Independent living centers: moving into the 21st century.

The independent living movement is a relative newcomer to the disability service scene, having emerged from the social activism of the late sixties and early seventies. As documented initially by DeJong (1979 & 1981), the independent living philosophy offered an alternative to traditional rehabilitation services. Traditional rehabilitation service approaches emphasize professional interventions designed to change the person with a disability so that he or she functions better in the environment. The independent living approach emphasizes giving control to the person with a disability so that he or she can alter the environment in ways that increase the full range of life options. The overriding theme of the independent living movement is to create opportunities for optimal control by people with disabilities over programs, services, and physical settings that influence capabilities to perform in school, job, family, and social roles. In operational terms, the independent living movement came of age in 1972, when the first independent living center was established in Berkeley, California, followed later that year by similar programs in Houston and Boston. Due in large part to the lack of services to support community living by people with severe disabilities, these early programs were of necessity residential programs in which consumers of services lived in congregate settings with shared support services. Although these early programs would appear very different from the nonresidential, community-based independent living centers of today, they were characterized by the critical element of control over services by service recipients.

With passage of the 1978 Amendments to the Rehabilitation Act, the legislative mechanism for supporting independent living programs was established through Title VII. In 1979, 10 Part B grants were awarded for establishment and support of 10 independent living centers. Funds for Part A of Title VII that were intended to purchase independent living services were not appropriated until 1986, and then only in the amount of approximately $11 million. Even today, the total funding for purchase of services (now called Part B) and operation of centers (now called Part C) through Title VII amounted to only $46.8 million in fiscal year 1993 - an average of less than $1 million per state.

With regard to funding, the independent living program represented a departure from approaches that had been used previously to promote community integration of people with disabilities. Rather than creating public service agencies, as had been done with the vocational rehabilitation program through a federal-state partnership, the approach taken with independent living was to provide funding to community-based, private nonprofit corporations set up by people with disabilities to develop and implement services in all but a few states. In a small minority of states, Part B funds were treated as support for purchase of independent living services by state VR agencies. Although oversight of these organizations was, for the most part, retained by state vocational rehabilitation agencies, general operation of the programs was intended to be the responsibility of organizations operated by and for people with disabilities living in the communities in which the programs were located.

In addition to the shift away from programmatic control by rehabilitation professionals, the independent living program was different from traditional rehabilitation service programs in the manner in which services were to be financed. The intent of the original legislation was to create a mechanism for centers to generate operating revenue through sale of services to vocational rehabilitation agencies and other programs for people with disabilities. Quoting from a report of the Seventeenth Institute on Rehabilitation Issues (Thayer & Rice, 1990, p. 43), "Many saw Part A primarily as a means for providing ongoing funding for ILC's [independent living centers] and not as an ILR [independent living rehabilitation] services program administered by the state rehabilitation agencies. Many similarly saw Part B as merely |start-up' or |seed' money and not as a source of ongoing core funding for ILC's."

In 1978, when the Rehabilitation Act was reauthorized and Title VII was added as a component of the Act, Congress authorized up to $209 million for all parts of Title VII; however, the total actually appropriated as of 1989 came to only around $44 million for all of Title VII programs. Unfortunately, Part A funding has never approached the amount originally authorized, and Part B funding - originally thought of as seed money by many - has grown at only a modest rate in the 15 years since funds were first appropriated. Notwithstanding the relatively modest commitment of federal support for independent living center services, requirements for evaluation of center services have continued to stress resource development, and, in fact, the 1992 Amendments to the Rehabilitation Act include an evaluation requirement in this area. In order for independent living centers to expand services and to address both the service and advocacy needs of their constituencies, they have been forced to develop creative approaches to revenue generation.

Although many centers have struggled with the requirement to develop alternative funding streams, while at the same time satisfying reporting requirements imposed by cognizant federal agencies, there has been ongoing growth and innovation in the field. Such growth and innovation was facilitated when, in 1989, after extensive advocacy by leaders in the independent living field, The Robert Wood Johnson Foundation (RWJ), the nation's largest private health-related foundation, committed in excess of $8.4 million to promote development of model approaches to independent living service delivery. With the Independent Living Research Utilization (ILRU) Program serving as the national program office for this initiative, The Robert Wood Johnson Foundation is currently supporting efforts of 11 independent living centers around the country in implementing and evaluating innovative service approaches to promote enhanced health and well-being of persons with disabilities and to test new approaches for generating revenue to support expanded services.

