Workforce Infrastructure 

in Support of People with 

Disabilities: Matching 

Human Resources to 

Service Needs 

National Council on Disability 

January 20, 2010 
National Council on Disability 

1331 F Street, NW, Suite 850 

Washington, DC 20004 

Workforce Infrastructure in Support of People with Disabilities: Matching Human 

Resources to Service Needs 

This report is also available in alternative formats and on the National Council on 

Disability (NCD) Web site (www.ncd.gov). 

Publication date: January 20, 2010 

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202-272-2074 TTY 

202-272-2022 Fax 

The views contained in this report do not necessarily represent those of the 

Administration, as this and all NCD documents are not subject to the A-19 Executive 

Branch review process. 
1331 F Street, NW Suite 850 Washington, DC 20004 

202-272-2004 Voice 202-272-2074 TTY 202-272-2022 Fax www.ncd.gov 

1

Letter of Transmittal 

January 20, 2010 

The President 

The White House 

Washington, DC 20500 

Dear Mr. President: 

The National Council on Disability (NCD) is pleased to submit this report, entitled 

Workforce Infrastructure in Support of People with Disabilities: Matching Human 

Resources to Service Needs. NCD’s purpose is to promote policies and practices that 

guarantee equal opportunity for all people with disabilities, regardless of the nature or 

severity of the disability, and to empower people with disabilities to achieve economic 

self-sufficiency, independent living, and integration into all aspects of society. Under its 

congressional mandate, NCD is charged with the responsibility to gather information on 

the development and implementation of federal laws, policies, programs, and practices 

that affect people with disabilities. This report is a result of that mandate. 

Americans with disabilities depend on the disability workforce infrastructure, which 

consists of health, education, and social services programs. The need for these 

services is expected to increase significantly in the coming decades as a result of 

several factors. First, the elderly population of the United States is large and growing 

rapidly. Since disability rates increase with age, population aging will bring substantial 

increases in the number of people with disabilities and will have a significant impact on 

the nation’s human service and support needs. Second, improvements in child survival 

rates mean that more children are born today with birth defects and developmental 

disabilities than ever before, and many of them will require access to a host of human 

services and supports throughout their lives. At the same time, large numbers of baby 

boomers are reaching retirement age, which means that many fewer human service 

workers will be available. These trends threaten both the availability and quality of future 

services for people with disabilities. 

NCD’s research for this report has been undertaken in an environment of significant 

social, political, and economic change, amid growing levels of unmet demand for 

services and supports across all sectors of the American workforce. The research has 

been aimed at better positioning the human resources sector for the future; for example, 

by providing data and information that organizations can use to understand the supplydemand gaps in the disability-related workforce and to make plans to fill those gaps. 

The research has also aimed at building industry capability to influence the nature and 

content of training, as well as capability to manage a sustainable, skilled disability 
workforce in the future. Finally, in an effort to reflect a holistic view of a community’s 

workforce expectations, the research has been aimed across all relevant segments of 

the disability workforce, not just at a select handful of human service occupations. 

Numerous forecasts based on diverse trends all point to a shortage of qualified workers 

to meet the needs of the disability population. People with disabilities occupy a strategic 

place in America’s ability to compete. Either their talents and ambitions will be 

developed into a resource for our society, or they will remain on the margins, battling for 

shrinking resources. 

This report from NCD presents recommendations (with a rationale for each) that call for 

partnerships among federal departments and agencies, their State counterparts, and 

the private sector, including organizations involved with education/training, health care, 

and employment services. NCD calls for policymakers at all levels of government to 

proactively address these shortages and examine how labor market changes are driving 

both current and future supply. 

We stand ready to work with you and the members of your Administration to improve 

the nation’s workforce infrastructure policies, programs, and practices for all Americans. 

Sincerely, 

Linda Wetters 

Chairperson 

(The same letter of transmittal was sent to the President Pro Tempore of the U.S. 

Senate and the Speaker of the U.S. House of Representatives.) 

