Differing Priorities of Counselors and Customers to a Consumer Choice Model in Rehabilitation.

The 1992 Reauthorization of the Rehabilitation Act placed considerable emphasis on the empowerment of individuals with disabilities through informed choice, partnerships with their counselor in planning services, and selection of service providers. The increase in numbers of people with developmental disabilities who are now working in the community (versus sheltered workshops) reflects this evolution, as individuals have routinely expressed interest in moving into regular apartments, holding community jobs, and having greater control over their futures (Klein, 1992).

The support for empowerment, as expressed through greater choice and partnership with professionals, is part of the evolving relationship between rehabilitation counselors and their clients. This trend is frequently referred to as consumerism in rehabilitation services. Patterson and Marks (1992) describe the differences between customers (or consumers) and clients from the perspective of service industry marketers, and argue that service quality and customer satisfaction become critical considerations when rehabilitation clients are viewed as customers. In 1993, this journal published an exchange on the use of the word "consumer" (Thomas, 1993a; Nosek, 1993; Thomas, 1993b) in which the authors discussed the nature of the counselor/client or consumer relationship and the implications for shared control in the decision-making process. Rhoades, McFarland, and Knight (1995) describe the evolution of consumerism in rehabilitation counseling as a shift toward a consumer-driven paradigm with emphases on quality and accessibility.

In discussing empowerment, Emener (1991) makes an important distinction between rehabilitation systems, counselors, and clients as areas in the rehabilitation process in which empowerment is critical. While systems factors (e.g. organizational philosophy, policies, effectiveness) certainly influence the experience of empowerment within rehabilitation services, so too do factors associated with counselors (e.g. competency, professional self-concept, collegiality) and with people who receive services (e.g. economic security, competency, healthy self-concept). Chan, Shaw, McMahon, Koch, and Strauser (1997) focus on the rehabilitation counselor-consumer relationship and offer a model for building a meaningful partnership. Their model includes the components of a working alliance (to ensure active consumer involvement), counseling expectations (to promote success of the partnership), and a conflict resolution approach to strengthening the relationship.

This article reports on an initiative in which a choice model for employment services was integrated into the service delivery of a state rehabilitation agency. This consumer choice model is grounded in the empowerment philosophy evolving in rehabilitation services. It includes person-centered planning, vocational profiling, employment advising, job carving, and job support. The integration of the model within state rehabilitation agency services was an effort to fully realize the empowering partnership promoted in the 1992 Reauthorization of the Rehabilitation Act. At the end of the first year of this initiative, consumers and counselors were asked to evaluate the model and its components. The hypothesis for this study was: given the diverse abilities and needs of consumers and counselors operating within a highly structured, outcome-oriented rehabilitation system, consumers and counselors often have differing priorities within the rehabilitation process.

Project Design

Collaboration: The project was developed collaboratively between a state vocational rehabilitation agency and the local chapter of a national advocacy organization. This organization had, in the preceding three years, successfully demonstrated a choice model for employment support that operated independently of the state vocational rehabilitation agency. The purpose was to establish the choice model (Callahan & Garner, 1997) within a limited number of local vocational rehabilitation (VR) offices while working out the issues of model implementation and integration within the VR service system. Following the first year of collaboration, additional VR local offices would be added each year for five years. At the end of the five-year implementation phase, the proposed choice model would be available at all offices throughout the state.

Model Components: The model included the following elements:

* Employment Advisors: The advocacy organization recruited, trained and coordinated a cadre of Advisors. Each customer selected and employed an Advisor. The Advisors provided support, advocacy, and information to the customer.

* Person-Centered Planning: This holistic planning process involved the customer, the customer's family and friends, as well as project staff. This assisted the customer in developing and clarifying goals and priorities related to employment.

* Vocational Profile: This involved a broad, asset-based exploration of information regarding a customer's skills and interests, as well as his/her preferences and contributions to employers. Information useful to employment choices is gathered from a variety of settings and people.

