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Consumer Direction in Disability Policy Formulation and Rehabilitation Service Delivery.



Disability is a natural part of the human experience. The ability to control one's existence is also an essential part of being human (National Institute on Consumer-Directed Long-Term Services [NICDLTS], 1996a). Many people with disabilities are often denied the opportunity to exercise choice and control over the most basic aspects of daily life. Consumer direction is an approach to the development of disability policy and delivery of rehabilitation rehabilitation: see physical therapy.  services whereby informed consumers have control and the opportunity to make choices. In a consumer-directed system, individuals with disabilities assess their own needs, determine how and by whom these needs should be met, and monitor the quality of services received.

Consumer direction can exist in differing degrees and may span many types of services. It ranges from the individual independently making all decisions and managing services directly to the individual using a representative to manage services (Kosciulek, 1997). The unifying theme in CD is that individuals with disabilities have the authority to make choices that work best for them, regardless of the nature or extent of their disability or the source of payment for services (NICDLTS, 1996a). Consumer choice and control are both prerequisites for an effective consumer-directed rehabilitation service delivery system (Dart dart

see blow dart.


dart gun
see blow dart.
, 1992; West & Parent, 1992).

Currently in American society, people with disabilities, as a group, remain poorer, less educated, and less employed than the population in general (Kosciulek, 1998; National Council on Disability, 1996). Higgins (1992) asserted that the problems faced by people with disabilities can be viewed as the consequences of the failure of social institutions that have been constructed to deal with a narrower range of variation than is in fact present in the disability population. Likewise, Szymanski and Trueba (1994) emphasized that at least some of the difficulties faced by people with disabilities are not the result of functional impairments related to the disability, but rather are the result of discriminatory dis·crim·i·na·to·ry  
adj.
1. Marked by or showing prejudice; biased.

2. Making distinctions.



dis·crim
 processes embedded Inserted into. See embedded system.  in societal so·ci·e·tal  
adj.
Of or relating to the structure, organization, or functioning of society.



so·cie·tal·ly adv.

Adj.
 institutions for rehabilitation and education and enforced by well-meaning professionals. Those individuals whose mobility, communication, medical needs, or cognition cognition

Act or process of knowing. Cognition includes every mental process that may be described as an experience of knowing (including perceiving, recognizing, conceiving, and reasoning), as distinguished from an experience of feeling or of willing.
 differs from social norms find themselves confronting institutions not well suited to meet their abilities and potential (Scotch scotch 1  
tr.v. scotched, scotch·ing, scotch·es
1. To put an abrupt end to: The prime minister scotched the rumors of her illness with a public appearance.

2.
 & Schriner, 1997).

Given the current status of people with disabilities in American society, the purpose of public disability policy and rehabilitation service delivery must be to enhance the quality of life of people with disabilities. Empowering people with disabilities to have control over the policies and practices that directly affect their lives can achieve this important objective. People with disabilities must play the central role in directing the disability policy formulation formulation /for·mu·la·tion/ (for?mu-la´shun) the act or product of formulating.

American Law Institute Formulation
 and rehabilitation service delivery that is central to their empowerment em·pow·er  
tr.v. em·pow·ered, em·pow·er·ing, em·pow·ers
1. To invest with power, especially legal power or official authority. See Synonyms at authorize.

2.
.

Underlying Assumptions of Consumer Direction

Three underlying assumptions of CD are presented to set the framework for a more specific discussion of the conceptual framework For the concept in aesthetics and art criticism, see .

A conceptual framework is used in research to outline possible courses of action or to present a preferred approach to a system analysis project.
 of CD.

Consumer-directed disability policy and rehabilitation programming should be based on the presumption A conclusion made as to the existence or nonexistence of a fact that must be drawn from other evidence that is admitted and proven to be true. A Rule of Law.

If certain facts are established, a judge or jury must assume another fact that the law recognizes as a logical
 that consumers with disabilities are the experts on their service needs. An informed consumer is the best authority on what his or her service needs are, how these needs are best met, and whether these needs are being met appropriately. The consumer should be presumed competent to direct services and make choices, regardless of age, or the nature or extent of disability (NICDLTS, 1996a).

