In
November of 1993, Vermont's Division of Vocational Rehabilitation (DVR) was
awarded a five year demonstration grant of approximately $595,000 annually to
explore strategies for providing service recipients with increased choice and
control in the state rehabilitation process. The project was designed to enhance
the current service system in a number of ways that would encourage
self-direction, expedite services, and empower both counselors and consumers in
the rehabilitation process.
The
major premise of this project was that by experimenting with informed choice
techniques and strategies within the existing DVR system, results would be
verifiable and easily transferable. (See Attachment A: The Implementation of
Informed Choice in Vocational Rehabilitation: A Functional Definition and
Self-Assessment Process) This in
fact proved accurate. By allowing current DVR staff to participate directly in
the project, report results to their peers, and grapple with the challenges of a
state system, the project reliably demonstrated the viability of its approach.
Four
DVR counselors were chosen to work within the project, with grant funds picking
up 80% of salaries. Case service funds for making needed purchases of goods and
services also came from the grant for those four counselors. Average caseload
sizes were the same as in the traditional program. Consumers entered the project
randomly so that the demographic profile of the client population would be
identical to those served in the traditional program.
The
DVR Director and other management staff were committed to using this grant award
as an opportunity to take a broad look at the organization with the intent of
improving service delivery. They intended to use the project as a "living
laboratory" to examine various consumer choice strategies.
After
about two years of project experience, DVR embarked on a long range planning
process involving a broad constituency of staff from all layers of DVR, State
Rehabilitation Council members, and consumers who met over many months to create
a vision of how DVR should conduct its business.
Choice
Project staff was also a part of the planning process and reported on the
success of various initiatives. Many
of these project initiatives were adopted as a part of the planning document
entitled "Vision 2000 - Creating a Consumer Directed Organization by
1999". (See Attachment B:
Vision 2000) By year 4, many of the project techniques and initiatives described
in the Vision 2000 document had been incorporated into the regular
rehabilitation program, thus transforming the grant from a demonstration project
to a true systems change initiative. (See video entitled: Vision 2000 –
Evolution of A Consumer Directed Organization)
The
basic belief of the project was that an individual provided with sufficient
information, resources and support will become better able to make informed
decisions which will lead to the achievement of their vocational goals.
All project activities were designed to reflect this basic premise.
The
goal was:
·
to enhance the ability of DVR consumers to make decisions by teaching
them relevant skills;
·
·
to provide an approach that encouraged personal responsibility within the
rehabilitation process; and
·
·
to remove barriers within the DVR system which would inhibit consumer
choice and the timeliness of service delivery.
One
of the first orders of business was to review DVR policies and procedures with
an eye on facilitating these goals. Great latitude was taken in defining the
"rules" so that policies and procedures that were designed solely to
make it easier for the system or staff were discarded. Approaches that enhanced
the consumer's ability to make informed decisions, take personal responsibility,
and move through the system in a more timely way were adopted. (See Attachment
C: Consumer Choice Procedure Manual) The key strategies that were designed for
comprehensive examination were:
·
the implementation of expedited eligibility determination,
to shorten the allowed 60 days, to facilitate instant delivery of
services;
·
the use of a wider array of vendors or providers of rehabilitation
services to better ensure that providers were accountable in meeting consumer
needs;
·
direct cash payments to consumers to enhance speed of service delivery
and anonymity in making purchases with state funds;
·
the provision of increased availability of funds at the local
rehabilitation offices to ensure quicker payment and delivery of services;
·
a shift in the role of the counselor from a more clinical approach to a
primary emphasis on education; and
·
the use of consumer feedback as the primary basis for improving or
altering methods of service delivery and evaluating program and staff
performance.
In
addition to exploring the original project goals, counselors met regularly to
examine issues within the counseling process that challenged their ability to
promote consumer control and empowerment. Options
for contending with these challenges were discussed in a peer setting that
helped the group learn more about the underlying tenets of informed choice.
