gram; Consumer- Community Rehabilitation Division, University of Enterprises run businesses, Mike Arizona (520) 917-0841 Shafer, University of [email protected] Arizona

Job Carving/Job Rural small business Roger Shelley, Rural Institute, Red Lodge, MT Creation carving (406) 446-2065 [email protected]

PASS Plans; Social Small business start-up David Hammis (406) 243-5485 Security Work In- and supported em- [email protected] centives; Re- ployment self- sources Ownership financing Marsha Katz, Rural Institute, Missoula, MT (406) 243-2821 [email protected]

Choice and Self- UCPA Choice Access Mike Callahan, United Cerebral Palsy Association, Determination Project; R.W. Johnson Gautier, MS (228) 497-6999 Self-Determination [email protected] Program Thomas Nerney, New Fairfield, CT (203) 746-7801 [email protected]

Rural Staff Various Training and Cary Griffin, Rural Institute, Missoula, MT Recruitment, Management Devel- (406) 243-2454 Training and opment Projects [email protected] Retention Katherine Carol, Tango Consulting, Denver, CO (303) 861-5256 [email protected]

Gayann Brandenburg, CTAT, Denver, CO (303) 355-2828 [email protected]

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Billings, E.P. (1998, December 9). Fastest-growing jobs pay less than livable wage. Independent Record.

Callahan, M. & Garner, B. (1997). Keys to the Workplace: Skills and Supports for People with Disabilities. Baltimore: Brookes Publishing.

Federal Reserve Bank of Kansas City. (1996). Economic forces shaping the rural heartland. Kansas City, MO: Author.

Friedman, S.E. (1996). Forming your own limited liability company. Chicago: Upstart Publishing.

Griffin, C.C. (1998). Rural supported employment fact sheet. Missoula, MT: Montana University Affiliated Rural Institute on Disability.

Griffin, C.C. (1999). Working better, working smarter: Building responsive rehabilitation programs. St. Augustine: Training Resource Network.

Griffin, C.C., Flaherty M., Hammis, D., Shelley, R., Maxson, N., Spas, D. (1998). Knowing the ropes: Reaching new heights in rural community employment. Missoula, MT: Montana University Affiliated Rural Institute on Disability.

Griffin, C.C. & Hammis, D. (1996). Street Wise Guide to Person-Centered Planning. Denver: CTAT.

Griffin, C.C. & Sherron, P. ( in press). Finding jobs for young people with disabilities. In P. Wehman (Ed.) Life beyond the classroom (3rd ed). Baltimore: Brookes Publishing.

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Hammis, D. & Griffin, C.C. (1998). Employment for anyone, anywhere, anytime: Creating new employment options through supported employment and supported self-employment. The Advance, 9, 2.

Henton, D., Melville, J. & Walesh, K. (1997). Grassroots leaders for a new economy. San Francisco: Jossey Bass Publishers.

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Inge,K.J. & Tilson, G.P. (1997). Ensuring support systems that work: Getting beyond the natural supports versus job coach controversy. Journal of Vocational Rehabilitation, 9, 133-142.

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177 McLoughlin, C.S., Garner, J.B., & Callahan, M.J. (1987). Getting Employed, Staying Employed. Baltimore: Brookes Publishing.

McNeil, J.M. (1993). Americans with disabilities:1991-1992. Washington, D.C.: United States Census Bureau.

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Moon, S.M., Inge, K.J., Wehman, P., Brooke, V., & Barcus, J.M. (1990). Helping Persons with Severe Mental Retardation Get and Keep Employment. Baltimore: Brookes Publishing.

Nisbet, J. & Hagner, D. (1988). Natural supports in the workplace: A reexamination of supported employment. JASH, 13(4), 260-268.

Number of jobless outstripping new jobs and those getting jobs. (1998, December 26). Missoulian Newspaper, p. A1.

Oldenburg, R. (1997). The great good place. New York: Marlowe & Company.

Rifkin, J. (1995). The end of work: The decline of the global labor force and the dawn of the post-market era. New York: Putnams Sons.

Rojewski, J. (1992). Vocational rehabilitation in rural America: Challenges & opportunities. American Rehabilitation, 18, 39-44.

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178 Workplace Supports: A View from Employers Who Have Hired Supported Employees

By: Darlene Unger

Supported employment has afforded an increasing number of people with significant disabilities an opportunity to enter and ABSTRACT compete in our nations labor force. Since the inception of supported employment as a federal program with the authorization of the This article describes employers assessment of the Rehabilitation Act Amendments in 1986, the number of individuals types of workplace supports receiving these services grew from 10,000 individuals in 1986 to available within their busi- 139,812 people in 1995 (Wehman, Revell, & Kregel, 1998). As nesses, the workplace ac- supported employment experienced rapid growth and employers commodations provided to became increasingly aware of the employment potential of people supported employees, and the role of human service with disabilities, increased efforts were directed toward identifying providers in facilitating those and developing supports that existed in the workplace to assist in- accommodations. Employee dividuals with disabilities in both learning how to do their jobs and support needs in the areas of maintaining employment. employee training and benefits, career advancement, and The job coach model of supported employment (see, e.g., work culture were addressed Rusch, 1986; Wehman & Kregel, 1985) has been the mechanism by the 53 employers who par- through which individuals with significant disabilities obtain competi- ticipated in the study. The tive employment. In this model, the job coach has typically been results indicated that em- the primary provider of support to an individual with a disability for ployers are quite capable of providing workplace accom- the duration of the individuals employment. However, commencing modations for workers with with the early days of supported employment implementation, the significant disabilities, draw- job coach model has always embraced the idea of using co-workers ing on existing employer and natural cues in the work environment to provide assistance to resources. The data indicated that employers are going individuals with disabilities (Moon, Goodall, Barcus, & Brooke, beyond mere compliance 1986; Rusch & Hughes, 1989; Wehman, 1981). As supported with the Americans with Disa- employment gained acceptance among its customers, the role of bilities Act of 1990 reason- the job coach evolved from being the primary provider of support to able accommodations pro- the role of a facilitator to assist individuals with severe disabilities in visions; employers reported responding to employee obtaining and maintaining competitive employment (Brooke, Inge, needs in such areas as career Armstrong, & Wehman, 1997; Fabian & Luecking, 1991; Unger, advancement, changing Parent, Gibson, Kane-Johnston, & Kregel, 1998). As the role of something about ones job, this role evolved, employers reported favorable perceptions of sup- and social integration. Often, supervisors and co-workers ported employees (Kregel & Tomiyasu, 1994; Shafer, Kregel, Banks, played instrumental roles in & Hill, 1988) and supported employ-ment (Kregel & Unger, 1993; providing support to co- Petty & Fussell, 1997). Increasingly, employers were more comfort- workers with disabilities. 179 able in collaborating with employment specialists people with disabilities in obtaining and main- and rehabilitation professionals to identify and taining employment. However, there is uncer- develop accommodations in the workplace for tainty surrounding employers level of awareness their employees with disabilities. and access to these types of employer or workplace supports, such as (a) government assistance WORKPLACE SUPPORTS in the form of financial incentives or federally Regardless of the size of the business, em- funded job training and employment programs ployers offer many types of support to their em- such as supported employment, and (b) training ployees. It is important for supervisors and co- and technical assistance pertaining to employ- workers to recognize that the support needs of ment polices and workplace supports designed employees with disabilities are similar to the variety to ensure access and/or maintain individuals with of employment-related issues that occur among disabilities in employment (OLeary & Dean, individuals with no known disabilities (Miano, 1998). Many employers may be unaware that Nalven, & Hoff, 1996). In addressing the sup- various types of workplace supports exist or that port needs of employees with disabilities, efforts resources and assistance are available from should be directed at identifying and accessing outside ones place of employment. For instance, accommodations that may be available within employers may be unaware of resources such as the employment setting. Examples of these the Job Accommodation Network (JAN), the business-mediated supports are: Business and Disability Technical Assistance Centers (DBTACs), or vocational rehabilitation (a) workplace accommodations such as assis- and supported employment services, which can tive technology, job restructuring, and assist employers or people with disabilities in iden- schedule modification; tifying and/or developing accommodations or (b) co-worker and employer supports; and providing employment-related support. Employers may be aware of resources but (c) employer-sponsored programs and policies because dissemination of disability-related infor- such as return-to-work policies, disability mation may be fragmented and uncoordinated, case management, and company polices regarding family and/or medical leave employers may be confused by the abundance (Wehman, Bircout, & Kregel, 1999). of information (OLeary & Dean, 1998). This confusion is especially alarming given that Butter- According to Hanley-Maxwell and Millington worth and Pitt-Catsouphes (1997) found that (1992), accommodations that exist in workplaces human resource administrators, supervisors, and include wellness programs, employee assistance co-workers who had worked with employees with programs, basic skills training, coaching, disabilities expressed concerns about not having mentoring, and apprenticeships. Often, em- the resources (e.g., time, money, experience, and ployers may not be aware of these inexpensive experise) to adequately support their employ- and unobtrusive accommodations or supports ment. Employers may express a willingness to that may be readily available within their busi- hire people with disabilities but may have con- nesses and can be utilized to provide support to cerns and reservations on how to identify and employees with disabilities. develop supports to assist with integrating them Supports also exist outside of the work- into the workforce, especially applicants with place that can be accessed or utilized to assist significant disabilities.

180 Article 13 EMPLOYERS AND THE EMPLOYMENT tions as being nonintrusive, not too costly, and REGULATIONS OF THE AMERICANS often causing only subtle shifts in workplace WITH DISABILITIES ACT procedures that employers might make for Employers expressed concern surrounding valued employees without defined disabilities. the implementation of Title I of the ADA (Pati & Even businesses that may be limited in per- Bailey, 1995). Employers fears regarding the sonnel or funds should be able to find innova- ADA may have been derived, in part, from the tive ways to effectively accommodate appli- lack of specificity regarding their responsibilities cants with disabilities (Magill, 1997). for providing reasonable accommodations. Despite employers concerns pertaining Under the ADA, employers are required to pro- to the ADA and reasonable accommodations, vide reasonable accommodations that will enable the percentage of employers who claimed to individuals with disabilities to successfully perform have made an accommodation for an em- their jobs when accommodations can be provided ployee with a disability increased from 51% without an employer sustaining an undue hard- in 1993 to 81% in 1995, according to a re- ship. Some professionals contend that the ADAs cent study (Harris et al., 1995). Additionally, reasonable accommodation requirement is un- a study by the Job Accommodation Network likely to maximize the employment of people with (JAN, 1994) revealed that 69% of employees disabilities, because it provides incentives to resist with disabilities required no special assistance accommodations (e.g., Rosen, 1991; Williams, and that half of the accommodations made 1993). For instance, the cost of a reasonable cost less than $500 to implement (52%), with accommodation is inextricably linked to eco- the typical cost being about $200. nomic analysis; employers weigh the accom- Since the implementation of the em- modation cost aainst the resources the employer ployment regulations of the ADA, much re- has and the benefit received from employment search has emerged that explores employers (Blanck, 1997). An employer whose only goal attitudes toward the ADA and the costs in- is to maximize profit might not hire an applicant curred in accommodating workers with disa- with a disability who requires an accommodation bilities. However, descriptions of the types of unless the cost is minimal. accommodations available in the workplace It is a well-documented fact that one of and the potential of employers to meet the the greatest concerns expressed by employers needs of employees with disabilities are very regarding reasonable accommodations is the limited. Further, with increased employer perceived cost they might incur. (Moore & initiatives directed toward improving the work Crimando, 1995; United Cerebral Palsy Associ- environment in an effort to retain valuable ation [UCPA], 1993). Even employers who re- human resources in this period of a shrinking port costs of accommodations for employees with labor market, a variety of resources are avail- disabilities were less than $100. With the major- able in the workplace to assist all employees ity of the accommodations costing little or to learn how to do their job, maintain their nothing, employers still expressed concerns about employment status, and advance in their the cost or the difficulty in providing accommoda- careers. Increasingly, employers are called tions (UCPA, 1993). However, Granger, Baron, on to deliver a number of supports to enhance and Robinson (1997), reporting on the types of the quality and productivity of their workforce, accommodations costs for employees with psy- as well as to retain valuable employees. The chiatric disabilities, described job accommoda-

181 purpose of this article is to describe the types of A total of 53 businesses participated in workplace accommodations provided to em- the study, with 16 individuals having worked at ployees with significant disabilities that help them one or more businesses during the time frame learn and maintain their jobs and enable them for the study. A majority of the employers to pursue career advancement opportunities. Ad- (62.3%) represented small businesses, employing ditionally, the role of the human service provider less than 100 employees (see Table 2 on the in assisting and identifying workplace accommo- following page). Prior to the individuals first dations for employees with disabilities is explored. day of work, the representative from the business responsible for hiring the individual was asked to complete the Employer Support Questionnaire (developed by VCU-RRTC Natural Supports METHOD Project staff).

