J Occup Rehabil DOI 10.1007/s10926-008-9154-z
Vocational Rehabilitation Services and Employment Outcomes for People with Disabilities: A United States Study Alo Dutta Æ Robert Gervey Æ Fong Chan Æ Chih-Chin Chou Æ Nicole Ditchman
Ó Springer Science+Business Media, LLC 2008
Abstract Introduction This study examined the effect of vocational rehabilitation services on employment outcomes of people with sensory/communicative, physical, and mental impairments in the United States. Methods The sample frame includes 5,000 clients for each of the three disability groups whose cases were closed as either rehabilitated or not rehabilitated by state vocational rehabilitation agencies in the fiscal year 2005. The dependent variable is employment outcome. The predictor variables include a set of personal history variables and vocational rehabilitation service variables. Results Sixtytwo percent of the clients in this study were gainfully employed after receiving vocational rehabilitation services. Individuals with sensory/communicative impairments had the highest success rate (75%) compared to 56% for the physical impairments group and 55% for those with mental impairments. Logistic regression analyses identified job placement, on-the-job support, maintenance, and other services (e.g., medical care for acute conditions) as
significant predictors of employment success across all impairment groups. In addition, diagnostic and treatment (D&T) services (odds ratio [OR] = 1.57; 95% CI: 1.35– 1.82) and rehabilitation technology services (OR = 1.97, 95% CI: 1.67–2.33) were found to uniquely contribute to employment outcomes for the sensory impairments group as well as the physical impairments group (D&T services: OR = 1.31, 95% CI: 1.15–1.48; RT services: OR = 1.41, 95% CI: 1.13–1.75), but not the mental impairments group. Substantial counseling was associated with employment outcomes for the physical (OR = 1.16, 95% CI: 1.02–1.32) and mental impairments groups (OR = 1.18, 95% CI: 1.03–1.35). Miscellaneous training (OR = 1.31; 95% CI: 1.09–1.49) was specifically associated with employment outcomes of the mental impairments group. Conclusion This study provides some empirical support documenting the association between vocational rehabilitation services and employment outcomes of people with disabilities. Keywords Vocational rehabilitation Employment Rehabilitation
A. Dutta (&) Department of Rehabilitation and Disability Studies, Southern University, 229 A. C. Blanks Hall, Baton Rouge, LA 70813, USA e-mail:
[email protected] R. Gervey F. Chan N. Ditchman Department of Rehabilitation Psychology and Special Education, University of Wisconsin, Madison, WI, USA F. Chan Stout Vocational Rehabilitation Institute, University of Wisconsin, Stout, WI, USA C.-C. Chou Department of Special Education, Rehabilitation, and School Psychology, University of Arizona, Tucson, AZ, USA
Introduction Work is fundamental to the physical and psychological well-being of people with and without disabilities [1]. Compared to persons who are employed, those who are unemployed tend to experience a higher prevalence of depression and anxiety disorders, use alcohol more frequently, and report lower scores on self esteem and quality of life measures [2–10]. Recognizing the importance of work, vocational rehabilitation professionals have consistently advocated for it as a fundamental human right of people with disabilities [11]. Therefore, job placement of
123
J Occup Rehabil
people with disabilities at the highest level possible has been central to the mission of many vocational rehabilitation programs [12–14]. The United States state-federal rehabilitation service program, which spends more than $2.5 billion annually, plays a large and instrumental role in helping people with disabilities obtain and retain employment [15]. The value of state vocational rehabilitation services has been supported in the rehabilitation literature [16–22]. In general, the employment rates of people with disabilities after receiving vocational rehabilitation services are consistently found to be around 60% [21, 22]. Employment outcomes achieved by state vocational rehabilitation agencies remain relatively constant among fiscal years, although considerable variance has been observed by disability type, with persons with sensory/communicative impairments having the best outcomes and people with mental impairments having the poorest [22]. Job placement and on-the-job support services appear to contribute most significantly to employment outcomes [22], and manufacturing and service jobs tend to be the most common job placement outcomes [21]. Recently, the evidence-based practice (EBP) movement in medicine has permeated and affected a wide array of health care and social service disciplines, and the field of vocational rehabilitation is no exception. The construct EBP is increasingly shaping vocational rehabilitation research and practice. For example, the United States National Institute on Disability and Rehabilitation Research (NIDRR) has, in recent years, underscored the need for NIDRR-sponsored research studies to meet standards for inclusion in evidence-based systematic reviews. The Rehabilitation Services Administration (RSA) of the United States Department of Education is beginning to emphasize vocational rehabilitation services that integrate the best research evidence with clinical expertise and client perspectives. Clearly, there are both internal and external pressures for rehabilitation agencies to continue to demonstrate that vocational rehabilitation is an effective service and that rehabilitation counselors are using an array of evidence-based interventions in their practice or risk losing funding and support. Bolton and colleagues [17] contend that rehabilitation outcome research needs to focus on answering the question: ‘‘Which approach works best for whom, how, and under what condition?’’ Answering this question will provide counselors with information regarding what personal factors and service provision patterns have a high probability of predicting successful outcomes for a specified group of clients. However, little is known about what personal factors and service patterns might contribute differentially to enhance employment outcomes of disability subgroups. For example, the state-federal vocational rehabilitation
123
program classifies people with disabilities into three major disability groups (sensory/communicative, physical, and mental impairments). The purpose of this study is to identify key factors associated with successful employment outcomes for each group. Specifically, this study poses the following research questions: 1.