Choice and control can be introduced into all service delivery environments. Systems can be designed to include a variety of options that cater to diverse groups of consumers, whether they wish to exert total control over services or very little control. The model of disability as human variation (Scotch & Schriner, 1997) considers disability as introducing complexity and disequilibrium disequilibrium /dis·equi·lib·ri·um/ (dis-e?kwi-lib´re-um) dysequilibrium.

linkage disequilibrium
 into service systems. By focusing attention on how systems respond to the variation introduced by disability, a consumer-directed model of service delivery might help policy makers and program administrators address the issue of how to best design rehabilitation systems to enhance consumer control. The range of preferences expressed by consumers provides the structure for expanding CD within a variety of service delivery environments (NICDLTS, 1996a). For example, a variety of accommodation and compensation techniques (e.g., memory notebook, visual or auditory auditory /au·di·to·ry/ (aw´di-tor?e)
1. aural or otic; pertaining to the ear.

2. pertaining to hearing.


au·di·to·ry
adj.
 cues) may be implemented during medical rehabilitation to promote choice and control for an individual with residual cognitive deficits Cognitive deficit is an inclusive term to describe any characteristic that acts as a barrier to cognitive performance. The term may describe deficits in global intellectual performance, such as mental retardation, or it may describe specific deficits in cognitive abilities  following a brain injury.

Consumer direction should be available to all, regardless of payer. People with disabilities who rely on services financed by public agencies or insurance companies have limited control over the services they receive. Inability to control the form of assistance received is severely dehumanizing (Hahn, 1991), particularly when the payer control extends to issues concerning day-to-day existence, such as eating times and living and working environments. Disability, whether mental, physical, sensory sensory /sen·so·ry/ (sen´sor-e) pertaining to sensation.

sen·so·ry
adj.
1. Of or relating to the senses or sensation.

2.
, or age-related, when combined with reliance on public assistance, should not provide a rationale for others to make decisions about important aspects of persons' lives (Kosciulek, 1997; NICDLTS, 1996a).

Conceptual Framework of Consumer Direction

The conceptual framework of CD is depicted de·pict  
tr.v. de·pict·ed, de·pict·ing, de·picts
1. To represent in a picture or sculpture.

2. To represent in words; describe. See Synonyms at represent.
 in Figure 1. As illustrated in this figure, the construct of CD comprises the following four components:

The ability of consumers with disabilities to control and direct the delivery of services. This component relates to the amount of control consumers have over how, when, and by whom services are delivered. It also focuses on the extent to which individuals with disabilities determine the type and influence the quality of services received (Kosciulek, 1997; NICDLTS, 1996a).

The variety and type of service delivery options available to consumers with disabilities. The second component of CD relates to the issue of whether consumers have a choice from a range of viable rehabilitation service options. For example, in both employment and community living, consumers with developmental disabilities developmental disabilities (DD),
n.pl the pathologic conditions that have their origin in the embryology and growth and development of an individual. DDs usually appear clinically before 18 years of age.
 have not been given a range of service options. Traditionally, the range has been from a single option to a few constricted con·strict  
v. con·strict·ed, con·strict·ing, con·stricts

v.tr.
1. To make smaller or narrower by binding or squeezing.

2. To squeeze or compress.

3.
 options (Taylor, Biklen, & Knoll, 1989; West & Parent, 1992). Limitations, risks, or restrictions to consumer control are also considered by this component. For example, if a consumer with a disability attempts to assert control over his or her rehabilitation program Noun 1. rehabilitation program - a program for restoring someone to good health
program, programme - a system of projects or services intended to meet a public need; "he proposed an elaborate program of public works"; "working mothers rely on the day care
 by designing and proposing an alternate service type not previously provided, do funding and program rules and regulations prohibit pro·hib·it  
tr.v. pro·hib·it·ed, pro·hib·it·ing, pro·hib·its
1. To forbid by authority: Smoking is prohibited in most theaters. See Synonyms at forbid.

2.
 such an option?

The availability of appropriate information and support. Consumers with disabilities and their families consistently record two chief criticisms of the current rehabilitation service system: (a) a lack of information and (b) a lack of long-term supports (Holmes, 1993; Kosciulek, 1995). Thus, the crux Crux (krks) [Lat.,=cross], small but brilliant southern constellation whose four most prominent members form a Latin cross, the famous Southern Cross.  of the third component of CD is whether information and support are available that enable consumers to take advantage of rehabilitation services (NICDLTS, 1996a). In a consumer-directed system, consumers are informed about the service options available and the personal, legal, and financial issues associated with each option.

The ability of consumers to participate in systems design and service allocation The apportionment or designation of an item for a specific purpose or to a particular place.