The 11 sites are currently in the second year of a 3-year implementation cycle. Significant accomplishments that have been realized at each of the 11 sites are briefly described below. A more thorough description of the original plans, activities to date, and problems dealt with at each of the sites can be obtained from ILRU at the address indicated at the end of this article. It is worth mentioning that each of the 11 sites pursued plans designed to address needs identified in their communities. This initiative was not intended to create a "cookie cutter" approach to innovation in independent living service delivery, but was rather intended to promote testing of innovations that might be replicable in other settings around the country. Consequently, there has been significant variation among sites with regard to the nature of projects undertaken, as well as with regard to the outcomes realized thus far.

The notion of case management has generally not been accepted by the independent living field because of the negative connotations associated with labeling people as "cases" and the implication of loss of consumer control associated with the term "management." Notwithstanding philosophical objections to the case management concept, it is clear that increasing levels of support are being committed to case management services, particularly by third party payers of services for people with disabilities and chronic health conditions.

Some in the independent living field view the shift toward case management services as an opportunity to promote adoption of the independent living philosophy through infusion of consumer control principles in enhancing coordination of the full range independent living support services, including health related services. This is a controversial issue for the field, with some leaders in the movement arguing that independent living centers should avoid any association with case management.

Ability Center of Greater Toledo

Sylvania, Ohio 

In Ohio, a Consumer Resource Center (CRC) was developed and implemented which includes a community resource database, a library database, and a network linking all of the independent living centers in the state. In addition, a technical assistance center on disability, the Accessibility Consulting Group, has been incorporated as a for profit subsidiary of the Ability Center. Accessibility Consulting Group staff are currently providing accessibility surveys, ADA trainings and workshops, and design and construction management consulting services, as well as other disability-related services to local government agencies, private businesses, schools, state human service organizations, and area townships.

Preferred Properties, a nonprofit housing development corporation was created by the center in partnership with the Lucas County Board of Mental Retardation and Developmental Disabilities. With capital funding from the Ohio Department of Mental Retardation and Developmental Disabilities, 11 properties have been purchased to date and 6 have been fully renovated and are occupied by people with disabilities. Purchase of nine additional housing units is planned and opportunities for additional funding to expand housing opportunities for people with disabilities in the greater Toledo area are being explored.

Other initiatives involve establishing a statewide personal assistance service (PAS) system and making changes in the curriculum of the local medical college to include increased emphasis on independent living and disability rights. Work is in progress on these initiatives.

Ability Resources

Tulsa, Oklahoma 

In Oklahoma, staff of Ability Resources are exploring the potential for tapping the increasing funds being committed to case management services.

However, in response to the dearth of support services for people in the Tulsa area, staff of Ability Resources have collaborated with the Long-Term Care Authority (LTCA) of Tulsa in drafting a Title XIX Medicaid waiver application for submission to the Health Care Financing Administration and have worked with the LTCA to co-sponsor two training programs on case management. In addition, Ability Resources staff have assisted the Department of Human Services in developing a policy document on long-term care reform. Currently, Ability Resources staff are working with the Community Services Council of Tulsa to form a statewide consortium to deal with cuts in Medicaid that have further restricted funding for the full range of services available to people with disabilities.

The priority for additional personal assistance and other independent living support services was identified through a comprehensive needs assessment. Ability Resources Staff are conducting focus groups throughout their five-county service area to identify more precisely specific service needs. These activities include expanded outreach to Native Americans with disabilities.

Ability Resources, like other centers around the country, has taken on the challenge of trying to address significant unmet service needs through efforts to recast traditional service concepts, such as case management, so that funds committed to such programs can be used for services delivered in a manner consistent with the independent living philosophy. This is a daunting challenge. The experience of Ability Resources and other centers around the country that are trying to address independent living service needs by accessing increasing levels of funding committed to case management services will be carefully monitored.