2.
How do demographic variables and the provision of cash or medical benefits relate to the employment outcomes of people with disabilities receiving vocational rehabilitation services? What rehabilitation services are directly related to the employment outcomes of people with disabilities who qualified for state vocational rehabilitation services?
Method Participants Data for this study were extracted from the United States Department of Education, Rehabilitation Service Administration Case Service Report (Form 911) which contains personal history, types of services, and employment outcome information on all clients receiving state vocational rehabilitation services in the United States. This large archival dataset is furnished annually to Rehabilitation Service Administration by state vocational rehabilitation agencies across the United States. The RSA makes available this dataset for rehabilitation researchers upon request. The fiscal year (FY) 2005 RSA-911 data were used for the analyses in this study because it was the most current dataset available at the time of this study. In FY 2005, 616,879 individuals exited the vocational rehabilitation program. Specifically, 260,650 individuals exited the system without receiving vocational rehabilitation services for reasons including: no disabling condition, unable to locate, transferred, death, and disability too severe for services. Additionally, 356,229 exited the system after receiving vocational rehabilitation services, i.e., 206,695 (58%) exited with employment and 149,534 (42%) exited without employment. The RSA-911 data grouped people with disabilities broadly into three major disability groups: sensory/communicative (e.g., visual impairment/blindness and hearing impairment/deafness), physical (e.g., arthritis, spinal cord injury), and mental impairments (e.g., depression, schizophrenia, and learning disabilities). In FY2005, 52,795 individuals with sensory/communicative impairments (15%), 104,093 individuals with physical impairments (29%), and 199,341 individuals with mental impairments (56%) were closed as either successfully or unsuccessfully rehabilitated. For the purpose of this study, a stratified
J Occup Rehabil Table 1 Demographic characteristics of vocational rehabilitation clients
Independent Variables
Variable
Three sets of predictor variables were used for this study: demographic variables; work disincentive variables; and VR service variables. Demographic variables included gender (male and female), race (African American, Native American, Asian American, European American (nonHispanic origin), and Hispanic/Latino), age, education (special education, less than high school, high school graduate, associate degree, and college degree), pre-service employment status (employed vs. unemployed), and cooccurring disability (alcohol or other drug abuse [AODA], depression). Disincentive variables included the number of government benefits (supplemental security income [SSI], social security disability insurance [SSDI], temporary assistance for needy families [TANF], general assistance, veterans’ disability benefits, workers’ compensation, and medical insurance not through employment). Vocational rehabilitation services variables included assessment, diagnosis and treatment of impairments, vocational rehabilitation counseling and guidance, college or university training, occupational/vocational training, occupational/ vocational training, on-the-job training, basic academic remedial or literacy training, miscellaneous training, jobreadiness training, disability-related, augmentative skills training, miscellaneous training, job search assistance, job placement assistance, on-the-job supports, transportation services, maintenance, rehabilitation technology, reader services, interpreter services, personal attendant services, technical assistance services, information and referral services, and other services. A description of these services is presented in Table 2.
Sensory (%) Physical (%) Mental (%)
Gender Men
49
53
56
Women
51
47
44
European American 72 (non-Hispanic) 72%
69
62 25
Race/Ethnicity
African American
16
19
Hispanic/Latino
9
10
9
Asian American
2
1
2
Native American
1
2
1
Education Special education
2
2
13
22
21
35
Completed high school 39
43
32
Some post-secondary/ Associate’s degree College degree or higher
23
26
15
13
9
4
Less than high school
Co-occurring AODA Yes
1
2
9
No
99
98
91
Yes
42
47
49
No
58
53
51
Work disincentives
random sample of 15,000 clients was selected (5,000 in each impairment group) to study the association of vocational rehabilitation services on employment outcomes of these three major disability groups. The demographic characteristics of the sample are presented in Table 1. Variables Outcome Variable The outcome variable used was competitive employment. Competitive employment was defined in the RSA-911 manual as employment for at least 90 days in an integrated setting, self-employment, or employment in a state-managed Business Enterprise Program (BEP) that is performed on a full-time or part-time basis for which an individual is compensated at or above the minimum wage (BEP refers to vending facilities and small businesses operated by individuals with significant disabilities as well as home industry that falls under the management of the state vocational rehabilitation agency). Unsuccessful outcome referred to clients who were not working after completing their planned vocational rehabilitation program.
