Vocational rehabilitation for persons with spinal cord injuries and other severe physical disabilities.

The 1990's must be the time when the dream becomes a reality that all persons with disabilities, regardless of the nature or severity of their disability, have the opportunity to work in the employment situation of their choice. For this to happen, there must be a renewed commitment to this goal and attention focused on developing innovative approaches for improving and expanding the provision of existing vocational rehabilitation services to individuals with spinal cord injuries and other severe physical disabilities. Unfortunately, the vast majority of people with severe physical disabilities have not yet entered community employment and largely remain unserved (Revell, Wehman, Kregel, West, & Rayfield, 1994). They continue to experience rates of unemployment and underemployment that far exceed those of the general population, even after completing postsecondary educational and training programs (Babbit & Burbick, 1990; Bowe, 1983; Liebert, et al., 1990). Many of these individuals could benefit from assistive technology, but they have not gained access to services and remain unserved (Mann, 1991). There are literally hundreds of thousands of people who could live and work independently with the proper application of assistive technology and supports but remain in state run institutions or nursing homes (Turner, Barrett, Cutshall, Lacy, Keingham, & Webster, 1995).

According to a Louis Harris Poll of persons with disabilities, low levels of employment exist among Americans with disabilities despite the passage of the Americans with Disabilities Act in 1990. As of 1994, 68 percent (greater than two-thirds) of people with disabilities between the ages of 16 to 64 were not employed; however, 79 percent of these unemployed individuals indicated that they wanted to work, with an even greater number (84 percent) in the 16-44 age group stating that they wished to work (Louis Harris and Associates, Inc., and The National Organization on Disability, 1995).

The cost of maintaining unemployed adults with disabilities is high. Approximately 42 percent are recipients of public support funds such as Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) (Bowe, 1983). The cumulative effect of supporting large numbers of people over their lifetime is indeed substantial (Hill, Seyfarth, Banks, Wehman, & Orelove, 1987). According to the President's Committee on Employment of the Handicapped (1987), the federal government spent $62 dollars in 1985 on subsidies, medical care, and programs for people with disabilities, more than 93 percent of whom were not working.

People with disabilities have cited that the number one barrier for not working is imposed by their disabilities. Other important barriers to employment identified by the Louis Harris Poll include the following:

* 42 percent stated that employers will not recognize that the person could do a good job;

* 31 percent were concerned about losing benefits or insurance;

* 24 percent cited unavailability of transportation;

* 24 percent expressed a need for a personal assistant; and

* 16 percent indicated a need for assistive technology.

Clearly, these are issues that should be addressed by employment programs.

Federal Policy Initiatives

Several major public policy initiatives hold promise for reversing this trend. First, supported employment, a vocational rehabilitation (VR) strategy authorized by the Rehabilitation Act Amendments of 1986, allows state VR systems to fund time-limited training and adjustment services in competitive employment for individuals who will need extensive ongoing support services to maintain their employment. This strategy has been refined and used for individuals with severe physical impairments in demonstration projects with great success (Cooper & Mank, 1989; West, Wehman, Kregel, Kreutzer, Sherron, & Sasler, 1991).

Second, PL 100-407, the Technology-Related Assistance for Individuals with Disabilities Act of 1988, provided funding to increase the availability of assistive technology services and devices for persons with physical impairments. Congress reauthorized and amended the Act in March of 1994, PL 103-218 (Technology-Related Assistance for Individuals with Disabilities Act of 1994). Two key components of this legislation include the following:

* Title I specifies that protection and advocacy services must be provided by each state in one of two ways. A state may provide funds to an already existing protection and advocacy organization, or it may request that the U.S. Secretary of Education annually reserve funds to develop a protection and advocacy organization in that state. If a state otherwise was providing protection and advocacy services as of June 30, 1993, it may continue to do so using the same plan of operation.

* Title III allows the Secretary of Education to award one-time grants to states for the establishment of alternative financing mechanisms through which consumers can obtain funds to purchase assistive technology devices and services. Each grant can be. for an amount not to exceed $500,000 and is contingent on the state at least matching the funds.

Third, the Americans with Disabilities Act of 1990, through its broad and progressive mandates, promises to bring persons with severe physical impairments into the American work and community mainstreams. Specifically ADA gives "civil rights protection to individuals with disabilities that are like those provided to individuals on the basis of race, sex, national origin, and religion. It guarantees equal opportunity for individuals with disabilities in employment, public accommodations, transportation, state and local government services, and telecommunications" (U.S. Department of Justice, p.1).

In essence, this legislation has removed many of the external barriers that have interfered with the ability of individuals who have disabilities to express their choices, to exert control over their lives, and to achieve employment. In the area of employment, ADA prevents discrimination of a qualified individual with a disability if he or she is able to perform the essential functions of a job with or without reasonable accommodation; therefore, employment opportunities for persons with spinal cord injuries can now be based upon individual choice and merit rather than on the lack of knowledge or the potential misconceptions of employers. Similarly, access to the community, including public accommodations, commercial facilities, and transportation, can now be determined by the individual with a disability rather than by external factors such as availability, accessibility, or attitudes.