SAMPLE Data were collected from employers for TABLE 1 -- EMPLOYEE DEMOGRAPHIC individuals with disabilities hired from October CHARACTERISTICS 1993 through September 1998. The purpose of the Natural Supports Demonstration Project Characteristic Frequency Percentage was to develop and implement a natural supports Gender Men 24 64.9% approach for achieving competitive employment Woman 13 35.1% outcomes for transition-age youth with significant disabilities. Natural supports were defined as Race any type of support that assists individuals in parti- Aisian 1 2.7% Black 9 24.3% cipating in the community and work environment Hispanic 1 2.7% of their choice. The seven-step community and White 26 70.3% workplace model (Parent et al., 1994), which Primary Disability Label incorporates the use of natural supports, indi- Mental Retardation 19 51.3% vidual choice, and self-determination into the Traumatic Brain Injury 6 16.2% existing supported employment service delivery Mental Illness 11 29.7% Other 1 2.7% system, was implemented with all individuals placed into supported competitive employment NOTE: Mean age = 23.27 years by project employment specialists. Individuals (range: 20-38 years) were referred to the project by parents, rehabilitation counselors, and special educators. Partici- INSTRUMENTATION pants represented of a variety of disability labels Data were collected with two different instru- and resided in rural, suburban, and urban geo- ments, the Employer Support Questionnaire and graphical areas in a southeastern metropolitan the Community and Workplace Support Form, city. The mean age reported for individuals at developed by the VCU-RRTC Natural Supports was 23 years with a range of 20 to 38 years. Transition Project staff. The instruments have been Table 1 contains a description of demographic previously validated and found to be highly reli- characteristics of the 37 individuals employed able and correlated with positive employment by the employers who participated in the study. outcomes for individuals with disabilities (Unger

182 Article 13 ported employment program, prior to the indi- TABLE 2 -- EMPLOYER DEMO- viduals first day of employment. During the GRAPHIC CHARACTERISTICS pilot study, feedback on the clarity of the instrument was obtained from employers and com- Characteristics Frequency Percent munity representatives. From their input and the results of the pilot study, the instrument Size of Business was modified and reviewed by a panel of small (99 or less 33 62.3% employees) employers and rehabilitation professionals. medium (100-999 18 34.0% employees) CONTENT OF THE EMPLOYER SUPPORT large (1000+ employees) 2 3.8% QUESTIONNAIRE Type of Business The final version of the seven-page restaurants & cafeterias 17 32.1% Employer Support Questionnaire consisted of industrial 3 5.7% 32 forced-choice questions, 9 of which re- service provider 3 5.7% commercial/retail 18 34.0% quested additional information regarding the education 6 11.3% employers response. The purpose of the form health 3 5.7% is to identify potential supports available from lodging 3 5.7% the employer or within the employment setting that might assist an employee with learning and/or completing his or her assigned job et al., 1998). The development of the instruments duties. Additionally, the form addresses the consisted of a three-step process: type of assistance available to employees in the area of training, advancement, and social (a) generation and selection of survey items, (b) review by expert panels, and or recreational activities, as well as examining (c) a pilot test of the instruments. the typical work routines of employees. Once an employer representative completes the form, The generation and selection of questions to be the employment specialist and employee with included on the instruments involved recommen- a disability reviews the form to identify potential dations from the projects advisory committee, sources of support for the new employee to which consisted of individuals with disabilities, address anticipated or future support needs. parents, rehabilitation counselors, educators, employers, and community representatives. Input DEVELOPMENT OF THE COMMUNITY collected from the advisory committee was used AND WORKPLACE SUPPORT FORM to develop initial drafts of the survey instruments. The Community and Workplace Sup- port form was developed by the VCU-RRTC EMPLOYER SUPPORT QUESTIONNAIRE Natural Supports Transition Project staff. The The initial draft of the Employer Support initial draft was developed with assistance from Questionnaire was field-tested with employers the projects advisory committee, which con- in the pilot study of the Natural Supports Transition sisted of individuals with disabilities, parents, Project to ensure clarity and potential for cap- rehabilitation counselors, educators, employ- turing the information. The instrument was comment specialists, advocates, employers, and pleted by a business manager or supervisor who community representatives. It was field-tested hired a person with a disability through a sup- with participants in the Natural Supports Tran-

183 sition Project to ensure the forms clarity and taining employment. A workplace support can potential for capturing the necessary information. be internal (e.g., co-workers, company check- During the field test, feed-back regarding the lists, wellness programs, etc.) or external (e.g., clarity of the instrument was obtained from em- tax credits, supported employment, etc.) to the ployment specialists administering the form, indi- work environment, with the common feature viduals with disabilities, and family members. On being that the support assists individuals in the basis of their input, the instrument was modi- obtaining and maintaining employment, as well fied and then reviewed by the projects advisory as advancing in their careers. Internal supports committee and rehabilitation professionals are supports that are available in the work setting familiar with natural support strategies. or from existing programs offered by the employer. The Community and Workplace Support External supports are identified or developed from Form consists of approximately 14 forced-choice sources outside the employment setting. questions. The questions address: SUPPORT NEED (a) the type of support needed or desired, Support needs are defined as any type of (b) support resources that have been identified, assistance required or desired by an individual that, when addressed, aids or facilitates parti- (c) support option selected, cipation in community and employment environ- (d) individuals primarily responsibility for ar- ments. Learning how to do the job, obtaining ranging or accessing the support, transportation to and from work, remembering how to complete required job duties, socializing (e) individuals primarily responsible for pro- with co-workers, and picking up and cashing a viding the support, paycheck are examples of support needs. A (f) the role of the employment specialist in ad- support need is identified anytime assistance dressing the support need, might be needed or obstacles are encountered that may impede or limit participation in com- (g) the costs of providing the support, and munity or work environments. Support needs (h) the person primarily responsible for over- may be identified by the employment specialist seeing the monitoring of the support. or communicated to the employment specialist by the individual or anyone involved in his or The purpose of this form is to identify the supports her life, such as family members or friends, needed and used in meeting the individuals employer, or co-workers. needs, and the type of assistance the employment specialist provided to address these needs. DATA ANALYSIS The Employer Support Questionnaire was WORKPLACE ACCOMMODATION completed prior to the individuals first day of For the purpose of this study, workplace employment by a representative from the business support is defined as any type of assistance or who was primarily responsible for hiring the indi- support provided to employees in or outside the vidual with a disability. The Community and work environment that assists employees in the Workplace Support Form was completed by an employment process, including pre-employment employment specialist when a support need was interviews and screenings, job training, advancing identified for an individual during the supported in ones career or changing jobs, and main- employment process.

184 Article 13 Data were collected for 37 individuals ability to advance within or between jobs and who were employed in 53 different businesses. included activities such as learning additional During the period of the study, 31 different duties, pursuing opportunities for promotion, support needs were identified for individuals that and other related needs. Employee benefit required some form of employer or workplace needs focused on enabling the individual to support. Support could be provided by the take advantage of benefits provided by the individual, employment specialist, or other work- employer, such as sick leave, pay raises, or place personnel. When an individual provided other benefits. Finally, needs in the area of his or her own support, it meant that he or she Workplace Culture focused on the ability of had the primary responsibility for implementing the employee to assimilate into the culture, or accessing a needed accommodation. social structure, and routines of a specific work setting. The relative percentages of reported needs in each of four categories are shown in RESULTS Table 3. Almost two-thirds of the identified employer or workplace support needs identified EMPLOYER CHARACTERISTICS were in the area of employee training (63.1%). Overall, 53 employers employing persons Identified employer or workplace support needs with significant disabilities participated in the study. under employee benefits (14.3%), career These 53 employers consisted of businesses from advancement (6.0%), and workplace culture the food and hospitality industry, grocery and (22.0%) were much less prevalent than needs department stores, human services (e.g., hospital, identified under employee training. day care, nursing home), and industrial and manufacturing. The majority of businesses employed fewer than 100 employees at the TABLE 3 -- EMPLOYER REPORTED location where the individual worked. A number SUPPORT NEED CATEGORIES of businesses reported previously employing people with disabilities. Category Percentage

Employee Training 63.1% IDENTIFIED EMPLOYER OR WORKPLACE Employee Benefits 14.3% SUPPORT NEEDS Career Advancement 6.0% During the time period of the study, the Workplace Culture 22.0% participating employers and consumers identified 31 different types of support needs. The identified support needs were categorized into the following EMPLOYEE TRAINING four areas: employee training, career advance- As indicated in Table 4 on the following ment, employee benefits, and workplace culture. page, the most frequently identified employee Employee training needs focused on an indi- training needs for individuals were learning viduals ability to learn and perform the job and how to do the job (32.8%), remembering how encompassed activities such as skill acquisition, to do the job (16.1%), completing job duties completing regular job duties, performing (14.6%), and signing in and out of work independently, and other activities. Career (13.1%). Others identified employer or work- advancement needs addressed an individuals place support needs addressed by employers

185 included recording and monitoring work schedule Employer Training Strategies. To iden- and hours, getting along with co-workers, tify ways in which employers responded to these addressing communication issues, requesting needs, information was obtained on the strategies time off, taking lunch and breaks, and pursuing used by employers to address training and per- career advancement opportunities. formance issues. The data collected from the Employer Support Questionnaire indicate that the majority (90.6%) of employers paired the new employee with seasoned co-workers to do TABLE 4 -- EMPLOYEE TRAINING the training. Employers also provided supervisor NEEDS (N = 198) instruction (54.7%), orientation meetings (34.0%), and company videos (30.2%) in order Employee Need Percentage to train new employees. Learning how to do the job 32.8% In addition to the employers, the employ- Remembering how to do the job 16.1% ment specialists also identified a variety of em- Completing all regular job duties 14.6% ployer or workplace supports available for em- Signing in and out of work 13.1% ployee training in the participating businesses, Orienting around the workplace 8.6% Being able to perform infrequent 5.6% in addition to what employers had recognized. duties Table 5 below summarizes all employer or work- Arranging follow-along 5.1% place supports that were identified by employment Addressing fatigue or stamina 2.6% specialists, employers, and workplace personnel Distractability management to address individual support needs in learning Handling a crisis at work .5% the job. The most frequently cited employer or Advocacy .5% workplace support available for learning the job TOTAL 100% was the use of a co-worker mentor (40.9%),

TABLE 5 -- Accommodations Available in the Workplace Employee Training (N = 198)

Supports for Learning How to do the Job Frequency Percentage

Coworker mentor or coworker training 81 40.9% Employment Specialist 72 31.3% Supervisor Instruction 33 16.7% Company Orientation videos 33 16.7% Standard company training procedures expanded/modified/ 24 12.1% extended Restructuring job duties, making accommodations, developing 20 10.1% compensatory strategies Training provided by a retired person 3 1.5% College student/volunteer 3 1.5% Classroom training 3 1.5% TOTAL 86

186 Article 13 followed by the employment specialist providing employee job responsibilities through career initial training (31.3%). To a much lesser extent, advancement or lateral job changes. However, other employer or workplace supports were also significantly fewer employers (44.2%) offered available to provide training to new employees, assistance in the form of instructional classes including supervisors, retired persons, college or departmental training to their workforce to students, and volunteers. afford individuals the opportunity to advance Role of the Employment Specialist in within the company. Addressing Training Needs. Supervisors For the individuals participating in the (40.0%) and co-workers and other workplace study, pursuing career advancement oppor- personnel (36.9%) were reported as the primary tunities, changing something about ones job providers of support to individuals with disabilities or changing jobs, and learning how to do in learning how to do the job. Employers reported something new at work were rarely identified that the employment specialists were the primary as key support needs as shown in Table 6 providers of support to the individual with a disa- below. However, this could be attributed to bility in only 13.8% of the cases. Though the the relatively short period of time captured by employment specialist was not providing training the study. to the employee, he or she was still instrumental in assisting workplace personnel in training the new employee. For instance, the employment TABLE 6 -- CAREER ADVANCEMENT specialists would advise or demonstrate the best UPPORT EEDS (N = 19) way to provide training to the employee based S N on their knowledge of the skills and abilities of Employee Need Percentage the individual with a disability. Duration of Training. A majority of the Pursuing career advancement 42.1% employers typically allocated almost 3 weeks to opportunities initial training of new hires (53.8%), with slightly Learning how to do something 31.6% more than one fourth of the employers (28.8%) new at work devoting as much time as needed to new em- Finding a different or second job 15.7% ployee training. However, an overwhelming majority of the employers (92.3%) reported Resigning from work 5.3% offering ongoing training for all employees in the form of co-worker mentoring, company Changing something about the 5.3% job videos, and supervisor instruction. The idea that ongoing training or co-worker mentoring is avail- TOTAL 100% able at a majority of the businesses is especially encouraging in light of the fact that remembering how to do the job and learning how to do the EMPLOYER BENEFITS job were frequently identified support needs by Reported support needs in the area of supported employment participants. employee benefits are summarized in Table 7 on the following page. Slightly more than one- CAREER ADVANCEMENT half of the employers offered paid vacation A majority of the employers (92.3%) and about one-third offered paid sick and offered assistance to employees in changing holiday leave for full-time employees. However,

187

Tttiitftlitdbi when employees identified support needs such WORKPLACE CULTURE as requesting time off from work, calling in sick Employers reported a small number of dif- or late to work, and arranging work schedule or ferent support needs in the area of workplace hours, employers accommodated individual culture. These support needs are identified below requests if it did not disrupt the operation of the in Table 8. The employers ability to deal with business. For example, less than one-fourth of disruptive or problem behaviors by the employee the employers (17.0%) indicated that employee was identified most frequently in this area. Other schedules are permanently set and slightly more needs addressed social interaction issues such than two-thirds (67.9%) indicated that employee as getting along with co-workers and addressing schedules are determined on a weekly or monthly communication problems, as well as scheduling basis. the employees time (arranging work schedules and taking lunch or breaks).

