Empowerment and assistive technology: the local resource team model.

Discussions regarding the delivery of rehabilitation services today frequently include some mention of consumer empowerment. Federal legislation such as the Americans with Disabilities Act and the Rehabilitation Act Amendments of 1992 mandated a continued growth in consumer involvement. Service delivery models that subscribe to a consumer empowerment model attempt to "...facilitate and maximize opportunities for individuals with disabilities to have control and authority over their own lives" (Emener, 1991, p. 8).

The traditional service delivery model, often called the medical model, encourages a passive role for the consumer with the ultimate decision making performed by the rehabilitation professional. A professional operating from this system would tend to dictate a solution to the consumer (e.g., "You need this training program"). Conversely, the consumer driven model expects the active support and participation of the person with a disability. A professional operating from this service delivery model would try to educate the consumer as to various options and facilitate decision making by the individual (e.g., "Here are some options that might work; which one is best for you?"). Anticipated benefits of following a more participatory model include increased service quality and consumer satisfaction (Patterson & Marks, 1992).

In addition to this trend toward consumer involvement in the rehabilitation process, an increased role in the use of technology in the lives of people with disabilities has occurred. Typically referred to as assistive technology (or rehabilitation technology), it has been defined as items and services that increase the functional capacities of people with disabilities (Institute on Rehabilitation Issues, 1986; Langton, 1991). Assistive items can range from "low-tech" devices (e.g., blocks of wood to raise the level of a desk) to "high-tech" equipment (e.g., laser activated communication boards) with many points in between. Assistive technology services might include evaluation, design, construction, repair, and training.

Assistive technology can impact any sphere of a person's life including education, social, recreation, mobility, work, daily living, transportation, etc. (Reed, 1993). This use of technology can be seen as an empowering tool as it can greatly increase an individual's functioning. The use of independent living aids such as a "grabber" (a device that assists a person in reaching and grasping items), for example, might reduce or even eliminate the need for home visits. Likewise, computer technology might assist a person to successfully complete a training or educational program not accessible without computer assistance. Technology can, therefore, greatly increase a person's options.

Recognizing the potential of assistive technology, Congress passed the Technology-Related Assistance for Individuals with Disabilities Act of 1988 (P.L. 100-407). By making federal monies available to individual states, Congress helped expand the role and public visibility of this technology. As of June 1992 forty-two states had been awarded a demonstration grant of a least $500,000 (RESNA, 1992). States receiving this federal support were required to promote assistive technology. Demonstration centers, training and support services for potential users and service providers as well as information and referral networks were some of the primary services required of grant recipients (National Institute on Disability and Rehabilitation Research, 1993). In addition to direct services, this legislation had a stated purpose of encouraging the development and initiation of assistive technology service delivery systems (Parette & VanBiervliet, 1991).

This article presents an overview of common service delivery models for the provision of assistive technology. With a continued trend toward increased consumer involvement and empowerment within the field of rehabilitation, the need for service delivery systems that encourage consumer empowerment is vital. A case will be presented advocating a consumer driven assistive technology model. The authors will also describe a model that has been practiced in Colorado. Additionally, some specific experiences, both positive and negative, from a local assistive technology project will be shared.

Service Delivery Models

Service delivery models are an integral part of the rehabilitation process. Many of the services provided in rehabilitation are based on service delivery models, including assistive technology. A service delivery model, as defined by Enders and Hall (1990), provides "a description of one approach to providing assistive technology services..." (p. 417). Different traditional service delivery models exist to help meet the needs of the individuals seeking assistance. Traditional service delivery models are examined as they pertain to assistive technology.

Durable Medical Equipment (DME) Model

The DME model acquired its name in the 1960s when Medicare and Medicaid used the term to refer to specific types of equipment that were considered reimbursable under their policies (RESNA, 1987). This term originally applied to such items as wheelchairs and splints that required a doctor's prescription. As the items known as durable medical equipment have grown to include most items carried by a medical equipment supplier, the knowledge of the supplier has also changed. Medical equipment suppliers are challenged to keep up with the changes in the medical and rehabilitation fields (RESNA, 1987; Seventeenth Institute on Rehabilitation Issues (IRI), 1990).