Data Analysis Data extracted from the RSA-911 data were analyzed using SPSS 13.0. Logistic regression analysis was used to examine the association among demographic characteristics, provision of cash or medical benefits, VR service patterns, and employment outcomes.
Results Descriptive Statistics There was significant age difference among the three major disability groups, F (2, 14997) = 1048.60, P \ .001. Posthoc analysis using the Bonferroni procedure indicated that clients with sensory/communicative impairments (M = 43.36 years, SD = 17.36) were significantly older than clients with physical impairments (M = 39.28 years, SD = 12.51) and clients with physical impairments were
123
J Occup Rehabil Table 2 Description of services provided by state VR agencies Type of service
Description
Assessment
Services provided and activities performed to determine an individual’s eligibility for VR services, to assign an individual to a priority category of a state VR agency that operates under an order of selection, and/or to determine the nature and scope of VR services to be included in the individual plan for employment (IPE); included in this category are trial work experiences and extended evaluation
Diagnosis and treatment of impairments
Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and supplies; this category includes diagnosis and treatment of mental and emotional disorders
Vocational rehabilitation counseling Discrete therapeutic counseling and guidance services necessary for an individual to achieve an and guidance employment outcome, including personal adjustment counseling; counseling that addresses medical, family, or social issues; vocational counseling; and any other form of counseling and guidance necessary for an individual with a disability to achieve an employment outcome; this service is distinct from the general counseling and guidance relationship that exists between the counselor and the individual during the entire rehabilitation process College or university training
Full-time or part-time academic training above the high school level that leads to a degree (associate, baccalaureate, graduate, or professional), a certificate, or other recognized educational credential; such training may be provided by a four-year college or university, community college, junior college, or technical college
Occupational/vocational training
Occupational, vocational, or job skill training provided by a community college and/or a business, vocational/trade, or technical school to prepare students for gainful employment in a recognized occupation; this training does not lead to an academic degree or certification
On-the-job training
Training in specific job skills by a prospective employer; generally the individual is paid during this training and will remain in the same or a similar job upon successful completion; this category also includes apprenticeship training programs conducted or sponsored by an employer, a group of employers, or a joint apprenticeship committee representing both employers and a union
Basic academic remedial or literacy Literacy training or training provided to remediate basic academic skills needed to function training on the job in the competitive labor market Job readiness training
Training to prepare an individual for the world of work (e.g., appropriate work behaviors, methods for getting to work on time, appropriate dress and grooming, methods for increasing productivity)
Disability-related, augmentative skills training
Service includes, but is not limited to, orientation and mobility, rehabilitation teaching, training in the use of low vision aids, Braille, speech reading, sign language, and cognitive training/retraining
Miscellaneous training
Any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma
Job search assistance
Job search activities that support and assist a consumer in searching for an appropriate job; may include help in preparing resumes, identifying appropriate job opportunities, and developing interview skills, and may include making contacts with companies on behalf of the consumer
Job placement assistance
A referral to a specific job resulting in an interview, whether or not the individual obtained the job
On-the-job supports
Support services provided to an individual who has been placed in employment in order to stabilize the placement and enhance job retention; such services include job coaching, follow-up and follow-along, and job retention services
Transportation services
Travel and related expenses necessary to enable an applicant or eligible individual to participate in a VR service; includes adequate training in the use of public transportation vehicles and systems
Maintenance
Monetary support provided for expenses such as food, shelter, and clothing that are in excess of the normal expenses of the individual and that are necessitated by the individual’s participation in an assessment for determining eligibility and VR needs or that are incurred while an individual receives services under an IPE
Rehabilitation technology
The systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of, and address the barriers confronted by, individuals with disabilities in areas that include education, rehabilitation, employment, transportation, independent living, and recreation; includes rehabilitation engineering services, assistive technology devices, and assistive technology services
Reader services
Services for individuals who cannot read print because of blindness or other disability; includes reading aloud and transcribing printed information into Braille or sound recordings if requested by the individual; generally are offered to individuals who are blind or deaf-blind but may also be offered to individuals unable to read because of serious neurological disorders, specific learning disabilities, or other physical or mental impairments
Interpreter services