* Vocational Profile Meeting: The profile meeting was the culmination of the entire process and the tool that ultimately lead to a job match. The purpose of the meeting was to clearly define the "ideal" employment situation based on the available information gathered from the vocational profile.

* Job Development/Carving: Job positions were developed using the information from the Vocational Profile. They were modified with employers to achieve the best match between a customer's assets and employers' needs, while minimizing the need for ongoing external support (i.e. job coaching) and building on the natural supports of the work place.

* Job Site Facilitation: This involved conducting a job assessment and working with the customer and employer to establish the necessary ongoing supports. Effectively making these decisions required an awareness of all of the conditions of the work culture and a full understanding of the job expectations of the employers.

* Customer Satisfaction: Customers determined acceptability of the services before authorizing payment to providers from their budgets of VR funds.

Having the Service Provider employed by the customer was a key element in the project design. To meet this demand, the project design stipulated that Service Providers were paid for services rendered only after the customer was completely satisfied. The VR counselors role included assisting customers to make informed choices about selecting participation in the project versus standard VR services, selecting Advisors and Service Providers, along with other decisions in the process. Counselors provided orientation to the project, assisted project customers with interviewing and hiring an employment advisor, and monitored services provided to the customer. The counselor's role frequently entailed directing the person-centered planning process, facilitating decision making, authorizing payments for services provided, and coordinating other support activities.

Employment Advisors were hired by project customers to assure that informed choice occurred. Roles included: assisting the customer to identify potential service providers; arranging meetings; assisting in deciding which providers might best meet customer needs and abilities; explaining contracts; verifying that services were provided satisfactorily; and resolving problems with service providers.

Support for Implementation: Staff from the advocacy organization provided initial training on the model to VR counselors as well as training for vocational service providers and others involved in the project, trained and coordinated Advisors, and provided training and technical assistance to interested VR counselors. The Coordinator from the advocacy organization additionally conducted joint staff meetings, provided technical assistance to the VR counselors, updated curricula, and supervised other project staff.

The Employment Advisor facilitated the use of Person-Centered planning, advocated for project customers, and monitored vocational profiles and job development activities. The Advisor Coordinator assisted state rehabilitation counselors to identify Employment Advisors, provided training, facilitated team building, and advocated for the customer.

Service Providers in the project's first year were individuals, agencies or companies the customer hired to provide employment services. Completion of training provided by the advocacy organization was a necessary condition for service providers to be eligible for hire.

Method

Population and Sample

Fifty-seven individuals received project services from six state rehabilitation offices during the project's first year, with 43 customers involved at the time of data collection. Attempts were made to include all individuals in face-to-face or telephone interviews. Thirty-six of the identified active customers participated in either face-to-face or telephone interviews. All of the 22 counselors who voluntarily participated in the first year were contacted. Each had caseloads of one to eight project customers. Seventeen of the 22 state rehabilitation counselors from this accessible population responded to the mailed questionnaires.

Sixty percent of the customer sample was male. Sixty-four percent was white, 19% African American, 6% Asian, 3% Arabic, with 9% not identifying their ethnicity. A profile of the project population compared to the general VR population for the same service area included the following characteristics (Michigan Jobs Commission, 1997):

* no identified statistical difference in educational levels between project customers versus all state customers,

* significant differences in types of disability (e.g. 51% of project customers had an orthopedic disability),

* 94.7% of project customers were unemployed at intake, and project customers were more likely to have a severe disability.

Instrumentation, Data Collection, and Analysis

Two questionnaires were developed: one each for customers and counselors. To improve content and face validity, five counselors and five project customers participated in the development and the pretest of the questionnaires. Issues under review included ease of use, appropriateness of inquiry, and validity of content. Customer questionnaires were administered through interviews, either face-to-face or via telephone, according to each customer's preference. The counselor questionnaires were administered as paper and pencil instruments. Independent t-tests (alpha = .05) and a Spearman's rank correlation coefficient were used in the data analysis.