Fourth, the Rehabilitation Act Amendments of 1992, PL 102-569, reflects values aimed at empowering persons with disabilities. The regulations specifically address the need for consumers to have choice and control over their rehabilitation services (Inge & Brooke, 1993). The "choice regulations" included in the amendments state that the individual with a disability must jointly develop his/her Individualized Written Rehabilitation Program (IWRP) with the rehabilitation counselor. The IWRP must be designed to include a statement in the individual's words describing how he or she was informed o and involved in choice related to employment goals, objectives, services, service providers, and methods used to procure or provide services. For persons with spinal cord injuries and other physical disabilities, the ability to exercise choice in a variety of situations is perhaps one of the most important accomplishments and one of the greatest benefits of ADA and the Rehabilitation Act Amendments of 1992.

PL 102-569 also refers to ADA and the Tech Act of 1988 for definitions of assistive technology, rehabilitation technology, and extended services. The Tech Act addresses the need for technology in the workplace for individuals with severe disabilities. Vocational rehabilitation counselors when assisting an individual with a severe disability must include in the IWRP "a statement of the specific rehabilitation technology services to be provided to assist in the implementation of intermediate rehabilitation objectives and long-term rehabilitation goals for the person." In addition, key report language states the following: " . . . the IWRP should provide for regular and periodic assessments to ensure that a match exists between the supports, the technology, and the current and changing needs of the individual who will be using the technology as well as other people involved in the provision of services who require the information.. . " (Senate Report 102-357, p. 39). Finally, each rehabilitation agency must:

* Describe how a broad range of rehabilitation technology services will be provided at each stage of the rehabilitation process [Sec. 101(a)(5)(C)(I)].

* Describe how a broad range of such rehabilitation technology services will be provided on a statewide basis [Sec. 101(a)(5?(C)(ii)].

* Describe the training that will be provided to vocational rehabilitation counselors, client assistance personnel, and other related services personnel [Sec. 101(a)(5)(C)(iii)].

* Describe the manner in which devices and services will be provided or worksite assessments will be made as part of the assessment for determining eligibility and/or needs of an individual [Sec. 101(a)(31)].

Consumer Involvement in Disability Program Planning

Clearly, consumer involvement in disability program planning, implementation, and evaluation has received considerable attention from consumer and advocacy groups, professionals, and policymakers (Bradley & Bersani, 1990; Gradel, 1991). DeJong, in a major address at the 1993 Annual Meeting of the American Academy of Physical Medicine and Rehabilitation, appropriately called for a "new compact" within medical rehabilitation between clinicians and disability rights advocates:

"I am urging that medical rehabilitation work toward a new alliance with people with disabilities to help forge a new sense of community at all levels of our society--local, regional, state, and national".

Unfortunately, consumer choice in employment seems to remain more the exception than the rule in practice. Within Virginia, lack of consumer involvement and choices has been identified as a major problem faced by supported employment participants across all disability groups (Brooke, Barcus, & Inge, 1992). Additionally, in a recent program evaluation of supported employment for persons with physical disabilities and traumatic brain injury (Virginia Institute for Developmental Disabilities, 1992), only 41 percent of the respondents indicated that they had exercised choice in types of jobs in which they were eventually placed, and 61 percent indicated that they did not like the jobs into which they had been placed and would like to change. These findings suggest that customer self-determination in employment is lacking for participants from these disability groups.

As previously noted, many individuals with spinal cord injuries or other severe physical disabilities require assistive technology services and devices to enter or re-enter the competitive work force. However, as Gradel (1991) notes, accessibility and personal preferences in assistive technology are limited for many individuals with severe physical impairments. She cites data from more than 15,000 consumers responding to the National Consumer Survey sponsored by the National Association of Developmental Disabilities Councils Qaskulski, Metzler, & Zierman, 1990) indicating that specialized services were needed by up to 40 percent of the sample. In addition, the services that are available continue to segregate and insulate consumers from other members of the community rather than integrate them with community life. Gradel further writes that most human service agencies, including employment programs, have not yet fostered a climate of responsiveness to consumers' wants, needs, expectations, preferences, and standards.

Turner and his colleagues (1995) addressed this lack of responsiveness to the customer's needs related to technology acquisition and use. Traditionally, consumers have assumed the "client" role deferring to the authority of professionals. Turner and his colleagues stated the following:

". . . many professionals view persons with disabilities as their clients whom they need to help. This professional attitude has a tendency to place the professional in the dominant role. The professional becomes the ruler and governor of agency policies, funding streams, and technical information related to assistive technology."

This very traditional approach to identifying technology has been described as one of the reasons that many consumers obtain technology only to take it home, store it in a closet, and never use the device for completing daily living and work tasks.

Good vocational rehabilitation programs must reject this old way of doing business and place customers at the center of the employment process, thus giving them choices in the labor force. To do so, service agencies need to develop a "customer service culture" that listens to its customers, involves them in service planning and delivery, and effects lifestyle changes that are valuable to them. However, there are many outdated service delivery practices that must change in order for this to happen. The following is a description of one approach to empowering individuals with spinal cord injuries and other severe physical disabilities to take control of the vocational rehabilitation process.

Developing a "Customer Service Culture"

Several demonstration projects at the Rehabilitation Research and Training Center (RRTC) at Virginia Commonwealth University have addressed the issue of developing a customer service culture. The components of these demonstrations have included the following:

* a peer-to-peer mentor program

* customer-directed career planning and

* jobsite enabling through assistive technology, personal supports, and other accommodations.