Sign language or oral interpretation services performed by specially trained persons for individuals who are deaf or hard of hearing, and tactile interpretation services for individuals who are deaf-blind; includes real-time captioning services; does not include language interpretation
123
J Occup Rehabil Table 2 continued Type of service
Description
Personal attendant services
Those personal services that an attendant performs for an individual with a disability such as bathing, feeding, dressing, providing mobility and transportation, and so on
Technical assistance services
Technical assistance and other consultation services provided to conduct market analyses, to develop business plans, and to provide resources to individuals in the pursuit of self-employment, telecommuting, and small business operation outcomes
Information and referral services
Services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the VR program
Other services
All other VR services that cannot be recorded elsewhere; included here are occupational licenses, tools and equipment, initial stocks and supplies, and medical care for acute conditions arising during rehabilitation and constituting a barrier to the achievement of an employment outcome
significantly older than clients with mental impairments (M = 30.57 years, SD = 12.35). The mental impairments group had a higher proportion of men and African Americans than the sensory and physical impairments groups. The mental impairments group also had a higher percentage of people receiving cash or medical benefits and individuals with lower educational levels at the time of application. The average time for persons with disabilities to become eligible for state VR services was 1.32 months. On average, people with sensory/communicative impairments spent 25 months in VR compared to 28 months for people with physical impairments and 24 months for people with mental impairments. Case expenditures were significantly higher on average for persons with sensory/communicative impairments (M = US$5,462) compared to physical (M = US$4,816) and mental impairments (M = US $3,006), F(2, 14,997) = 87.91, P \ .001. For the overall sample, the employment success rate was 62%, with individuals with sensory/communicative disabilities having the highest success rate (75%) compared to 56% for people with physical disabilities and 55% for people with mental impairments. Nineteen percent of individuals with sensory/ communicative impairments reported finding employment at the professional/technical level as compared to 16% for people with physical impairments and 7% for individuals with mental impairments. Logistic Regression Analyses A logistic regression analysis was computed separately for each impairment group to examine the association between vocational services and employment outcomes. The first set of variables to be entered into the logistic regression analysis were demographic variables, which included age (with age 16–34 as the reference category), gender (with men as the reference category), race/ethnicity (with European American (non-Hispanic origin) as the reference category), education (with college graduate as the reference category), provision of cash or medical benefits, and
employment status at application. Co-occurring psychiatric disabilities and AODA were not included in this analysis because of low occurrence (\5%). In step 2, all VR services were entered as predictors. Table 3 presents the logistic regression analysis results. The omnibus tests for each of the three logistic regression models were found to be statistically significant. The Negelkerke R2 for the three models ranged from .16 for the mental impairments group, to .18 for the physical impairments group, to .28 for the sensory impairments group, indicating medium effect sizes for the associations between vocational services and employment outcomes. The nonsignificant Hosmer and Lemeshow goodness of fit tests indicated all three models fit the data reasonably well. Several demographic covariates were found to be significant including the race/ethnicity factor. African Americans with sensory impairments were found to have a 20% lower chance of finding successful employment after receiving vocational rehabilitation (OR = 0.80; 95% CI: 0.67–0.96), Native Americans with physical impairments were found to have a 51% lower chance of finding successful employment after receiving vocational rehabilitation (OR = 0.49; 95% CI: 0.31–0.78), and Native Americans with mental impairments were found to have a 50% lower chance of finding successful employment after receiving vocational rehabilitation (OR = 0.50; 95% CI: 0.31–0.82) than European Americans. Age was also found to be a significant predictor for the sensory impairments group, but not for the physical and mental impairments groups. Compared to clients between the ages of 16 and 34, those between the ages of 35–54 were 1.39 times more likely to be employed (OR = 1.39; 95% CI: 1.19–1.63), those between 55 and 64 were 1.88 times more likely to be employed (OR = 1.88; 95% CI: 1.47– 2.39), and those 65 years or older were three times more likely to be employed (OR = 3.30; 95% CI: 2.40–4.54). Education is a significant predictor for the sensory impairments and physical impairments groups. People who were more educated (at the time of application) had a higher chance of employment success. Clients with sensory
123
J Occup Rehabil Table 3 Odds ratio for vocational services by disability group Service
Sensory disability OR (95% CI)
Physical disability OR (95% CI)
Mental disability OR (95% CI) 1.03 (.90–1.17)
Assessment
1.10 (.94–1.30)
1.00 (.88–1.15)
Diagnosis and treatment
1.57 (1.35–1.82)*
1.31 (1.15–1.48)*
Counseling and guidance
.99 (.87–1.14)
1.15 (.98–1.34)
1.16 (1.02–1.32)***
University training
.82 (.66–1.04)
1.22 (1.04–1.43)***
1.20 (.99–1.46)
Vocational training
1.30 (1.00–1.69)
1.08 (.91–1.28)
1.71 (1.43–2.04)*
On-the-job training
–
–
Remedial training
–
–
Job readiness training
.96 (.73–1.26)