TABLE 7 -- EMPLOYEE BENEFITS UPPORT EEDS (N = 54) S N TABLE 8 -- WORK CULTURE

Employee Need Percentage SUPPORT NEEDS (N = 62) Calling in sick or late 48.1% Employee Need Percentage Purchasing/selecting/main- 14.8% taining uniforms Dealing with aggressive, disrup - 24.2% tive, or problem behaviors Picking up and cashing a pay- 14.8% check Arranging work schedule/hours 22.6%

Requesting time off from work 13.0% Taking lunch and/or breaks 19.3%

Receiving a raise or increased 5.6% Getting along with coworkers 11.3% benefits Recording and monitoring 9.7% Addressing sexual issues 3.7% schedule/hours

TOTAL 100% Addressing communication issues 9.7%

Participating in social activities 1.6% Transportation is one of the most fre- during work hours quently cited barriers to employment for people Developing friendships 1.6% with disabilities (Unger et al., 1998; West et al., 1998). Employers in this study revealed a small TOTAL 100% percentage of employers (15.4%) provided or arranged transportation for their employees. The Certainly the arrangement of the work- employers who provided or arranged transpor- place and the contact among employees tation frequently indicated that they assisted throughout the workday may enhance or prohibit employees in identifying co-workers who carpool the ability of co-workers or other personnel to or assist in transporting co-workers who need a provide any type of support. Several questions ride to and/or from work. on the Employer Support Questionnaire ad-

188 Article 13 dressed the typical routines of co-workers and and workplace culture. This is especially their physical proximity in the work environment encouraging since, under the ADA guidelines, for identifying potential sources of support for employers are only required to provide individuals with disabilities. Almost three-fourths reasonable accommodations that would en- (71.2%) of the employers reported that co-workers able qualified individuals with disabilities to were in a close proximity to each other through- perform essential job functions. The types of out their workday. Furthermore, the majority of workplace accommodations provided by em- employers (61.5%) reported that assistance was ployers in this study go beyond the legal con- available for employees throughout the day from cept of reasonable accommodation. For other co-workers. In almost three fourths of the example, though almost two-thirds of the em- businesses, employers also claimed that super- ployee support needs occurred in the area of visors were readily available to provide assistance employee training, employers also accommo- to employees. dated numerous support needs in other areas as well. These findings are promising given the fact that businesses represented in this study DISCUSSION are relatively small; almost two-thirds of the businesses employed fewer than 100 employees at the location where employees with The results of the study describe employers disabilities were working. Typically, smaller assessment of workplace supports available within businesses do not have extensive human re- their businesses, workplace accommodations source staff, disability management programs, provided to employees with disabilities, and the employee benefit services, or the depth of role of human service providers in facilitating resources that might be available at larger those accommodations. Employers indicated that companies. The small employers ability to pro- a variety of workplace accommodations were vide workplace accommodations to address available within their employment environment. the diverse needs of their workforce contradicts This finding is consistent with information reported the belief that workplace accommodations in professional literature (e.g., Hanley-Maxwell represent overwhelming challenges to small & Millington, 1992; Wehman et al., 1998). In- businesses and that they are less flexible in creasingly, employers are being relied on to pro- providing accommodations (Mills, 1997). vide training to employees with disabilities. One might infer that if businesses Because some employees will require accom- employing 100 or fewer employees have a modations that will extend throughout the course variety of workplace accommodations avail- of the individuals employment, employers are able within their workplaces, then businesses beginning to identify and develop formal and employing larger numbers should, at the mini- informal types of support within the workplace mum, be able to provide similar accommoda- to provide assistance to their employees. tions. Many large corporations have well- For people with disabilities employed at developed and effective human resource and/ participating businesses, workplace accommo- or disability management programs (Akabas dations were provided to address a variety of & Gates, 1993; Hunt, Habeck, Owens, & identified support needs in the areas of employee Vandergoot, 1996) to assist supervisors and training, career advancement, employee benefits, other personnel in identifying and developing

189 accommodations and resources that, arguably, plays in facilitating workplace accommodations. smaller, independently-owned employers might Just because a support is available does not mean not have access to and/or the financial or human that employees with disabilities can easily access resources to support. Consistent with the findings the accommodation. For example, over one- reported by Granger et al. (1997) and Miano fourth of the employers (28.9%) in this study re- and colleagues (1996), the majority of accom- ported that one of benefits offered to employees modations provided to employees with significant was access to an employee assistance program. disabilities in this study were readily available in However, employee assistance programs were not the employment environment and/or facilitated reported as an accommodation in addressing by employment specialists. the variety of support needs for employees with disabilities. The employer may be aware the COSTS OF WORKPLACE ACCOMMODATIONS program exists but may be less familiar with the The results of this study support the services offered through the program or how findings of other research showing that the costs employee assistance programs can be used in of the majority of accommodations are not less typical capacities (e.g., job carving, job re- prohibitive (e.g., Blanck, 1992; Daly & Bond, structuring, modifying employee schedules, etc.) 1996; Presidents Committee on Employment of to provide workplace accommodations to em- Persons with Disabilities, 1994; JAN, 1995). ployees with disabilities. Supervisors may also Additionally, employers making accommodations dismiss the employee assistance program as a for employees with disabilities often find that the potential source of accommodations because accommodations are effective and useful for other they believe the services offered through the pro- workers, thereby enhancing the economic value gram cannot meet the support needs of the of the company (Kregel, 1999; Magill, 1997). employee with a disability. A number of accommodations for em- In order to maximize existing employer ployees in this study relied on either modifications supports, employment specialists and human ser- of preexisting resources (e.g., training materials, vice personnel must be able to identify, assess, equipment), work routines, or assistance provided negotiate, and modify accommodations or by co-workers or other work personnel. In situa- supports existing in the workplace, while con- tions where accommodations involved the actual sidering the abilities and preferences of the purchase of items, equipment, or services, the employee with a disability. The extent to which costs were nominal. For instance, an individual employment specialists can assist employers to employed at a restaurant received a carry-all recognize accommodations available in the work to enable her to retrieve all of the necessary con- setting should assist in alleviating employers diments from the back in one trip so she could concerns and apprehension surrounding the idea more expediently restock the lobby area. Another of reasonable accommodation and the idea employee benefited from the use of a watch with that accommodations are costly. By developing numerous alarms to prompt him to the next task partnerships with employers, employment spe- or to take a break and return from break. cialists and rehabilitation professionals play a critical role in the identification and development EMPLOYMENT SPECIALISTS ROLE IN of workplace accommodations for employees FACILITATING WORKPLACE SUPPORTS with disabilities. The data resulting from this study also As demonstrated by the responses to reflect the critical role the employment specialist questions on the Employer Support Question-

190 Article 13 naire, employers may be knowledgeable about with photos, diagrams, and icons. The training accommodations available within their organi- manual, with photos, diagrams, and icons, zations. However, results also confirm, they are could be modified to aid an employee with a less aware of how to access, modify, and utilize disability in remembering how to complete all the resources identified within their businesses to necessary job tasks. It is vital that supervisors provide accommodations to employees with and co-workers understand that the support disabilities. The experiences of employment spe- needs of employees with disabilities are ana- cialists indicate that employers are not unwilling logous to the variety of employment-related or unable to provide workplace accommodations, issues that occur among individuals with no but they may not (a) be aware that the accommo- apparent disabilities (Miano, et al., 1996). dation need exists, (b) know how to best assist Further, employment specialists can assist em- individuals with disabilities in identifying and ployers with matching or modifying exiting developing workplace accommodations, and (c) workplace accommodations to address sup- be able to formulate some type of workplace ac- port needs of employees with disabilities. commodation that might address the individuals needs. ROLE OF SUPERVISORS AND Employers may also overlook workplace CO-WORKERS IN PROVIDING WORKPLACE SUPPORTS accommodations readily available within or The data also confirm the instrumental through their businesses. The ability of employ- role of supervisors and co-workers in providing ment specialists to collaborate with employers support to co-workers with disabilities. Super- and other workplace personnel is critical in visors and co-workers were the primary pro- identifying and developing existing employer viders of support for individuals with disabilities supports. In most instances when a support need in a number of areas, including learning how was identified, such as assisting employees in to do the job, completing regular job duties, remembering how to do their jobs, or punching being able to perform infrequent duties asso- in and out of work and taking breaks, the em- ciated with the position, learning how to do ployer had both the capacity and the resources something new at work, and taking lunch and available to provide accommodations to workers other breaks. These findings are consistent with disabilities. However, their limited experience with the ideas described in the supported em- in the areas of employing people with significant ployment literature that advance and/or des- disabilities and identifying and developing work- cribe the use of workplace personnel to pro- place accommodations may prohibit their ability vide support to employees with significant to identify and develop needed accommodations disabilities (e.g., Fabian & Luecking, 1991; already available. Hagner, Butterworth, & Keith, 1995; Unger For instance, a large national department et al., 1998). store chain developed a formal training program The employment of people with disa- designed to address the problem of illiteracy in bilities is evolving, due in part to more favor- its workforce and training new employees. Prior able employer attitudes toward individuals with to implementing the training program, in which disabilities in the workforce, workplace cultures they desired to retrain entry-level workers such that embrace workforce diversity, assistive tech- as cashiers, snack-bar attendants, and others, nology, progressive laws designed to ease the they revised the employees training manuals by entry of people with disabilities into the work- removing almost all the words and replaced them force, and the perseverance of individuals with 191 disabilities. In the mid-1980s, supported em- willingness to provide accommodations that assist ployment and human service professionals were in retaining valuable employees. Not only are uncertain whether people with severe disabilities employers providing support for initial job site could perform to the expectations of employers training, they are also assisting employees with or whether employers would embrace the idea disabilities in pursuing career advancement op- of individuals with disabilities in their workforce. portunities, accessing inhouse employee work- In an effort to get people with significant disa- shops and personal development seminars, and bilities into the workforce, employment specialists assisting in or arranging their transportation. and human service professionals convinced Overall, the findings of this study parallel skeptical, but willing, employers of their ability the results of other research describing the types to identify appropriate jobs then provide the of accommodations in the workplace for people necessary training and support to ensure that with disabilities. For example, Granger and col- the individual would be successful in performing leagues (1997) described the types of job accom- his or her job. Now, after the success of millions modations provided to employees with psychiatric of Americans with disabilities, supported employ- disabilities as benign and relatively nonintrusive; ment providers find themselves collaborating with often subtle shifts in workplace procedures are potential employers who feel confident and are made that employers, who wish to keep valued willing and able to provide training and support employees, might also make for those without to individuals with disabilities in the workforce. defined disabilities. The present findings are unique, because they demonstrate that employers are quite capable of providing workplace accommodations for workers with significant disabilities SUMMARY by drawing on existing employer resources. Additionally, this study has shown that the types of workplace accommodations provided by em- The results of the present study depict employers in the survey go beyond the legal concept ployers who have gone above and beyond mere of reasonable accommodation and address em- compliance with the Americans with Disabilities ployee needs in such areas as career advance- Act. By addressing a variety of employee support ment, changing something about ones job, and needs for the duration of the employment rela- social integration. tionship, employers have demonstrated the

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195 196 Workplace Supports in Practice