Each of these components are interdependent; however, they will be discussed individually for clarity of presentation.

Peer-to-Peer Mentor Program: Professionals cannot understand all of the issues that an individual with a spinal cord injury or other physical disability will face when entering the workplace for the first time or re-entering after an injury. The most powerful support can only come from someone who has overcome employment berries and achieved his/her dream. A peer-to-peer mentor program can afford customers access to individuals who have achieved what they wish to achieve. As such, projects at the RRTC have designed and implemented a process in which customers of services are matched to peer mentors of their choice.

The first activity of the peer-to-peer mentor program is a formal self-advocacy institute which occurs over a 2-3 day period. The institute introduces the customers to person-centered planning services designed to support and enhance their employment potential. Mentors and other community consumer advocates comprise the training cadre. A sample agenda is provided in Table 1.

Table 1
Agenda for Project Access Peer-to-Peer Mentor Institute

Day 1

8:30 to 9:15    Welcome
                Introductions and Expectations of the Training
                What is a mentor?
9:15 to 10:00   Levels of Self-Advocacy
                Understanding and Using Self-Advocacy
10:00 to 10:15  Break
10:15 to 11:45  Know Your Employment Rights
                Title I-ADA
                Questions and Answers
11:45 to 1:00   Lunch and Networking
1:00 to 2:15    Know Your Rights Under Social Security
                and Medicaid
                Understanding SSI/SSDI
                Understanding Medicaid
                Navigating the Systems
                Using the Systems to your Advantage
2:15 to 2:30    Break
2:30 to 3:30    Making It Happen: A Panel Discussion
                Deciding to Act
                Assertiveness
                How to Deal with Stonewalling Situations
3:30 to 4:30    Role Play and Case Study Examples

     Day 2

9:00 to 9:30    Review Activity of Day 1
9:30 to 10:15   The Rehabilitation Act and You
                Being Eligible for Services
                Customer Choice and Services
                Client Assistance Program
10:15 to 10:30  Break
10:30 to 11:00  Supported Employment Services
                What are they?
                How do I use them?
                What can they do for me?
11:00 to 12:00  Role Play and Case Study Examples
12:00 to 1:00   Lunch
1:00 to 2:30    Exploring the Pathway to Effective Mentoring:
                A Discussion
                What is your vision of a mentor?
                What are your expectations of a mentor
                How can a mentor best meet your needs?
2:30 to 2:45    Break
2:45 to 3:30    How do we get started?
                What are our first steps?
                Develop an action plan.
3:30 to 4:00    Closing Activity

The curriculum for the institute includes self-esteem and disability, appropriate interpersonal advocacy, rights and responsibilities, information needed for life assessment planning, and self-advocacy training. Customers learn how to exercise choices in the rehabilitation system and provide direction to those providing services. They learn skills for leading and facilitating teams, how to function proactively in the rehabilitation process by defining their own needs, and techniques for directing their own service plans. Training also is provided on key federal laws such as ADA, the Rehabilitation Act Amendments of 1992, and Social Security provisions, such as the work incentives program. The overall objective of this training is to give individuals with spinal cord injuries and other physical disabilities an awareness of their rights and responsibilities in directing and participating in the rehabilitation process. The following table lists the guiding principles for these training institutes.

Table 2
Consumer Institute Guiding Principles

1. Teaching customers with spinal cord injuries and other severe
physical disabilities to understand their role as
customers who can use choice as a tool of empowerment:
   a. assisting customers to understand their role as a customer
      with a right to make choices in everyday life;
   b. encouraging customers to exercise options in choosing
      their rehabilitation services; and
   c. obtaining desired employment.

2. Training customers with spinal cord injuries and other severe
physical disabilities to be effective self-advocates by:
   a. understanding and using effective self-advocacy techniques;
   b. having the knowledge to become good decision makers;
   c. learning to be assertive and persistent when
      faced with stonewalling situations;
   d. becoming skilled at the art of negotiating;
   e. using role-play exercise to assist customers in practicing
      methods to obtain vocational rehabilitation and
      other services.
   f. using case history assignments to teach problem solving
      strategies.

3. Training customers with spinal cord injuries and other severe
physical disabilities to be mentors who are
equipped to train other customers by:
   a. inviting customers who are experienced in using self-advocacy
      to initial institutes to serve as examples of good
      self-advocates;
   b. use customers as trainers who can serve as role models;
   c. have follow-up institutes to teach individuals to become
      mentors; and
   d. have unstructured evening activities designed to encourage
      networking and bonding between customers that will facilitate
      their working together as mentors.

4. Empowering customers with spinal cord injuries and other
severe physical disabilities by:
   a. teaching the value of employment to increase self-esteem,
      be productive, and make friends in the workplace;
   b. training customers to know what agencies can assist them
      in their advocacy efforts;
   c. training customers on ways to obtain what services they need
      from the establishment.