In the law of trusts, the allocation of cash dividends earned by a stock that makes up the principal of a trust for a beneficiary usually means that the dividends will be treated as
. Disability policy development continues to take place in large part without the participation and involvement of people with disabilities (Hagner & Marrone, 1995; National Council on Disability, 1996). The fourth component of CD centers on the level and quality of participation that consumers have at the policy making level; for example, in policy formulation, design of rehabilitation services, and allocation of financial resources (NICDLTS, 1996a). An example of a current effort to increase consumer involvement and control in policy making is the 1992 Rehabilitation Act Amendment regulation that each state vocational rehabilitation Noun 1. vocational rehabilitation - providing training in a specific trade with the aim of gaining employment
rehabilitation - the restoration of someone to a useful place in society
 (VR) agency implement a State Rehabilitation Advisory Council which includes individuals with disabilities.

The four components of CD merge to form a system that is directed by people with disabilities to meet their needs. One implication of this conceptual framework is that information about all of the components must be collected to develop a complete picture of CD. Collecting information on only one component or a couple of components results in an incomplete picture. All four components must be measured to capture CD.

Measurement of CD, however, is problematic. First, CD is an open-ended construct. As recommended by Zimmerman (1995), the assessment of open-ended constructs such as CD must include measures that are appropriate for the population and context under study. Open-ended constructs may not be fully captured by any one specific operationalization. For example, observational terms may take on different forms in different populations, contexts, and time. Second, the open-ended nature of many disability and rehabilitation constructs implies that the facts and rules used to represent a construct may change over time, depending upon the context in which it is measured. For example, a measure of CD in the operation of a group home for individuals with developmental disabilities would differ from a measure of CD in the medical rehabilitation process following a traumatic brain injury Traumatic brain injury (TBI), traumatic injuries to the brain, also called intracranial injury, or simply head injury, occurs when a sudden trauma causes brain damage. TBI can result from a closed head injury or a penetrating head injury and is one of two subsets of acquired brain . Consequently, the development of universal and global measures of CD is not an appropriate goal because it is theoretically inconsistent with the construct given the specific demands and characteristics of different public policies, service delivery institutions, and life situations of people with disabilities.

Consumer direction, therefore, may be considered an open-ended construct because it depends upon context, population, and developmental period. The measurement of CD may be especially difficult because (a) CD manifests itself in different perceptions, skills, and behaviors across people; (b) CD may require different actions and skills for its attainment in various settings; and (c) CD may fluctuate over time. Each of these qualities suggests that the construct of CD cannot be easily reduced to a universal set of operational rules and definitions. As a result, the development of context and population-specific measures of CD will be challenging. However, given the significantly limited and often diminishing di·min·ish  
v. di·min·ished, di·min·ish·ing, di·min·ish·es

v.tr.
1.
a. To make smaller or less or to cause to appear so.

b.
 resources of money, personnel, and programs, relevant measures of CD may further the development of consumer-driven disability policy and rehabilitation services to maximize such resources. More specifically, standardized standardized

pertaining to data that have been submitted to standardization procedures.


standardized morbidity rate
see morbidity rate.

standardized mortality rate
see mortality rate.
 quantitative and open-ended qualitative measures of CD would provide data for assessing the magnitude and quality of CD in various programs and settings (e.g., choice of vocational goal, consumer satisfaction with services), for observing how CD changes over time, and for evaluating the efficacy of policies and programs designed to improve the quality of life of people with disabilities (Kosciulek, in press).

Further development of the construct and theory connected to CD should examine how the control, service variation, information and support, and policy making components interact to form CD. Questions include: (a) How do these four components relate to one another?; (b) Are some components of CD contingent upon Adj. 1. contingent upon - determined by conditions or circumstances that follow; "arms sales contingent on the approval of congress"
contingent on, dependant on, dependant upon, dependent on, dependent upon, depending on, contingent
 others?; (c) What is the link between the components and crucial disability policy and rehabilitation process outcomes of community integration, empowerment, and quality of life?; and (d) Who will be in control of services and financial resources in a more consumer-directed rehabilitation system? It is noteworthy that the conceptual framework presented refers to both the individual and organizational levels of analysis. Consumer-directed outcomes in disability policy formulation and rehabilitation service delivery require both quantitative and qualitative individual and organizational levels of measurement.