Although
the project goals were strongly supported by management, there was
understandable skepticism among front line staff at first. The project had
difficulty overcoming an "us versus them" mentality and discovered
widespread misinformation about project goals. Even the State Rehabilitation
Council, consisting primarily of consumers, was unsure of the broad implications
in its initial reaction to the project. The
advent of something very new and very innovative brought out predictable
reactions of fear, concern, and cynicism.
After
a year of experience directly with clients, project staff interaction among DVR
peers, and concerted education efforts, the project began to be better
understood. It took that long for the project to clearly define its mission and
disseminate those philosophies. The opportunity for peer interaction within
district offices on a day to day basis was a key to the widespread adoption of
project policies and practices. The philosophies and strategies of choice would
not have been accepted otherwise. Staff members needed to see something in
action, and this project created a learning laboratory from which to float
ideas, experiment with approaches, and work within a small scale.
The
Consumer Choice Project experienced many early successes that have held up over
time. Most of these initiatives
were incorporated into the regular DVR program before the end of the five years.
Specific
initiatives of the project that were very rapidly successful and subsequently
adopted by DVR, through Vision 2000 were:
Expedited
Eligibility
(See Attachment D: Division of Vocational Rehabilitation’s Policy on
Eligibility)
Consumers
may now become eligible for services on the day they apply by using a
combination of available documentation, counselor observation, and consumer
reporting. Additional documentation of a disability can still take place but is
consumer directed for the purpose of gaining more information that could be
useful in planning or in assessment. If
a counselor is unsure of the existence of a disability, additional information
can be gathered within the 60 days framework.
The
project determined that there were only rare instances of individuals who came
to DVR with no discernable disability and that counselors felt competent to make
fairly rapid judgments in most situations, saving the individual consumer an
average of 60 days of waiting time. Most DVR counselors have now changed their
documentation process and are practicing expedited eligibility procedures.
Choice
of Vendor and Service Provider
Expanding
the choice of vendors and service providers has enabled individuals to
negotiate, in many cases, better prices and services than was afforded under the
state purchasing contract, thus saving case service dollars. (See Part VII:
Participant Data for further information) Additionally, individuals are given
the opportunity to learn new skills in purchasing, comparison shopping,
evaluating options, and making informed decisions. By taking the responsibility
for the purchase, individuals were more likely to receive goods or services that
reflect what they really need to accomplish their vocational goals.
Direct
Cash Payments
(See Attachment E: Procedures for Imprest Cash)
Individuals
receiving cash are able to make their own purchases (goods and services)
anonymously and with greater dignity. The cash system also speeds up the
process, avoiding the cumbersome state finance system.
The project determined that consumers were generally responsible with
cash if there were adequate supports around decision making prior to obtaining
the cash. In the rare instances
where money was used for something other than was
intended,
the counselor was able to use the experience as a counseling opportunity.
Increased
availability of funds
The
Choice Project believed that to truly empower the individual service recipient,
the counselor needed to be empowered as well.
Each counselor needed to be able to support individuals without system
barriers to providing timely, respectful service.
As one Choice counselor put it, "When I feel respected by the
system, I pass that respect on to the consumer." By having, the ability to
write checks directly to the individual, DVR counselors felt respected and
trusted. Counselors were able to
provide immediate services when the situation warranted it.
Initially
each Choice counselor was given a checkbook with $500. However because of slow
turn-around time, the checkbooks were frequently depleted. Consumer satisfaction
surveys confirmed that speed of processing checks for equipment and services was
unacceptably slow. Project staff
met with the State finance staff. Turn-around
time was increased and checkbook amounts were increased to $ 1,500. Counselors were then able to satisfy most purchasing needs
directly through their checkbooks.