Augmentative skills training
1.11 (.87–1.40)
Miscellaneous training Job search assistance
1.13 (.90–1.41) 1.06 (.85–1.33)
1.14 (.90–1.45) – .94 (.76–1.17) 1.29 (1.010–1.52)**
1.18 (1.03–1.35)***
– – 1.12 (.94-1.34) – 1.31(1.09–1.58)** 1.28 (1.09–1.49)**
Job placement assistance
1.66 (1.34–2.06)*
2.23 (1.91–2.61)
2.12 (1.83–2.44)*
On-the-job supports
2.23 (1.68–2.96)*
1.97 (1.59–2.44)
2.40 (2.05–2.81)*
Transportation services
.69 (.57–.83)*
.93 (.80–1.08)**
Rehabilitation technology
1.97 (1.67–2.33)*
1.41 (1.13–1.75)**
Maintenance
1.49 (1.17–1.89)*
1.27 (1.06–1.52)**
Interpreter service
1.11 (.86–1.43)
Attendant service Reader service Technical assistance Information and referral Other services
.96 (.83–1.10) – 1.37 (1.15–1.63)*
–
–
–
–
–
–
–
–
1.05 (.72–1.52) .97 (.78–1.20) 1.51 (1.27–1.80)*
–
–
1.08 (.89–1.30)
1.07 (.88–1.29)
1.25 (1.08–1.44)**
1.41 (1.22–1.62)*
Note: OR odds ratio, 95% CI = 95% confidence intervals. Some services were not included as predictors because the number of clients receiving these services was minuscule * P \ .001; ** P \ .01; *** P \ .05
impairments who were graduates of a special education program had a 58% lower chance of obtaining employment (OR = 0.42; 95% CI: 0.27–0.67) compared to clients with sensory impairments with a college degree [the highest degree]; high school dropouts had a 38% lower chance (OR = 0.62; 95% CI: 0.48–0.82); and high school graduates had a 26% lower chance (OR = 0.74; 95% CI: 0.58– 0.96) of obtaining employment. Similarly, high school dropouts had a 50% lower chance (odds ratio [OR] = 0.50; 95% CI: 0.39–0.65), high school graduates had a 36% lower chance (OR = 0.64; 95% CI: 0.51–0.81), and individuals with some postsecondary education or AA degrees had a 32% lower chance (OR = 0.68; 95% CI: 0.53–0.87) of obtaining employment when compared to those with at least a college degree. Education had no bearing on employment outcomes for people with mental impairments. Employment status at the time of application was significantly related to rehabilitation outcomes for all three major impairment groups. People with sensory impairments who were employed at the time of application were four times more likely to be employed at the time of closure (OR = 4.05; 95% CI: 3.43–4.77). The OR is 2.79
123
(95% CI: 2.37–3.28) for clients with physical impairments and 1.53 (95% CI: 1.29–1.82) for clients with mental impairments. Provision of cash or medical benefits reduced the chance of finding employment. Clients with sensory impairments had a 40% lower chance of obtaining employment (OR = 0.60; 95% CI: 0.52–0.70). The reduction in chance for those with physical impairments was 37% (OR = 0.63; 95% CI: 0.56–0.71) and 39% (OR = 0.61; 95% CI: 0.54– 0.69) for people with mental impairments. Co-occurring psychiatric disabilities was a risk factor for people with physical impairments, resulting in a 42% lower chance of obtaining employment (OR = 0.58; 95% CI: 0.48–0.71). Job placement, on-the-job support, maintenance, and other services were significant predictors of employment success across all impairment groups. For job placement, people with sensory impairments receiving this service were 1.66 times (OR = 1.66; 95% CI: 1.34–2.06) more likely to be employed than those who did not; for physical impairments, it was 2.23 times (OR = 2.23; 95% CI: 1.91– 2.61); and it was 2.12 times (OR = 2.12; 95% CI: 1.83– 2.44) for people with mental impairments. For workplace
J Occup Rehabil
support, people with sensory impairments receiving this service were 2.23 times (OR = 2.23; 95% CI: 1.68–2.96) more likely to be employed than those who did not; for physical impairments, it was 1.97 times (OR = 1.97; 95% CI: 1.59–2.44); and it was 2.40 times (OR = 2.40; 95% CI: 2.05–2.81) for people with mental impairments. Maintenance services increased the odds of employment by 1.49 times (OR = 1.49; 95% CI: 1.17–1.89) for people with sensory impairments; 1.27 times (OR = 1.27; 95% CI: 1.06–1.52) for people with physical impairments; and 1.37 times (OR = 1.37; 95% CI: 1.15–1.63) for people with mental impairments. Other services also increased the odds of employment by 1.51 times (OR = 1.51; 95% CI: 1.27– 1.80) for people with sensory impairments; 1.25 times (OR = 1.25; 95% CI: 1.08–1.44) for people with physical impairments; and 1.41 times (OR = 1.41; 95% CI: 1.22– 1.62) for people with mental impairments. In addition, diagnostic and treatment (D&T) services (OR = 1.57; 95% CI: 1.35–1.82) and rehabilitation technology (RT) services (OR = 1.97, 95% CI: 1.67–2.33) were found to uniquely contribute to employment outcomes for the sensory impairments group as well as the physical impairments group (D&T services: OR = 1.31, 95% CI: 1.15–1.48; RT services: OR = 1.41, 95% CI: 1.13–1.75) but not the mental impairments group. Substantial counseling (SC) was associated with employment outcomes for the physical (OR = 1.16, 95% CI: 1.02–1.32) and mental impairments groups (OR = 1.18, 95% CI: 1.03–1.35). Job search assistance increased the odds of employment by 1.29 times (OR = 1.29; 95% CI: 1.10– 1.52) for people with physical impairments and 1.28 times (OR = 1.28; 95% CI: 1.09–1.49) for people with mental impairments. University training was significantly associated with employment outcomes for the physical impairments group. People with physical impairments who received university training were 1.22 times (OR = 1.22; 95% CI: 1.04–1.43) more likely to be employed than those who did not receive university training as a service. Miscellaneous training (OR = 1.31; 95% CI: 1.09–1.49) and vocational training (OR = 1.71; 95% CI: 1.43–2.04) were specifically associated with employment outcomes of the mental impairments group. Transportation services was negatively associated with employment outcomes for people with sensory impairments, with a reduction of 31% in odds of obtaining employment for those who needed transportation as part of their vocational rehabilitation services.