Department Within a Comprehensive Rehabilitation Program 

This model includes programs that offer a comprehensive rehabilitation program utilizing a multidisciplinary team approach (Seventeenth IRI, 1990). The goal of the comprehensive rehabilitation program is to address as many "functional deficit areas" as possible (RESNA, 1987, p. 16), with assistive technology being one possible component.

Mann (1991) argues that while this approach may be effective in addressing physical limitations while in the rehabilitation program, there is very little carry-over into the individual's life at home. For instance, many rehabilitation centers work with medical suppliers in their area rather than from the individual's community. If the individual lives in a rural area without access to the original medical supplier or rehabilitation center, equipment repair and maintenance will be difficult. Without the input of the user, the item prescribed in a rehabilitation center may not be appropriate for the person outside of the facility.

Technology Service Delivery Center in a University

Under this model, the emphasis is placed on the research goals of the University associated with the center. The focus on service delivery is placed on disseminating research and development information through conferences and professional publications (RESNA, 1987). Due to this focus, there is a narrow field of services available. Often these technology centers are based in metropolitan areas and not accessible to those from less populated areas (RESNA, 1987).

State Agency-Based Program

This model often concentrates on delivering services through an approved agency within the state system such as state Vocational Rehabilitation, Pubic Instruction, and Commission for the Blind. One difficulty in using this model is that the individual seeking services must meet the specific requirements of the agency in order to receive services. Another difficulty is that not all of the case workers will have sufficient knowledge or familiarity with assistive technology (RESNA, 1987).

Private Rehabilitation Engineering/Technology Firm

Businesses associated with this model tend to be for-profit enterprises that specialize in a particular area (Seventeenth IRI, 1990). These businesses tend to focus on a particular type or group of disabilities, based on the background of staff members. One advantage of this model is that the businesses are located within the community and focus on the local area to provide services. A disadvantage is that these businesses tend to have a narrow focus in the types of disability areas they can serve.

Local Affiliate of a National Non-profit Disability Organization

Service delivery through this system is focused on the members of the organization itself. Organizations such as the Muscular Dystrophy Association, National Easter Seal Society, and the American Foundation of the Blind help provide information and funding to their members. Problems with this model arise in shortages of funding in terms of applying for equipment and the availability of informational programs (RESNA, 1987).

Volunteer Groups and Information/Resource Centers

This category of service delivery models can include a wide variety of groups. These services may originate from a community organization that has an interest in technology, such as a group of retired engineers. It may also involve a national service group such as the Telephone Pioneers, comprised of telephone service personnel and technicians, who focus on sharing their professional knowledge with the community at large (Seventeenth IRI, 1990). While this type of organization does not specifically focus on issues of persons with disabilities, the knowledge they possess can be applied to various situations. For example, a group such as the Telephone Pioneers could work with an individual with a hearing impairment in devising a telephone system that would be appropriate for that particular situation. Problems with this model include being limited to the expertise of the volunteer or organization and the amount of time the individual would have to spend on a project (RESNA, 1987).

Assets and limitations can be found for each service delivery model. Depending on the service needed, one delivery system may be more appropriate than another. Due to the highly individualized needs of persons with disabilities, no single traditional service delivery model will be effective in addressing those needs (Enders & Hall, 1990). Strict adherence to one form of service delivery models over another may not be possible due to the complex considerations that must be weighed when choosing an assistive device. Rather, a combination of service delivery models or concepts may be employed to help the individual explore options. Enders and Hall (1990) support the move from traditional service delivery models by stating that, "assistive technology services frequently do not fit well into our traditional service delivery systems geared to cure, closure, aging out, or some other fixed endpoint" (p. 421). Mann (1991) also expresses concern over the use of traditional service delivery when examining assistive technology options, citing a lack of a clear service delivery model. He further proposes a new service delivery model entitled the "Consumer Purchase" model where the client is at the center of the process making the decisions.

