UNITED STATES DEPARTMENT OF EDUCATION

OFFICE OF SPECIAL EDUCATION AND

REHABILITATIVE SERVICES

REHABILITATION SERVICES ADMINISTRATION

WASHINGTON, DC 20202

INFORMATION MEMORANDUM

RSA-IM-98-18

> DATE: July 7, 1998

ADDRESSEES: STATE VOCATIONAL REHABILITATION AGENCIES (GENERAL)

> STATE VOCATIONAL REHABILITATION AGENCIES (BLIND)
>
> STATE REHABILITATION ADVISORY COUNCILS
>
> CLIENT ASSISTANCE PROGRAMS
>
> REGIONAL REHABILITATION CONTINUING EDUCATION

PROGRAMS

AMERICAN INDIAN VOCATIONAL REHABILITATION PROGRAMS

RSA SENIOR MANAGEMENT TEAM

SUBJECT: Informed Choice and Service Provider Issues

CONTENT: Attached are two papers that discuss the relationship of
service providers to the implementation of informed choice. The papers
outline issues that emerged during implementation of the choice projects
and discuss ways in which the projects addressed these issues. Neither
paper is intended to provide final solutions, but rather to frame a
comprehensive discussion of the issues within the vocational
rehabilitation community.

> *Impact of Informed Choice on Providers* is written by Abby Cooper,
> Director of the Participant Empowerment Project (PEP), Washington
> Division of Vocational Rehabilitation (DVR). The paper describes PEPs
> experiences with ways in which the implementation of informed choice
> changed relationships among the funding agency (PEP), community
> service providers, and the individuals receiving services. Challenges
> voiced by community service providers as they initially considered
> whether or not to work with PEP are identified. Also identified are
> changes implemented by providers who did work with PEP, issues that
> need additional exploration, and general recommendations. Outcome data
> from an evaluation done by Washington DVR that compares selected
> individuals served by PEP with selected individuals served by
> Washington DVR are included.
>
> *Options for Qualifying Providers and Assuring Quality Employment
> Services* is written by Michael Callahan, Director of the Choice
> Access Project, United Cerebral Palsy Associations. The paper explores
> four options for determining that a service provider is qualified,
> including the licensing approach described in the Rehabilitation Act,
> the building code approach used by the Choice Access Project,
> contracting, and measuring consumer satisfaction. Characteristics of
> quality services are compared with characteristics of quality
> providers. The author recommends that State VR agencies and others
> blend the traditional approach of licensing and certification with the
> other options, in order to expand the range of service providers while
> maintaining fiscal responsibility.
>
> The opinions expressed in the papers are those of the project
> directors and not necessarily those of RSA. The papers are being
> disseminated as part of RSAs efforts to facilitate the exchange of
> information about informed choice between the Choice Projects, State
> vocational rehabilitation agencies, and other relevant parties.

INQUIRIES: Each paper provides contact information for that author.
Within the Rehabilitation Services Administration, for matters related
to informed choice, the contact person is Suzanne Tillman at
202-205-8303.

> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Fredric K. Schroeder, Ph.D.
>
> Commissioner

CC: NCIL

CSAVR

NAPAS

> RSA Regional Offices
>
> (Regions II, IV, V, VIII, and X)

**Impact of Informed Choice on Providers**

A paper by:

Abby Cooper

Washington State Division of Vocational Rehabilitation

Choice Demonstration Project, Participant Empowerment Project

2001 Sixth Avenue, Suite 2016

Seattle, Washington 98155

\(206\) 587-4444

Prepared For:

Rehabilitation Services Administration

U.S. Department of Education

**Impact of Informed Choice on Providers**

One of the foundations of the Rehabilitation Act, as amended in 1992 is
that recipients of vocational rehabilitation services have \"Informed
Choice.\" Informed Choice has been discussed in section 361.52 of the
preamble of the final regulations for implementing the Rehabilitation
Act as: \"a decision-making process in which the individual analyzes
relevant information and selects, with the assistance of the
rehabilitation counselor or coordinator, a vocational goal..\". This
definition and the concept behind it are changing the traditional
relationship between the rehabilitation community and individuals with
disabilities. Persons served by Vocational Rehabilitation have
traditionally been the people that we do things to or for, but not with.
They have rarely been considered equal partners, much less drivers of
the process.

Recently, much attention has focused on what needs to change in the
bureaucracy of Vocational Rehabilitation in order to ensure informed
choice for persons receiving services. Discussions have ranged from
policies, to payment processes, to counseling techniques and strategies.
Surprisingly, little attention has focused on how informed choice
impacts the provider community and on the major role that providers play
in determining the extent of choice in rehabilitation services and
outcomes. This is particularly startling when one considers that State
Vocational Rehabilitation Agencies can spend up to half their federal
budget on purchasing services from providers and that providers are
frequently more familiar with the participant than the counselor due to
the frequency of their contact and the nature of their services. If a
provider thinks a participant\'s choice is not feasible, or too costly
to explore, then it will probably not occur. Certainly many providers
are in a position to control the type of choices available to
participants.

For the purpose of this paper, community providers are defined as
individuals or organizations that sell their services to publicly funded
vocational rehabilitation agencies and that secure results for
individuals with disabilities; for example, job developers, job coaches,
travel trainers, assistive technology providers, etc. Vendors are
defined as companies or individuals that sell a product, such as,
software, computers, or augmented communication devices.

This paper will focus on how Informed Choice changes relationships for
the provider community. It will examine the challenges that Washington
State\'s Choice Project, The Participant Empowerment Project (PEP), as
well as the other Choice Demonstration Projects, have observed the
provider community struggle with over the last four years.

In a recent training session for providers, The Center for Continuing
Education in Rehabilitation of Western Washington University pointed out
that the impact of client choice is the \"paradigm shift from
agency-centered to customer-centered orientation.\" Many in the provider
community have been initially reluctant to embrace this shift. There was
a feeling that they were already providing choice. When PEP started four
years ago, only three certified DVR providers in King County, out of a
possible pool of seventy providers, would agree to work with the
project\'s participants. Most providers leaned toward business as usual.
Today, PEP works with about half the certified providers available to
DVR.