Discussion In this study, individuals with sensory/communicative disabilities were found to have a significantly higher
successful employment rate (75%) than people with physical disabilities (56%) and people with mental impairments (55%). Whereas, time spent in vocational rehabilitation by individuals with mental impairments (i.e., 2 years) was the least followed by those with sensory/ communicative disabilities and consumers with physical disabilities. This disconnect between time spent in the vocational rehabilitation system and relatively low employment outcomes of populations with mental impairments and physical disabilities could have been due to a renewed legislative focus on provision of services to people with most significant disabilities demonstrating the greatest need. Individuals with sensory/communicative impairments (19%) and people with physical impairments (16%) had significantly higher percentages of professional/ technical placement than individuals with mental impairments (7%). Job placement assistance, on-the-job support, maintenance, and other services were found to be related to employment success for all three disability groups. Medical rehabilitation treatment services and RT services were not as important as predictors for clients with mental impairments as for clients with sensory/communicative or physical impairments. Conversely, vocational training and miscellaneous training (e.g., general educational development [GED] training) were found to be significant predictors of employment success for people with mental impairments but not for the other two impairment groups. For people with physical impairments, SC, and job search assistance services were found to contribute additionally to successful employment outcomes. Importantly, provision of cash or medical benefits, was found to be a significant risk factor across all three impairment groups. For people with sensory/communicative impairments, the need for transportation assistance during rehabilitation was a risk factor that significantly reduced the odds of employment outcome. For people with physical impairments, cooccurring psychiatric disabilities (e.g., clinical depression) reduced the odds of successful rehabilitation outcomes. This study reported the highest cost of services and employment success rate was for those with sensory/ communicative impairments, followed by those with physical impairments and then mental impairments. In this study, the R2 for the sensory/communication impairments group was the highest, indicating that this group may be the most homogeneous and that vocational rehabilitation services that could benefit people with these disabilities may be more well-defined and established. An important finding of this study is the adverse effect of receiving provision of cash or medical benefits on employment outcome. One of the major barriers to gainful employment for persons with severe disabilities is weighing the financial benefits of paid work against the real possibility of losing disability-related benefits. Hennessey
123
J Occup Rehabil
[23] reported that \3% of SSDI recipients left the rolls because of working at what the Social Security Administration (SSA) calls the ‘‘substantial gainful activity’’ level. However, he also reported that if SSDI beneficiaries had knowledge of the trial work period and the extended period of benefits eligibility under new laws, as well as confirmation that they would receive Medicare benefits, the effects of receiving cash or medical benefits would dissipate. Therefore, rehabilitation health professionals need to be familiar with disability-related benefits (e.g., social security, Medicaid, Medicare, food stamps, state health care programs, TANF benefits, housing, veteran’s benefit, vocational rehabilitation, fuel assistance, etc.) received by their clients and the benefits counseling training provided by the SSA. Diagnostic and treatment services were associated with employment outcomes for people with sensory and physical impairments. Providing needed surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and supplies appear to help improve functioning and health status of people with disabilities and improve functioning leads to employment. Low-income people with disabilities also need basic services (i.e., maintenance services and other services). For example, monetary support could be provided for expenses such as food, shelter, and clothing that are in excess of the normal expenses of the individual and that are necessitated by the individual’s participation in vocational rehabilitation. African Americans and Native Americans were found to have lower odds of obtaining competitive employment compared to European Americans. Disparities in vocational rehabilitation services have been studied extensively. In general, research has revealed that people from racial and ethnic minority backgrounds do experience more problems than their European American counterparts at every step in the vocational rehabilitation process [24]. For example, numerous researchers have found that African American vocational rehabilitation applicants were less likely to be accepted for vocational rehabilitation services, compared with European Americans [24–30]. If found eligible for services, African Americans were also less likely than European American clients of vocational rehabilitation services to be rehabilitated [24, 30, 31]. Individuals with visual impairments aged 65 years or older were found to be three times more likely to obtain employment than individuals with visual impairments between the age of 16 and 34. A close examination of this older adult group indicated that 75% of these clients were employed at the time of application. Apparently, they utilized vocational rehabilitation services to help them maintain their jobs, receiving mainly comprehensive assessment (78%), D&T (57%), counseling (65%), and RT services (45%).