By: Pat Rogan, Becky Banks, & Michelle Howard

INTRODUCTION ABSTRACT

This article reports the findings of a study Since the beginning of supported employment, inte- that investigated ways in which workplace gration has been a defining feature of good practice. Both supports are being conceptualized and implemented by four organizations that physical and social integration are considered critical provide supported employment services. aspects of supported employment. Job coaches or employ- Data were collected during two-day site ment specialists are also a core feature of supported visits at each organization. Site visits included observations at 39 work sites; employment. In recent years, the concept of natural sup- semistructured interviews with 126 pri- ports has emerged, focusing on the importance of adhering mary stakeholders (individuals with to the norms and practices of workplaces and tapping disabilities, co-workers, employers/supervisors, and agency employment staff); supports that exist or can be developed. This effort to de- document analysis (e.g., program des- fine, implement, and evaluate natural or workplace sup- criptions, training and marketing mate- ports has addressed the rationale and scope of natural rials); and a written survey about supported employment beliefs and practices. supports (Nisbet, 1992), social relationships between em- Findings indicate that each agency was ployees with disabilities and their coworkers (Chadsey, driven by strong leadership, vision, and Linneman, Rusch, & Cimera, 1997), the climate or culture values. Each organization had a history of innovation and change. Staff were of workplaces (Hagner, 1989), business practices used to well-trained, committed, and professional, support diverse workforces (Fabian, Luecking, & Tilson, and worked collaboratively with each 1994), and employment consultant roles and strategies other and with businesses. The use of natural supports was promoted within (Hagner, Rogan, & Murphy, 1992; Murphy & Rogan, each organization, but there was a wide 1992; Parent, Unger, Gibson, & Clements, 1994; Shafer, variety of interpretations and practices 1990). An ongoing national study of supported employ- among staff. The discussion highlights areas with which these organizations ment practices by Mank, Cioffi, and Yovanoff (1997, struggle, including: serving people with 1998) indicated that the more typical (or natural) the high support needs; developing a strong process of job acquisition, training, and support, the better emphasis on person-centered approaches to planning and service delivery; the outcomes for employees in terms of wages, integration, assisting staff to facilitate workplace sup- and benefits. Furthermore, the study indicated that the ports and social relationships; actively greater the integration, the higher the wages and benefits. involving job seekers in the job search Thus, implications for supported employment providers are process; and increasing work hours and/ or responsibilities of the employees with great. How are supported employment providers con- disabilities. ceptualizing and facilitating workplace supports? What strategies are being used to maximize workplace supports,

197 while assuring additional supports are provided identified within and across data sets. A draft of as needed? How are people with high support this report was sent to each organization for re- needs being supported on the job? view and feedback prior to being finalized. The purpose of this study was to investigate This article describes the characteristics the ways workplace supports are conceptualized of these organizations, staffing patterns, supported and implemented by a subset of organizations employment practices, and strategies related to involved in the Mank, Cioffi, and Yovanoff workplace supports. The discussion section sum- (1997, 1998) study. Four of the organizations marizes key findings and proposes further areas that ranked highest on measures of typicalness for research. were selected for this qualitative study. These organizations were Life Skills Foundation in St. Louis, Missouri; Elwyn, Inc. Employment Support Services in suburban counties near Philadelphia, CHARACTERISTICS OF THE Pennsylvania; Eastside Employment Services in ORGANIZATION Seattle, Washington; and Enable in Syracuse, LIFE SKILLS FOUNDATION, New York. ST. LOUIS, MISSOURI Two-day site visits were conducted at each Life Skills Foundation was established in organization. Site visits included: participant ob- the 1960s by family members. It is a large servations at a total of 39 work sites; semi- organization serving approximately 1000 individ- structured interviews with a total of 126 primary uals and employs over 400 staff. Programs and stakeholders (43 employees with disabilities, nine services include supported employment, sup- co-workers, 29 employers/supervisors/managers, ported living, a summer work program, and a 44 agency employment directors, coordinators, non-work day program. The supported employ- or consultants, and one parent); document anal- ment program, covers urban and suburban areas, ysis (e.g., mission statements, program descrip- serves about 200 people per year with 15 staff. tions, marketing materials, training manuals); and Organizational Philosophy and Val- a brief written survey about beliefs and practices ues. Life Skills has had a traditional organiza- completed by supported employment personnel. tional structure, but a history of pursuing progres- The interview protocol for each constituency is sive services in supported living, supported em- provided in Appendix A. When possible, inter- ployment, and related areas. The mission of the views were tape recorded and transcribed ver- organization states: Life Skills Foundation assists batim. Detailed notes were taken when tape people with disabilities to live and work with recording was not possible. dignity in our community. Supported employ- A constant comparative method of data ment personnel stated that: analysis (Wolcott, 1994) was used to sift through the data as it was gathered from each source. a) Individuals should have choice in the type That is, researchers (the authors) met at the end of job they want. of each day of data collection to reflect on the b) Individuals should achieve independence information gathered and to identify emergent from paid supports. c) Individualization means tailoring supports to themes, perceptions, and interpretations across meet each persons needs. observations and interviews. In addition, interview transcripts were analyzed and independently Leadership. The current Director of Em- coded by each researcher. Key themes were ployment Services, Jocelyn Jones-Waller, has a 198 Article 14 long history with the organization, serving for years as the organization has hired more full- 13 years in supported living and socialization time positions and developed a team structure. services. This background significantly impacted Funding. Life Skills operates under her orientation toward holistic and comprehensive an outcome based funding system. The organi- services, and individualized, person-centered zation receives $1440 per assessment (half at planning processes. She brought this orientation referral and half at completion), and $1440 to the employment arena. Jocelyn provides per placement. Job coaching is reimbursed strong leadership with an open, collaborative via purchase of service agreements with voca- style. Her strong values and vision have enabled tional rehabilitation. County monies cover staff to make many positive changes in a short follow-along services, and are reimbursed at period of time. According to Jocelyn, the employ- $28-$32 per hour. ment program is seen as somewhat radical within the larger organization. In her words, We are ELWYN, INC. EMPLOYMENT SUPPORT able organizationally to adjust and move quickly. SERVICES, PENNSYLVANIA We have that flexibility to just go for it. Identify Like Life Skills Foundation, Elwyn is a the outcome and just go for it. very large organization that serves Philadelphia Staffing Patterns and Roles. A Pro- and surrounding suburban counties, and has gram Coordinator hires, trains, and supervises divisions in New Jersey, California, Delaware, 12 full-time job consultants. A Corporate Devel- and Israel. Elwyn began in 1852 with residen- oper works with Life Skills and provider agencies tial cottages for boys. It now runs a school on in the area to work with businesses and develop their organizations campus, and provides jobs. The 12 job consultants are divided into early intervention, residential, short-term men- two self-directed work teams that meet weekly tal health, genetic counseling, and employ- three times per month, and together once a month ment services. Adult day programs include a for training. Each team has a team leader. In day habilitation program, three sheltered addition, part-time on-site consultants are workshops, and a supported employment pro- hired to provide job coach services at work sites. gram (since 1985). Staff Training. Life Skills prefers to hire Organizational Mission and Values. people with real world experience, maturity, and While the larger organization has discussed good attitudes. New staff members are given a closing their segregated programs, it has not two to three day orientation/training emphasizing been until recently that there has been real natural supports by a senior staff person and an interest in doing so. The overall mission of employment services handbook outlining sup- Elwyns employment services is matching the ported employment procedures. Experienced job labor needs of employers with the employment consultants take new staff to visit sites where needs of people. people are working. Staff are trained as gen- Leadership. Like Life Skills Founda- eralists who are involved in all aspects of the tion, Elwyns employment support services has employment process from assessment through job a strong female director who has been with coaching. However, part-time staff are assigned the organization for over ten years. Cindy to provide ongoing support or back-up support. Sterling began as an employment specialist. Staff Retention. Staff retention ranges She has clearly set the tone for the development from 1 1/2 to six years, with an average of two of innovative services. Her program is viewed to three years. Retention has improved in recent as radical within the larger organization.

199 Staffing Patterns and Roles. There are Leadership. The Executive Director, 35 staff serving a two county region. Staff are David Schlesinger, has been with the organization not formally organized in a team structure, but for 12 years providing an involved, low-key there is strong collaboration among staff. leadership. His role is an articulator of quality, Staff Training. Staff are trained as gener- as well as, reading the curve and being ahead alists who are involved in all aspects of the em- of the curve while positioning the organization ployment process. Training involves a three-day for the future. employment specialist workshop, inservices, and Staffing Patterns and Roles. As with shadowing an experienced job consultant. Job the two agencies described above, all staff posi- consultants are to continually access information tions are designed as generalists, although this through training opportunities such as Association has not always been the case. Staff roles are for Persons in Supported Employment (APSE) based on peoples strengths. Staff work closely conferences, and written materials. The budget together as an informal team and meet every includes $500-$700 per staff for training. Cindy two weeks. The Program Manager is responsible Sterling, Director of Employment Services said, for quality assurance and staff training. We do a lot of reading and talking about things Staff Training. New employees receive related to supporting people. an employee handbook and learn about the or- Staff Retention. Elwyn staff are adults ganizational values, procedures, and policies from diverse backgrounds, including careers in and shadow experienced staff mentors. Eastside business. Current staff had been with employ- supports ongoing staff development via confer- ment services from a few months to six years. ences and training opportunities according to Funding. Supported employment has a needs and interest. Staff exhibit a high level of $1.5 million dollar budget, comprising a small professionalism in their dress and behavior. portion of the total organizations budget of $120 Staff Retention. Staff turnover is low with million. The largest funding source is the County staff being with the agency from three to seven mental health/mental retardation with vocational years. The executive director treats the hiring rehabilitation providing a smaller portion process as a getting to know the job seekers. ($90,000). County funding is set up as a fee- He gathers information about the person and for-service, vocational rehabilitation uses a provides quality training once they are hired. performance based funding system. Situational Turnover is reduced by hiring wisely, providing assessments are authorized for up to 20 days at competitive salaries and benefits, giving bonuses, a fee of about $179 per person per day. Authori- and investing heavily in personnel. zation for job development and support services Funding. Eastside Employment Services up to 90 days is usually 100 hours per individual. receives block funding from the county for serving There is flexibility in negotiating each package. a given number of people. County monies are used for general job development and follow- EASTSIDE EMPLOYMENT SERVICES, along. They also receive fee-for-service dollars SEATTLE, WASHINGTON from vocational rehabilitation for job training. Eastside Employment Services began in 1984 as a spin-off of a sheltered workshop. The ENABLE, SYRACUSE, NEW YORK organization is small, providing only community Enable, an affiliate of United Cerebral employment services to 71 individuals with 7.25 Palsy, has been operating since 1948. It is a full-time staff, with five providing direct services. large, multi-service organization that provides

200 Article 14 early intervention and inclusive preschool services, involved in monthly inservices and are encour- medical and clinical services, assistive tech- aged to attend other training events. nology, family support, self-directed personal ser- Staff Retention. Staff turnover among vices, community living, day habilitation, and coordinators is low, ranging from 5 to 12 years community employment services. at Enable. Turnover among employment con- Organizational Mission and Values. sultants is fairly low compared with other pro- The principles espoused by the organization viders in the area due to the reputation Enable include choice, inclusion, individualization, and has earned for providing quality services. empowerment. The philosophy of Enables Funding. Enable is funded at a higher Community Employment Services is to: rate than other organizations ($9600/person), because they have traditionally served people support employers and people with with high support needs. Their follow-along disabilities by setting up jobs that satisfy rate is $3200 per person per year. both person and the employer. We believe all persons with disabilities have the right to the same opportunities and AN OVERVIEW OF SUPPORTED experiences as non-disabled citizens. EMPLOYMENT PRACTICES A persons choice is our priority when The primary purpose of visiting these seeking employment opportunities. organizations was to learn about their workplace support strategies. It was important to Leadership. In the past, Community understand their entire approach to supported Employment Services had a director, they now employment in order to learn when they attend operate as a self-directed team, with a coordi- to support issues and how supports are facili- nator for the four teams. Each coordinator had tated. The following sections address assess- previously been an employment consultant in ment, job development, training, and ongoing the agency. As coordinators, they do not carry support procedures used by these programs. a caseload. This approach is unique nationally, All names of people are pseudonyms. The and epitomizes a flat organizational structure and reader is reminded of the Mank, Cioffi, and team approach to supported employment. Yovanoff findings (1997, 1998) the more typi- Staffing Patterns and Roles. Com- cal the job process, the better the outcomes. munity Employment Services has 25 staff. In addition to four coordinators, there are typically five employment consultants per team who support 6-10 individuals each. Six job coaches GETTING TO KNOW AND provide only support on the job. Employment PLANNING WITH JOB Consultants have traditionally operated as SEEKERS generalists; however, a job developer and voca- All four agencies referred to the process tional counselor position were recently added to of getting to know, and planning with, job supplement the efforts of staff. seekers as intake and assessment, tradi- Staff Training. Enable invests heavily in tional terms in supported employment. Various staff training, which involves a period of up to forms of person-centered planning were used six weeks during which the new staff person learns by the organizations. Approaches included: primarily through hands-on experiences with meeting with job seekers at their home or senior employment consultants. All staff are agency offices to gather information; spending

