Community rehabilitation organizations: transition to what?

The purpose of this article is to bring some discussion to the issues confronting community rehabilitation organizations, but it will focus on organizations that have as their primary mission and purpose to facilitate vocational outcomes for individuals served.

Community rehabilitation organizations, it has been said, need to change. This is probably true, given the basic business practice that without change any organization or program will stagnate and die. The difficulty the community rehabilitation organizations need to deal with is the question of "change to what?"

It is extremely difficult to generalize about community rehabilitation organizations. This is true particularly since this industry, more than most, has done little to define its own role, purpose, and mission. Our industry, being reactive rather than proactive in defining ourselves, has been pervasive for more than 50 years. This characteristic is typified in the recent passive acceptance by community rehabilitation organizations of allowing others to define the term "facility" to reflect a philosophy as opposed to an address.

There was an assumption made by individuals who advocate a particular and specific philosophy that rehabilitation organizations (facilities) represent a generally accepted philosophy and way of doing business rather than a location to coordinate program services, administration, and support services. This assumption was then accepted as a realistic description of facilities, and operators of facilities found themselves on the defensive.

It has been said, "The facilities group encompasses a variety of often dissimilar groups whose interest is the same: Helping individuals with disabilities to improve their daily lives and function independently to the greatest extent possible. Different organizations and programs have grown and prospered, particularly over the last 80 years, to fulfill that common goal" (Brabham & Jones 1992).

In reviewing the history of rehabilitation facilities, it becomes quite obvious that the provider community was viably linked to the state-federal vocational rehabilitation (VR) system. The growth of the facility movement was in direct relationship and responsive to the priorities and funding established by the federal government through the years. During the late fifties and early sixties, there was considerably expanded federal funding made available specifically for the construction of new rehabilitation facilities. The state-federal VR program appropriations during that time quadrupled, with a significant portion of that money targeted for facilities.

Even then the rehabilitation facilities movement was a series of reactive organizations linked to the emphasis and philosophies being generated at the state and federal levels defining how to serve people with disabilities. The facilities community, in fact, worked specifically toward the development, implementation, and expansion of programs that were based on the then described requirements of that influence. The rehabilitation industry even went so far as to construct specific disciplines and professions responsive to the directions being communicated by the state-federal VR system.

The requirement to be responsive and sensitive to customer need is a laudable business decision. The concept, however, can be taken to the extreme when the customer is not necessarily the consumer and there is an absence of a single unified voice defining the philosophical approaches to the provision of services to people in need. Facilities then became community rehabilitation organizations because it was determined that that would be an appropriate alternative name for this industry. The industry accepted the pejorative connotation assigned to "facility" rather than debate the merits or program value. That was augmented by the development of new enterprises to respond to the emerging philosophy of supported employment. We then accepted community rehabilitation organizations as if they represented a single, specific, cohesive, well-defined industry. That is not the case, given the broad, divergent philosophical orientations that the regional, state, and local agencies and organizations have in relationship to how services shall be provided to people with disabilities. Even though community rehabilitation organizations became the agreed and accepted upon title, it in no way reflects a true shift in philosophy or approach by the various entities renamed.

For many community rehabilitation organizations there has been a recognized requirement that to stay in business they should take a look at what type of business they are in. The answer for many has been the recognition that vocational rehabilitation is an employment and training business with the primary focus of helping individuals with barriers to employment to "get a job." Community rehabilitation organizations, especially those that have a vocational emphasis, need to define their long-term role and their function within the community. For those oriented to vocational outcomes, the answer becomes self-evident. Their business is to help provide a means by which people with barriers to employment can avail themselves of a process to help reduce the barriers and achieve meaningful, gainful employment.