The measurement of CD in a specific setting for a particular sample of individuals (e.g., consumers of state-federal VR services, patients in a medical rehabilitation program, a residential program for individuals with developmental disabilities) is possible, but it "must be connected to the experience of the research participants as they state it, and contextually grounded in their life experiences" (Zimmerman, 1995, p. 598). As indicated by Zimmerman (1995), this approach necessarily limits generalizability to other persons or contexts, but this trade-off may have to be accepted in order to adequately and appropriately measure CD. All research efforts must inevitably make trade-offs between the competing demands of internal and external validity External validity is a form of experimental validity.[1] An experiment is said to possess external validity if the experiment’s results hold across different experimental settings, procedures and participants.  (Szymanski & Parker, 1992; McGrath, 1982). Research on CD is not unique in this regard, as the development of the theoretical and applied aspects of any construct requires programmatic pro·gram·mat·ic  
adj.
1. Of, relating to, or having a program.

2. Following an overall plan or schedule: a step-by-step, programmatic approach to problem solving.

3.
 research that builds a body of knowledge (McGrath, 1982; Zimmerman 1995).

Examples of Consumer Direction

Five examples are presented to illustrate how the principle of CD and components of the conceptual framework of CD may be infused into disability policy making and rehabilitation services. The first four examples focus on systems-level CD. Infusing CD in systems is vital as organizational constraints CONSTRAINTS - A language for solving constraints using value inference.

["CONSTRAINTS: A Language for Expressing Almost-Hierarchical Descriptions", G.J. Sussman et al, Artif Intell 14(1):1-39 (Aug 1980)].
 are frequently identified as major barriers that impede im·pede  
tr.v. im·ped·ed, im·ped·ing, im·pedes
To retard or obstruct the progress of. See Synonyms at hinder1.



[Latin imped
 meaningful, active consumer involvement in policy making and service delivery (Chan, Shaw, McMahon, Koch, & Strauser, 1997). The last example focuses on individual-level CD. The examples discussed include: (a) voucher A receipt or release which provides evidence of payment or other discharge of a debt, often for purposes of reimbursement, or attests to the accuracy of the accounts.  systems; (b) the Michigan Rehabilitation Renaissance Project; (c) consumer-directed mental health services health services Managed care The benefits covered under a health contract ; (d) participatory action research Action Research or Participatory action research has emerged in recent years as a significant methodology for intervention, development and change within communities and groups. It is now promoted and implemented by many international development agencies and university programs CCAR, as ; and (e) counselor-consumer relationships.

Voucher Systems

Trends in VR have stressed the need for increasing both consumer involvement and participation and the quality of services provided (Kosciulek, Vessell, Rosenthal, Accardo, & Merz, 1997; Seelman & Sweeney, 1995; Thomas & Strauser, 1995). A voucher system in rehabilitation would empower empower verb To encourage or provide a person with the means or information to become involved in solving his/her own problems  consumers to decide which services they wished to purchase and whether they wanted to receive these services from a public or private agency. By encouraging competition between agencies and promoting accountability, the implementation of a voucher system may also improve the efficiency and effectiveness of the rehabilitation delivery system (Thomas & Strauser, 1995). Consistent with the CD concept, the major advantage of implementing a voucher system would be to increase consumer choice. In addition, a voucher system would appear to be a "viable means of reforming the current state-federal VR system and empowering clients so that they can receive the maximum benefit from rehabilitation services" (Thomas & Strauser, 1995, p. 18).

The Michigan Rehabilitation Renaissance Project

The Michigan Rehabilitation Services and United Cerebral Palsy United Cerebral Palsy (UCP), sometimes known as United Cerebral Palsy Associations, is a network of affiliated groups in the United States which works to "advance the independence, productivity and full citizenship of people with disabilities" (from UCP's mission statement),  Association of Detroit developed a joint program, the Rehabilitation Renaissance Project, intended to transfer control and authority in the VR process to consumers with disabilities through empowerment training and person-centered planning (Callahan & Skiba, 1997). The project was designed intentionally in·ten·tion·al  
adj.
1. Done deliberately; intended: an intentional slight. See Synonyms at voluntary.