Providers share the same nervousness about informed choice as public
agencies but have received less training and support on adapting to the
changes. They wonder: \"What is my role?\" \"Who has the control?\"
\"What impact does this have on current practice?\" \"How can I make
money with this new system?\" At the heart of the concern are the
unspoken questions: How much control and power will be taken away from
me and given to participants? Can I trust the participant and will this
work?

There is an attitudinal change at the heart of the struggle that will
take time to integrate into the system. The provider\'s perception must
include accepting the participant as trustworthy, powerful and in
control. There is a dichotomy in rehabilitation in that we want
employers to believe in participants and hire them, but we in the
profession want participants to prove themselves before we trust them to
make good choices.

**[Shift in Relationship]{.underline}**

Informed Choice offers providers, vocational counselors and other
rehabilitation professionals the opportunity to change current
relationships with individuals with disabilities and with each other.
When providers view people with disabilities as the primary customer and
funding source, all traditional relationships will change.

\"Customer service runs deeper than friendliness, listening skills and
positive attitude. Customers want more control over the relationship
with us. They want to choose who serves them, they want influence over
the terms of the sale, they want choice in the way the product or
service is delivered to them, they want to contact one person, even
though their answer may require the cooperation of four different
departments.\" Peter Block, *Stewardship - Choosing Service Over
Self-Interest,* pg.20.

Traditionally, community based providers have built their businesses by
establishing symbiotic relationships with vocational counselors, with
limited involvement from the participant. The vocational counselor
benefits from the outcomes providers produce, and the provider benefits
from the revenue the outcomes generate. These relationships have insured
that providers continue to stay in business. Providers can market their
services to a unit of vocational counselors and be relatively assured of
referrals, if they place people in jobs. In contrast, a provider
answering to one participant at a time does not guarantee numerous
referrals from the public rehabilitation agency or a viable livelihood.
This leaves many providers wondering if it is worth it.

The established practice for most public rehabilitation agencies is that
counselors dictate the amount of money to be spent on services.
Participants may reap the benefits from the service, but have limited
input on the costs and how services are provided. Their roles
traditionally have been to accept both the services and jobs providers
offer them. It is not unusual for both the provider and counselor to
consider a participant uncooperative if he or she turns down a job
offered by the provider or requests that the provider offer the service
differently.

Providers view the DVR counselor and the business community as their
customers. Participants are interchangeable with the next referral, what
stays constant is the relationship between the provider and vocational
counselor. Participants have been considered to be interchangeable
because all they bring to the table is their need for service. They do
not bring money or expertise. A paradigm shift will be required for
providers to view participants as the paying customers who are
knowledgeable about what they want.

**[Employment Outcomes]{.underline}**

Traditionally, vocational rehabilitation counselors do not typically
work with the business community and have relied on the expertise of
community providers to develop contacts with employers and produce the
coveted jobs. This expertise has placed the provider community in the
position to decide what type of work was feasible for participants in
their community. This arrangement has led to an inordinate number of
participants receiving entry level jobs with limited growth potential
that were not only feasible but that were easy to obtain. Providers have
developed their expertise in a labor market approach. Working from a
pool of referrals, they fit participants in jobs they have mass
marketed. Empowered participants may ask providers to individually
develop jobs. Individual job development may not be as cost effective as
a large scale labor market approach and it requires different skills. A
depiction of this is a PEP participant who designed a prorated contract
with a provider. He contracted their services for fifty dollars an hour,
if they could find a job for him within two weeks. After two weeks, the
rate would fall to thirty dollars an hour, and after three weeks, the
rate would drop to twenty dollars per hour.

The informed choice process causes even more anxiety for providers when
participants have numerous issues in obtaining employment. Many
providers have been trained to first look at participant\'s deficits
rather than their strengths. They believe that they are just being
realistic in determining what a person can and can not do. It is
difficult for providers to believe that it makes sense to answer to a
person who has significant disability and limited perceived ability. It
is far more comfortable to deal with professionals and view the job the
individual wants as unrealistic.

PEP found that providers are frequently concerned that participants will
ask for unrealistic job opportunities, have unrealistic expectations, or
misrepresent their skills. This has not been PEP\'s experience. However,
we did find that participants asked for a wide range of job types and
services and for jobs that are unique and sometimes difficult to obtain.
Washington State DVR conducted a study of PEP participants and DVR
participants. PEP provides services to the same participant population
as the traditional state vocational rehabilitation program in the
largest county in the state, King County. The PEP office is centrally
located in the city of Seattle. Seventy-nine closed cases were randomly
chosen from PEP\'s data base by a systems analyst of Washington State
DVR who was not related to PEP. The systems analyst then matched those
seventy-nine cases to closed cases from Washington State DVR Cherry
Street office. The participants were matched on the following
characteristics: age (within two years), disability, and ethnicity. The
study found:

[79 PEP Participants]{.underline} [79 WA. State VR
Participants]{.underline}

Thirty-eight Different Job Types Nineteen Different Job Types

Average Wage at Closure \$12.55/hr Average Wage at Closure \$7.42 hr

Closed Rehabilitated 41 Closed Rehabilitated 23

Time in service: 420.38 days Time in service: 401.06 days

Overall Average Cost \$1552.22 Overall Average Cost \$1785.99

As reflected in the table above PEP participants had a wide range of job
types, and the wages PEP participants earned were almost double that of
Washington State VR participants. Almost twice as many individuals were
closed employed in PEP than in DVR. Seventy percent of PEP participants
in this study used a variety of job seeking approaches simultaneously,
such as hiring a traditional provider, networking, self directed job
search, and PEP staff job developing for them. Seventy percent of DVR
participants relied solely on traditional providers to find them a job.
This data indicates that when participants control the process, their
job choices are not unrealistic as traditional community providers
feared.