If, in fact, the community rehabilitation organizations are gravitating toward an understanding that they are an employment and training industry, they then can define their broad range role of fitting into the community. Once that question is answered for the industry, the subsequent question is "Who needs us?" If, in fact, the goals of the system are to assist individuals with barriers to employment to become self-sustaining and contributing members of the community, then it may well be recognized that the skills and techniques that have evolved over the last 50 years are appropriate and applicable to multiple populations. The community rehabilitation organizations may need to understand that what we do is not population specific but profession specific. Our industry has developed a series of technologies and processes that result in an outcome.

Given the evolving nature of employment and training programs across government and within local communities, it may be almost too late for our industry to recognize that we can apply all the skills that we have developed over time to emerging program and population concerns in local communities.

The successful future of the community rehabilitation organizations, especially those focused on vocational outcomes, will require structured, strategic thinking and planning. Not the least of this structure will focus on the definition of what business we are really in, defining who needs us, and, more important, determining who pays. There are many issues that confront community rehabilitation organizations, but this paper will focus essentially on three that are considered to be extremely critical. The issues to be discussed are:

* Consumer Choice

* Accountability/Outcomes

* Construction of a Service

Delivery Model

Consumer Choice

Community rehabilitation organizations are often in conflict over opposing philosophies of consumer choice versus integration. There is a proliferation of writing that indicates that community rehabilitation organizations should have as their sole focus integration of all programs, services, and employment opportunities in community sites.

Even though the amendments to the Rehabilitation Act clearly call for an emphasis on consumer choice, the preponderance of industry literature puts emphasis on the need for a single focused transition philosophy of community-based programming only. This single focused philosophy is characterized in the following recommendation: "If integrated employment is a priority, then state and federal policies and practices must be supportive by creating fiscal incentives, adopting licensure and regulatory standards that reflect inclusion values, and establishing individually designed and consumer-focused services. A clear message from funding agencies, such as tying funding to a commitment to develop integrated employment, could facilitate program conversion" (Kierman, Butterworth, & McNally). This type of philosophy continues to be pervasive despite some of the recent data indicating that consumers are, in fact, satisfied with the range of options for services and programming available to them. A recently released interim report of a longitudinal study by the Rehabilitation Services Administration indicates that 69 percent of the consumers indicate that they were very much a part of the decision making process for services. Further, the study asked consumers whether the counselors gave them information that was helpful in making the best possible choices of providers. The data indicates that 76 percent of those served thought that the counselors provided information for them to make appropriate choices. Of those, 54 percent were very satisfied with the available choice of providers, with an additional 26 percent somewhat satisfied. In this study, only 5 percent reported being dissatisfied with the available choice of providers (U.S. Department of Education). "Overall, then, consumers reported a high level of satisfaction with the choices available to them as they selected their goal, planned their services, and made decisions about providers of services. In most instances, decisions about these occurred as a joint process between consumer and counselor or with the consumer autonomously making a decision" (U.S. Department of Education). Continuing advocacy for complete transition in the service delivery field appears then to be generated by individuals other than those truly concerned about this being a consumer driven process.

Many community rehabilitation organizations have already made significant movement toward assuring that consumer choice is the driving force in the identification of appropriate services.

For example, Goodwill Industries as an organization developed and printed a philosophy statement to be communicated to individuals served by their respective organizations that articulates a clear commitment to the issue of consumer choice. Among the commitments guaranteed to the person served are the following: "That each will:

* Receive services which will enable each to acquire information; make career decisions; and negotiate and balance information, decisions and external factors that have an impact on work;

* Receive skills training which reflect current labor market demands consistent with the community;

* Have the option to refuse, accept, or modify services because participation is voluntary. Each individual and the organization should negotiate the best possible arrangement for services, including referral to other agencies;

* Have the right, as well as the responsibility, to participate in the development of program planning. To whatever extent possible, each individual must be encouraged to take responsibility for him or herself and the processes and outcomes of services made available;

* Make informed choices."

Other community rehabilitation organizations have also made commitments to give particular attention to the issues of consumer choice.