Alpha One

South Portland, Maine 

Alpha One is an independent living center serving the entire state of Maine. At the start of its Robert Wood Johnson Foundation project, Alpha One provided services through four offices in different parts of Maine and operated a for profit subsidiary durable medical equipment and repair business, Wheelchairs Unlimited, through its Portland location. Since receipt of Robert Wood Johnson Foundation support, Alpha One has opened a new branch office in Augusta, including a Wheelchairs Unlimited sales and service office. They have also purchased a 10,000 square foot building in Portland that is being remodeled to demonstrate how easily and inexpensively many structures can be modified to come into full compliance with ADA and other mandated accessibility requirements.

The new facility in Portland will house Alpha One's Portland offices and its Wheelchairs Unlimited store. With the new space available, the product lines offered through Wheelchairs Unlimited have been expanded and aggressive marketing efforts have been mounted with healthcare personnel and providers of rehabilitation services. In addition, excess space in the building will be made available as rental property.

Other revenue generating opportunities being explored include working with Workers' Compensation authorities in Maine to formulate a program for assessment of work capacities for injured workers and developing a joint venture with a statewide health maintenance organization to provide "case management" services in a manner consistent with the independent living philosophy. Both of these activities are in the formative stage.

As regards healthcare, Alpha One has assumed a lead role in advocating for the healthcare needs of people with disabilities in Maine. A statewide forum on healthcare reform is currently being planned and will be held in the coming months, with state and national leaders, including Senator George Mitchell, scheduled to participate. The basic goal of the forum is to examine how to best address the healthcare needs of people with disabilities in the context of proposed national healthcare reform initiatives.

For the remainder of the project period, Alpha One plans to develop a new business venture focusing on the healthcare needs of people with disabilities, to further expansions of the Bangor-Brewer offices to enhance service capabilities for people in that area, and to establish additional Wheelchairs Unlimited locations throughout the state.

Ann Arbor CIL 

Ann Arbor, Michigan 

One focus of the Ann Arbor CIL's project has been eliminating obstacles to employment and career advancement for people with disabilities. To address this issue, the Ann Arbor CIL established and incorporated a Disability Community Development Corporation (DCDC). DCDC has published a directory of area businesses owned and operated by people with disabilities. This directory will be updated on a periodic basis. In addition, DCDC is providing staff training in community development techniques.

Staff of the Ann Arbor CIL have also begun implementing an independent living-oriented, fee-for-service "case management" program to enhance access to and effective use of health and rehabilitation services by people with disabilities. Two staff persons have been hired and are working in the program. Both have taken and passed the state case management certification exam in late 1993 to allow for billing of services provided. A thorough marketing package has been developed, distributed, and presented to area insurance companies, workers' compensation providers, and healthcare and rehabilitation service providers. As with other independent living centers that are trying to access case management dollars to support independent living services, the Ann Arbor CIL will need to demonstrate the effectiveness of the services they provide so that significant revenue generation can be realized from these efforts.

Ann Arbor CIL has entered into partnership with Home Care of Michigan to operate a for profit subsidiary durable medical equipment business. Incorporation of the business has been completed, and startup is anticipated in Spring 1994. Profits from this business venture are expected to be returned to the CIL to support independent living services.

An ADA consulting service has been established and staff are working with an attorney and architect on a contractual basis. ADA-related services available include architectural assessments, information and referral, technical assistance, development of ADA training and promotional materials, and the provision of ADA trainings, workshops, and seminars. In addition, a subscription newsletter, Barrier Free Digest, targeted to architecture professionals is being published.

To support these diverse initiatives, Ann Arbor CIL has hired a marketing and sales consultant. Also, planning processes have been revised to accommodate new development and expanded staff training on effective communication, team building, and customer service. These activities will be continued over the remainder of the project.

Atlantis Community

Denver, Colorado

Changes in the Rehabilitation Act with the 1992 Amendments no longer allow independent living centers receiving Title VII funding to operate residential facilities. These changes were designed to promote development of service programs in community settings most similar to mainstream living arrangements. However, in many housing markets affordable accessible housing is lacking and there are few housing options for many people with disabilities.