2
National Council on Disability Members and Staff 

Members 

Linda Wetters, Chairperson 

Patricia Pound, First Vice Chairperson 

Marylyn Howe, Second Vice Chairperson 

Victoria Ray Carlson 

Robert R. Davila, Ph.D. 

Graham Hill 

Lisa Mattheiss 

Heather McCallum 

Katherine McCary 

Lonnie Moore 

Anne M. Rader 

Tony Williams 

Staff 

Martin Gould, Ed.D, Director of Research and Technology 

Mark S. Quigley, Director of Public Affairs 

Julie Carroll, Senior Attorney Advisor 

Joan M. Durocher, Senior Attorney Advisor 

Sharon M. Lisa Grubb, Special Assistant, Coordinator of Administration 

Geraldine Drake Hawkins, Ph.D., Senior Program Analyst 

Anne C. Sommers, Legislative Affairs Specialist 

Stacey S. Brown, Staff Assistant 

Carla Nelson, Administrative Specialist 

3
Acknowledgments 

The National Council on Disability expresses its deepest appreciation to Martha Artiles 

of Manpower, Inc. Bojan Cubela, and David Vandergoot of CEMS for developing this 

vitally needed report. NCD also thanks Ray Glazier, Andrew Houtenville, and Peter 

Mead, who provided critical information, analysis, and research guidance throughout the 

course of this project. 

4
Contents 

Executive Summary ...................................................................................................... 7

SECTION 1. Introduction and Background............................................................ 13

Disability Services Infrastructure ................................................................ 15

Gaps and Barriers ...................................................................................... 15

Purpose of the Report ................................................................................ 15

Methodology............................................................................................... 16

SECTION 2. National Trends, Gaps and Barriers, and Their Implications for 

People with Disabilities and the Disability Services Industry......... 19

Disability, Age, and the Baby Boom ........................................................... 22

Institutions .................................................................................................. 23

Type of Disability ........................................................................................ 23

Needs, Gaps, and Service Barriers ............................................................ 25

Education................................................................................. 25

Employment............................................................................. 26

Health Care.............................................................................. 26

Independent Living and Quality of Life..................................... 26

Summary.................................................................................................... 27

SECTION 3. Disability Services Infrastructure Occupations: Supply and 

Demand................................................................................................ 29

Occupations with Future High Demand...................................................... 30

Supply Issues ............................................................................................. 32

American Recovery and Reinvestment Act (ARRA) of 2009...................... 34

Competencies in Demand .......................................................................... 40

SECTION 4. Private Sector Strategies for Building and Maintaining a 

Sufficient Supply of Disability Infrastructure Occupations............. 43

Workforce Management ............................................................................. 43

Recruitment Strategies............................................................................... 49

Successful Return-to-Work Strategies ....................................................... 51

5
SECTION 5. Public Sector Strategies for Building and Maintaining a 

Sufficient Supply of Disability Infrastructure Occupations............. 55

Employment Services for People with Disabilities ...................................... 56

State-Federal Vocational Rehabilitation Services System ....... 56

Department of Veterans Affairs................................................ 59

Ticket to Work of the Social Security Administration................ 60

Workforce Investment Act (WIA) and One-Stop Centers......... 62

New Technologies, New Opportunities ...................................................... 63

Health Care for People with Disabilities ..................................................... 66

Education and Youth with Disabilities......................................................... 69

Community Colleges................................................................ 71

Summary.................................................................................................... 72

SECTION 6. Recommendations .............................................................................. 73

APPENDIX A. Literature Abstracts ............................................................................ 79

APPENDIX B. Supply-Demand Charts of Infrastructure Occupations ................. 171

APPENDIX C. Mission of the National Council on Disability................................. 229

Endnotes.................................................................................................................... 233

Tables 

Table 1. 2006 U.S. Population, by Age, Residence Type, and Disability Status ....... 24

Table 2. Occupations Projected To Be in High Demand Over the Next 10 Years..... 31

Table 3. Legislative Initiatives ................................................................................... 35 

Figures 

Figure 1. 2006 U.S. Population, by Age Group .......................................................... 22 