However the data do not answer the question, foremost in providers\'
minds, whether choice will result in less business for them. It has been
PEPs experience that providers do have less business if they are not
willing to tailor their approaches to the individual participant.

**[Information]{.underline}**

Much of the discussion about informed choice has centered on how to
convey information to the participant and what information is essential
for a participant to obtain.

Providers are apprehensive about having to reveal information about
their organization that they have not previously shared with
participants. Many are sensitive that the information could cause them
to be judged unfairly. One provider told PEP staff, \"I serve only
individuals with significant disabilities in obtaining employment. My
numerical outcomes are less then my peers and my costs are higher.\"
Considering the data used to evaluate performance, this provider\'s
performance could appear worse than other providers. If purely fiscal
and quantitative objective measures are presented without consideration
of the qualitative measures of service provision and outcomes, some
providers will be placed at a competitive disadvantage. Certainly the
data that State Vocational Rehabilitation currently collects focuses
almost solely on quantitative measures, e.g., How many people placed?
How long did it take? Average wages? There is mounting pressure on state
agencies for increased emphasis on quantitative outcome measures. There
is a challenge before the system to also identify qualitative measures
that examine the quality of the process from the participant\'s
perspective, the extent to which the participant\'s specific employment
goals and service needs were met, and the extent to which the services
will help the individual in the future.

Providers frequently do not know how to present information about
themselves and their services to participants. They are experienced in
selling themselves and their services to other professionals. In this
context they are very good at presenting themselves in the best possible
light. They have developed this marketing strategy over time. When
providers market to funders and other professionals the underlying
assumption is that the audience knows how to interpret the providers\'
presentations and how to evaluate the information. However, VR
participants frequently have not had the opportunity to hire a provider.
They do not know the questions to ask or how to evaluate the responses
the provider offers. A provider can be in an awkward position if they
have to sell themselves and then instruct the participant on how to
evaluate the information. A number of the choice demonstration projects
have resolved this dilemma by utilizing rehabilitation teams, community
connectors, employer advisors, and others to assist the participant in
evaluating provider information.

PEP held a focus group of providers to learn their concerns about
informed choice. Repeatedly voiced was the concern about whether
providers could trust the information a participant would give them. If
it was inaccurate, it would hurt the providers\' ability to provide the
contracted service. As a system we are skeptical of the people we serve
and providers are not immune to this problem. We have all been taught to
believe that being optimistic equals being unrealistic and being
skeptical equals being realistic. Providers tend to believe that they
are just being realistic with concerns they hold about informed choice
and providing services.

In the process of exchanging information, participants may ask providers
to explain and justify their practices and to provide a full accounting
of their services, such as the number and type of employers that have
been contacted on their behalf. Revealing such information to
participants is a change in roles and it takes away some of the
provider\'s control and power.

Initially, PEP providers were uncomfortable with the prospect of sending
reports directly to participants. They were uncertain on how to write
reports to participants instead of professionals. As providers gained
experience with this, many providers have developed skills needed to
write reports to participants. Providers have learned to ask
participants what type of information would be most useful to them in
the report, what information will help participants understand what the
provider has done, and what information will help participants reach
their goals.

**[Control]{.underline}**

The current vocational rehabilitation regulations prescribe the type of
information a participant must receive when choosing a provider but they
do not specifically address how to help participants take control of
their own rehabilitation process. A provider, in theory, could give the
information required in the regulations and not offer any choices in the
process or outcomes. If participants are going to have informed choice
and control in their rehabilitation, providers must help the participant
take the control. However this is only possible if the provider
willingly gives up control traditionally held by the provider.

Many participants are at a fragile point when they seek rehabilitation
services. Making choices surrounding their rehabilitation often
frightens them. Many have not had the experience of making good choices
for themselves and fear that they may fail. They may not have the
knowledge base to know how to evaluate information and make decisions.
The fear of making a decision and taking responsibility for one\'s
action is an age old problem for society as a whole, not just the
disability community. In Fyodor Dostoevsky\'s, *The Brothers Karamazov*,
the Grand Inquisitor suggests that people are afraid of choice and
invent systems to avoid having to take responsibility for their own
actions. It is easier to follow a ritual or have someone tell you what
to do. When participants allow providers to control the choices, if
things do not work out, it is the provider\'s fault. Whereas if
participants make their own decisions and something goes wrong, then
participants must accept the responsibility. Choice can be a double
edged sword.

The provider must help the participant take the control as well as to
accept the responsibility that comes with it. Providers need to be
willing to use their expertise to help participants make the decisions
about their rehabilitation services and outcomes, even when the choices
are different from the ones they might make. This requires a high degree
of skill on the providers part, especially when the provider is under
pressure to produce outcomes. Providers and vocational counselors are in
tricky positions. They need to provide their expertise in a manner that
allows the participant to accept it and evaluate the information without
directing the participants\' decisions. Acquiring these difficult skills
and putting them into practice would help participants accept the
responsibility that comes with choice.

**[Shift In Practices]{.underline}**

**Contracting with Participants**

The new RSA regulations mandate that participants choose the provider.
One strategy that PEP demonstrated was allowing participants to contract
directly with providers for the required services. Choosing and
contracting with providers places participants in the driver\'s seat. It
begins to help the provider view participants as having the authority
and power.

All people enter into some type of contractual relationship in their
daily lives. When we pay for a service, whether from an economic
advisor, house painter, baby-sitter or auto mechanic, we are using
contracts. When we purchase such services, we expect to state our needs,
to be treated respectfully and to interview the person providing the
service. As a purchaser, we then choose whether we want to hire persons
as well as determine how much we are willing to pay. We do not expect to
be interviewed extensively by the person we are hiring, or have to
expose sensitive information about ourselves, or to prove we are \"ready
for\" the service we are buying. We do not expect to be left feeling
powerless. In the larger community, the experience of feeling powerless
in the contract process is frequently expressed by women who talk about
how they feel when purchasing a vehicle.