2. Having to do with intention.
 to address the following criticisms of the VR process: (a) consumers with disabilities are not empowered; (b) consumers do not have a true choice in their rehabilitation plans; (c) the professional brings all the answers to the rehabilitation equation; and (d) the professional is responsible for whatever happens to the consumer. Embracing the CD concept, the project has as its primary values and practices: (a) consumer choice, empowerment, and responsibility; (b) a focus on consumer strengths; and (c) consumer "expertise" on her or his rehabilitation needs. Project outcomes, as compared to the traditional VR process, suggest increased efficiency in service delivery and more positive employment outcomes for consumers with disabilities (Callahan & Skiba, 1997). A lesson learned from this project was that both service providers and consumers with disabilities benefited from increased consumer involvement in the VR process.

Consumer-Directed Mental Health Services

Harp harp, stringed musical instrument of ancient origin, the strings of which are plucked with the fingers. Harps were found in paintings from the 13th cent. B.C. at Thebes. In different forms it was played by peoples of nearly all lands throughout the ages.  (1994) and Campbell (1991) have written papers on the consumer movement among people with psychiatric psy·chi·at·ric
adj.
Of or relating to psychiatry.


psychiatric adjective Pertaining to psychiatry, mental disorders
 disabilities from consumer and provider viewpoints, respectively. Their propositions embody em·bod·y  
tr.v. em·bod·ied, em·bod·y·ing, em·bod·ies
1. To give a bodily form to; incarnate.

2. To represent in bodily or material form:
 the philosophy and application of CD. Harp (1994) defined empowerment of people with disabilities as possessing the same degree of control over one's life as is generally possessed by people without disabilities. The author asserted that, in order to attain empowerment, mental health consumers must be involved at every level of the planning, implementation, and ongoing operation of VR services. Harp (1994) hypothesized that, in a consumer-directed model, benefits accrued ac·crue  
v. ac·crued, ac·cru·ing, ac·crues

v.intr.
1. To come to one as a gain, addition, or increment: interest accruing in my savings account.

2.
 to both consumers and service providers. Mental health consumers would make progress and have positive outcomes, while programs would develop positive track records for ensuring future funding and referrals. Harp (1994) thus concluded that both consumers and providers would "win" if consumers had a meaningful role in the development and implementation of services.

Similarly, Campbell (1991) affirmed af·firm  
v. af·firmed, af·firm·ing, af·firms

v.tr.
1. To declare positively or firmly; maintain to be true.

2. To support or uphold the validity of; confirm.

v.intr.
 that the VR service system must recognize the consumer movement among individuals with psychiatric disabilities. This movement supports the notion of reduced professional interference in consumer decisions and choices. The author declared that the state-federal VR service model is in the process of radical alteration Modification; changing a thing without obliterating it.

An alteration is a variation made in the language or terms of a legal document that affects the rights and obligations of the parties to it.
 as consumers with psychiatric disabilities demand change from its traditional physical disability orientation. Campbell (1991) challenged organizations serving individuals with psychiatric disabilities to empower consumers by involving them at all levels of operation, including policy formulation and front-line service delivery.

Participatory Action Research

The leadership of the National Institute on Disability and Rehabilitation Research National Institute on Disability and Rehabilitation Research (NIDRR) is a United States governmental institution that provides leadership and support for a comprehensive program of research related to the rehabilitation of individuals with disabilities.  (NIDRR NIDRR National Institute on Disability and Rehabilitation Research (US Department of Education) ), in promoting the concept of participatory action research (PAR) (Bruyere, 1993; Graves, 1991; Walker, 1993), provided an excellent example of consumer-directed disability policy. Because PAR values the importance of involving those whom the research will affect (Whyte, 1991), it is conceptually analogous analogous /anal·o·gous/ (ah-nal´ah-gus) resembling or similar in some respects, as in function or appearance, but not in origin or development.

a·nal·o·gous
adj.
 to CD. In addition, because PAR acknowledges the legitimate interests of persons with disabilities to self-determination and full participation, including participation in the research process, it is an empowerment strategy. Graves (1991) called attention to the credibility problem of rehabilitation research, noting that persons with disabilities often see research as irrelevant, and that many rehabilitation professionals view research as impractical im·prac·ti·cal  
adj.
1. Unwise to implement or maintain in practice: Refloating the sunken ship proved impractical because of the great expense.

2.
. The participation of consumers with disabilities in identifying research problems increases the probability of relevant research results. More specifically, PAR may maximize the impact of research on real-life consumer situations, an outcome that is "highly desirable in this era of limited research resources and pressing program needs" (Bruyere, 1993, p. 62).