The instruments included parallel items using both Likert Scale and open-ended formats regarding satisfaction with the model, customer satisfaction with services, and counselor questions about the relative time required to implement each component. Trained graduate students and professionals who were in the disability services field but not involved in the project conducted the interviews. Some interviews were conducted in the presence of a family member or other person needed to assist with communication, as the customer desired. The questions to which counselors and customers responded regarding their perceived level of importance included:

1. Person-Centered Planning has been important in providing effective services in the project.

2. The Vocational Profile has been important in providing effective services.

3. Employment Advisors were important to providing effective services.

4. The use of Job Carving has been important in achieving rehabilitation goals.

5. The use of Job Support (e.g. job facilitation, co-worker support, assistive technology) has been important in achieving rehabilitation goals.

Results

Customers and counselors reported a high level of agreement with positive statements concerning the model's components. On the six-point scale (1 = strongly disagree to 6 = strongly agree), each component for each group had a mean greater than 4.0, therefore indicating a positive response. Job carving was the only component of the model with a statistically significant difference between counselor and customer means. Counselors placed greater importance on this tool than did customers. However, a post hoc ranking of the components based upon the group means showed the relative values to be nearly opposite between customers and counselors. Employment advising and Person-Centered Planning were rated highest by the customers; these same components were rated lowest by counselors.

Table 1 contains the rankings of the customers and counselors on their relative satisfaction on the various project components by the customers and counselors. The three items on which customers expressed their greatest agreement all focused on Employment Advisors. These included:

* Satisfaction with the services provided by his/her advisor.

* Their advisor's assistance in making good decisions.

* The advisor as an important part of the services.

Table 1: Customer and Counselor Ranking of Importance

  Rank of
Importance     Customers                   Counselors

1st            Employment Advising         Job Carving
2nd            Person-Centered Planning    Job Support
3rd            Job Support                 Profiling
4th            Job Carving                 Employment Advising
5th            Profiling                   Person-Centered Planning

When customers were asked what they liked most about the project, they cited the focus on obtaining employment (13 of 36 respondents) with five specifying the choice of their jobs. The quality of the experiences were identified by 13 individuals with seven reporting that they enjoyed working with the people on the project. Three described the process as positive, and three reported that they were given a chance by the project. Five individuals specifically said there were no negative aspects of the project. The most common complaint was the long wait for projected employment outcomes.

On the open-ended questions, counselors most often cited the customer's enhanced role in services due to greater insight and involvement (4) as a positive measure. Three counselors cited time demands as the greatest drawback. The three closed-ended items on which counselors expressed their highest agreement were:

* Importance of job carving in achieving rehabilitation goals.

* High value of the ongoing assistance in implementing the rehabilitation model.

* Use of job supports as having been important in achieving rehabilitation goals.

Counselors were asked to compare the time needed for implementation of each model component with their typical methods for the same activity (e.g. Person-Centered Planning vs. typical planning methods). The importance of components were strongly correlated (.97 Rank Correlation Coefficient) to the amount of time required for their implementation. As demonstrated in Table 2, the less time counselors believed they needed to use the tool, the greater the perceived importance of the tool.

Table 2:
Counselor Rating of Importance vs. Time Required to Use Components

                                       Counselor       Time
Rank(*)         Model                   Rating       Required
              Component              of Importance   (by rank)

1st       Job Carving                    5.21          3.00
2nd       Job Support                    5.18          3.00
3rd       Vocational Profile             4.94          3.94
4th       Employment Advisors            4.59          3.62
5th       Person-Centered Planning       4.41          4.38

(*) Rank Correlation Coefficient of .97 obtained.

Several components in the project model were used by counselors in providing services to consumers not enrolled in the project. These components included:

* Person-Centered Planning: Used by 42% of counselors with customers who are not in the project (22 instances).

* Profiling: Used by 24% of counselors with customers not in the project (19 instances).

* Job Carving: Used by 18% of counselors with customers not in the project (18 instances).