PEP\'s initial experience was that community providers did not know how
to be interviewed by participants. The shift of power made providers and
frequently participants feel uncomfortable. Providers quickly turned the
tables so that they were interviewing the participant. This was almost
an unconscious process on both the provider and participant\'s part. It
just felt more \"natural.\"

Providers requested that participants reveal sensitive information and
evaluated whether the person was \"work ready\" prior to the participant
even deciding to work with that provider. Providers were frequently
trying to figure out what their costs would be to place the participant
and if capacity issues would allow the provider to accept the person.
Providers did not seem to acknowledge that the initial decision was the
participant\'s. After the participant selects a provider, then the
provider has the prerogative to determine if they want to work with the
participant and whether they are able to meet the participant\'s needs.

As part of its demonstration, PEP developed strategies that allowed
participants to choose and contract with community providers for desired
outcomes. Initially, the contracting process, which in theory seemed
effective, was very frustrating for all involved parties. Participants
felt that providers did not listen to them or allow themselves to be
interviewed. Ninety percent of the evaluations PEP received in its first
year from participants indicated that interviewing providers was largely
a waste of time. Many providers felt it was unreasonable to have
participants interview them. They felt that participants were not
effective at interviewing and thus it was a waste of everyone\'s time.

This is not dissimilar to the changes that are occurring in the medical
community. Patients more and more are encouraged to interview doctors
before choosing one. The first time potential patients interview a
doctor, they frequently do not know the questions to ask and wonder if
the interviewing is a waste of time. However over time patients are
learning the questions to ask and doctors are learning how to respond.
It has been PEP\'s experience that VR providers are also learning how to
respond to participants as the individuals with the power to select the
provider of their choice.

There is an evolution occurring in the provider community surrounding
informed choice. One provider who works with PEP noted that a year ago,
the only participants who wanted to interview staff from her agency were
from PEP, but today she receives daily calls from state VR participants
wanting to interview her and her staff. According to her, she used to
view having participants interview her as waste of time. Now she
considers it good customer service.

Feedback from providers found that many of them were hesitant to enter
into contractual relationships with participants. Providers did not like
the idea of contracting with participants or of participants having the
ability to hire and fire them. Providers were also concerned that having
participants authorize payment for their services would delay payment.
However, in PEP\'s experience, any delay of payments was due to
programmatic inefficiency, not due to participant delay in
authorization.

**[Provider Survival]{.underline}**

A major barrier to change involves funding. Providers face the issue of
balancing the demands of multiple funding sources. Providers may receive
funding from sources that seem to embrace the exact opposite values as
informed choice, such as Temporary Aid for Needy Families (TANF) under
welfare reform. The basic tenet of welfare reform is often get them a
job, any job. Providers might begin to wonder if it is worth it to
balance these contradictory funders. This struggle is overlaid with
uncertainty about the impact of implementing informed choice practices
on their revenue.

Providers are a business and many are under constant pressure for
billable hours. Informed choice does frequently demand that the process
is slowed down to the speed appropriate for the participant. This is not
always cost effective. One illustration of this was a participant from
PEP who needed to buy an augmented communication device. His speech
therapist had a very clear idea of the best device for him and wanted
him to follow her recommendation. However, the individual and his
support group wanted the therapist to recommend three different devices
and have one friend, his therapist, and himself weigh the pros and cons
of each device. The individual would then decide which device best met
his needs. The therapist found this a time consuming and frustrating
approach. She felt she knew what was best and her expertise should just
be accepted. The participant did, in the end, choose the same device the
therapist recommended. However he learned how to choose the device that
was appropriate for him. He learned what the considerations were and how
to evaluate the pros and cons of the different devices. He also had a
full understanding of the maintenance and care of the device. This
information will allow him to take more control and responsibility of
his choices in the future. The therapist\'s acknowledgment that it was
more time consuming was tempered with the realization that the
individual was committed to making and accepting the final decision.

**[Recommendations]{.underline}**

The old idiom \"money talks\" certainly has bearing here. One sure way
to have providers view participants as the people who are contracting
for their services, and have all the power associated with that role, is
to actually have participants be the contractor. This requires the
system letting go of and giving to participants the power, the authority
and resources to contract with providers.

The power component of the equation would require Public Vocational
Rehabilitation agencies to have polices and procedures that encourage
and honor participants contracting directly with the provider. This
would place the vocational counselor in a consultant role of providing
information and support to the participant during the contracting
process.

The authority, a component of the equation, would require public
agencies working with the provider community to understand that it is
not business as usual and that participants are the ones who have the
authority to contract with them. This includes having the authority to
negotiate contracts and payment rate, state the conditions and
expectation of the purchased services, and to end the contract if
dissatisfied.

The resource component is, as previously mentioned, placing some or all
of the money under the control or shared control of the participant.
Many of the Choice Demonstration Grants have looked at different
approaches to participants having more control of their service dollars.
The traditional funding relationship in which the Vocational Counselor
controls the purse strings encourages providers to view the counselor as
the person with the power, since in reality they are the ones who pay
for the provider. Under the traditional arrangement the participant will
at best only have a pseudo contract with the provider because they do
not have the real control: the money. The idea of giving participants
control over their money so they can negotiate and contract with
providers is critical; the problem is figuring out how to maintain some
fiscal control and responsibility for the process in a time when the
general public is demanding more scrutiny of public dollars.
Administrators must be willing to examine how to do business differently
if we are going to start helping participants control the process.

A large component of informed choice is structuring services and
supports so that individuals can take control of and responsibility for
their decisions. Helping individuals take control of their services,
however, is not easy. It can be difficult, frustrating and confusing.
Counselors and providers need training on how to help an individual with
disabilities take more control of their rehabilitation process. This
training could be offered to both individuals with disabilities and
professionals at the same time. Currently Washington State DVR is
sponsoring solution focused training for counselors.