123
Finally, successful employment outcome is defined by the U.S. Department of Education Rehabilitation Services Administration as employment for at least 90 days in an integrated employment setting. Ninety days is a relatively short time. It may be more accurate to examine employment outcomes based on job tenure that is at least six months or one year. Alternatively, state vocational rehabilitation agencies provide follow-along services for some of their clients and it may be useful to examine the associations between vocational services and employment outcomes with clients who received follow-along support services. Implications for Occupational Rehabilitation Practice The findings of this study suggest that state vocational rehabilitation services are associated with employment outcomes. State vocational services can be of value to other rehabilitation health professionals in this era of managed care. Fawber and Wachter [6] contended that vocational intervention is also appropriate in medical rehabilitation. They recommended a treatment-oriented job placement process that seeks to distribute responsibility for employment outcomes among all interdisciplinary team members throughout the entire medical-vocational rehabilitation continuum. The important benefit of aggressive vocational programming within the overall operation of any medical rehabilitation treatment program is its capacity to provide direction, focus, and meaning to other therapies or services [6]. In this sense, VR is best regarded as a ‘‘pull factor’’ therapy (i.e., the therapy that provides direction) and, as such, is distinguished from other ‘‘push factor’’ therapies (i.e., those that focus on improving functioning) [32]. Hence, the probability of a successful vocational outcome is enhanced when all therapies can be related to work, and vice-versa. The value of addressing vocational issues within an acute or post-acute rehabilitation program at an early stage after injury/illness is therefore immense [33]. In addition, Horn et al. [34] indicated that acute care patients who lack socio-economic resources (e.g., private insurance) can benefit from vocational rehabilitation services. Since a large segment of people with disabilities is from lower socioeconomic background, they can benefit from vocational rehabilitation services, both pre- and post-discharge. Therefore, the findings of this study can be of interest and use to practitioners in occupational therapy, physical therapy, speech and language therapy, and recreation therapy. Acknowledgments This study was supported in part by funding from the Rehabilitation Research Institute for Underrepresented Populations (National Institute on Disability and Rehabilitation
J Occup Rehabil Research Grant #H133A031705) at Southern University, Baton Rouge, Louisiana.
References 1. Chan F, Leahy M, Saunders J. Case management for rehabilitation health professionals (volume 1): foundational aspects. Osage Beach, MO: Aspen Professional Services; 2005. 2. Bruffaerts R, Sabbe M, Demyttenaere K. Effects of patient & health-system characteristics on community tenure of discharged psych inpatients. Psychiatr Serv (Washington DC). 2004;55:685– 90. doi:10.1176/appi.ps.55.6.685. 3. Dooley D, Fielding J, Levi L. Health and unemployment. Annu Rev Public Health. 1996;17:449–65. doi:10.1146/annurev.pu. 17.050196.002313. 4. Dooley D, Catalano R, Wilson G. Depression and unemployment: panel findings from the epidemiologic catchment area study. Am J Community Psychol. 1994;22(6):745–65. doi:10.1007/BF0252 1557. 5. Dooley D, Catalano R, Hough R. Unemployment and alcohol disorder in 1910 and 1990: drift versus social causation. J Occup Org Psychol. 1992;65:277–90. 6. Fawber HL, Wachter JF. Job Placement as a treatment component of the vocational rehabilitation process. J Head Trauma Rehabil. 1987;2:27–33. doi:10.1097/00001199-198703000-00006. 7. Kasl SV, Rodriguez E, Lasch KE. The impact of unemployment on health and well-being. In: Dohrenwend B, editor. Adversity, stress and psychopathology. New York: Oxford University Press; 1998. p. 111–31. 8. Lennon MC. Work and unemployment as stressors. In: Horwitz A, Scheid T, editors. A handbook for the study of mental health: social contexts, theories and systems. New York: Cambridge University Press; 1999. p. 287–94. 9. Linn MW, Sandifer R, Stein SS. Effects of unemployment on mental and physical health. Am J Public Health. 1985;75(5):502–6. 10. Van Dongen CJ. Quality of life and self-esteem in working and non-working persons with mental illness. Community Ment Health J. 1996;32:535–48. doi:10.1007/BF02251064. 11. Marrone J, Golowka E. If you think work is bad for people with mental illness, then try poverty, unemployment, and social isolation. Psychiatr Rehabil J. 2000;23(2):187–93. 12. Chan F, Wong DW, Rosenthal DA, Kundu MM, Dutta A. Eligibility rates of traditionally underserved individuals with disabilities revisited: a data mining approach. J Appl Rehabil Counsel. 2005;36(3):3–10. 13. Chan F, Reid C, Roldan G, Kaskel L, Rahimi M, Mpofu E. Vocational assessment and evaluation of people with disabilities. Phys Med Rehabil Clin N Am. 1997;8:311–25. 14. Rubin S, Roessler R. Foundations of the vocational rehabilitation process. 5th ed. Austin, TX: Pro-Ed; 2001. 15. U.S. Government Accountability Office. Vocational rehabilitation: better measures and monitoring could improve the performance of the VR program (GAO-05-865), Washington, DC; 2005. 16. Bellini J, Bolton B, Neath J. Rehabilitation counselors’ assessments of applicants’ functional limitations as predictors of rehabilitation services provided. Rehabil Counsel Bull. 1998;41(4):242–59.