Counselor-Consumer Relationships

There are also changes that can be made to promote CD at the individual level. Enhancing rehabilitation counselor-consumer partnerships is one of these changes. Chan et al. (1997) described how the "working alliance" could be used as a framework to ensure active consumer involvement in the rehabilitation process. Theoretically, the working alliance is viewed as a collaborative effort in which the counselor and consumer make equal contributions to the counseling relationship. It reflects a belief that the consumer can participate in the counseling process based on a sense of ownership (Al-Darmaki & Kivlighan, 1993). Illustrating the potential significance of individual-level CD, Chan et al. (1997) concluded that a "strengthened working alliance between the counselor and the consumer will result in more positive rehabilitation outcomes and higher levels of consumer satisfaction" (p. 135).

Implications of Consumer Direction

Implicit within the underlying assumptions, conceptual framework, and examples of CD, is the belief that increased CD would facilitate more effective policy making, program implementation, and research. Consumer-direction thus has the potential to significantly improve rehabilitation service delivery and enhance the quality of life of consumers with disabilities. This potential impact of CD has several direct implications for consumers with disabilities, service providers, and funders of rehabilitation services. These implications include (a) the changing roles of consumers and service providers, (b) the empowerment of consumers with disabilities, and (c) specific benefits to consumers and service providers and funders.

Roles of Consumers with Disabilities and Service Providers

In a consumer-directed rehabilitation service system, the roles of consumers and providers differ from those in traditional service systems, such as the state-federal VR program, workers' compensation workers' compensation, payment by employers for some part of the cost of injuries, or in some cases of occupational diseases, received by employees in the course of their work.  programs, and medical rehabilitation. The primary difference is that the consumer has the ultimate responsibility for the services he or she receives. In a consumer-directed model, the consumer is responsible for choosing a service delivery process that meets his or her needs and for monitoring the quality of services received (Racino & Williams, 1994). Consumer direction implies that consumers should assess their own needs, select service options that reflect personal preferences, and communicate openly and frankly with service providers about changing needs (NICDLTS, 1996a).

The provider reports directly to the consumer in a consumer-directed rehabilitation service model. Individual service providers are responsible for meeting the consumer's expectations for quality and training and for providing reliable services as directed by the consumer (Racino & Williams, 1994). Provider organizations that have incorporated elements of CD in their mission assume the following set of responsibilities: (a) ensuring a maximum range of service options that reflect consumer preferences; (b) providing clear, easily understood information to consumers about service options and eligibility criteria for options; (c) including consumers in agency planning in a meaningful way; and (d) administering an evaluation process that provides consumer feedback to staff (NICDLTS, 1996a).

Consumer Direction as an Empowering Process

Empowering processes are those in which people create or are given opportunities to control their own destiny and influence the decisions that affect their lives (Bolton & Brookings, 1996; Hahn, 1991; Zimmerman, 1995). These processes provide individuals the opportunity to achieve goals, obtain greater access to and control over resources, and gain mastery over their lives (Cornell Empowerment Group, 1989; Mechanic, 1991; Zimmerman, 1990). Efforts to gain control, to access resources, and to critically understand one's sociopolitical so·ci·o·po·li·ti·cal  
adj.
Involving both social and political factors.


sociopolitical
Adjective

of or involving political and social factors
 context are fundamental aspects of CD. As empowering processes, consumer-directed disability policy development and rehabilitation service delivery include the opportunity for consumers to enhance resource development skills, to work with others on a common goal, and to develop leadership abilities.

Benefits of Consumer Direction

There are many potential benefits of a consumer-directed approach to rehabilitation. For example, research has shown that consumers with disabilities who participated in a consumer-directed personal assistance services (CD-PAS CD-PAS Consumer-Directed Personal Assistance Service ) program were significantly more productive (p [is less than] .05) than a matched control matched study, matched control

a comparison between groups in which each subject animal is matched by a comparable animal in terms of age and all other measurable parameters. Called also matched or paired control.
 group of consumers who did not participate in the program (NICDLTS, 1997). Results of this study also indicated that the consumers who were involved in CD-PAS had significantly higher (p [is less than] .05) rates of involvement in paid and unpaid work, education, active homemaking home·mak·er  
n.
One who manages a household, especially as one's main daily activity.



homemak
, recreational activities, and self-improvement than prior to their involvement in CD-PAS. Additional direct benefits of consumer-directed services for people with disabilities may include: (a) increased autonomy in decision making about service needs; (b) control over the ways in which services are arranged; (c) enhanced life management skills and feelings of competence as a result of the ability to manage services; and (d) increased ability to determine and shape individual lifestyles (NICDLTS, 1996b). Furthermore, a consumer-directed delivery system may also provide significant benefits for funders and providers of rehabilitation services including (a) increased consumer satisfaction, (b) improved quality of services, and (c) decreased costs.