Customers also receive support from their mentors through various other activities to include peer support groups and one-to-one sessions in which the customer and mentor identify personal employment barriers and develop strategies that will facilitate employment. In addition, mentors are available for such activities as

* learning to navigate the public transportation system;

* talking with social security and/or other agency representatives;

* exploring funding sources for obtaining needed technology;

* visiting assistive technology vendors or attending conferences;

* accessing leisure-recreation opportunities in the community (e.g., concerts, ballgames, movies, and so forth).

While many service providers have paid professionals to perform these activities, the resource is clearly more powerful if provided by former customers of services.

Customer-Directed Career Planning and lob Placement Process: The career planning and job placement process allows project participants to explore employment options using a "customer-driven support team." This team may consist of the customer, his/her identified mentor, project staff (e.g., community support specialist, employment specialist, technology specialist, etc.), friends and family members, vocational rehabilitation counselor, Medicaid case worker, and others. The team consists only of those individuals selected by the customer. While the project staff may feel that a particular individual should participate, he or she is not invited to attend team support meetings if this is the wish of the customer.

The team uses a person-centered approach to determine the customer's employment interests and strengths that have been described in the literature under such titles as "personal futures planning," "lifestyle planning," "MAPS," and "PATH" (O'Brien & Lovett, 1992; Pearpoint, O'Brien, & Forest, 1993). Specifically, the PATH process has been used to identify each customer's dreams and goals for employment, specify accomplishments which will occur in a 1-year time period, and establish intermediate 3-month, 1-month, and 1-week objectives and activities toward meeting the customer's career goal. Literally, the process identifies a "path" or course of action for the customers to pursue. Each customer and his/her mentor and support team are responsible for monitoring the plan and checking off the accomplishments as they occur.

Other components of the customer-directed career planning and job placement process include assisting the customer to return to preinjury employment, if this is the employment goal, or to select a new career option. This is accomplished by determining situational assessment opportunities for the customer based on his/her interests. These assessments entail identifying potential work environments in which the customer may ultimately be employed and observing him or her in the actual setting performing work demanded by that environment (Moon, Inge, Wehman, Brooke, & Barcus, 1990). Please refer to Table 3 for a "path" of one customer who has chosen to pursue a new career option and is participating in situational assessments.

Table 3
Sample PATH Career Planning Activities for One Customer

     Career Dream for the Future:

A job where I...

  * can help others.
  * can work around people.
  * work with animals (e.g, pet store, veterinarian's office,
    boarding facility, park, etc.); or
  * work with flowers, such as at a florist; or
  * work in a department store.

1-Year Goals:

I have...

  * selected a job, and I am working!
  * opened a checking and savings account.
  * bought new clothes with earnings.
  * joined a woman's group such as the garden club.

I am...

  * earning enough money to pay my own bills (e.g., long distance
    phone bill).
  * making new friends.
  * going out into the community independently (e.g, attending
    concerts on own, going shopping, going out to dinner,
    etc.)

3-Month Goals and Objectives:

I have...

  * completed a situational assessment at three different
    worksites based on my specific interests (e.g., pet store,
    florist, department store).
  * narrowed my job interests and choices (hopefully identified
    a job!).
  * gone on 3-4 job interviews.
  * identified where I want to go and used the accessible bus system
   at least 3 times by myself.
  * gone to a concert with friends at least once without
    assistance!
  * gone out to dinner with a friend at least once without
    assistance!

1-Month Goals and Objectives:

I have...

  * picked out my interview outfit.
  * identified the sites for my situational assessments.
  * ridden the accessible bus system with my mentor at least once
    a week.
  * attended regularly scheduled support group meetings.

Next Week's Activities:

I will...
  * buy a day planner to keep up with my new schedule.
  * talk with my personal care nurses about my job goals.
  * visit at least one jobsite to begin narrowing my choices for
    situational assessment.
  * review the want ads to get an idea about available jobs.
  * role play having an interview with my mentor.
  * attend a support group with other project customers.

An employment specialist or other identified support person assists the customer in completing these assessments in which they identify the customer's work-related support needs to include such things as assistive technology needs, wheelchair access issues, mobility and space requirements, and other critical work related issues (e.g., self-care needs, need for personal care attendant, and so forth). Please note that assistive technology needs assessment occurs within these real work environments and not within clinical or hospital settings. This type of functional assessment of a customer's needs yields valuable information that cannot be obtained in clinical settings. In addition, technology is purchased once the customer obtains employment and actual needs can be identified. Clearly, technology must be determined based on the customer's actual needs rather than on anticipated or perceived need. Table 4 lists questions that are considered when identifying potential assistive technology devices.

Table 4
Considerations for Evaluating Assistive Technology Devices for the
Workplace

1. Does the device assist the customer in more efficiently
performing the job task that he/she is trying to complete?

2. Can the customer accomplish more of the task(s) when using the
device than without it?

3. Is there a simpler device (low technology device) available or
can one be made that will get the job task done just as
efficiently?

4. Is the appearance of the device acceptable to the customer?

5. What is the device's dimensions? Will it fit within the work
environment where it is going to be used?

6. If needed, is the device portable? (If not, does another
device meet the same needs and is portable?)

7. How does the device need to be positioned? Can it be positioned
or mounted in order for the customer to use his/her best motor
response?

8. What operating techniques can be used with the device (e.g.,
direct select, scanning, encoding)? Does this match the needs of
the customer?