Because
of the success of this system in enhancing consumer outcomes, DVR has adopted
the "checkbook" process and all district and regional offices have
check writing capability. There is
unanimous agreement about the empowering nature of this process with numerous
examples of clients who have made purchases without feeling labeled and who have
been able to purchase where and what they truly needed to further their
employment goals.
Educational
Approach
(See Attachment F: Consumer Education)
One
of the common misconceptions in the early days of the project was the notion
that the DVR counselor would turn into a check writing machine, giving consumers
anything they wanted. Finding a balance between consumer empowerment and
counselor oversight has proved a tricky concept.
Even today we find a need to explain the difference between consumer
empowerment and reasonable management.
Emphasis
on education rather than clinical aspects of rehabilitation has allowed
counselors to look practically at consumer needs. Counselors must use their judgment
to assess skill levels and then teach individuals how to self-advocate in the
community, find needed resources, make decisions, and generally manage their own
rehabilitation. (See Attachment N: Consumer Choice Project Skills Checklist)
Often the counselor must use teaching strategies such as role-playing providing
information, breaking down tasks, and homework to help an individual become more
self-directed. (See Attachment G: The Changing Consumer-Counselor Relationship)
Sometimes
the counselor needs to say that they can't support the decision of the
individual if it appears that the decision is not well informed.
Helping the individual to gather the necessary information to become
informed becomes the focus. With this approach, the counselor can become
creative in assessing needs and finding solutions rather than blindly applying
rules from the manual.
As
more and more counselors have embraced this educational approach, many new forms
of counseling have developed as creative solutions to counseling dilemmas.
For example, group work has taken a high priority for experimentation in
several offices as counselors seek to offer peer support and improve time
management. Teamwork within offices
has also taken a high priority as counselors have begun to see themselves as
creative counselors rather than rules enforcers.
Consumer
feedback
(See Attachment H: Consumer Choice Participant Survey and Attachment I: Consumer
Choice Program Final Evaluation Report)
The
project sought to use consumer feedback as the only true source of information
upon which to base program change, determine training needs, and assess
counselor performance. Using an independent evaluator to compile and analyze
data, the project interviewed each participant every six months until six months
after closure to determine their level of satisfaction with the quality, amount
of control, and timeliness of the services received. Information from these
surveys was provided to the project twice a year.
Additionally,
survey data could be sorted according to project counselor and used as a basis
for performance evaluation. This part of the consumer feedback system generated
the most discussion and anxiety as regular DVR counselors envisioned poor
ratings from disgruntled consumers. However,
Choice counselors discovered that in fact the few who complained, no matter what
DVR had done, stuck out as obvious anomalies in an evaluation. The data did show areas in need of improvement and served as
a baseline for future growth and the identification of additional training
needs.
As
the project talked about consumer feedback, others in DVR began espousing the
concept of the 360-degree evaluation in which performance reviews are based on
feedback from not only consumers but from referral agencies and peers.
This concept has taken hold and is now used in each regional and district
DVR office. An independent
evaluator has been retained to survey a random sample of DVR consumers and
referral agencies to determine satisfaction and provide information to be used
in performance reviews.
The
Consumer Choice Project had some promising and not so promising results.
One area that was surprising to project staff was the explosion in
self-employment goals. Experiments
with group work have also been exciting. However, experiments that provided
mentors and peer reviews for disagreements proved less successful.
Self-employment
(See Attachment J: The Option of Becoming Self Employed)
In
honoring consumers' choices in vocational goals and creatively looking at
alternatives, the project began to notice an increase in the number of
individuals who pursued self-employment. In trying to understand this
phenomenon, we began to realize that self-employment allowed individuals to
capitalize on strengths in a non-traditional setting that could accommodate
their disability-related needs. Providing
for flexible schedules was a major component of entrepreneurial success.
Additionally, individuals who had not been successful in competitive employment
were able to set their own parameters for working while continuing with a line
of work that satisfied their needs, interests and abilities.