201 time in community settings; observing job seekers interests and skills of each job seeker. Three of during job try-outs; and obtaining information the four organizations used this approach. East- from files, parents/guardians, and other sources. side Employment Services uses a jobs first ap- Planning involved staff, the job seeker, parents/ proach in which they find people to fill jobs. As guardians, and funders. an Eastside job consultant said, In the job devel- As stated by a job coach supervisor, opment phase we try to sell a pool of people Getting to know the person well is the key to willing to work. The agency feels this approach successful workplace support. However, due to is appropriate due to two factors: pressures from funders and systemic issues, each organization differed in the amount of time they 1) the nature of their clientele (most do not spent with job seekers and the activities in which have intensive support needs), and they engaged. One organization used a fairly 2) the local practice that no organization standard approach with job seekers that involved owns job seekers; they are free to seek situational assessments at three job settings in services from any provider. the community. Afterwards, individuals could be deemed not ready to work, an out-come The use of personal connections to secure not considered appropriate by supported employment has long been a common practice employment advocates. It did not appear that in our society. Each organization has shared any of the agencies commonly used Personal examples of using connections to find jobs, or Futures Planning, PATH, or other planning tools. starting with the contacts that individuals have. For example, neighbors of Johns have connections with the manager of the grocery store and helped him secure his job, and Larry found his JOB DEVELOPMENT AND job through connections with a board member EMPLOYER CONTACT who works with the dental laboratory. Staff also used their personal connections to open doors Staff were asked to describe their ap- to employment for individuals: One of the proach to job development and employer con- managers at Keiths job was friends with someone tact, while job seekers were asked how they got from Life Skills. their job, and employers were asked how they Cold calls and drop-in visits were also were contacted. Each of the organizations shared commonly used, especially for people considered common approaches to job development, but more capable. For individuals who could fill also used unique strategies that met their needs. existing job openings, employment consultants While all four organizations considered staff to or job seekers called to ask, Are you hiring? be generalists, three of the organizations added Job seekers had varying levels of involve- a job or corporate developer position in recent ment in their job search. If job seekers were in- years to supplement the efforts of employment volved, staff assisted in completing job appli- consultants. At one agency staff do not do job cations and interview for jobs. development until they have sufficient experience Employment consultants were asked how providing supports on the job. they approached employers. The following Supported employment has largely fol- quotes represent efforts to learn about the needs lowed a person-first approach to job develop- of employers, and to provide the support they ment. That is, jobs are sought based on the may need:

202 Article 14 We can meet your needs to fill high if it had been done differently at the beginning, turnover jobs or jobs you cant fill. fading would be easier. Once we build a I find out from employers what their rapport with an employer, we stress that youre needs are. I sell that I am on call and the employer, you do training and supervision, there for the long haul. but the job coach can help. I come in and help you with training; Since these organizations were selected help you understand their needs and due to higher ratings on natural support mea- get to know the person. sures, it is not surprising that they were so attuned to workplace support issues. This section sum- One agency executive pointed out that marizes perspectives on natural or workplace Typical is not always good. For example, Brent supports discussed by employment consultants (an employment consultant) sniffs out job open- and workplace personnel. ings within the company and goes to Alison (an Perspectives on natural supports. employer). They dont even let the process open Employment consultants offered various defini- up to others or our person wouldnt get it. In tions/descriptions of natural supports. The fol- other words, the employer hires an individual lowing quotes are representative of comments with a disability without advertising the position. addressing the work environment, work-related Each of the organizations secured a wide supports, integration, and social relationships. variety of jobs, most of which were part-time and Natural supports are other than offered at least minimum wage. Eastside Employ- paid agency staff (e.g., co-worker, ment Services was the only organization that friends, calendars, clocks, objects steered away from fast food and high turnover used for support). Supported em- jobs: We dont do Burger Kings and other high ployment staff start facilitating natural supports when a barrier is iden- turnover jobs. These are not seen as valued jobs. tified, and look for unpaid ways We target full-time or close to full-time work. to eliminate barriers. Table 1 on the following page provides a listing of the jobs that were observed for each agency. Getting the person integrated in the workplace as close to the way we are integrated. We try to integrate them in the workplace so they are not an island. JOB TRAINING AND SUPPORT Connect with existing resources first, even during job development and other support activities. Being avail- The primary discussion area regarding able for the individual when neces- workplace supports is job training procedures. sary, but not taking front and center Job coaches train employees, then fade from stage. Rather, allow the individual the job site once the individuals learned their and employer to conduct the show. jobs. Attention to natural supports has caused My role is helping co-workers feel employment consultants to rethink their role in comfortable enough to treat them relation to workplace personnel. An employment like anyone else. consultant summed up the issue well when he The work environment, employees said, Its our industrys fault that employers think proximity of job--consider all of these we should do the training. We have some people, natural supports.

203 TABLE 1 -- WORK SITES OBSERVED

LIFE SKILLS FOUNDATION, ST. LOUIS ENABLE, SYRACUSE

Grocery Store -- bag groceries, collect Label Company -- shred paper, clean carts, price checks Bottle Redemption Center -- sort Fast Food Restaurant -- clean dining bottles area Bagelry -- cleaning Dental Lab -- clean casting molds Print Shop -- duplicating Videotape & Recording Distributor -- State Senators Office -- clerical sort mail, unpack shipments Copy Products Sales & Service -- Phone Refurbishing Company -- clean telemarketing and test telephones Restaurant -- cleaning License Photo Lab -- license photo Data Processing Service -- data entry operator Teleservices -- photocopy, shred, deliver mail EASTSIDE EMPLOYMENT SERVICES, Hotel -- dishwashing, custodial SEATTLE ELWYN, INC., PHILADELPHIA Sign Making Business -- custodial Recycling Plant -- recycle Fast Food Restaurant -- custodial City Court -- filing Court House -- custodial Bank -- clerical Condominium -- grounds work School District Admin. Bldg. -- clerical College Food Services -- food Circuit Board Company -- assembly preparation Software Manufacturer -- clean/supply Convenience Store -- custodial, stock kitchen, mail room Car Dealer -- wash cars, custodial State Division of DD -- clerical Restaurant -- food preparation

Employment consultant strategies. First I start out at 100%. Im there Employment consultants offered various accounts everyday, every hour they work. Its required that were there 100% to see of the way they approach training and support and observe. You start at 100% and for employees with disabilities. Despite an eventually fade to 25%. When they organizational orientation toward natural sup- are at 25% we put them in retention. ports, some employment consultants described a prescribed process that was driven by the Another employment consultant reiterated his role agency and job coach: as the primary trainer:

204 Article 14 I try to learn the job myself, then model they all have lunch together, or if it. I get the person to do the job, then the consumer has a question or I get the employer involved. problem, saying, Why dont you go to this co-worker here and helping In contrast, most other employment consultants the consumer pick out people and know they can go to other people. offered a completely different orientation that was based on typical procedures used in businesses: Just get a lot of feedback from the other employees and the employer, I prefer not to do the training because being very open and communicative thats not really our job. If another with them, and seeing how the con- employee came in, they would do the sumer is doing and asking them how training. they feel. Its trial and error. Pick people who The executive director of one agency described are interacting, who show interest at their philosophy of workplace supports in this the same place and time. Often way: people will volunteer, sometimes I have to cultivate it more. As little as possible, as much as necessary. I pay attention to who is paying attention to the individual.

As a standard practice, one organizations I figure out from an employers per- staff does a formal Welcome on Board presen- spective Whats in it for me? I iden- tation for personnel that addresses such questions tify barriers and provide sugges- as, what is supported employment, what can you tions. expect from us, what do we expect from you, and what are developmental disabilities? The All of the organizations had worksites goal of this training is to develop natural supports where more than one person with a disability and build bridges. The other three agencies worked. Half to two-thirds of the worksites of used an informal approach of sharing informa- one organization had multiple people working tion and involving co-workers. in different areas of each business. One of The following tips were offered for the agency directors felt that through multiple facilitating natural workplace supports: placements in one company, the environment trains itself. From day one ask co-workers for Several of the larger businesses that em- input and ideas. They know the job; ployed up to eight individuals with disabilities you have to get to know them and look had a supervisor or manager who acted as a to them for help. You have to help them see they are so important. champion for supported employment. While these company personnel spoke eloquently of The more time the job coach puts in the benefits of supported employment, they (at the worksite), the less bonding the also viewed it as a program, and spoke of the employer and co-worker have. If the job coach only works with the con- supported employees as a group. sumer, it is an us and them kind of When asked how their role as a job thing. coach had changed over the years, an employment consultant since 1985 addressed I help develop supports myself by introducing people and suggesting that the shift from a social service to a business

205 mentality, and from taking care of people to Deluxe Teleservice in Syracuse is another building their skills in workplaces. She said, It supportive company. An employee described it is the difference between social services, caring, as a very diversity-oriented, people-oriented and hands-on experience with disability, to staff organization. The company hires many people with business experience, social skills, ability to with different abilities. It offers uplifting, encour- interact, and good appearance. We figured it aging programs for professional development. would be easier to teach people about disability. Awards are given to recognize people for their Another person who had been an employment good work performance. Chefs are brought in consultant for ten years said, Weve changed! I occassionally to fix food. Deluxe sponsors a used to wear a uniform at Wendys. We were 50s day, ice cream socials, and other fun events perceived as an employee and expected to per- for their employees. The employee with a disa- form. I remember one co-worker saying, Get bility knows everyone and is well known through- up and go start those fries! Now were here as out the workplace. He even mentioned that co- a consultant or facilitator to assist with training. workers had attended a party at his home. Tube Art, a sign-making company in Seattle, was described by one of the managers as being very family-oriented. Managers work WORKPLACE CULTURES OR side by side with employees. The company offers CLIMATES diversity training through their human resources department. This training occurs during staff Attention to workplace supports must also orientation as well as through their management involve attention to the culture or climate of the training. The training has been expanded to work setting. Each work setting is unique, with include disability training. However, one of the characteristics that can enhance or impede the managers felt that the most effective method of success of individuals with disabilities. This sec- addressing employee support issues was during tion provides a discussion of several of the work- department head meetings. Personnel issues were places that were positive for emplyees. discussed at these meetings, including discussions The employers or managers of some about supports for Mitch, who has a disability. workplaces had reputations for being supportive One individual described the difference of a diverse workforce. Diversity and disability in workplaces between his two part-time jobs. awareness was part of their orientation and At one worksite, people are nicer. They get training programs. One such company was along, talk together, and help. They celebrate Deirbergs grocery stores in St. Louis, which hired special days. At the other site (fast food) he numerous people with disabilities. A manager feels there are no interactions. at one of the stores grew up with an individual with a disability and was described as caring and treated people fairly in comparison to their competition. Within such an environment, co- SOCIALIZATION AT WORK workers are more apt to be supportive. For one employee, whose grooming could be a problem at work, the head checker had a razor, shaving Social interactions are difficult for many cream, comb, and an extra white shirt and tie at individuals, but are a critical aspect of workplace work in case he needed these. supports. Why are some people well integrated

206 Article 14 on the job while others remain peripheral to the down and realized I wasnt going to social routines of the workplace? Several factors fire her. I took her under my wing. That seemed to be the turning point need to be examined. Most of the employees in for her. I think it is good for us. this study worked part-time. Thus, they arrived Yeah, she is not easy to deal with at at work late, left early, and/or worked fewer days. times, but if that happened to me tomorrow, I would hope someone As a result, they missed out on the daily routines would help me feel productive in and social rituals that often serve to bond co- society. Thats what drives me to workers together. Observations and interviews keep her here. revealed that many employees with disabilities took their breaks and ate their lunches alone. Management spoke of their employees When people appeared to be socially involved work ethic: He is a hard worker, willing to at work, there was always at least one ally work on his day off, or will work later than who truly enjoyed the individual and watched scheduled. He needs to be told to take a out for him or her. These allies were often both break or hell skip it. The manager at a car proud and protective. For example, a co-worker dealer said, With John, we feel part of the at the dental lab feels responsible for supporting community. You need to give back. Besides, Mark and talking things through with him when hes a hell of a worker. he has problems. If he gets particularly upset, Other employers spoke about the she contacts a supervisor in another department positive impact their employees have on the who has taken Mark under his wing. work environment: Another co-worker said, When Bob has a seizure, I will go to him, hold him, tell him it is They help to bring us down to earth. OK, and I let him get back in sync. I tell his Sometimes they cut through hidden agendas because they see things parents and I track the occurrence of the sei- more in black and white. They have zures. pride in their work. They are concerned about all of us. We have learned sensitivity because they wont play the corporate game. Their presence has affected the atmosphere in EMPLOYER/SUPERVISOR/ the workplace. MANAGER PERSPECTIVES Some employers, supervisors, and man- Most employers, supervisors, and agers went out of their way to accommodate managers had wonderful things to say about their individuals with disabilities. The supervisor at employees as workers and as people, even with a Seattle software manufacturer says the some rough moments. One supervisor had support she gives is just the common things invested in the success of the employee, said: any manager would do: finding out what moti- Im not going to say it was easy. For vates them, and how to champion them. the first six months she was just about Some atypical things she has done include all anybody could handle. She would explaining bus schedules, talking them through get mad for no reason at all other than bad days, working with their families to if what she did wasnt up to quality standards. She would blow a gasket, describe benefits packages, and developing cussing and screaming. The second checklists to keep the employee focused. half of the year she began to calm

207 Not all employers had glowing comments l Staff were generally well trained, professional, about supported employees, of course. It was and committed. Agencies invested in their development. apparent that some held negative stereotypes and low expectations. For example, a bank manager l Staff demonstrated strong collaboration and said, supported employment is a good idea teamwork. because they do jobs that other people get bored l Staff invested in long-term relationships with with. businesses and focused on customer service. l Staff worked hard to find good job matches and supportive work place cultures/climates. ONGOING SUPPORT l Most people were paid at least minimum wage, and efforts were made to secure good paying jobs with benefits. Each of the four organizations demon- l strated a commitment to long-term relationships Each organization promoted the use of natural supports. with employers and the people they supported. People were assisted to find multiple jobs over l Organizations demonstrated a commitment time and, in some cases, were being supported to reserve individuals after they had fallen out of previous jobs. without additional funding. Ongoing support was defined by these organizations as a site visit Because these are learning organizations, two times per month. In some cases, this sched- they struggle with how to move from conceptuali- ule was appropriate. In others, it is system-driven, zation to practice, and from a system-centered not employer or supported employee driven. to a person-centered mode of service delivery. Some of the areas needing additional attention are discussed below.