In the text *Interviewing for Solutions*, Peter De Jong and Insoo Kim
Berg explore the need to move away from a medical model of problem
solving to a solution focused model. In the medical model, the
professional is expected to identify the problem and provide the
solution. DeJong and Berg suggest a focus on the solution presented by
the client. They use Saleebeys definition of Empowering: \"helping
people discover the considerable power within themselves, their families
and their neighborhoods.\" (Saleebey, D. 1992. *The strengths
perspective in social work*. New York: Longman. pg.8) Providers and
vocational counselors should start from the point of an individual\'s
strengths and come to understand how the individual is willing to use
those strengths and resources in the rehabilitation process. This will
assist the individual to become empowered. Many participants also need
to receive training on how to be effective customers. This could occur
either from vocational rehabilitation counselors, or independent living
counselors, as some states are already doing, or a consumer consultant.
The training should focus on what information participants need to start
controlling the rehabilitation process and taking responsibility for
their choices.

Public Rehabilitation Agencies need to acknowledge that providers are
businesses and that informed choice will impact on how providers must
conduct their businesses. Agencies must clearly state what the
parameters of informed choice are from the public rehabilitation
agency\'s perspective. Washington State DVR conducted a state-wide
training for all providers on the parameters of informed choice. This
offered providers clear information on the direction that was being
taken and it opened the door for the provider community to start having
discussions on the impact of the changes.

Lastly, State Rehabilitation and provider agencies need to put a greater
focus on tracking and evaluating subjective measures that look at the
individual\'s perspective, and the quality of service individuals
believe they received. This could be done by designing and implementing
a participant satisfaction process that examines the following:

a\) amount of satisfaction with the outcomes that individuals felt,

b\) the frequency of individuals getting the outcome they requested,

c\) the level of perceived control individuals felt they had in the
process.

Each participant at the end of the service could provide information on
their experiences by completing a survey, verbally responding to
questions or attending a focus group to provide feedback. Each agency
could track their results and share them with potential participants.
Some accrediting entities such as CARF already require such consumer
satisfaction data. Many providers already compile this information; they
just need to share it with participants as well as funders.

**[Conclusion]{.underline}**

Informed choice requires that business practices change. Participants,
providers, and Public Agencies all need to establish new game rules and
parameters for working together. Old ways are hard to break and there
needs to be allowances for the time and mistakes we all will make in
trying to implement the change. Both the provider community and
participants need to be educated and given opportunities to practice new
skills. Participants need information on how to choose and work with
providers. Providers need information on how to market their services to
participants, how to establish a contractual relationship with
participants, and how to view the participant as the primary customer.
Providers need to start thinking of different ways to offer services
that allow the participant to be in control. The more the system can
give the control of money to the participant, the quicker the provider
community will adapt their ways of answering and listening to
participants. Providers can and will learn how to function in a market
based economy, if as a system, we are serious about participants being
equal partners in their rehabilitation.

**Options for Qualifying Providers and Assuring Quality Employment
Services**

*a paper by:*

*Michael Callahan*

*United Cerebral Palsy Associations*

*Choice Access Project*

*4101 Gautier-Vancleave Rd. #102*

*Gautier, MS 39553*

*(228) 497-6999*

*Fax (228) 497-6966*

*Prepared for:*

*Rehabilitation Services Administration*

*U.S. Department of Education*

*Grant #H235D30067*

*June, 1998*

***Options for Qualifying Providers and Assuring Quality Employment
Services***

***by Michael Callahan***

The issue of securing *Qualified Providers* is inherent in any
discussion of the exercise of informed choice in employment for persons
with severe disabilities. The regulations for the State VR programs (34
CFR 361.51 \[b\]), require that:

> \...providers of vocational rehabilitation services shall use
> qualified personnel, in accordance with any applicable national or
> State-approved or recognized certification, licensing, or registration
> requirements, or, in the absence of these requirements, other
> comparable requirements (including State personnel requirements), that
> apply to the profession or discipline in which that category of
> personnel is providing vocational rehabilitation services.

The regulations further require (34 CFR 361.52 \[b\]) that:

> \...the State unit shall provide the individual, or assist the
> individual in acquiring, information necessary to make an informed
> choice about the specific services, including the *providers* of those
> services, that are needed to achieve the individuals vocational
> goal.

These regulations reflect a clear concern of the Federal government that
individuals with disabilities have access to quality services and, at
the same time, have the right and opportunity to choose the providers of
those services. These regulations also have the possibility of bringing
the role and importance of providers in delivering quality
rehabilitation services into possible conflict with choices made by the
individual. The intent of the regulations that call for qualifying
providers is that if providers attain a qualified status, there is a
greater likelihood that the services they offer to the individual with a
disability are effective and meaningful. However, when individuals are
offered increased choice, qualifications that focus on and favor
traditional providers will likely decrease the options available. In
fact, in some areas, there may only be one or two qualified providers
\-- or perhaps none at all \-- which meet strict organizational
regulations. This reality would not represent much of a choice for
individuals with disabilities.

It is therefore essential for funders such as VR and State Developmental
Disability agencies, to strike a balance among issues that are often at
odds: a) to assure that consumers receive quality services, b) to offer
a range of options from which individuals may choose, c) to determine
who monitors quality, and, d) to decide who gets to determine the
relevance of outcomes. One way to deal with these challenges, especially
issues a and b, is to identify qualification strategies that apply
to a wide variety of potential providers of service, including
non-traditional providers and that complement the regulatory
requirements for qualified services personnel. In this way, individuals
with disabilities would have a larger pool of providers from which to
select and be able to exercise a true choice in selecting supports. VR,
and other funding systems, can also assure that services are delivered
in a quality manner. To accomplish this, it will be necessary to look
for flexible strategies currently used inside the existing system and
generic solutions employed outside the traditional rehabilitation
industry for compatible strategies to qualify providers.