Atlantis Community addressed this problem by establishing a nonprofit subsidiary to secure and renovate properties that provide affordable living arrangements for people with disabilities and people without disabilities. The profits generated from rental income are then available to provide other services, such as personal assistance, to people with disabilities who require them. Rather than operate a residential facility for people with disabilities, Atlantis' efforts address the need for affordable housing in the Denver area, while generating funds that can be used to provide needed services.

During the first project year, Atlantis, through a separate nonprofit corporation, purchased and renovated the first of three housing projects - a 34-unit apartment building with 8 accessible units - using a creative financing package that included funding from local government sources at below market interest rates, grants, tax credits, and Community Reinvestment Act funds. In addition, Atlantis is attempting to secure a 198-bed facility that was previously a nursing home in a Denver suburb. This property will be rehabilitated into 52 one- two- and three-bedroom housing units using a universal design concept that allows conversion to an accessible unit if needed. Plans have also been made to secure an 8.9-acre building site in the Durango area. A "how-to" manual outlining the steps in obtaining and rehabilitating properties using the universal design is being prepared. This will be marketed to other nonprofit agencies, housing developers, and disability-related agencies. Most of these properties have been purchased from the Resolution Trust Corporation (RTC). Earlier this year, Atlantis staff were invited to Washington, DC, by RTC to showcase their housing concepts at an RTC open house. In addition, these ideas have been shared with other RTC property purchasers, through onsite visits and in a recent RTC publication entitled, A Dream Realized. RTC has been particularly interested in Atlantis' success in securing low mortgage rates, allowing for low-cost rentals while still generating revenue to provide necessary services to the tenants.

Atlantis has also opened a mental health clinic, licensed by the state. Two psychologists, a registered nurse, a physician, and an executive director have been hired to staff the clinic. However, the clinic relies extensively on peer provided services in addressing the needs of persons served. In addition to providing mental health services to people with disabilities, ongoing training and educational information is made available to mental health providers regarding the specific needs of people with disabilities. Clinic staff have developed masters and doctoral curricula with the intent of pursuing the establishment of mental health and disability as a distinctive clinical discipline within psychology. Finally, clinic and center staff plan to sponsor and conduct a national symposium in Denver on Mental Health and Disability sometime in the spring of 1994.

Over the remaining project period, Atlantis will focus on completing its housing plans, as well as continuing to enhance the overall operation of its mental health clinic. Particular effort will be directed toward expanding the delivery of these services to children and adolescents currently involved in the Colorado judicial system and to persons transitioning from living in institutions to living independently in the community.

Center for Living and Working

Worcester, Massachusetts

Staff of the Center for Living and Working (CLW) have been developing and implementing a fee-for-service independent living based case management services program referred to as a "health advocate" service. Demonstration projects have been established with two health maintenance organizations (HMO's) in the area to test approaches for integrating independent living services into case management service models. Particular attention will focus on using health advocates to foster appropriate use of healthcare services. Two health advocates have been hired and trained.

To ensure that demonstration data is correctly managed for accurate outcome results, two consulting groups are assisting with a program audit, assessment of weaknesses in the existing program, and development of a program evaluation tool. Once the demonstration period is completed, this service will be provided on a fee-for-service basis.

Center staff are expanding the project's outreach efforts to additional healthcare providers in the area and are developing a database of healthcare providers. The database can be accessed by persons with disabilities to obtain information on a variety of topics, including provider accessibility. Continuing education courses are also being developed for nurses employed by collaborating HMO's. The courses will provide training on the project, people with disabilities, and the role of nurses in promoting independent living for people with disabilities.

Massachusetts has recently enacted a new requirement for all Medicaid recipients to be enrolled in managed care programs. Project staff have been actively involved in forums and other meetings related to this requirement to ensure that disability related issues are being addressed. This endeavor is helping to heighten the visibility of the project in the state and in local medical communities. Other marketing and public awareness activities are underway to educate the healthcare community about the project and the needs of people with disabilities for accessible healthcare services.