DISCUSSION Serving people with high support needs. Although each of the agencies involved in This study looked at workplace supports this study served at least one person con- from the perspectives of provider agency per- sidered to have high support needs, only sonnel, employees with disabilities, employers, one organization had a strong history of and co-workers. The organizations that were doing so. While trying to maintain this stan- studied demonstrated many positive features cur- dard; however, this organization has recently rently considered best practices in our field, as opted to reduce the number of individuals discussed below. with high support needs being served in order to meet their contract goals. This situa- l The leaders of each employment program tion parallels national data which indicates articulated a clear vision and held strong 10.3% of people with mental retardation in values that served to guide the direction of services they offered. supported employment are considered to have severe/profound disabilities (Wehman, l Each organization had a track record of Revell, & Kregel, 1998). Although sup- innovation and change, and was willing to ported employment was initially targeted for take risks. individuals who needed intensive, ongoing

208 Article 14 support to get and keep employment, this Actively involving job seekers in their population continues to be underserved. Two job search. primary reasons for this situation are insuffici- Traditionally, job coaches have sought and ent funding and inadequate knowledge secured jobs for people with disabilities. about employment options and assistive With the national movement toward self- technology. determination and choice, professionals are attempting to involve the individuals Developing a strong emphasis on person- in all aspects of the job process. Data centered approaches to assessment and from the Mank, Cioffi, and Yovanoff study planning. (1997, 1998, in press) indicate that the If the assessment and planning processes more typical the job search, job training, used by agencies still resemble traditional and general support procedures, the better habilitation plan procedures controlled by the outcomes for the individuals. Thus, it professionals, agencies must invest in using behooves providers to involve job seekers approaches that are truly person-centered as much as possible in all aspects of the and driven. It is important to invest in getting job process. to know each job seeker in order to make good job matches. Shortcuts taken during Increasing the work hours of those who this phase may lead to job loss or dissatis- desire more work. faction. Again, funding dictates the amount Most of the individuals in this study worked of time allowed for assessment and plan- part-time. Many expressed a desire to ning. Despite these constraints, agencies work more hours. If most other employees must continue to invest in indepth, individ- in a business work full-time, how does ualized approaches that build the involve- part-time status impact the status, sup- ment and self-determination of job seekers. ports, and social relationships? This question requires further study, but one Building the expertise of staff to facilitate might hypothesize that part-time status workplace supports and social relationships. puts individuals at a distinct disadvantage. Although the organizations in this study were clearly aware of, and oriented toward, natural supports, there were a wide variety of interpretations of natural supports among staff. FUTURE RESEARCH In practice, many employment consultants used a more traditional training, then fade approach. That is, employment consultants Many questions were raised by this study provided the initial training, then faded from that lend themselves to future research. They the work site as the individual demonstrated include: more independence. In a few cases, employ- l Are there differences in workplace supports ment consultants sat with or near the em- between those who work full-time and ployee throughout their work shift. While those who work part-time? some employees need intensive, ongoing supports, efforts should be made from the l How do employers and co-workers describe typical workplace supports available start to build internal workplace supports. to any worker?

209 l Does the use of personal networks for job their workers while making quality products and development correlate with better outcomes? profits. Employers benefit from hiring employees l Does formal or informal training for worksite who meet their labor needs, and from the support personnel reap better outcomes? they receive from employment agencies. Employ- ment consultants strive to walk the fine line that there is between too much and too little support, and between responsiveness to individuals with CONCLUSION disabilities employed, employers, and funders. This study attempted to better understand the dynamics of workplace supports from the per- Workplaces are fascinating envirionments, spectives of all of those individuals who were they are complex entities that strive to support involved.

210 Article 14 eferences: R Chadsey, J., Linneman, Rusch, F., & Cimera, R. (1997). The impact of social integration interventions and job coaches in work settings. University of Illinois at Urbana-Champaign.

Fabian, E., Luecking, R., & Tilson, G. (1994). A working relationship: The job development specialists guide to successful partnerships with business. Baltimore: Paul Brookes Publishing Company.

Hagner, D. (1989). The social integration of supported employees: A qualitative study. Syracuse, New York: Syracuse University Center on Human Policy.

Hagner, D., Rogan, P., & Murphy, S. (1992). Facilitating natural supports in the workplace: Strategies for support consultants. Journal of Rehabilitation, 58(1), 29-34.

Mank, D., Cioffi, A., & Yovanoff, P. (1997). Analysis of the typicalness of supported employment jobs, natural supports, and wage and integration outcomes. Mental Retardation, 35(3), 185-197.

Mank, D., Cioffi, A. & Yovanoff, P. (1998). Employment outcomes for people with severe disabilities: Opportunities for improvement. Mental Retardation, 36(3), 205-216.

Mank, D., Cioffi, A. & Yovanoff, P. (in press). The impact of co-worker involvement with supported employees on wage and integration outcomes. Mental Retardation.

Nisbet, J. (1992). Natural supports at work, at home, and in the community for people with severe disabilities. Baltimore: Paul Brookes Publishing Company.

Murphy, S. & Rogan, P. (1994). Developing natural supports in the workplace: A practitioners guide. St. Augustine, FL: TRN.

Parent, W. Unger, D. Gibson, K. & Clements, C. (1994). The role of the job coach: Orchestrating community and workplace supports. American Rehabilitation, 13-22.

Rogan, P., Hagner, D., & Murphy, S. (1993). Natural supports: Reconceptualizing job coach roles. Journal of the Association for Persons with Severe Handicaps, 18(4), 275-281.

Shafer, M. (1990). Using co-workers to supplement job placement efforts. Journal of Job Placement, 6(1), 21-27.

211 ppendix A: Interview Protocol A The following questions guided interviews. Supported Employment Customers

1. Describe your job. What do you like/dislike about your job? What do you like best about your job? Is there anything you would like to change about your job? 2. How did you get this job? (What role did you play in finding this job?) 3. How were you trained to do your job? Who taught you your job? Describe how training was provided. 4. Do you need help to get ready for work? If so, who helps you? How do you get to work? 5. Do you need help to do your work? What kind of help do you need? Who helps you? 6. Who do you talk with most at work? Who do you take a break with? Who do you eat lunch with? Do you have friends at work? 7. Do you have social get-togethers or parties at work? Outside of work? Do you get together with any of your co-workers outside of work?

Employment Consultants

1. How long have you been in your current position? Describe the training you Received for this job. 2. Describe your organizations philosophy and values regarding the provision of employment services. 3. Describe how you assist people to become employed (planning, job development, employer contact, job training, ongoing support). 4. How do you define natural supports? Where in the process do you start to focus on natural supports? How do you balance, or mix, natural supports and employment consultant support? 5. What are your most successful approaches for facilitating supports? What are your biggest barriers? 6. What is your role in facilitating connections and supports outside of work? 7. Discuss the focus persons work situation.

Employers/Supervisors/Managers

1. Does your business provide diversity and/or disability awareness training? 2. How were you contacted about (supported employment)? How was the person hired and trained? 3. In what ways are (persons) work conditions (e.g., hours, wages, benefits, responsibilities, work location) the same or different from co-workers? 4. Describe the type of support provided (person). What accommodations, if any, have been needed? What role has agency staff played?

212 Article 14 5. Describe the nature of (persons) social interactions at work. Is person involved in employer-sponsored social activities outside of work? 6. How would you describe the work climate/culture here? 7. Describe the most positive aspects of having (person) as an employee. Do you have any concerns or needs that have not been met?

Co-workers

1. How long have you been working here? How long have you known (person)? Describe your involvement with (person). 2. Who trained (person) to do the job? How was training provided? 3. Describe (persons) social interactions at work and outside of work. With whom does she/he interact? 4. How would you describe the work climate here?

Director of Employment Services/Coordinators

1. How long have you been in this job? Describe your background and training. 2. Describe your organization and its services (brief history, current organizational structure, characteristics of people served, philosophy and values related to employment services, general supported employment approach). 3. How are staff recruited, trained, and supported? 4. To what do you attribute your outcomes (e.g., staff skills? Employer relations? Family support? Self-advocacy? Community connections? 5. What issues or barriers do you face in the provision of quality supported employment services?

Protocol for Observations at Job Sites

1. Type of work being performed by focus person and coworkers. 2. Physical description of setting. 3. Nature of interactions and supports across all employees. 4. Adaptations/accommodations used by focus person. 5. Climate/culture of setting.

Document Analysis

1. Mission/vision statement 2. Training materials 3. Marketing materials 4. Media articles 5. Other

213 214 Supported Employment and Natural Supports: A Critique and Analysis

By: Paul Wehman & John Bricout

Supports are one way to help people with disabilities become more independent and able to control the direction of their lives. ABSTRACT In recent years, a strong shift has occurred towards designing education and human service programs to emphasize the role of This paper provides a brief supports in enhancing the success of persons with disabilities. No but critical review of the concept of natural supports. In one person is the same, with or without a disability. Every individual order to analyze what hap- needs some level of assistance to succeed. There are some people, pens during extended ser- for example, with very severe disabilities who need a great deal of vices for supported employ- support to succeed in school, work, home, and the community. ment, studying the workplace The challenge is to match each person to an individualized array of environment is an important indicator. It is wtihin this en- supports to meet personal goals directed at living and working in vironment that the natural the community. support mechanisms of co- Ongoing supports, as defined in the amended regulations workers and supervisors for the Federal Supported Employment Program (Federal Register, come into play. We look at June 24, 1992, p. 28438), are those needed to support and how to define natural supports and the implications of maintain an individual with severe disability in supported employ- the work environment quality ment. Ongoing supports are activities and relationships that help on employee satisfaction and a person maintain a job in the community. Supports differ for each retention. individual and vary in type and intensity for the duration of employment. Those provided through the services of a job coach or employment specialist may be job specific or individual community supports. It is difficult typically for a person with severe disabilities to take full advantage of all the support resources available to assist him or her achieve personal education, community living, or employment goals. Just because a support is available at the workplace or in the community does not necessarily mean that he or she will automatically access it or benefit from its use. Frequently, individuals with disabilities do not know what potential supports are available, how to choose among the alternatives, or how to go about accessing a desired support. A critical factor in the use of a variety of supports is the presence of a knowledgeable resource who assists the individual with a disability identify, choose, and access needed supports at whatever level of assistance he or she prefers.