Towards the Consumer Driven Model

As the field of assistive technology advances and more professionals and support persons are brought into the decision making process, it is important to focus on the opinions and needs of the individuals using the device. Johnson (1991) states, "the consumer is the most important member" of the decision making team (p.125). McAlees and Menz (1992) advocate an equal partnership in service delivery where individuals with disabilities and service providers each possess skills and knowledge. In this style, a consumer has an active role and a more participatory exchange can take place.

When the person with a disability has the support necessary to pursue feasible assistive technology options, empowerment results. This requires a system of bringing together information that includes: equipment vendors, service and repair issues, funding sources, as well as training and support issues. Once the individual has access to this information, an informed decision making process can begin (Johnson, 1991). As questions arise, the knowledge of various community members can be beneficial in finding the most appropriate form of technology for the individual.

Mann (1991) argues that the focus of all assistive technology investigations should center on the needs of the individual. The best person to describe what the needs are is the individual who will be using the device. Considerations including style, color, and accessories to the assistive device should always be decided by the consumer. A sense of ownership, and consequently a desire to use the device, arises when the individual feels involved in the decision making process.

The Local Resource Team Model

In response to the original request for grant proposals from P.L. 100-407 (also referred to as the "Tech Act"), the state of Colorado submitted a bid. State-wide efforts were channeled through the Rocky Mountain Resources and Training Institute (RMRTI), a non-for-profit, state funded project. RMRTI acquired a three-year demonstration grant in 1989 entitled the Colorado Assistive Technology Project.

One of the key elements of the Colorado project was the service delivery component. Embracing a consumer driven model, the proposal called for the development and implementation of Local Resource Teams (LRTs). Such teams, comprised of technology users, family members, professionals, educators, rehabilitation counselors, and volunteers, would be the direct link between the end user and RMRTI. To facilitate consumer involvement, RMRTI stated that people with disabilities would comprise at least 33% of each team (National Institute on Disability and Rehabilitation Research, 1993). Each LRT would also be the contact point within a given community for assistive technology needs. Envisioned was a delivery model that would allow the teams to be intimately aware of the specialized needs and issues existing within their service area. RMRTI provided the needed funding, training, and support to LRTs. The acquired services and expertise were then shared by the LRTs with the communities they served.

State-wide Augmentative/Alternative Communication (SWAAC) Teams

The concept of LRTs had its historic roots in another Colorado project, the SWAAC teams. According to Betsy Minor Reid, Senior Consultant for the Colorado Department of Education, previous attempts to evaluate K-12 school children for augmentative communication needs were not as successful as desired. Following a medical model approach, potential users were assessed in a hospital environment; little interaction occurred with parents, teachers, or the classroom setting in determining needs.

It was clear that another approach was needed. In 1986, the SWAAC team model was initiated. Team members were recruited from the public school system. While speech and language professionals were the most typical member, others came from psychology, mobility, and assistive technology backgrounds. Members were provided with appropriate training.

Augmentative communication evaluations were performed by the team in the potential user's school setting; input from parents and teachers was actively sought. Thorough training and follow-up services were designed.

This approach of assessing needs in the "real world" rather than in a clinical environment proved to be very effective. In 1990, the SWAAC project received funding to expand its services to include students with needs related to visual, auditory, and learning limitations. With this expansion, all assistive technology options were explored, not only communication needs. As of December 1993, 40 SWAAC teams were operating throughout the state of Colorado. The unqualified success of this service delivery model lead to its imitation, with SWMC assistance, by the Colorado Assistive Technology Project.