17. Bolton B, Bellini JL, Brookings JB. Predicting client employment outcomes from personal history, functional limitations, and rehabilitation services. Rehabil Counsel Bull. 2000;44:10–21. doi:10.1177/003435520004400103. 18. Capella-McDonnall ME. Predictors of competitive employment for blind and visually impaired consumers of vocational rehabilitation services. J Visual Impair Blind. 2005;99(5):303–15. 19. Chan F, Cheing G, Chan JYC, Rosenthal DA, Chronister JA. Predicting employment outcomes of rehabilitation clients with orthopedic disabilities: a CHAID analysis. Disabil Rehabil. 2006;28:257–70. doi:10.1080/09638280500158307. 20. Gamble D, Moore CL. The relation between VR services and employment outcomes of individuals with traumatic brain injury. J Rehabil. 2003;69:31–8. 21. Kaye HS. Vocational rehabilitation in the United States. Disabil Stat Abstr. 1998;20:1–4. 22. Rosenthal DA, Chan F, Wong DW, Kundu M, Dutta A. Predicting employment outcomes based on race, gender, disability, work disincentives, and vocational rehabilitation service patterns. J Rehabil Adm. 2006;29:229–43. 23. Hennessey JC. Factors affecting the work efforts of disabled worker beneficiaries. Soc Secur Bull. 1997;60:3–20. 24. Atkins BJ, Wright GN. Vocational rehabilitation of Blacks: the statement. J Rehabil. 1980;46(2):42–6. 25. Dziekan KI, Okocha AG. Accessibility of rehabilitation services: comparison by racial-ethnic status. Rehabil Counsel Bull. 1993;36:183–9. 26. Herbert J, Martinez MY. Client ethnicity and vocational rehabilitation case service outcome. J Job Placement. 1992;8(1):10–6. 27. Feist-Price S. African Americans with disabilities and equity in vocational rehabilitation services: one state’s review. Rehabil Counsel Bull. 1995;39(2):119–29. 28. Wilson KB. Predicting vocational rehabilitation acceptance based on race, education, work status, and source of support at application. Rehabil Counsel Bull. 2000;43(2):97–105. doi:10.1177/ 003435520004300205. 29. Wilson KB. Exploration of VR acceptance and ethnicity: a national investigation. Rehabil Counsel Bull. 2002;45(3):168–76. doi:10.1177/003435520204500306. 30. Wilson KB. Vocational rehabilitation closure statuses in the United States: generalizing to the Hispanic/Latino ethnicity. J Appl Rehabil Counsel. 2005;36(2):4–11. 31. Ross MG, Biggi IM. Critical vocational rehabilitation service delivery issues at referral (02) and closure (08, 26, 28, 30) in serving select disabled persons. In: Walker S, Belgrave F, Banner AM, Nicholls RW, editors. Equal to the challenge: perspective, problems, and strategies in the rehabilitation of the nonwhite disabled: Proceedings of the National Conference. Howard University, Washington DC; 1986. p. 39–50. 32. Cardoso E, Romero M, Chan F, Dutta A, Rahimi M. Disparities in vocational rehabilitation services for Hispanic consumer. J Head Trauma Rehabil. 2007;22(2):85–94. 33. Main L, Haig J. Occupational therapy and vocational rehabilitation: an audit of an outpatient occupational therapy service. Brit J Occup Therapy. 2006;69(6):288–92. 34. Horn W, Yoels W, Barolucci A. Factors associated with patients’ participation in rehabilitation services: a comparative injury analysis 12 months post-discharge. Disabil Rehabil. 2000;22(8):358– 62. doi:10.1080/096382800296601.
123