Another
benefit of self-employment was that other individuals with disabilities were
hired in some of these budding businesses, providing an employment opportunity
for other clients. Approximately
20% of employment goals attained by consumers in the project were in
self-employment compared to the 2% in the regular DVR program.
Due
to the tremendous success of self-employment, DVR rewrote its policy on
self-employment and held a two-day training for staff on how to provide support
for those individuals wishing to pursue a business start-up. (See Attachment K:
Division of Vocational Rehabilitation’s Policy on Self-Employment) DVR set up
a special fund to be used solely to support start-up costs for DVR clients
pursuing self -employment. The
project provided consultation on how to administer the money and provide
individuals with adequate supports. The experience of the project has also had
an effect nationally by sparking other federal demonstration projects in this
area.
Group
Services
As
mentioned previously, DVR counselors began to view their role as an educator and
a facilitator. Creative counseling approaches have been experimented with in the
regular VR program. Many counselors are now running group sessions in vocational
exploration and job finding skills. Most
agree that the group process helps individuals learn socially appropriate skills
for the workplace, helps to clarify skills, provides for peer interaction and
support, and can be an economical way to provide services.
A
benefit of the group approach is that through shared responsibility for running
groups by office staff, clients and counselors and even case aides get to know
each other better. Clients can gain
benefits from interaction with staff other than their own counselor. When an
individual comes into the office to talk to their counselor and that counselor
is not there, another staff member can often help out since they know that
individual. This saves waiting time for the consumer and empowers other staff to
provide services when needed.
Additionally,
the Choice Project experimented with a group process on values clarification,
goal setting and decision making for those individuals who seemed unable to make
progress toward developing or implementing a vocational goal.
The target group consisted of DVR customers who had poor self-esteem, a
lack of skills in problems solving and decision making, a poor family or friend
support network, and a lack of knowledge of community resources. These target
characteristics, and indeed the workshop curriculum, evolved out of the
project’s mentor program. (See
Mentor Services section immediately below.)
Project
staff developed a comprehensive curriculum that provided participants with an
opportunity to identify and explore their interests, values and skills, begin to
define goals and learn techniques for decision making.
This workshop proved very successful, and the Choice project has produced
a report on the outcomes of these workshops.
(See Attachment L: A Report on the Choice Workshop)
Mentor
Services
(See Attachment M: Mentoring)
The
original grant proposal spoke of the need for individuals to be able to choose
additional supports to help them in their rehabilitation process. Mentors, as
envisioned in the original grant proposal, would be recruited from the local
community and would assume a support role. However, when it came to implementing
this idea, project staff had difficulty defining the parameters within which
this service would function.
Four
Lead Mentors were hired to recruit and train individuals from the community and
match them with interested consumers. Initially, a large percentage of
individuals chose to have a mentor and great confusion arose as to what a mentor
should and should not do. Many
mentors subconsciously encouraged dependence on their services by doing for
rather than teaching how. The project scrambled to re-train the mentors to learn
techniques for teaching self-reliance.
As
the service became better defined, fewer consumer chose to have a mentor.
There were several shining moments when consumers, under the
encouragement and support of the mentor, were able to make great strides in
achieving vocational and related goals. The project began to understand that
those who benefited most from mentor support were those individuals who had many
barriers to employment besides their declared disability. They tended to be
crisis driven, had little family or community support, and lacked skills needed
to integrate into their communities and access needed resources.
However,
the services were expensive to administer and showed little promise for
integration into the regular DVR program. The program then began to experiment
with serving clients with this type of profile in a group setting described
above. This has shown promise and is still being used by DVR.
Peer
Review Process
The
project established a Peer Council to conduct the consumer satisfaction surveys.
Some of the council was also trained in conflict resolution techniques so
members could assist consumers in resolving disagreements with their counselors.
The idea was that rather than go to a more formal appeal process already in
place in DVR, individuals could have a peer assist in a mediation effort so that
conflicts could be resolved and services resumed more rapidly and avoid
unnecessary delay and confrontation.