Weld Coalition for Assistive Technology (WCAT)

After receiving the National Institute on Disability and Rehabilitation Research demonstration grant in 1989, RMRTI made the grant monies available within the state of Colorado. By design, successfully awarded projects would be consumer driven and be unique to that particular area's needs. One of the original projects was WCAT located in Greeley, Colorado, and serving Weld County, Colorado. The territory covered by WCAT was a mostly rural area. The project, of which the authors were all actively involved, was housed at the Rehabilitative Services clinic, Department of Human Services, at the University of Northern Colorado. Although based at the university, much effort went into making WCAT a community based project open to all people with disabilities from the area.

WCAT was awarded a three-year grant from RMRTI with a budget of $60,000. The primary goal was to increase public awareness as to the efficacy of assistive technology. To meet this end, WCAT conducted numerous public presentations, providing outreach to outlying areas, workshops, and training sessions; over 150 presentations were made to 1600 interested individuals. Additionally, WCAT produced three videos demonstrating the benefits of technology that continue to be used in educational settings. Approximately 2,000 telephone calls, mostly local, were received regarding assistive technology during the 3-year project.

Another key component of WCAT activities involved the acquiring of a wide range of assistive devices kept on-site. This equipment was used for demonstrations, training, and loaning to potential users. As an example, three computer systems (Apple, Macintosh, and DOS based) were adapted for use by people with various disabilities. The project was able to then offer free, brief computer training to people with disabilities from Weld County. Forty-two individuals with disabilities received free, adapted computer training. In effect, these individuals were able to "test drive" computer equipment prior to a possible purchase, something not typically possible at a local computer school when specialized needs are required.

Through an application process, qualified people could request funding for equipment purchases. A total of 39 individuals received financial support. Recipients ranged in age from 3-62 years old with an average age of 28. Many disabling conditions were represented including hearing impairments, developmental disabilities, muscular dysrophy, multiple sclerosis, visual impairments, quadraplegia, and learning disabilities.

It was a WCAT commitment to award a wide range of devices and services assisting a variety of needs. Awards such as modified toys for infants, computer equipment, architectural modifications at the home, and flashing fire alarm systems are just a few examples. Costs of equipment ranged from $9.20 to $5,775 with the average device costing $694.

It was rapidly discovered that this award money could, in effect, be greatly increased by networking with other funding sources. State vocational rehabilitation, civic groups, local government, disability advocacy groups, and volunteer organizations are just some of the sources that WCAT was able to work with and receive contributions.

Experiences

Numerous issues emerged from the administration of this project, many positive and some negative. Some observations related to the LRT model of service delivery are presented.

Positive

(1) Empowerment - With an ongoing focus on consumer education and decision making, WCAT did have a positive impact upon facilitating empowerment. As often as possible, options were presented with the user making the final decision. For example, if a person was applying for funding for a device, WCAT volunteers, upon request, would assist that individual in determining an appropriate device. The final decision, however, as to the exact device requested was the consumer's. This process was seen as an empowering one with benefits far beyond the application process.

(2) Individualized approach - Consumer needs were considered individually. While this may appear to be common sense, well intending professionals can easily fall into a trap of treating disability groups as homogenous. For example, there may be a tendency to expect all computer users with mobility limitations to need the same modifications; in reality, there is a wide range of needs and solutions. WCAT handled each request from an individualized perspective.

(3) Multidisciplinary team - The very concept of the LRTs model dictated that the project be comprised of a wide variety of people. Users, family members, computer specialists, educators, rehabilitation professionals, and people representing a wide variety of occupations (.e.g., maintenance) were all involved. Not only did this bring a healthy mix of ideas and perspectives, but it also greatly increased WCAT's ability to network.