9. What type of feedback does the device give (e.g., auditory click,
movement when activated, tactile input)?

10. How flexible is the device? Can it be used with other devices
used by the customer?

11. Is the device expandable? (Will it be useful within other
environments in which the customer functions or is its usefulness
limited to the workplace?)

12. Is the customer safe with the device?

13. What type of warranty is offered? Is there service available?

14. If the device breaks down, will the vendor rent or loan the
customer another device so he/she can continue working?

15. Is the cost reasonable?

16. Can the customer or third party payer afford the cost of the
device? Can the cost of the device be shared (employer, customer
through a PASS plan, family, vocational rehabilitation, etc.)?
Or is there a less expensive alternative that is just as effective?

17. Is the device commercially available or does it need to
be custom fitted?

18. Can this device be obtained in a timely fashion? If not,
can the customer rent the device until his/hers can be obtained?

(Adapted from Inge & Shepherd, 1995)

At the end of this phase, the customer has decided on a career goal, identified potential assistive technology devices and/or services that may support this goal, selected a customer-driven support team, and identified a jobsite support person (employment specialist) or persons who will assist with meeting the career goal.

Jobsite Enabling Through Assistive Technology, Personal Supports, and Other Accommodations: For persons with severe physical disabilities, the term jobsite enabling is often used to describe the process of bringing specialized training, assistive technology, ongoing support, advocacy, and consumerism to the workplace. This may be in the form of assisting the customer in completing work tasks, maintaining health and physical functioning, or contributing to a general independence or social integration. Enabling may involve the negotiation of job duties or requirements, environmental modifications for accessibility, adaptations to tools or procedures, the use of coworkers or personal assistants, or any combination of methods as directed by the customer's circumstances, needs, and preferences. A number of these strategies are described below.

Task Restructuring: The key activities associated with a specific job may be viewed as a series of tasks and duties. A task is a specific activity (i.e., writing a memo); a duty is a group of related tasks (maintaining ongoing contact with clients). Task restructuring may be defined as the process of reorganizing or modifying the tasks or duties that presently comprise a specific job so that they more readily match the abilities of the individual with a spinal cord injury. Those tasks that are viewed as marginal may be eliminated. Those viewed as essential can be targeted for redesign and modification. Examples of task restructuring include combining duties from other jobs to create a new position (job carving), or trading off tasks that are outside the range of the consumer's abilities. Also, task restructuring may also involve changing the time of day when tasks are performed to allow the worker to coordinate key job duties with the need for personal assistance services.

Task Modification: Task modification is an essential component of the job enabling process which requires the combined efforts of the individual with a spinal cord injury or other physical disability, the employment specialist, and the employer. Task modification refers to the development of alternative methods or compensatory strategies that allow an individual to complete a specified activity. Redesigning the manner in which a task is performed, substituting construction materials, or using specialized equipment are only some of the techniques that can be used to alter the manner in which a task is performed without changing the major tasks and duties of a job. For example, as opposed to using reference books as resource guides to answer questions in a nursery, an individual in a landscape design position could convert these resources to computer files that could be accessed by individuals using various types of assistive devices.

Assistive Technology: The availability of various forms of assistive technology may be essential to the job enabling process. The individual with a spinal cord injury must work with his or her employer to determine the amount and type of technology which will be viewed as contributing to the individual's overall productivity. The individual's employment specialist and other professionals may be very involved in

* helping determine situations in which assistive technology may enhance job performance,

* designing various "low tech" assistive devices specific to single job tasks, and

* accessing the services of rehabilitation engineers and other assistive technology specialists.

Assistive technology ranges from low tech items such as calculators or day planners to sophisticated items like speech synthesizing devices, voice recognition software, or expert system shells for specialized computer applications.

Environmental Accommodations Environmental accommodations may involve assistive technology, but the term refers to job enabling strategies used to improve the overall accessibility of the work station or job setting. Obvious examples of these strategies include reengineering work stations (raising height of work tables, widening doorways) for maximum efficiency. Other examples may include changing the location of an employee's work station to increase its proximity to the individual's supervisor, coworkers, or customers; improving or modifying lighting; or even allowing the individual to perform some or all of his or her duties from a home office by installing a different type of computer network and establishing electronic mail as the primary source of intra-office communication.

Providing Direct Assistance in the Job Placement Process

Some individuals with spinal cord injuries or other physical disabilities will need little or no assistance as they locate jobs that meet their career objectives. Those individuals may not benefit from specialized job placement assistance, while other individuals may view this support as valuable. It is essential that these vocational rehabilitation customers have access to the amount of job placement assistance and support they desire. Depending on the individual's specific needs, direct job placement assistance might include:

* assistance provided to the customer, including the development of job-seeking and resume development, referrals to employment workshops and career days, and job application assistance; and

* specialized assistance as identified in the customer's career plan, including locating a job, facilitating communication between the customer and the employer, and coordinating services provided through career centers or vocational rehabilitation.

Postemployment Follow-Along Services

Through the provision of the job placement supports described above, many customers with spinal cord injuries and other physical disabilities can succeed in meaningful and satisfying jobs of their choice. However, some may need support beyond the initial placement stage to ensure their long-term employment success. These postemployment services are intended to assist the customer in identifying the need for and development of accommodations (e.g., compensatory strategies, assistive devices, environmental accommodations, etc.) that can enhance the customer's learning and promote one's ability to perform independently at the jobsite. Getzel and Kregel (1996) have identified a number of guidelines to be used in the development of jobsite accommodations. Table 5 summarizes these guidelines.