There are several commonly-used, generic models, used throughout
business and industry, that may be applied as a means of offering
clarity to the process of qualifying providers:

 Licensing

 Building Codes

 Contracting

 Customer Satisfaction

**Licensing**

This approach requires providers to meet a set of standards, prior to
the provision of services. Providers who meet the standards are assumed
to offer quality services to individuals with disabilities. Terms
typically used in the human service field relating to this concept
include:

a\) *credentials* based on education and training,

b\) *certification* relating to the completion of a set of requirements,
and/or

c\) *experience* and *performance of quality outcomes* in the field of
concern.

An assurance approach based on *credentials* would require that a course
of study and/or training classes be developed and approved by the State.
Factors such as contact hours, course content, underlying values and the
approval of instructors would need to be determined. Personnel of
providers would then need to individually meet the outcome standards of
the approved credentials. *Certification* requires the development of a
set of indicators and responsibilities that a provider would accomplish
as an organization. The provider would be responsible for showing proof
that the standards have been met. This approach requires that a
certifying body, similar to the Rehabilitation Accreditation Commission
(CARF) or the Accreditation Council, be used or created within the
State. Providers, individually or as an organization, can also cite
their *experience* and *performance* in employment as an indicator of
qualification. This approach would involve decisions concerning the
types of employment experiences that would be accepted as well as the
number of years in employment services.

Under the current system of qualifying providers the most fundamental
pact is between the State VR agency and the providers, on behalf of
participants who need services or products. This perspective results in
a system in which providers contract with and please funders. In theory,
successful outcomes achieved in this manner satisfy participants. A
system for qualifying providers by funders typically involves a form of
quality accreditation, such as CARF, and assurance of programmatic and
fiscal stability. While this approach was developed primarily to assure
that overall bureaucratic outcomes were met and that the public dollar
was effectively spent, there are features of this traditional method
which might be useful to participants. In Indiana, the State has
implemented the Hoosier Assurance Plan that provides a provider report
card on community mental health agencies. This strategy connects the
information collected by the State with the informational needs of
participants as they make decisions concerning service providers.

This and other licensing alternatives fit well with states and other
funding entities in that they allow a level of quality control regarding
providers and they are consistent with approaches traditionally used in
the rehabilitation field. These also represent strategies that the
provider industry is likely to support, in that competition is reduced
by the requirements set for each option. Additionally, employment staff
would favor this alternative in that it gives them access to a career
ladder, which seems to be a recurring theme in the suggestions job
coaches have made to the Association for Persons in Supported Employment
(APSE) and other representative bodies. However, this option almost
certainly constrains individual choice on the part of persons with
disabilities in that traditional service providers will likely find it
easier to conform to the requirements than non-traditional, generic,
personally-related sources of assistance.

**Building Code**

An alternative to licensing is to identify a set of process and outcome
standards that are to be implemented during the provision of employment
services. This approach is similar to the building codes that
municipalities and counties use throughout the country to assure the
quality of construction processes and materials. In the human service
field, a curriculum, manual or other carefully described process can be
used to identify the components of quality employment, much in the same
way a building code specifies the size of lumber, number of electrical
outlets and type of roofing materials that are to be used in
constructing a home. In addition to the specifications identified in the
curriculum or manual, this option also requires inspection points
during the implementation of the employment process. These points might
involve written products that describe certain outcome markers of
employment and/or the direct observation of the process by the human
service equivalent of a building inspector.

This strategy has been used since 1993 in the United Cerebral Palsy
Associations (UCPA) Choice Access Project, a five year demonstration
funded by the Rehabilitation Services Administration on informed choice
in employment. The UCPA project has relied on a personal

budget approach and uses a publicly-available Self-Directed Staff
Training Curriculum on supported employment, developed through a
previous federal grant.

Recently, the Oklahoma Department of Rehabilitation Services (DRS) has
instituted a Milestone Payment System that has features of a building
code approach. The Milestone approach not only identifies payment
points, it also provides a structure, or building code, in which
providers, individuals with disabilities and funders can function.

Other curricula, detailed manuals or payment approaches could also be
used. Funding agencies would have to make a decision as to the specific
approach(s) to be adopted as well as to adapt staff role changes, as
necessary, to provide quality inspection of documents and behavioral
indicators of outcomes. This approach has the significant benefit of
opening the doors to non-traditional providers \-- friends, next door
neighbors, personal contacts, and even family and relatives. This
flexibility, of course, is threatening to some traditional providers who
want to restrict, rather than expand, the number of providers able to
offer services to persons with disabilities. Another concern with this
option is that, while flexibility can be built into the process,
individuals with disabilities may feel that they have to follow the
procedure in a lockstep way that constrains choice. This option is ideal
when dealing with complex services, especially for the person with
significant disabilities, for whom the system has struggled to provide
successful employment outcomes.

**Contracting**

This option involves the use of clearly detailed agreements that specify
the desired outcomes of the individual and the responsibilities of the
service provider. If contracts can be designed with sufficient
specificity and if payments for services are made contingent upon
concrete outcomes that are consistent with the individuals specific
requests, this approach can be used to the benefit of funders,
traditional providers, non-traditional providers and persons with
disabilities. The problem with this alternative is that rather than
wasting their money, people may waste their time contracting with
providers who do not deliver on the services promised. There needs to be
an indication of the providers reputation and capacity in advance so
that people with disabilities would not be as likely to waste their time
contracting with ineffective providers. Additionally, it is possible,
maybe even likely, that people with disabilities might pay for services
that do not truly match with the agreed-upon specifications. Indeed, we
all do that to some degree. The benefit to this approach is that it can
be tailored to the specific needs of individuals and it welcomes
non-traditional providers by focusing on outcomes rather than on
credentials, certification or experience.

The contracting approach is useful as a stand alone approach for
discrete purchases of equipment and other products. Contracts are also
an integral component of more complex service delivery, when used with
licensing, building codes and/or customer satisfaction approaches.