If this commitment is to have meaning, the community rehabilitation organizations, as well as the rehabilitation industry as a whole, need to emphasize services that facilitate learning of the decision making process. Just saying that an individual has choices is insufficient; we must ensure that the person has the opportunity and skills to be an active participant in the decision making process.

The deficiency in the existing system is that it assumes that the individual, even though he or she may have come out of a dependency environment, can now make an immediate transition to being an active partner in the construct of long-term planning for program services and outcomes.

It is the function of the rehabilitation organization to facilitate learning that helps a person understand the process of becoming an interdependent participating and contributing member of society. It should be recognized that there are certain assumptions associated with choice. Some of those assumptions are:

* Making choices is a dynamic process.

* For a choice to be viable, the rehabilitation process should allow for the customization of information.

* Choice should be an inherent factor in the operating standards of providers.

* Choices must be understood to be meaningful.

* Labor market information affects choice.

* Resources affect choices.

* Choice is affected by the nature of assistance available and the type of assistance needed.

* Comfort with opportunities to choose are affected by the individual's knowledge of the providers' past performance.

* Competition will affect choice.

* Who the consumer is will affect choice (Morrissey).

Additionally, there are some assumptions that the community rehabilitation organization should make in the process of facilitating the acquisition of decision making skills by the individual. These assumptions include:

* All legal and ethical work has value.

* No form of paternalism, no matter how well intended, is justified.

* Deficit model thinking is unacceptable.

* Integration is defined by the individual; providers of services are facilitators not directors.

Community rehabilitation organizations should work more toward the construction of commonly acceptable activities of career development that are "a process which provides information, understanding, knowledge, and skills that an individual needs to establish and develop plans for a long-range career goals" (Shaw, 1994). This process would include skill building in the area of self-awareness, career and personal assessment, career awareness, career decision making, career planning, career preparation, and, ultimately, placement.

Accountability/Outcomes

The second area of emphasis for community rehabilitation organizations has to do with accountability or measurement of outcomes. Recently there has been a renewed emphasis by major influences to have rehabilitation organizations prove their value and efficiency in the solution of the social problems they say they address.

In almost every government program authorizing employment and training there is language that clearly calls for the development of "benchmarks," "standards and indicators," "outcomes," and "accountability."

For years, community rehabilitation organizations have attempted to demonstrate accountability and stewardship of resources through the accreditation process. Unfortunately, only a minor piece of accreditation truly addresses outcome measurement, and even those standards addressing outcomes measure the process rather than accomplishment. For example, even though an organization's evaluation system may indicate that the organization is not achieving any of its goals, the organization could still be accredited, simply by having the system and executing the functions of the system. More and more, external influencers are expecting community rehabilitation organizations to measure more than efficiency and effectiveness in assisting people to get employment. The emphasis is shifting to assuring the longevity of employment and the quality of work as measured by wages, benefits, and upward mobility.

Recent studies done by the U.S. General Accounting Office have indicated that almost all employment training programs serving people with barriers to employment have limited long-term impact or effect on the acquiring and maintaining of employment for those served. Success should be measured in terms of whether a person can keep a job and if the job significantly impacts that person's quality of life.

Community rehabilitation organizations, in order to prove their long-term value, should incorporate an evaluation system that addresses:

* helping people get a job;

* helping people keep a job;

* helping people get off of government subsidies;

* helping people increase the number of hours they work;

* requiring benefits as part of employment;

* helping individuals increase upward mobility; and

* ensuring that people obtain the skills they need to obtain alternative employment since most individuals change jobs several times in their life (Shaw).

Community rehabilitation organizations should be able to measure their contribution to the selection of the social problems they address, change their way of doing business to ensure that their objectives are achieved, or go out of business.

Service Delivery Model

The final topic to be addressed in this paper has to do with the way individuals are served in community rehabilitation organizations. Traditionally, our industry has been focused on the provision of "programs."