However,
it became apparent that the few conflicts that did occur were over money issues
that ended up in appeal anyway. The types of individuals who generally reached
an impasse with their counselors were those who were unwilling to compromise
which was the greatest benefit to the peer review process - that of reaching a
compromise in order to move forward. Only three individuals during the first few
years of the project requested a peer review and after no one requested a peer
review in over a year, the process was dropped.
There
have been several key elements to making the integration of these new
philosophies and strategies so successful.
Committed
Leadership
From
the beginning the Director of DVR and other administrative staff in the central
office were supportive of the project and made their commitment known to those
in the field. The attitude was "We are definitely going in this direction
but how we go can be up to you." Staff
was active in the system design process and was strongly encouraged to
experiment with local strategies. However,
leadership was unwavering in its commitment to move forward.
Integration
In
the very beginning DVR counselors were recruited to work within the project.
Although the project coordinators were contractual employees through the
University of Vermont, project counselors were DVR employees operating out of
district offices. This gave
credibility to the results when discussed among their peers. Additionally, the project worked with exactly the same
demographic population as the regular program so that there could be no
accusations of 'creaming" from the applicant pool.
Division-wide
Participation in Planning
Throughout
the last three years of the project, the Division undertook a long range
planning process that involved staff from all levels of DVR.
Initially, representatives from DVR staff, project staff, the State
Rehabilitation Council, and consumers got together to develop a
"vision" of how the Division should look by the year 2000. This plan was developed to include specific goals and
objectives, timelines and responsible persons and was called the Vision 2000
document.
After
the plan was developed, a smaller representative group, called the
Implementation Team, was formed to oversee the progress and keep the momentum
going. This group continued its work for several years to ensure continued
progress and adherence to the goals of the plan.
Included in the plan were objectives for creating a welcoming environment
in each DVR office, enhancing staff development, ensuring consumer direction of
services and expanding collaborations with the business community and with other
agencies and service providers.
Training
and Sharing
To
disseminate the results of the project and share thoughts on project-related
philosophies and techniques, four separate two-day sessions were held for all
staff. The experiences of the project were related to the Vision 2000 goals and
staff was better able to understand the goals and outcomes of project
activities. Because of the commitment to follow through with the Vision 2000
goals and objectives, DVR administration has sponsored training in
self-employment, informed decision making and in other areas related to Vision
2000.
Additional
sharing is being encouraged through days set aside for inter-office visiting,
interactive television sessions and a state-wide retreat.
The Director toured the state and documented the progress being made
toward creating a consumer directed organization.
That document was then shared with all staff and the State Rehabilitation
Council. All of these efforts keep the Division's eye on the future of the
organization and keep momentum going for making the changes needed to conform to
the long-range plan.
As
the project winds down, the efforts of the Division as a whole seem to be
intensifying. There has developed a
sense of pride in each office and in the organization as a whole that was not
there six years ago. Creative new ways to make a consumer's experience warmer
and more beneficial have enhanced the atmosphere within the Division. Consumer
respect has been heightened due in large part to the increased ability of staff
to use their own judgment and to offer a more streamlined service.
Challenges
are always present. Work is needed to create a consumer-directed effort in the
area of Supported Employment services. The Division is unanimous in its
agreement to carry out this mandate. The details of how are just now being
explored. Additionally, momentum must continue to keep the spirit of change
alive so DVR staff does not become complacent in their efforts. For example, the
Choice project developed an Informed Choice Self Assessment Guide to assist the
organization in looking practically at program practices to ensure continued
consumer direction at every level. (See
Attachment A: The Implementation of Informed Choice in Vocational
Rehabilitation: A Functional Definition and Self-Assessment Process)
Consumer satisfaction surveys and training and sharing efforts will help
to keep the attention on consumers and keep staff interested in maintaining a
high quality service delivery system.