In mid-1993, a fee-for-service ADA consulting component was also initiated, and will be expanded over the duration of the project.

Center for independence of the

Disabled in New York (CIDNY)

New York

CIDNY's original goal was to open and operate a freestanding independent living health clinic (ILHC). As these efforts began, it became increasingly apparent that, due to a number of factors, including requirements for a Certificate of Need for the state, it would be most effective to begin the ILHC in collaboration with an existing healthcare provider. The project was awarded an additional planning year grant to complete the process of identifying an appropriate collaborating healthcare facility and to complete operational and structural plans for the clinic. These activities included development of a set of criteria that would have to be met by the affiliating hospital prior to execution of a formal agreement to collaborate. Staff then began talking and meeting with representatives from several area hospitals to determine which ones best met the criteria. Three hospitals expressed great interest in hosting the clinic. New York Downtown Hospital in Manhattan was selected earlier this year. CIDNY has completed a memorandum of understanding with the hospital, generally defining the roles and responsibilities for the ILHC's delivery of medical and nonmedical services, as well as laying out procedural specifications on each party's contributions to the ILHC. Agreement on sharing of any revenue generated through clinic activities has also been reached.

The project received a 2-year implementation grant from RWJ, beginning July 1, 1993. Final negotiations are taking place with the hospital, and a formal contract will be signed in the near future. New York Downtown Hospital and CIDNY are currently working to locate an offsite location for the clinic. They hope to find space in a storefront location which could be made fully accessible to persons with disabilities. Current plans call for opening the ILHC by Winter of 1994.

Montana independent

Living Project (MLP)

Helena, Montana 

The Montana Independent Living Project has two general goals:

* development and implementation of a rural independent living case management service model to improve the health and independence of adults with disabilities in southwestern Montana; and

* implementation of income generating activities around ADA.

When the project began, a consumer panel was formed with representatives from eight counties in southwestern Montana. The role of the cross-disability consumer panel was to provide ongoing input on the feasibility and appropriateness of project activities and products. With input from the panel, project staff have developed a case management practices manual which describes the center's program and outlines the step-by-step delivery of independent living case management services from referral to follow-up. Activities are also underway to develop additional informational materials defining independent living case management services and outlining case studies of persons with disabilities who have benefitted from independent living services. These materials will be widely distributed.

Project staff wanted to be able to analyze and evaluate the effectiveness and cost benefits of the demonstration model. However, adequate literature on case management cost effectiveness could not be identified. Therefore, project staff are developing their own approach to cost benefit analysis through review of previous service delivery and outcome data and restructuring of methods for capturing and analyzing data currently generated on service delivery and outcomes.

To improve community awareness and education regarding disability and the current healthcare system, as well as to facilitate the receptivity and support for new approaches which improve the coordination of healthcare services, staff have developed an educational presentation used with healthcare providers in the center's delivery area. In addition, project staff have begun organizing and coordinating healthy lifestyle groups for people with disabilities in four counties of their service area. Efforts are also underway to develop business relationships with professionals in the healthcare, insurance, and rehabilitation arenas to whom independent living case management services may be marketed on a fee-for-service basis.

ADA accessibility surveys have been developed and recruitment and training for people with disabilities to perform accessibility surveys under the direction of an ADA Coordinator is underway. To support these activities, staff are researching development of five marketing products related to ADA which have potential for generating revenue. Results of this research will guide ADA-related service development.

Southeastern Minnesota Center

for Independent

Living (SEMCIL)

Rochester, Minnesota

SEMCIL serves the rural southeastern area of Minnesota. To address the service needs of people with disabilities in the area, SEMCIL has established satellite offices in six counties - one serving two counties - to better serve their seven-county service area. Consumer advisory councils were formed for each of the seven expansion counties in order to provide direction to SEMCIL in the organization of each office's policies and programs in a manner that would address needs of consumers in each area. In addition, representatives from key community organizations were identified and contacted to inform them about the new SEMCIL office and the services that would be available to consumers. Media and public awareness activities were also planned and implemented prior to the opening of each office.