Table 5
Guidelines for Developing Jobsite Accommodations

1. Review with the customer any learner accommodations they have
used previously in academic or employment settings.

2. Assist the customer in meeting with his or her supervisor to
discuss the use of any type of accommodation.

3. When possible, obtain the assistance of coworkers and
supervisors in the design of jobsite accommodations.

4. Seek customer input on potential strategies to use in order to
enhance current performance.

5. Recognize that some strategies may be used temporarily, to
facilitate learning the job. Other strategies may be used
permanently, to enable the customer to perform the job.

6. Recognize that the customer is responsible for all
decisions regarding the design and use of jobsite accommodations.
The role of the employment
support specialist is to assist the customer throughout the
decision making process.

(Adapted from Getzel and Kregel, 1996)

Postemployment services should be designed so that the customer receives all the support he or she desires during the initial stages of employment; then the assistance is gradually removed over time as the customer becomes comfortable and satisfied in the work setting. Supports should be provided in a way that will not disrupt the relationship between the supervisor and the employee. Various types of effective supports have been designed, including tools such as location aids, portable cue devices (e.g., templates of routine forms, letter folding protocol, task analyses, code books, notes), electronic cue devices (e.g., computer-generated messages), visual or audio enhancements (e.g., enlarged print directories, task analysis), motor skill enhancements (e.g., handles, electronic staplers), assistive devices (e.g., modified tools, fabricated tools, specially designed, orthopedic chairs, wooden/plastic/plexiglass templates, separators), mobility aids, and protective devices.

Identifying and Obtaining Other Needed Services and Supports

An often neglected component of job enabling for customers with spinal cord injuries and other physical disabilities involves identifying the entire array of other services and supports that they may need to maintain employment. Kregel, Parent, and West (1994) found that the major obstacles impeding the ability of individuals with physical disabilities to obtain and maintain employment have little to do with their performance of specific job duties and tasks. Efforts are needed to ensure that difficulties encountered by the customer in other areas such as healthcare and transportation do not impede an individual's work performance.

Most individuals with spinal cord injuries are able to advocate effectively for needed services and supports. Other customers, however, may need assistance to identify and obtain the needed supports. To address this issue, the individual with a spinal cord injury or other physical disability should work with his or her employment specialist and family members to make certain that person centered plans identify all needed services and supports, not just those related to an individual's employment situation. Major areas for possible support are summarized in Table 6.

Table 6
Employment Related Support Needs of Persons with Spinal Cord
Injuries or Other Physical Disabilities

Transportation--Assistance may be needed in accessing
specialized, door-to-door transportation services, acquiring
vehicular modifications to allow the individual to operate a
motor vehicle, obtaining driver's education, arranging
car pools, or other transportation alternatives.

Housing--Assistance may be needed in obtaining affordable and
physically accessible housing options, obtaining financial
assistance to pay for housing costs, home modifications, and
other services.

Financial Assistance--Many individuals with disabilities may be
receiving SSI or SSDI benefits at the time they enter
employment. Assistance may be needed in accessing and using
available work incentives that allow the individual
to maximize their personal income while participating in these
programs.

Independent Living Services--Services that can be provided through
a Center for Independent Living (CIL) include
peer counseling to assist the individual in obtaining all needed
services and supports, training in a variety of independent
living skills, and information and referral services.

Medical Assistance--Assistance may be needed in enabling
individuals to access available medical assistance, obtain
supplemental health insurance, or other services.

Assistive Technology--Assistance may be needed to allow
the individual to become aware of available assistive
technology devices, evaluate the relative utility of
various devices, and then selecting and securing devices
which may aid the individual in both their employment and
independent living settings.

Personal Assistance Service--Assistance may be needed in
identifying the need for a personal assistant; determining
eligibility for a particular personal assistant program; hiring,
supervising, and evaluating the personal assistant;
and funding personal assistant services.

To obtain the needed support services, the employment specialist and the individual may need to obtain information from a number of community agencies. The state rehabilitation agency, the Social Security Administration, the local housing development authority, the local developmental disabilities service program, and the local or regional Center for Independent Living may all be investigated and potentially contacted for information. Transportation, residential, healthcare, and other resources should be investigated and accessed as needed to provide supports identified in the person centered plans.

Case Study Example

Client History: Peter is a 32-year-old male who sustained a C4 motor C5 sensory complete quadriplegia secondary to a gunshot wound. As a result, he is unable to ambulate and requires the use of a wheelchair for mobility. He has limited use of his upper extremities; specifically, he is not able to write or grip small objects and is dependent on others for activities of daily living.

At the time of the injury, Peter, who is a high school graduate, had been a long-distance truck driver for a moving company. Due to the nature of his injury, Peter and his physician determined that he would not be able to return to this type of occupation. As a client of the state vocational rehabilitation agency, Peter then attended and received therapy for 3 months at a state residential rehabilitation center.