Conclusion

In this article, the construct of consumer direction was applied to disability policy formulation and rehabilitation service delivery. The underlying assumptions and conceptual framework of CD were described in detail. In addition, specific examples of CD were provided and the implications of CD were discussed.

Consumer direction is a construct of great interest to the field of rehabilitation because it relates directly to the empowerment of people with disabilities. As illustrated in the examples of CD, the issue of CD spans all consumer groups, service types, providers and funders of rehabilitation services, and policy makers at local, state, and national levels. As such, CD should be a primary focus of disability policy making, program development and evaluation, and rehabilitation research. As aptly stated by Seelman and Sweeney (1995), "there must be continuing stress on increased consumer participation and involvement in all rehabilitation programs at all levels of operation" (p. 11).

Given the changing context of rehabilitation (Ryan, 1995; Leahy & Szymanski, 1995), increased CD would extend the range of variation of systems designed to serve people with disabilities. The CD components of increasing the variety of service options and enhancing consumer input into systems design suggest that consumer-directed models would better acknowledge the variation associated with disability than traditional service delivery models. As such, CD can help us address "legitimate issues of resource allocation resource allocation Managed care The constellation of activities and decisions which form the basis for prioritizing health care needs  and the need for creative adaptation by established institutions" (Scotch & Schriner, 1997, p. 156), such as the state-federal VR program and managed health care providers. Further, and most importantly Adv. 1. most importantly - above and beyond all other consideration; "above all, you must be independent"
above all, most especially
, increased CD in disability policy formulation and rehabilitation service delivery may facilitate the empowerment of people with disabilities. Empowerment, in turn, would promote the increased community integration and enhanced quality of life of individuals with disabilities.

Given the importance of debate on disability rights (Schroeder, 1995), now is the opportune op·por·tune  
adj.
1. Suited or right for a particular purpose: an opportune place to make camp.

2. Occurring at a fitting or advantageous time: an opportune arrival.
 time for discussion of new paradigms New Paradigm

In the investing world, a totally new way of doing things that has a huge effect on business.

Notes:
The word "paradigm" is defined as a pattern or model, and it has been used in science to refer to a theoretical framework.
 such as the one described here. A great deal of work remains to be done to shape public policy so that it promotes the achievement of independence for persons with disabilities (Scotch and Schriner, 1997). Consumers with disabilities, rehabilitation practitioners, and policy makers need new conceptual tools to understand the nature of disability and how it should be addressed in public policy and rehabilitation service delivery. The ideas presented in this article are intended as a guide in this important endeavor.

References

Al-Darmaki, F., & Kivlighan, D. M. (1993). Congruence con·gru·ence  
n.
1.
a. Agreement, harmony, conformity, or correspondence.

b. An instance of this: "What an extraordinary congruence of genius and era" 
 in client-counselor expectations for relationship and the working alliance. Journal of Counseling Psychology Counseling psychology as a psychological specialty facilitates personal and interpersonal functioning across the life span with a focus on emotional, social, vocational, educational, health-related, developmental, and organizational concerns. , 40, 379-384.

Bolton, B., & Brookings, J. (1996). Development of a multifaceted mul·ti·fac·et·ed  
adj.
Having many facets or aspects. See Synonyms at versatile.

Adj. 1. multifaceted - having many aspects; "a many-sided subject"; "a multifaceted undertaking"; "multifarious interests"; "the multifarious
 definition of empowerment. Rehabilitation Counseling rehabilitation counseling,
n counseling started in the United States in 1920 to assist individuals disabled by industrial accidents; originally included physical, psychologic, and occupational training; expanded over the next 70 years and laid the
 Bulletin, 39, 256-264.

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John F. Kosciulek, Ph.D., CRC (Cyclical Redundancy Checking) An error checking technique used to ensure the accuracy of transmitting digital data. The transmitted messages are divided into predetermined lengths which, used as dividends, are divided by a fixed divisor. , Director - Rehabilitation Counseling Program, Department of Educational & Counseling Psychology, 16 Hill Hall, University of Missouri-Columbia, Columbia, MO 65211.
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Author:Kosciulek, John F.
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Date:Apr 1, 1999
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