Services offered at each of the seven sites include the four core independent living services - peer counseling, information and referral, advocacy services, and skills training. In addition, each office is providing (or will provide in the coming months) additional services, including support groups, transition from school to community living for youth, PAS development and implementation, facilitation of access to healthcare services, and development and implementation of informational networks serving the larger organization and each of the satellite offices. Each office is also developing fee-for-service programs in the areas of accessibility, disability awareness training, and ADA training and consultation. SEMCIL hopes to develop a fee-for-service independent living case management program and will be looking at results realized through other projects that have taken on the case management challenge.

To assure that consumer preferences are being addressed in each of the county service areas, SEMCIL has developed and implemented an innovative program evaluation component. Evaluation data is being gathered and will be analyzed on an ongoing basis to determine if project efforts are on track. Also, an organizational goal of SEMCIL is to enhance the overall operation of the center and its service components by improving board and staff communication, planning, and goal setting and implementation skills. For the remaining project period, staff will work to implement additional services in the county offices while seeking additional funding to support expanded services.

Stavros

Amherst, Massachusetts 

Stavros has established two primary goals:

* to develop and implement a comprehensive consulting service to bring assistive technology, design, and education together in environments (home, work, and community) which support independence and improves quality of life for people with disabilities; and

* to enable persons with disabilities to take full responsibility for their personal care and health through the expansion of personal assistance services to underserved populations.

To achieve its first goal, the center developed and implemented an access consulting business, Access Plus, which offers a flexible package of services to consumers, including assessment and recommendations on the physical and programmatic environment. The primary emphasis is on site surveying, structural barrier identification, and design of barrier-free solutions. An ADA coordinator and site surveyor staff the business. The center has developed two comprehensive assessment tools - a physical access survey tool and a program assessment tool-that can be used by municipalities with assistance from Access Plus staff to conduct self-evaluations under Title II of ADA. In addition, the center has developed several ADA information brochures and other training materials that are used for instructional and promotional purposes. The center currently provides an array of consulting services, including site surveys, design adaptations, and ADA workshops and trainings. Through its marketing efforts, the center has developed contracts with several local community agencies and municipalities to conduct ADA compliance services. Its largest project to date involved conducting an accessibility survey and providing recommendations for improving accessibility in the island-town of Nantucket.

Activities to date have focused on the development of Access Plus. However, work is underway to improve and expand personal assistance services to underserved populations. A primary focus in this area will be on addressing the PAS needs of persons with cognitive limitations who require assistance with executive functions in order to live independently. An accessible PAS manual to assist program participants in managing their assistance services more independently is being developed. In addition, staff are working to improve funding and accessibility of PAS services statewide and to develop pilot projects on prevention of secondary health problems for people with disabilities.

Summit ILC 

Missoula, Montana 

The Summit ILC project has three primary goals:

* to implement a rural outreach program to increase the number of persons with disabilities, particularly in rural areas, who have access to independent living and other community services;

* to establish a program to assist persons in transitioning from the hospital or rehabilitation center back into the community by providing information related to prevention of secondary disabilities and overall health promotion; and

* to develop funding mechanisms and strategies for the overall financial development of the organization.

Significant progress has been made in all three goal areas. Satellite offices have been established in four county service areas (one county office serves two counties). Staff of these offices are providing all core independent living services, as well as ADA services and training to people in these areas. Plans call for making each of these satellites freestanding ILC's. Prior to the opening of each office, a needs assessment was conducted throughout the center's service area and county consumer advisory councils were formed to assist in identifying the specific needs and priorities for each of the four counties. Outreach efforts in rural areas have been aided by the purchase and implementation of a computerized benefits screening system that facilitates identification of appropriate benefit programs to support independent living goals.

The center is collaborating with a local rehabilitation center to assist persons with disabilities in effective transition back into their communities and to ensure that these persons receive needed independent living and other support services. Staff have developed a patient and family education manual which can be tailored to fit individual needs. A full-time occupational therapist has been hired to provide independent living services to consumers in their homes through formal contracts with two home healthcare providers. Medicare certification to obtain reimbursement for occupational therapy and independent living services is being explored. A healthy lifestyles fitness class for persons with disabilities has been developed in conjunction with the Missoula YMCA; expansion of this venture to other area communities is being considered.