Discussion

Results support the hypothesis that customers and counselors often have differing priorities within the rehabilitation process. While counselors and customers expressed overall positive responses to the model, the two groups expressed divergent views regarding the most important components of the model. As rehabilitation counselors and other professionals continue integrating these components into their practice, it will be beneficial to assess the underlying reasons for this discrepancy. Customers valued most the components that consumed the greatest amount of the counselor's time. In the context of increasing caseloads, such conflicts need resolution. These issues may negatively affect the successful adoption of the model, and threaten the proposition that the customer and counselor act in partnership.

Although counselors identified Person-Centered Planning as tools they used with their general caseload, they rated it as the least important of the model's components and identified it as the most time consuming. Of particular interest for future research will be the strong relationship between the components that counselors found most important and the amount of time required to perform the tasks. Additional research would benefit from investigating time constraints placed on rehabilitation counselors and the partnerships they are able to develop with their customers.

In addition to the time involved in each component, there may also be an issue of the model's "fit" within the rehabilitation system. The vocational profile "fits" as a means of assessment, and Person-Centered planning "fits" as a planning method, with assessment and planning being fundamental components of rehabilitation counseling. However, employment advising, as an activity separate from what the counselor does, is different. Customers rated it highest among the components, while counselors rated it as fourth of the five components. If one of the benefits of adopting the project model is that it offers flexibility to meet the needs of people who historically have not "fit" into the rehabilitation system, then it will be important to effectively integrate the employment advisor role into the rehabilitation process. Both counselors and customers valued the model, yet each group valued the components differently. Customers valued more the components involving relationships (the employment Advisor, Person-Centered planning), while counselors valued more the outcome-oriented components (job carving and job support). This reflects the challenge that rehabilitation counseling faces in balancing the values of partnerships and empowerment with the conditions of large caseloads and outcome-based performance expectations.

References

Callahan, M. J., & Garner, J. B., 1997. Keys to the workplace: Skills and supports for people with disabilities. Paul Brookes Pub. Baltimore, MD.

Chan, F., Shaw, L.R., McMahon, B.T., Koch, L., and Strauser, D., 1997 A model for enhancing rehabilitation counselor-consumer working relationships. Rehabilitation Counseling Bulletin 41.

Emener, W., 1991. An empowerment philosophy for rehabilitation in the 20th century. Journal of Rehabilitation, 57 (4).

Klein, J., 1992. Get me the hell out of here: supporting people with disabilities to live in their own homes. In J. Nisbet (Ed.), Natural Supports in School, at Work, and in the Community for People with Severe Disabilities, Paul H. Brooks Pub, Baltimore, MD.

Patterson, J. B., & Marks, C., 1992. The client as customer: Achieving service quality and customer satisfaction in rehabilitation. Journal of Rehabilitation 58, (4).

Michigan Jobs Commission, 1997. Characteristics of Rehabilitation Renaissance Project Customers Compared with All Project Customers, unpublished document.

Nosek, M.A., 1993. A Response to Kenneth R. Thomas' commentary: Some observations on the use of the word "consumer". Journal of Rehabilitation 59 (2).

Rhodes, D., McFarland, K., & Knight, P., 1995. "Evolution of consumerism in rehabilitation counseling: A theoretical perspective." Journal of Rehabilitation 61 (2).

Thomas, K.R., 1993. Commentary: Some observations on the use of the word "consumer". Journal of Rehabilitation 59 (2).

Thomas, K.R., 1993. Consumerism vs. clientism: A reply to Nosek. Journal of Rehabilitation 59 (2).

United States, 1993. "Reauthorization of the Rehabilitation Act: The state vocational rehabilitation services program," Federal Register 58 38482.

Michael Wolf-Branigin Michael Daeschlein Wayne State University 

Barbara Cardinal United Cerebral Palsy of Metropolitan Detroit

Mary Twiss Michigan Department of Career Development-Rehabilitation Services

Michael Wolf-Branigin, Developmental Disabilities Institute at Wayne State University, 268 Leonard Simons Building, 4809 Woodward Avenue, Detroit, MI 48202.