A vocational evaluation was also conducted. It recommended that Peter receive academic classes in reading, math, and spelling; consultation with a rehabilitation engineer for adaptive equipment; and revaluation for a dispatcher position after significant improvement in academic and work tolerance was achieved. One year later, he was reevaluated and the second examiner concurred with the previous advice; in addition, a classroom program or on-the-job training as an office helper was suggested. Future evaluation was suggested if significant improvement was noted in his academic skills or physical capacity.

Approximately 2 years later in 1990, Peter was referred for a third vocational evaluation through the state vocational rehabilitation agency. When questioned if a return to his previous employer as a dispatcher had ever been pursued, Peter indicated that the job was never developed. This evaluation stated that barriers to employment included a lack of marketable skills for competitive employment without training, lack of motivation, and a lack of desire to become competitively employed. In order to remove barriers to employment training in an area that would enhance his marketable skills, counseling and motivational activities to build self-esteem were advised. It recommended that Peter return to the state rehabilitation facility for vocational training and independent living skills training and referral to rehabilitation engineering for an adaptive equipment evaluation.

Job Placement

In December 1990, Peter was referred to a supported employment program at the RRTC. Job development focused on exploring options with his previous employer. Approximately 3 months after referral, Peter was offered part-time work at his previous place of employment as a telephone clerk for the sales department earning $4.50 per hour. The job duties included appointment setting, telemarketing, and maintaining a mailing list.

The employment specialist assisted with identifying the essential job functions and required accommodations. Next, services were coordinated with the rehabilitation engineer and recommendations on possible solutions were made. The following accommodations and modifications were made for Peter.

* A computer program was designed that allowed Peter to use the computer as a means of storing and analyzing data collected.

* A headset was purchased and the telephone was attached to a box with sliding rails which allowed better access.

* A pencil was attached to a hand splint to enable him to use the keyboard.

* A lap tray was made to fit his wheelchair which allowed better access to the computer keyboard.

* A space-saver keyboard was purchased to reduce the required movements that Peter had to make to input data into the computer.

The employment specialist also was responsible for ensuring that Peter could access the various modifications introduced to the jobsite; and she provided training on the accommodations. Peter became independent in his work tasks after approximately 60 days of on-site intervention. At that point, the employment specialist began to withdraw her assistance until she was no longer present in the workplace. During the first year, the employment specialist returned to the site to assist with resolving work performance problems related to productivity and a change in job duties.

To date, the employment specialist continues to contact Peter and/or the employer twice a month in order to be proactive at identifying areas that require intervention. Most interventions have focused on updating computer software, training on the use of the software, and coordinating adaptive equipment repairs. Over the past 5 years, Peter has assumed more responsibility; currently he is responsible for maintaining daily equipment reports. The employer reports being very satisfied with Peter's performance, and Peter expresses contentment with his job.

Summary Comments

Peter's case study illustrates several important points. First, he was unsuccessful in a more traditional rehabilitation program which specified that he needed training to acquire skills prior to gaining employment. Although extensive evaluations were conducted, Peter remained unemployed. While many programs continue to conduct evaluations in clinical settings, Peter's case study example demonstrates that this often does not lead to employment.

Second, Peter required more intensive intervention with individualized services specific to job finding and jobsite modifications. In other words, a job placement program such as supported employment that assists the customer in finding and acquiring a job based on his or her strengths and career preferences is critical. Supported employment that has been referred to a "place and then train model," allows the customer to obtain employment and then learn the skills necessary for maintaining employment with the assistance of a job coach.

Third, Peter was able to obtain the assistance of the rehabilitation engineer in identifying and modifying the actual worksite and supplies. The employment specialist was then available to provide training on the use of these accommodations. This is of critical importance, because devices that are purchased prior to identification of the worksite can easily result in useless and unnecessary technology.

Finally, Peter has been assisted to maintain employment with ongoing support from the employment specialist. Not every customer will need this ongoing assistance, but it has been beneficial to Peter. For instance, the employment specialist has worked with him and the employer to negotiate time off from work due to ongoing healthcare needs when Peter has pressure sores. In addition, he receives ongoing training in new work tasks as well as in new worksite modifications, which continues to make the difference for this customer with a spinal cord injury.

Preparation of this manuscript was supported by the U.S. Department of Education, National Institute of Disability and Rehabilitation Research. The opinions expressed here do not necessarily reflect those of the supporting entity, and no official endorsement should be inferred.

References

[1.] ADA Enforcement Status Report. (1993, Fall). U.S. Department of Justice, p. 1.

[1.] Americans with Disabilities Act (ADA) of 1990, PL 101-336. July 26, 1990). Title 42, U.S.C. 12101 et seq: U.S. Statutes at Large, 104, 327-378.

[2.] Babbit, C.E., & Burbick, H.J. (1990). Note on the perceived occupational future of physically disabled college students. Journal of Employment Counseling, 27(3), 98-103.

[3.] Bowe, F. (1983). Disabled adults in America: A statistical report drawn from Census Bureau data. Washington, DC: President's Committee on Employment of the Handicapped.

[4.] Bradley, V.J., & Bersani, H.A. (1990). Quality assurance for individuals with developmental disabilities. Baltimore: Paul Brookes Publishing Co.

[5.] Brooke, V., Barcus, J.M., & Inge, K. (1992). Consumer advocacy and supported employment: A vision for the future. Richmond: Virginia Commonwealth University, Rehabilitation Research and Training Center.