Summit board and staff have undertaken several activities to promote financial development of the organization. A for-profit subsidiary medical supply business was incorporated and opened in Missoula. Also, efforts are underway to increase the number of fee-for-service contracts with area business, healthcare and rehabilitation providers, and human service agencies for the provision of ADA accessibility surveys and other ADA services. To support these diverse activities a comprehensive marketing and public relations plan has been developed and implemented. Efforts are underway to establish a financial development board to assist the center in fundraising activities and other financial development.

Conclusions

The brief summaries of project accomplishments provided above do not, in any sense, tell the whole story of this innovative project and its goals for improving the quality and availability of services for people with disabilities. Thanks to the generous support of The Robert Wood Johnson Foundation, these 11 consumer-controlled, community-based organizations have been able to test some approaches and take some risks that they would not have been able to attempt without the foundation's support. These ventures have included forays into the business world through initiation of retail businesses and reorganization of basic service programs in housing and personal assistance.

They have also included reconsideration of service concepts, such as case management, that many adherents to the independent living philosophy construe as inherently contradictory to the philosophy, both with regard to the identification of people as "cases" and in the connotation of external control implied in the term "management." With the case management concept receiving ever increasing attention through professional and lay media coverage of efforts toward healthcare reform, it is a notion that is increasingly likely to be embraced by third-party payers of services. The efforts undertaken through this program and through initiatives undertaken in other independent living centers and consumer-oriented service organizations will test the efficacy of the more positive aspects of case management (i.e., improved service coordination) within the construct of the independent living philosophy, with its emphasis on consideration of the person - not the case - and optimal control by the service recipient.

The efforts underway and preliminary results that have been documented through this program suggest that a great deal of information will be generated that will be valuable to the independent having field as well as to other disability-related service fields. Not only will new approaches to financing and delivery of services be developed and refined, but lessons about the risks of various service approaches and financing mechanisms will be learned. This last point is particularly important. As with new ventures in other public and private arenas, this initiative involved certain levels of risk. Fortunately for the participating independent living centers, a good portion of the risk was assumed by The Robert Wood Johnson Foundation through its support of these endeavors. However, even with Foundation support, each of the participating centers has committed significant board and staff time, discretionary funds, and other resources to trailblazing efforts to move the field forward.

This program will yield results that will have a major influence on the delivery of independent having services in the 21st century. Not only will new service delivery approaches emerge - offering essential community-based support and creating new employment opportunities for qualified people with disabilities - but new concepts of service financing will be tested that will, through economic empowerment, move people with disabilities a step closer to the goal of being fully participating members of their communities.

The authors wish to acknowledge the generous support of The Robert Wood Johnson Foundation through its national program, "Improving Service Systems for People with Disabilities." Just as important, we wish to acknowledge the extraordinary dedication and hard work of the boards and staffs of the 11 centers whose accomplishments are profiled in this article. Not only have these organizations and individuals made substantial contributions to the field, but they have also given freely of their time and resources in the development of this manuscript. We extend a special acknowledgment to Tajauna Dunning, ILRU's Robert Wood Johnson Program Assistant, for her contributions and assistance in the development of this document. We also wish to acknowledge the important contributions of Drs. Susan Stoddard and Ted Benjamin, who direct the external evaluation of this program. Finally, we would like to express our appreciation to the many advisors, consultants, and others who have contributed to making this program successful. There have been dozens, and their willingness to share their expertise and resources has been an important factor in any success realized to date.

Bibliography 

1. Thayer, T. & Rice, D.B. (1990). Vocational Rehabilitation Services in Independent Living Centers. Report from the Study Group Seventeenth Annual Institute on Rehabilitation Issues. Arkansas Research Training & Training Center in Vocational Rehabilitation.

2. DeJong, G. (1981). Environmental Accessibility and Independent Living Outcomes. University Center for International Rehabilitation. USA/Michigan State University.

3. DeJong, G. (October, 1979). Independent Living: From Social Movement to Analytic Paradigm. Arch Physical Medicine Rehabilitation, Vol. 60.