**Customer Satisfaction**

Possibly the most basic assurance of quality service and outcome in our
society comes from the indication of satisfaction by the customer. Of
course the achievement of satisfaction is not simply based on
acknowledgment after the delivery of a product or service. It is
dependent on the skills and willingness of the customer to actively
monitor and negotiate the delivery of services. Many would say that
customer satisfaction is the foundation of all quality outcomes.
However, this is true only if the customer has the control and
prerogative to reject unsatisfactory

services and the information and support to negotiate with providers.
Otherwise, the customer satisfaction strategy becomes Let the buyer
beware.

In relation to the issue of qualifying providers for the provision of
employment services for persons with disabilities, the customer
satisfaction strategy provides the possibility of significantly
broadening access to a variety of providers and vendors. Rather than
limiting the purchasing of services from a small number of certified
or qualified providers, this approach allows individuals with
disabilities virtually unlimited choice. As long as the services
provided are satisfactory to the individual, in relation to a set of
approved and agreed-upon conditions, it can be assumed that the provider
is qualified. However, it must be recognized that the typical
relationship between customers and providers in the generic society, as
well as the unique and traditionally hierarchical relationship between
human service providers and persons with disabilities, is fraught with
complexity and difficulty. In order to employ a customer satisfaction
strategy as a means of qualifying providers, it is necessary to offer
extensive, point-of-the-problem support and information to persons with
disabilities to assure that both the perception and reality of their
satisfaction results in quality outcomes.

Realistically, the use of customer satisfaction as a means of qualifying
providers requires that funders, as well as those closest to the person,
provide individuals with disabilities access to both training and
supports to deal with the difficult interactions that all people
experience when advocating for quality outcomes from service and product
providers. It is also likely that

this approach will not stand alone, but will be used with a combination
of other strategies to offer flexibility in qualifying providers.

**Quality Outcomes vs. Qualified Providers**

The preceding strategies represent a range of options that may be used
to broaden individual choice while, at the same time, to assure that
services are delivered in a quality manner. In the past, there has been
an assumption that by qualifying  a provider, the funding source could
insure the delivery of quality outcomes. However, limitations on
personal choice are inevitable if qualified providers only represent a
limited number of organizations with connections to the professional
rehabilitation bureaucracy. The shift suggested by the experiences of
the choice demonstration projects focuses more on quality outcomes and
less on provider-based qualifications. It is not necessary, however, to
decide on a single approach. In fact, quality outcomes and qualified
providers represent two sides of the same coin that may be used by both

individuals with disabilities and funders. By implementing a combination
of the strategies discussed above, it is possible to balance individual
choice and fiscal responsibility.

This balance requires an understanding of the characteristics of quality
service outcomes as well as the characteristics of qualified providers:

**Characteristics of**

**Quality Services**

 The outcome of the service is consistent with what the individual
wants.

 Service interactions with the individual are delivered with respect
and concern for personal impact.

 A fair price is charged for the service.

 The agreed-upon work is performed in a reasonable time or within the
time targeted.

 The service is delivered in a safe and responsible manner and results
in a safe outcome.

 The individual gets a copy of paperwork that represents the delivery
of the outcome as well as any data or observational notes taken during
service.

 The individual is treated as a partner in the service delivery
relationship.

 Services and outcomes are accessible to the individual and family.

**Characteristics of**

**Qualified Providers**

 The provider has experience, skills and/or educational credentials in
the area service delivery.

 The provider of service does not have any past or current legal
restrictions or history that might compromise the services offered.

 The provider is available to provide the services in a timely manner.

 The provider has financial resources and stability sufficient to
perform the service outcomes before being paid.

 The provider is willing to treat the individual with a disability
respectfully, as a individual rather than as a service recipient.

 The provider offers a reasonable guarantee to the individual to redo
services/products that are not acceptable or successful.

 The provider works to offer individualized outcomes, rather than
stock options.

**Resolution and Discussion**

It seems evident that each of these approaches to qualifying providers
has merit. They all seek to assure quality outcomes for individuals with
disabilities and value for the funding sources \-- the VR system, State
DD agencies, and, ultimately, the taxpayer. However, no single option

seems to contain all the answers. The solution is likely to be found by
implementing a blend or combination of these alternatives.
Rehabilitation agencies and other funders could implement a flexible
approach that continues to recognize the value of traditional approaches
to qualification, such as credentials and certification, and yet expands
options for individuals with disabilities by allowing a blend of other
options such as building codes, contracting and customer satisfaction.

It is also necessary to distinguish between providers of a service and
vendors of a product. The approaches described here refer more
appropriately to service providers than product vendors. However, it is
traditional for State rehabilitation agencies and other funders to limit
the sources for purchasing products to an approved list of companies. In
order for individuals who receive rehabilitation services to enjoy a
fuller range of choices and to promote creative, and possibly less
expensive, options it is necessary to loosen the requirements of State
purchasing regulations. The contracting and customer satisfaction
approaches described above can offer a way for states to manage this
shift and maintain fiscal responsibility.

**Successful approaches used by choice demonstration projects**

(Submitted by each project)

**[Vermont Division of Rehabilitation]{.underline}** (Waterbury, VT,
statewide)

In hiring for any service provision or making any purchase, any one of
the counselors of the Vermont choice project is available to research
the options within the community. They also ask for references, read the
information available in generic publications such as *Consumer
Reports*, asks friends and relatives and uses a variety of input to
assist individuals in the project to make decisions.

Therefore, when a person with a disability wants a particular service or
product, the [only]{.underline} roles of the VR counselor are to: 1)
assess the ability of the individual to use the above approaches in
decision making; 2) provide appropriate support to the individual to
gather information; 3) ensure that the individual receives appropriate
support in making a final choice of provider.