215 The commitment to ongoing supports is (Test & Wood, 1996 a,b). Consequently, some the unique feature of supported employment that important questions arise, such as: What are nat- makes it possible for people with severe disa- ural supports? What are work supports? What bilities to sustain employment over time. Supports is the relationship of natural supports to the that continue indefinitely are provided both at implementation of supported employment? and away from the job site, an approach signifi- Since Nisbet and Hagner (1988) first cantly different from services provided in day introduced the term natural support, this con- programs and other segregated models. For cept has been discussed and applied with varying example, more traditional models move people interpretations (West, Kregel, Hernandez and through a continuum of job readiness criteria Hock, 1997). Paradoxically, this much dis- before attempting to transition them to competitive cussed, widely practiced concept has yet to be work. Unfortunately, actual successful movement clearly and unambiguously defined. In fact, to competitive employment is rarely achieved by authors in the supported employment literature people with severe disabilities when served do not appear to have a consensus on two basic through this approach. issues. First, what distinguishes natural supports The U.S. Congress recognized the value from other workplace or work-related supports, of supported employment in 1986 and identified a question that is sometimes framed in terms of this approach as a vocational outcome in the what does the qualifier natural mean? Second, Rehabilitation Act Amendments (Federal Register, what is the contribution of the job coach as a 1987). It authorized funding under Title I and paid service provider vis-a-vis the contribution Title VI (Part C) for time-limited post-employment of co-workers, supervisors or employers to the services leading to supported employment. The integration of supported employees (Granger, Act included ongoing support services as an Baron & Robinson, 1997)? It can be seen that essential element of supported employment and these two questions are related inasmuch as the required the availability of extended services job coach-initiated support strategies may be per- before vocational rehabilitation funding could ceived of as less natural than those initiated begin. Natural supports are identified in the by co-workers, supervisors, or employers. Rehabilitation Act as one form of ongoing sup- The first issue, difficulty in limiting the ports. In order to more fully analyze and explore scope of natural supports, has been recognized the issue of extended service and long-term by authors as confounding attempts to define supports, a critique of natural supports follows. the concept (Hagner, Butterworth & Keith, 1995). Nonetheless, natural supports have been disting- uished from other strategies by some investigators (Storey & Garff, 1997), with one result being DEFINITION OF NATURAL several authors electing to define their own natural support-like concepts. One opted for a term SUPPORTS of more limited scope, internal supports (Fabian One of the major mechanisms for & Luecking, 1991); other authors developed a extended supported employment services is the term of more limited application, typicalness use of what has been popularly termed natural (Mank, Cioffi, & Yovanoff, 1997, 1998). supports (Nisbet and Hagner, 1988). Un- The second issue, paid versus unpaid sup- fortunately, the concept of natural supports ports, appears to underlie the general approach has not been easy to define or operationalize to natural supports. For example, some writers

216 Article 15 appear to hold untested assumptions about how In order to examine how other writers much a job coach facilitates or hinders the inte- have denoted natural supports, we looked at gration of workers with disabilities into a com- nine articles on natural supports. Table 1 petitive workplace. At this point in time, the below provides a succinct overview of each of contribution of a job coach compared to co- these papers. The type of study varied con- workers, the employer and/or supervisor in the siderably among the seven empirical articles. successful integration of an employee with a Two of the studies were surveys (Unger, Parent, disability has not been empirically tested. How- Gibson, Kane-Johnston & Kregel, 1997; ever, Lee, Storey, Anderson, Goetz and Zivolich West, et al. 1997). Three studies were quali- (1997) conducted a study comparing job coach tative, using staff notes and activities (Fabian, training to employer mentoring. Their findings Edleman, & Leedy, 1993), case examples suggested that mentors helped facilitate more (Rogan, Hagner & Murphy, 1993), or social interaction than job coaches. Unfortun- interviews (Hagner, Butterworth & Keith, ately, they were unable to rule out differences in 1995). One study was observational using training methods and participant characteristics, repeated measures (Lee, et al., 1997), and and more importantly, one year lapsed between one employed archival data (Mank, et al., training and data collection (Lee, et al., 1997). 1997; Mank, Cioffi, & Yovanoff, 1998). The This year-long lapse allowed for the possibility remaining two non-empirical articles were a that other factors may have confounded what is conceptual piece (Fabian & Luecking, 1991) presumed to be a job coach training effect and a review article (Storey & Certo, 1996). compared to an employer mentoring effect.

TABLE 1 -- CONCURRENT DEFINITIONS OF NATURAL SUPPORTS

Source/Title: Fabian, Edelman, & Leedy (1993) -- Linking workers with severe disabilities to social supports in the workplace: Strategies for addressing barriers. Design: Qualitative Data Analysis of Naturl Support Workplace Demonstration Project using staff notes and activities. Definition of Concept: A natural support approach refers to enhancing or linking individuals to existing social supports in the work environment that are available either informally (from co-workers and peers on the job) or formally (from supervisors and company sponsored employment programs) (p.30).

Natural workplace support approaches require more intensive efforts up-front to link the employee to available supports since the approach does not rely on the continuing presence of the job coach (p.31).

Source/Title: Fabian, E.S., & Leucking, R.G. (1991) -- Doing it the company way: Using internal company supports in the workplace. Design: Conceptual Article Definition of Concept: Natural workplace supports include such examples as using co-workers as job trainers for the supported employee, promoting mentoring relationships between (continued) 217 the supported employee and others in the environment, and using the environmental cues as a means of sustaining new behaviors by the supported employee (p.32).

Source/Title: Hagner, Butterworth, & Keith (1995) -- Strategies and barriers in facilitating natural supports for employment of adults with severe disabilities. Design: Guided/Semi-Structured Interviews of 33 subjects on natural supports strategies and barriers to schools and voc. service agencies. Definition of Concept: Natural sources of support include an individuals network of family and friends, and an employees employers and co-workers on the job. Such natural supports may occur spontaneously or through human service facilitation or consultations (p.110).

Source/Title: Lee, M., Storey, K., Anderson , J.L., Goetz, L., & Zivolich, S. (1997) -- The effect of mentoring versus job coach instruction on integration in supported employment settings. Design: Observational study/assessment of interactions of 30 workers in different training conditions (10 Job Coach; 10 Mgr- Mentor; 10 Co-worker & Mgr) Definition of Concept: Natural Supports refers to the utilization of coworkers from the onset of placement to train and support workers with disabilities throughout their employment period. Basically, this approach utilizes supports and strategies that are inherent to the particular work environment such as coworkers, supervisors, and managers. Support may involve continuing skill training, social skills training, crisis intervention, advocacy, community skill training, validating instructional strategies, collecting subjective evaluations, collecting social comparison information, job modifications, and adaptations (p.152).

Source/Title: Mank, D., Cioffi, A., & Yovanoff, P. (1997) -- Analysis of the typicalness of supported employment jobs, natural supports, and wage and integration outcomes. Design: Demographic data on 462 subjects in 13 vocational programs across 8 states; data supplied by support persons. Definition of Concept: The focus on natural supports emphasizes the participation of supervisors and co-workers in the hiring, training and supervising supported employees. The concept of natural supports underscores an understanding of worksite culture that, in turn, dictates what is natural or typical for that particular situation (p. 185).

Source/Title: Rogan, P., Hagner, D., & Murphy, S. (1993) - Natural Supports: Reconceptualizing job coach roles. Design: Four case examples to illustrate provider strategies used to promote non-intrusive supports. Definition of Concept: The term natural supports has evolved to signify the involvement of worksite per-sonnel and others in providing support to employees with disabilities. Natural supports may be described as any assistance, relationships, or interactions that allow a person to secure, maintain, and advance in a community job of his or her choosing in ways that correspond to the typical work routines and social actions of other employees and that enhance the individuals social relationships. natural flow of worksite rather than impose human service facilitat(ed) as both a process and an outcome role of job coaches facilitation and consultation (p.275).

Source/Title: Storey, K., & Certo, N.J. (1996) -- Natural supports for increasing integration in the workplace for people with disabilities: A review of the literature and guidelines for implementation (continued) 218 Article 15 Design: Review Article Definition of Concept: Natural supports are people who are not disability service providers but who provide assistance, feedback, contact or companionship to enable people with disabilities to participate independently, or partially independently, in integrated employment settings or other community settings. Typically, individuals providing natural supports receive assistance and consultive support from disability service providers and provide natural supports with or without compensation (School and human service agency staff typically facilitate) natural support relationship(s). Natural support people are usually endemic to a job, a community environment, or community activity (p.63).

Source/Title: Unger, D., Parent, W., Gibson, K., Kane-Jonston, K. & Kregel, J. (1997) -- An analysis of the activities of employment specialist in a natural support approach to supported employment. Design: Survey of 36 individuals placed into SE by the VCU-RRTC natural supports project. Used community and workplace supports form. Definition of Concept: Professional literature suggests that the role of the employment specialist when using natural supports is to serve as a consultant or facilitator to the employer by building on supports which exist in the workplace, as well as the expertise of the employer (p.111).

Sourct/Title: West, M.D., Kregel, J., Hernandez, A., & Hock, T. (1997) -- Everybodys doing it: A national study of the use of natural supports in supported employment. Design: Survey of 385 Supported Employment Provider Agencies on use of natural supports in time- limited and extended services. Definition of Concept: (Cite from S. Rep. No. 357, 1992) Natural supports within the VR service context were intended to include: (a) individuals at the job site, such as employers, supervisors, or co- workers. (b) friends or family members in supportive roles; and (c) volunteers or members from work or the community.

The term natural supports refers to the resources inherent in community environments that can be used for habilitative and supportive purposes.

Recently, several writers in the field have further broadened the context to include other types of community and workplace resources, such as employee assistance programs, transportation providers, community service organizations, recreational and social associations, and governmental supports that are not limited to persons with disabilities such as subsi- dized housing, income tax assistance (p.175).

The discussion of natural supports found the other end of the spectrum, Lee and in these articles varies a great deal in terms of associates (1997) specify not only by whom how specific each author is about what con- and how, but also when natural supports are stitutes natural supports. Probably the least spe- created: Natural supports refers to the cific definition, provided by Hagner and associ- utilization of co-workers from the onset of ates (1995), simply enumerates those who consti- placement to train and support workers with tute natural supports: an individuals network disabilities throughout their employment of family and friends, and an employees em- period...Supports and strategies that are ployers and co-workers on the job. (p.32). At inherent to a particular work environment such

219 as co-workers, supervisors and managers...It may The notable example is Storey and Certo (1996), involve continuing skills training, social skills who seem to exclude job coaches in their defi- training...advocacy...job modifications and nition: Natural supports are people who are adaptations (p.152). The obvious merits of this not disability service providers (p.63). Oc- definition lie in its specificity about who, where, cupying the middle ground on the issue of job when and in several instances, how natural coaches and unpaid natural supports, Fabian supports are to be effected. and associates (1993) seem to suggest that the Looking at all of the articles, it becomes job coach will fade out of the natural supports clear that a testable and measurable definition process in time: Natural workplace support is not easily found. However, these different efforts approaches require more intensive efforts up front do help us in understanding (1) who is involved to link the employee to available supports since with natural supports, (2) in what settings natural the approach does not rely on the continuing supports are found, and (3) the kinds of activities presence of the job coach (p.31). To the extent or features that constitute natural supports. Let that the concept of natural supports is extended us begin with the question of what parties or beyond the workplace or worksite, other parties persons we might associate with natural supports. may be involved in natural supports as well, in- The co-worker is the most commonly reoc- cluding friends, families, and community mem- curring figure in discussions of natural supports, bers (Hagner et al., 1995; West, et al., 1997). appearing in almost every definition (Fabian, et This introduces the next topic of where natural al., 1993; Fabian & Luecking, 1991; Hagner, supports are to be found. et al., 1995; Lee, et al., 1997; Mank, et al., According to most authors, the setting for 1997; Rogan, Hagner & Murphy, 1993; West, natural supports seems to occur largely or exclu- et al., 1997). In those instances in which the sively in the workplace (Fabian, et al., 1993; co-worker is not explicitly mentioned in conjunc- Fabian & Luecking, 1991; Lee, et al., 1997; tion with natural supports, the employer is men- Mank, et al., 1997; Rogan, et al., 1993). Some tioned (Storey & Certo, 1996; Unger, et al., authors talk about natural supports in terms of 1997). There is a high degree of consensus being inherent typical or endemic to the that natural supports involve those individuals workplace (Lee, et al., 1997; Mank et al., 1997; in the employees work environment. Rogan; 1993; Storey & Certo, 1996; West, et When the job coach is considered, how- al., 1997). A different perspective seems to be ever, there is less consensus. According to several articulated by authors who mention promoted authors, the job coach and/or provider agency or facilitated natural supports (Fabian, et al., has an important role in developing and main- 1993; Fabian & Luecking, 1991; Unger, et al., taining natural supports for the duration of em- 1997). A third possibility is that natural supports ployment (Brooke, Wehman, Inge & Parent, can be both spontaneous and/or facilitated 1995; Rogan, et al., 1993; Storey & Certo, (Hagner, et al., 1995). Perhaps a better way of 1996; West, et al., 1997; Unger, et al., 1997). conceptualizing natural supports, as it straddles According to these authors, the role of a job the workplace and other locations, is as a coach is to facilitate natural supports. While network reaching to and from the workplace, this does not imply that job coaches are natural with the employees job prospects, performance supports, it does not rule them out from acting and career progress at the center. as such. Other authors; however, view job This leads us to the critical activities, such coaches as wholly exogenous to natural supports. as social networks, that constitute natural supports