[6.] Cooper, A., & Mank, D. (1989). Integrated employment for people with severe physical disabilities. American Rehabilitation, 15(3), 16-23.

[7.] Gradel, K. (1991). Customer service: What is its place in assistive technology and employment services? Journal of Vocational Rehabilitation, 1(2), 41-54.

[8.] Hill, J.W., Seyfarth, J., Banks, P.D., Wehman, P., & Orelove, F. (1987). Parent attitudes about working conditions of their adult mentally retarded sons and daughters. Exceptional Children, 54(1), 9-23.

[8.] Inge, K.J., & Brooke, V. (1993, Winter). Rehabilitation Act Amendments of 1992 Newsletter. Richmond: Virginia Commonwealth University, Rehabilitation Research and Training Center on Supported Employment.

[9.] Inge, K.J., & Shepherd, J. (1995). Assistive technology: Application and strategies for school system personnel. In K. Flippo, K.J. Inge, & J.M. Barcus (Eds.). Assistive technology: The time is now! (pp 133-166). Baltimore: Paul H. Brookes Publishing Co.

[10.] Jaskulski, T., Metzler, C., & Zierman, S.A. (1990). The 1990 reports: Forging a new era. Washington, DC: National Association for Developmental Disabilities Councils.

[11.] Kregel, J. Parent, W., & West, M. (1994). The impact of behavioral deficits on employment retention: An illustration from supported employment. Neuro Rehabilitation, 4(1), 1-14.

[11.] Louis Harris and Associates, Inc., and The National Organization on Disability. (1995). The N.O.D./Harris survey on employment of people with disabilities. New York: International Center for the Disabled (ICD).

[12.] Liebert, et al., (1990). Postsecondary experiences of young adults with severe physical disabilities. Exceptional Children, 57, 56-63.

[13.] Mann, W. (1991). Statewide planning for access to technology applications for individuals with disabilities. The Journal of Rehabilitation, 1(2), 55-64.

[14.] Moon, M. S., Inge, K. J., Wehman, P., Brooke, V., & Barcus, J. M. (1990). Helping persons with severe retardation get and keep employment; Supported employment strategies and outcomes. Baltimore: Paul H. Brookes.

[15.] O'Brien, J., & Lovett, H. (1992). Finding a way toward everyday lives: The contribution of person centered planning. Harrisburg, PA: Pennsylvania Office of Mental Retardation.

[16.] Parent, W. (1992). Assessment of the supported employment for persons with physical disabilities: Findings and recommendations. Richmond: Virginia Commonwealth University, Virginia Institute for Developmental Disabilities.

[16.] Pearpoint, J., O'Brien, J., & Forest, M. (1993). PATH a workbook for planning positive possible futures: Planning alternative tomorrows with hope for schools, organizations, businesses,families. Toronto, Canada: Inclusion Press.

[17.] President's Committee on Employment of People with Disabilities. (1986). Washington, DC: U.S. Government Printing Office.

[17.] Rehabilitation Act Amendments of 1992, PL 102-569. (1992, October 29). Title 29, U.S.C. 701 et seq: U.S. Statutes at Large, 100, 4344-4488.

[18.] Revell, G., Wehman, P., Kregel, J., West, M., & Rayfield, R. (1994). Supported employment for persons with severe disabilities: Positive trends in wages, models, and funding. Education and Training in Mental Retardation and Developmental Disabilities, 29(4), 256-264.

[19.] Technology-Related Assistance for Individuals with Disabilities Act of 1988, PL 100-407. (1988, August 19), Title 29, U.S.C. 2201 et seq: U.S. Statutes at Large, 102-1044-1065.

[20.] Technology-Related Assistance for Individuals with Disabilities Act of 1994, PL 103-218. (1994, March 9), Title 29, U.S.C. 2201 et seq: U.S. Statutes at Large, 108-50-97.

[21.] Turner, E., Barrett, C., Cutshall, A., Lacy, B.K., Keiningham, J., & Webster, M.K. (1995). The user's perspective of assistive technology. In K. Flippo, K.J. Inge, & J.M. Barcus (Eds.), Assistive technology: A resource for school, work, and community (pp. 283-290). Baltimore: Paul H. Brookes Publishing Co.

[22.] U.S. Senate (1992, August 3). Senate Report 102-357: Rehabilitation Act Amendments of 1992. Washington, DC., p.39.

[22.] West, M., Wehman, P., Kregel, J., Kreutzer, J., Sherron, P., & Zasler, N. (1991). An analysis of costs associated with operating a return to work program for traumatically brain injured individuals. Archives of Physical Medicine and Rehabilitation, 72, 127-131.

Katherine J. Inge, Ph.D., O.T.R. Paul Wehman, Ph.D. John Kregel, Ed.D. Pam Sherron Targett, M.Ed.

Dr. Inge is Director of Project Access and Director of Tech Link. Dr. Wehman is Director of the VCU Rehabilitation Research and Training Center on Supported Employment, Dr. Kregel is Director of Research, and Ms. Targett is Director of Employment Services at the Rehabilitation Research and Training Center on Supported Employment, Virginia Commonwealth University, Richmond, VA.