This project believes that when a funder takes on the role of
qualifying providers, that funder is essentially sending a message
that the individual is not capable of making that determination
themselves. Any controls of choice of providers misses the important
point that the role of VR is to educate individuals in methods of
locating resources, weighing options, and making decisions. When VR
facilitates an investigation process by the individual with a
disability, it ensures that the individual is judging qualifications as
to the [own]{.underline} standards and needs. This also helps assure
that the person performs an important skill necessary to function
independently in society. If the individual needs support in this
process, there are many options for providing the support in an manner
that preserves the self-determination of the individual and does not
compromise the education process.

**[SWBIRAs Client Choice Project]{.underline}** (Scottsdale, AZ)

SWBIRA developed and delivered a proposal instruction packet
consisting of information and instructions for submitting proposals,
selection and referral criteria, and forms for presenting requested
information to potentials providers as selected from previous SWBIRA
projects and experiences. Resultant submitted proposals were screened
for acceptability according to cost per unit, time necessary to schedule
an appointment for a client, provider location, qualifications of staff,
certification of agency, and acceptability of documentation. Those
providers who met the criteria were entered into the main case
management database as authorized to provide services.

Performance of providers is closely monitored by the Case Managers and
the Program Director with direct contact and written feedback from
clients. SWBIRA demands that clients make reasonable informed choices
and that providers adequately perform contracted services. As a result
SWBIRA leads all of the Client Choice projects in the number of clients
placed into

competitive employment.

**[Arkansas Commitment to Client Choice Project]{.underline}** (Pine
Bluff, AR, regional in SE Arkansas)

This project is committed to assuring quality providers for vocational
services and pursues this aim in a number of ways. They assure that all
vendors are registered appropriately with the State, which includes
completion of a W-9 form. If the vendor applicant is a physician, the
person must complete an application which is sent to the State of
Arkansas who investigates to assure they are bonafide physicians and
then approves/disapproves vendorship. This research varies from assuring
that appropriate licenses are in place to reviewing the vendors
experience in providing the services desired.

Contracts are issued with service vendors to provide specific services
which also include signing assurances of non-discrimination. Project
staff monitor client satisfaction with service vendors and track client
progress to evaluate ongoing quality of vendor services. Contracts are
terminated in the case of poor client satisfaction or lack of progress,
as well as for lack of fulfillment of contracted services. To assure
quality in the provision of Consumer Connector services (these persons
assist, advise, inform and support project participants to get the
services and results they want), the project contract with a company
experienced in providing choice and facilitating person-centered
planning to create a three-day course, ending in a competency-based
test. The services of Connectors are monitored closely and, as a result,
several providers have been removed due to provision of poor quality
services. In those situations in which an individual wishes to contract
with a new vendor whose qualifications the project question, they tend
to err on the side of the individuals choice.

**[The Development Team, Inc. - Career Choice Project]{.underline}**
(Jacksonville, FL, San Francisco, CA, Washington, DC, Vermont)

Career Choice has concentrated on preparing participants to know what
they really want and in their having direct control over negotiation
with and payment of providers and suppliers. Thus, mainstream consumer
protection techniques and observance of federal and state laws covering
licenses has enhanced choices where vendor lists would have restricted
choices. The experience of the project is that participants can and will
manage to achieve very good quality and very good value for the money
spent when they have a specific financial commitment for their purchase
of a services for a product. We have used two-party checks where the
participant endorses the check only when the arrangement for service or
product purchase is satisfactory to them. We have voided checks and
written new ones to other providers or suppliers. With the range of
additional services and products purchased by participants, the majority
being mainstream in type, prior actions to qualify providers/suppliers
and produce a vendor list would have been not only unwise but
impossible.

**[Washington State Division of Voc. Rehabilitations Participant
Empowerment Project (PEP)]{.underline}** (Seattle, WA & King County)

This project primarily uses contracts as a means to assure quality
services for partcipants and as an alternative to qualifying providers.
Although the State rehab agency certifies providers for the traditional
program, this status would only be one of many factors on which
participants would based a decision. Instead, PEP provides training to
participants on how to select a provider and how to develop a contract
for services. Participants can receive assistance in choosing providers
from the projects counselors, from their rehabiliation team, and/or
from friends and close associates. The rehabiliation team consists of a
group of persons chosen by the participant to assist in making
decisions.

Factors discussed during training include the potential providers
reputation, how much a participant trusts the provider, whether they
like the provider, length of anticipated time to achieve outcomes,
willingness to customize employment services and cost of services. In
addition to these factors, the central focus for selection is whether
the provider is willing and able to get participants what they want for
themselves.

**[UCPAs Choice Access Project]{.underline}** (Washington, DC,
regional, New Orleans, Detroit, Pittsburgh)

The UCPA project uses a combination of a generic building code approach
(described earlier in this paper) with other strategies to help assure
that participants have the maximum opportunity for choice while having
access to effective safe and respectful services. Since this project
targets persons who are among the most under-represented in
rehabilitation services \-- persons with severe physical disabilities
which impact communication, mobility [and]{.underline} communication \--
it was felt that a successful process needed to be available to both
participants and providers so as to achieve employment outcomes. Each
participant may choose how closely, if at all, they will ask providers
to adhere to the process. A handbook of boiler-plate contract forms are
provided to each participant and to all providers. These forms, or
similar personalized forms, must be negotiated between the participant
and potential providers in order for services to be initiated. Supports
are offered to participants by their Employment Advisor and local Choice
Coordinator and to providers by the local Choice Coordinator and the
areas assigned technical assistance consultant. In addition to the
building code and contract strategies, this project will pay only on
participant satisfaction of the services rendered.

Potential providers are recruited by the local Choice Coordinator and
are divided into two groups: agency provider and individual providers.
The licensing aspect of qualifying providers is used only as a
consideration of individual choice and not as an absolute requirement.
This offers the participant a wide variety of options from which to
choose. All providers must fill out a detailed application that is
available to participants for their consideration, attend at least one
training provided by the technical assistance consultant assigned to the
local area and agree to work for the participant for the outcomes listed
specifically in the contract(s).