220 Article 15 (Hagner, et al., 1995; Rogan, et al., 1993; design and results of the 15 studies conducted. Storey & Certo, 1996). In the community, natural It is noteworthy that less than 100 subjects supports may include such diverse elements as were included in all of these studies. transportation, government subsidies and As noted earlier, there is very limited funding, and recreation and companionship research designed to determine functional vari- (Storey & Certo, 1996; West, et al., 1997). In ables in supported employment as a whole the workplace, natural supports may also include therefore, it is not surprising that research does static features such as environmental cues or not exist within the area of natural supports processes such as skills training of various types, strategies, unfortunately leaving supported employee assistance programs, job modification employment vulnerable to anyone who calls and adaptations (Fabian & Luecking, 1991; Lee, what he is doing supported employment. In et al., 1997; West, et al., 1997). others words, if someone says she is doing Considered as a whole, these articles still supported employment, then it must be leave unanswered some fundamental questions. supported employment. This same situation For example, what are the implications of our can be applied to natural supports strategies. current understanding of natural supports for Additional research on natural supports future research and practice? How are natural strategies and related outcomes is clearly supports related to the larger topic of supported needed. Many strategies have been suggested employment? These are some of the questions (e.g., Nisbet & Hagner, 1988; Rogan et al., that will be addressed in the next section on what 1993; Shafer, Tait, Kee & Jesiolowski, 1989), the research literature tells us about natural only one study was found that investigated a supports. specific strategy suggested by the literature, paid co-worker supports (Hood, et al., 1996). Research is needed to determine what strategies based on the concept of natural supports lead to improved consumer outcomes. Studies in- WHAT DOES THE RESEARCH vestigating procedures should include descrip- LITERATURE TELL US ABOUT tions of subjects, replicable procedures, re- NATURAL SUPPORTS? search methodology descriptions, and specific Test and Wood (1996a) reviewed pro- intervention times. cedural information and supports literature. Each One recently published major study of the 15 studies identified contained a (West, Kregel, Hernandez, and Hock 1997), specifically stated purpose; one third of which reported findings from a survey of 385 (5) involved case studies (Fabian, Edelman, & supported employment provider agencies on Leedy, 1993; Hagner & Farris, 1994; Rogan, et their use of natural supports in time-limited al, 1993; Shafer, Tait, Keen & Jesiolowski, 1989; and extended services. This study provided a West & Parent, 1995). There were also two large scale descriptive analysis of what surveys designed to describe the current status of practices community rehabilitation providers natural supports (Hagner, Butterworth, & Keith, are following in natural supports. An over- 1995; Peterson, 1995), and two which provided whelming majority, 85% of all respondents, objective data on co-worker involvement (Rusch, reported that their agencies emphasize natural Johnson, & Hughes, 1990; Rusch, Hughes, supports in delivering supported employment Johnson, & Minch, 1991). Test and Wood services and that these supports have been (1996a) provided a detailed table showing the

221 successful and useful for all individuals on their organizations, churches, etc.) in the natural caseloads. Among the problems identified by support effort. In addition, most programs seem the respondents were resistance to natural sup- familiar with using natural support strategies ports by employers and co-workers, as well as during the training and follow-along stages of difficulty in locating natural supports at the job supported employment. Natural supports are site. used far less frequently during the consumer Those agencies that emphasized natural assessment, job development, and job placement supports reported that they have used co-workers phases of supported employment. or supervisors for initial training for an average The findings of the West, et al. (1997) of 41.5% of their consumers; for ongoing survey point to the potential impact of natural monitoring and support, this percentage in- support methodologies on service access for per- creased to over half (56.3%) of their consumers. sons needing supported employment. An encour- Natural supports appear to be used far less fre- aging finding is that better than eight of ten quently in job development and placement, respondents indicated that they had found nat- although the family-and-friends network is the ural supports to be useful and relevant for all typical avenue for early employment experiences members of their caseload, presumably including for most people starting out in the work world. those who are the most difficult to place, train, The findings of West, Kregel, Hernandez, and maintain in employment. Among those & Hock (1997) give clear and powerful support reporting to the contrary, the primary reason was to the arguments made earlier relating to the based on the characteristics of the employment lack of a clear and concise definition of natural settings into which individuals were being placed, supports. When 85% of all programs indicate not on the types of individuals served. Among that they emphasize the use of natural supports the reported instances where natural supports in service delivery, the distinction between natural did not work, factors included fast-paced or supports and job coaching is no longer meaning- high stress jobs or environments, highly competi- ful. Most programs are using components from tive businesses, and workplaces that werent par- a number of different supported employment ticularly friendly to any worker, disabled or not. models in the design and delivery of services. Most programs felt that the use of natural Natural support strategies have become estab- supports had contributed to the overall success lished as one of these components. of their supported employment programs. How- Provider agencies seem to agree about ever, about two-thirds of the programs using what constitutes a natural support. However, natural supports indicated that they had experi- the natural supports being used by supported enced problems in the implementation of natural employment agencies appear to be limited in support strategies. These problems over- scope. When local programs describe their use whelmingly fell into two areas. First, employers of natural supports, they are almost always talking were unwilling to implement the natural support about the involvement of co-workers in the strategies recommended by the supported provision of job skill training or ongoing moni- employment program and were resisting the toring. Programs are far less likely to describe notion that they should assume sole responsibility efforts at involving employer resources (i.e., for the training, supervision, and support of the employee assistance programs), family members employee with a disability. Second, local pro- or friends, consumer resources, or community grams were having a difficult time identifying involvement (e.g. civic groups, professional potential staff members with the skills necessary

222 Article 15 to implement natural support strategies, as well the consumers, the characteristics of the service as providing training to current staff members in program, and the monetary and non-monetary the use of natural support techniques. outcomes experienced by the individual con- Taken in total, the perceptions of the re- sumer. spondents clearly illustrate the changing nature of supported employment service delivery. Natural supports have become interwoven with all facets of supported employment implementation that it CLINICAL IMPLICATIONS OF is no longer relevant to discuss the efficacy of NATURAL SUPPORTS natural supports versus the success of the job coach model of supported employment. It is no The clinical implications of natural sup- longer helpful to criticize natural support pro- ports are not new. In the early 1980s, Wehman grams that place individuals into situations with- (1981) talked of the critical role of coworkers out providing sufficient support to enable the indi- and supervisors in job retention and job vidual to retain employment for an extended per- training. Seven years later Nisbet and Hagner iod of time, or to chastise job coach programs (1988) introduced a broadening of the team that create unnecessary employer dependence as natural supports. As the previous analysis on the presence and assistance of the job coach. shows, since then there has been a plethora Instead, it is now time to focus our energies on of papers discussing this topic as well as books identifying those program characteristics that (e.g., (Natural Supports in Action), DiLeo, contribute to a programs ability to generate high Luecking, and Hathaway, 1995) quality, satisfying employment outcomes for But in the end, several points are clear. individuals, regardless of the philosophical First, many persons with truly significant orientation of the program. disabilities may need some rehabilitation sup- At the level of the local supported em- port and assistance at different points in their ployment program, there are really no longer employment tenure. This support may be a pure natural support programs or job coach guidance role, a consultant role, or more of a programs. In reality, most local supported em- facilitator than job trainer, but typically there ployment programs use a variety of different will need to be some support and assistance. service delivery techniques. Far more important If people with severe disabilities such as autism, is the recognition that some supported employ- quadriplegia, or severe mental retardation did ment programs are far more successful than not need some extra support, they would have others in terms of their ability to generate high already been competitively employed in large quality employment outcomes for the consumer numbers over the past several decades. receiving services. Numerous factors con-tribute Clearly, this has not been the case. to individuals in supported employment earning Secondly, there will be different roles higher wages, retaining their jobs for longer for those involved in employee support. This periods of time, experiencing larger degrees of is not a case of one size fits all. We now know integration in the work setting, and expressing definitely that people with varying functional, greater satisfaction with their job is a complex learning, and physical characteristics will need activity. Understanding these factors is a complex different levels and intensity of supports. The activity involving a close examination of the qualitative nature of what supports are provided demographic and functional characteristics of will be defined by the care with which a job

223 placement and subsequent job analysis is per- the effectiveness of natural support approaches. formed. This has implica-tions for hiring employ- Yet, neither approach has been particularly ment specialists who have diverse backgrounds effective in allowing individuals with significant and clinical expenses. cognitive disabilities to participate in competitive The third point we have learned is that employment, and neither has fully encouraged effective supports, whether they are natural or consumers to choose their jobs and plan their more intrusive, must be maintained long term. careers. Framing the argument in an either/ People with disabilities who participate in sup- or manner trivializes our real problems and hides ported employment still fall out of their jobs too the fact that supported employment needs to quickly and too easily defeat the whole purpose move beyond all current models. We must iden- of supports. tify new strategies that empower consumers and Table 2 on page 226 provides a concise enable all individuals with significant disabilities listing of questions and answers associated with to benefit from employment. many of the clinically related natural support The problems facing supported employ- issues. We have conceptualized these issues ment are challenging and very real. Our nations more in the context of workplace supports. system of segregated day programs remains firmly It is noteworthy to observe that the vast entrenched (Braddock, 1998). Millions of indi- majority of employers view the job coach as a viduals continue to be denied access to high positive presence within the work place, as quality employment programs that would enable opposed to an intrusive or disruptive influence. them to take charge over their careers. The ADA The clear message from them is that they continues to be assailed as an unfunded federal want the job coach to be immediately accessible mandate that places burdensome constraints and responsive to their needs (Kregel & Tomiyasu, on well-meaning businesses. Finding solutions 1994; Kregel & Unger, 1993; Petty & Fussell, to these challenges will require a renewal of the 1997). Denying employers the opportunity to spirit of innovation and risk-taking that has been hire individuals, because they need more assis- a defining characteristic of supported employ- tance and support than the employers them- ment since its inception. selves can provide does a disservice to the indi- Support strategies must be developed that viduals and the employers. enable people with disabilities to direct their own It makes little sense to continually discuss careers and obtain jobs of their choice. To do the pros and cons of job coaches versus support that, the best components of the job coach model facilitators. The job coach model has contrib- and natural support strategies must be combined, uted substantially to more than 139,000 complemented as needed by assistive tech- (Wehman, Revell, & Kregel, 1998) individuals nology, person-centered planning, compen- gaining and retaining competitive employment. satory strategies, personal assistant services, and Efforts are only now underway to fully determine many other strategies and approaches.

224 Article 15

TABLE 2

1. Have natural supports changed the concept of supported employment?

NO -- The basic premise on which supported employment was established has not changed, however it has expanded to include new service technologies. People with disabilities want to work in real jobs, and supported employment offers the means for achieving this goal. No support strategy or methodology, regardless of how good it sounds, should compromise the values on which this vocational model was based. Individuals have the right to be employed by community businesses where they earn comparable wages, work side-by-side with thier co-workers, and experience all of the same benefits as other employees of the company. Most importantly, they must be able to choose the characteristics of their jobs, as well as the community and workplace supports that will assist them in maintaining employment.

2. Can using workplace supports facilitate consumer choice?

YES -- The evolution of supported employment into a consumer-driven approach with opportunities for choice from an endless selection of support options is the next logical step to improve an established and successful service modality. Use of community and workplace supports puts consumers in the drivers seat, allowing them to direct their careers and choose the type and amount of assistance they want to receive.

3. Can natural supports eliminate the need for job coaches?

NO -- As supported employment evolves to incorporate consumer choice initiatives and a variety of new support technologies, the job coaches role becomes even more critical. It is evident that community and workplace supports do not automatically meet the needs of individuals with severe disabilities. The job coach is the one constant person who possesses the skills to identify and develop support resources, assist with accessing services, evaluate the effectiveness, and arrange alternative provisions as need arises. Consumers should choose who will assist them, how assistance will be provided, and be able to change their minds, while maintaining a circle of support from job coaches who are available to orchestrate or provide the desired support.

4. Will consumers needs for workplace supports differ?

YES -- Each consumer needs different types of assistance, as well as varying levels of support at different times in the employment process. For example, an individual with extensive job site training needs may choose to have: a co-worker teach one task; the job coach teach another; the parents arrange transportation; the rehabilitation counselor purchase uniforms; a friend assist with managing her paycheck; a cateteria worker support her during lunch breaks; the supervisor monitor work performance, and a social security consultant assist with writing a PASS plan. The management of these many support resources is a function which falls naturally within the parameters of a job coachs role.

5. Cant consumers access community and workplace supports on their own?

NO -- Taking advantage of the support resources that are available in the workplace does not occur automatically for people with severe disabilities. Just because a support exists does not mean that a consumer will access or benefit from its use. It is not uncommon for an individual to be unaware of potential supports that are available, how to choose among the alternatives, or how to access a desired support. A critical factor in the use of a variety of options is the role of the job coach who assists the consumer in identifying, choosing, and accessing needed supports at whatever level of assistance he or she prefers.

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