(4) Local services - As a community based program, WCAT was often able to access local services and vendors. When dealing with specialized equipment and services, this can be an advantage. A person who uses an electric wheelchair typically would prefer to have it serviced and repaired locally and save "down" time. By establishing a personal relationship with a vendor, the possibility of such services as "loaner" equipment increases. WCAT was also able to refer individuals to different community agencies that could provide services in other areas. For example, when an individual came to WCAT with a question regarding employment services, a referral was made to Colorado Rehabilitation Services, the state rehabilitation agency. Thus, WCAT was able to help the individual access not only assistive technology services, but other services located within the community.

(5) Community resource - WCAT came to be known within Weld county as the contact point regarding assistive technology. Local school districts, hospitals, occupational and physical therapists, employers, college students, families, and individuals with disabilities came to use the WCAT office as a resource. It was felt that the LRT model with its emphasis on a multidisciplinary, community based approach facilitated this development.

Negative

(1) Duplication of services - The independent nature of each LRT within Colorado lead to some services being duplicated. For example, WCAT established its own information network related to assistive technology vendors, services, etc. Much of this information was also available from the Colorado Assistive Technology Project as well as national networks.

In hindsight, WCAT may have made more effective use of time by simply referring many information requests to already established sources. A more thorough monitoring and coordinating of the LRTs may have helped prevent duplication of services.

(2) Administration - From a management perspective, a community based, consensus building style organization can make effective operation cumbersome. The decision making process was often slower than desired. As the project evolved, more of the management became centralized with less involvement from the multidisciplinary team.

(3) Volunteers - Also from an administrative viewpoint, the reliance upon volunteers (only the project coordinator received any compensation) created some problems. Keeping volunteers motivated and productive throughout the three-year project presented ongoing challenges. WCAT, over time, came to depend more upon college student labor (typically practicum rehabilitation students) to meet its goals. Without this student involvement, WCAT accomplishments would have been more modest. RMRTI recognized this situation by making more salaries available in continuation grants.

Conclusion

The Local Resource Team (LRT) service delivery model proved to be an effective one within the state of Colorado. With an emphasis on consumer involvement and decision making, an empowerment philosophy was actively embraced. Technology users and potential users were given relevant information regarding technology options and encouraged to make personal decisions. It is felt that such empowerment leads to greater active involvement by the user with a disability which, in turn, leads to a higher rate of technology utilization.

Evidence emerged that users with disabilities responded favorably to the LRT model. The Weld Coalition for Assistive Technology (WCAT), the LRT that the authors administered, assessed consumer satisfaction of those receiving assistive devices. Of the 39 individuals who received devices from WCAT, 30 responded to post-service telephone satisfaction surveys (or written, mailed surveys, if necessary); 29 reported satisfaction with the device(s) and the acquisition process. One respondent requested and received follow-up consultations with the device vendor. Overall, this level of consumer satisfaction from 29 out of 30 respondents (97%) indicated a high level of satisfaction.

Unsolicited comments from participants support the premise of the positive nature of consumer empowerment. The feeling of being treated as an equal or a partner in the rehabilitation process was mentioned as a benefit. Other consumers discussed enjoying and responding to a process that provided education and training and then allowed for individual decision making. These are not new concepts to rehabilitation providers nor concepts unique to WCAT. However, at times, personal testimonials by consumers are powerful reminders to rehabilitation professionals.

Direct community involvement by each LRT helped facilitate the building of local connections and networks. Especially for LRT's such as WCAT that served a largely rural population, the ability to develop local resources and ties proved to be beneficial. Users living in rural settings are not as likely to access metropolitan based services, for a variety of reasons. It was found that serving as a local resource center offered an attractive alternative to many technology users. It is felt that this was a major contributing factor for the high level of involvement from community people with disabilities with the WCAT project.

In conclusion, the Local Resource Team model was effective in providing assistive technology services to individuals with disabilities in the state of Colorado. Consumer empowerment was encouraged, leading to more active involvement. This consumer driven, community based model appears to have relevance to many rehabilitation service delivery settings.

References

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Bruce J. Reed, Ph.D., University of Texas-Pan American, Edinburg, Texas 78539.