"Essentially, a program model serves the organization. It is a collection of related and prescribed services defined in procedures that when applied consistently result in a general outcome. Program models are consistent with the present accreditation models used now in the rehabilitation industry. Although program models have served us well in the past, given the present emphasis on serving the individual, a new paradigm needs to be constructed. It has been suggested that the organizations look at the development of a service model. A service model utilizes an activity or series of activities that respond to a specific area of need and results in a specific outcome. The collection of activities might result in the construction of a program, but that program would be individual specific" (Shaw).

Instead of assuming that all individuals need all the same services (program model) it is suggested that we look at the specific requirements and expectations of the person served and respond with only those activities and services required to address a specific barrier or need. The difference between a program and service model is depicted in Figure 1.

Figure 1

Program Characteristics

* Menu model

* Have fixed outcomes

* Have fixed services

* Are controlled by staff

* Limit choices

* Are driven by funders

* Are consistent with present education system

* Are consistent with accreditation

* Are understood by community

Service Characteristics

* Cafeteria model

* Individual specific

* Flexible

* Based on personal choice

* Require staff flexibility

* Require new funding orientation

* Require educating existing publics

It is recognized that transition from any existing model to a new way of doing business is disruptive to the organization and difficult to communicate to existing publics. Additionally, a service model is inconsistent with the present structure of accreditation/certification requirements and the general philosophy of referral and funding organizations. If, in fact, we are serious about the issues of choice, we will need to develop a truly individualized service plan for each person served, and that plan will be dependent upon the unique and specific needs as well as the expectations and desires of the person served.

Instead of having a listing of traditional programs such as work evaluation, work adjustment, and the various forms of employment programs, we would rather have an array of specific types of services that we either provide or arrange for to assure the accomplishment of the individual's goals. A possible array of services is depicted in Table 1 (Shaw 1994).

[TABULAR DATA 1 NOT REPRODUCIBLE IN ASCII]

Summary

The community rehabilitation organizations, rather than arguing about differences in philosophy, should cohesively band around the principles in the Rehabilitation Act of 1992. The Act asserts that: "Millions of Americans have one or more physical or mental disabilities and the number of Americans with such disabilities is increasing:

"Individuals with disabilities constitute one of the most disadvantaged groups in society;

"Disability is a natural part of human experience and in no way diminishes the right of the individual to

* Live independently;

* Enjoy self-determination;

* Make choices;

* Contribute to society;

* Pursue meaningful careers; and

* Enjoy full inclusion in the economic, political, social, cultural, and educational mainstream of American society."

All rehabilitation organizations should assure the availability of appropriate and meaningful services to people with disabilities.

Bibliography 

[1.] 2nd Interim Report of the Longitudinal Study (1997). Rehabilitation Services Administration, Office of Special Education and Rehabilitative Services, U.S. Department of Education.

[2.] Goodwill Industries International, Inc. (1992). Our Philosophy Concerning The People We Serve.

[3.] Jones, C.T., & Brabham, R.E. (1992). An Overview of the Rehabilitation Facilities Movement: A Report of the 16th Mary E. Switzer Memorial Seminar.

[4.] Kiernan, W., Butterworth, J., McNally, L., & Gilmore, D. (1997). Integrated employment: Provider perspective and implications, Journal of Rehabilitation Administration, 20, 1.

[5.] Morrissey, P.A. (1995) Consumerism and choice: Basic standards for judging efforts and expectations in the vocational rehabilitation process. A Report on the 18th Mary E. Switzer Memorial Seminar.

[6.] Rubin, S.E, & Roessler, R.T. (1987). Foundations of the Vocational Rehabilitation Process, PRO ED, Austin, Texas.

[7.] Shaw, K.J. (1996). Outcome Measurement: A Renewed Emphasis. Goodwill Forum.

[8.] Shaw, K.J. (1994). Transition from Traditional Rehabilitation Facility to Employment, Educator and Training Center: A Model for the Next Decade. Goodwill Industries International, Inc.