Figure 2. 2006 Disability Prevalence Rate, by Age Group.......................................... 23 

Figure 3. Forecasting and Planning for Future Retirement-Related Talent Deficits.... 45 

Figure 4. Optimizing Talent Flow................................................................................ 46 

Figure 5. Managing the Talent Pipeline...................................................................... 49 

6
Executive Summary 

Americans with disabilities depend on the disability services infrastructure, which 

consists of health, education, and social services programs. The need for these 

services is expected to increase significantly in the coming decades as a result of 

several factors, most notably the aging of the baby boom generation and declining 

birthrates. These trends threaten the future availability and quality of services for people 

with disabilities. As the threat grows, so do the downsides to the American economy 

and society, which are increasingly engaged competitively on a global basis. People 

with disabilities occupy a strategic place in America’s ability to compete. Either their 

talents and ambitions will be developed into a resource for our society, or they will 

remain on the margins, battling for shrinking resources. This report from the National 

Council on Disability (NCD) presents recommendations (with a rationale for each) that 

call for partnerships among federal departments and agencies, their State counterparts, 

and the private sector, including organizations involved with education/training, health 

care, and employment services. A concerted effort is needed by these sectors to ensure 

that the projected shortfall in the workforce of the disability services infrastructure 

entities can be quickly overcome. Unless everyone works together to meet this goal, the 

quality of life for people with disabilities will be threatened. The gains made over the 

past two decades in the levels at which people with disabilities participate socially and 

economically will be lost, and achieving levels of independence comparable to those of 

people who are not disabled will be pushed farther into the future. The national health 

care debate, so much a part of the political scene in 2009, as well as the stimulus funds 

made available by the Obama Administration and Congress, create a unique 

opportunity to focus attention on the current and future needs of people with disabilities. 

The potential for refocusing priorities to ensure that the resources are available in the 

critical areas of employment, education, and health care services for people with 

disabilities is great and must be realized. 

Numerous forecasts based on diverse trends all point to a shortage of qualified workers 

to meet the needs of people who are disabled. NCD calls for policymakers at all levels 

7
of government to proactively address these shortages and examine how labor market 

changes are driving both current and future supply needs. This six-section report covers 

the following topics: 

1. Introduction and background 

2. National trends, gaps and barriers, and their implications for people with 

disabilities and the disability services industry 

3. Disability services infrastructure occupations: supply and demand 

4. Private sector strategies for building and maintaining a sufficient supply of 

disability infrastructure occupations 

5. Public sector strategies for building and maintaining a sufficient supply of 

disability infrastructure occupations 

6. Recommendations 

Section 1 outlines the strategies used to examine the current and future supply and 

demand associated with labor markets of the disability services infrastructure. This 

examination began by identifying organizations and government agencies serving 

people with disabilities to determine what services currently exist. An extensive 

literature search identified the best available sources regarding disability service worker 

shortages and gaps in service delivery. Information from the Bureau of Labor Statistics 

(BLS) of the U.S. Department of Labor was used to identify specific occupations and 

future projections. While existing resources help identify trends affecting the demand for 

future disability services and workers, the supply side has a dearth of resources, 

requiring more extrapolation and development. The model described in this section and 

detailed throughout the report provides an expanded research foundation that can be 

further developed through successive iterations into a tool for guiding policy formation. 

Section 2 reviews issues and trends relative to skill shortages in the disability-related 

service industry as examined by Manpower Inc., including the aging baby boom 

generation and declining U.S. birthrates. The baby boomers are beginning to retire, thus 

8
increasing demands on health care, mobility support, and other services. These 

demands will generate further restrictions on services available to people with 

disabilities. This section lays the foundation for the first iteration of a more robust 

approach to project demand for disability services, which is a key unmet need in policy 

formation. 

Section 3 summarizes data currently available from the Employment Outlook 

Projections of the BLS related to the supply-demand gap in disability-related 

occupations. According to the BLS, many infrastructure occupations are projected to be 

in high demand, particularly those associated with health care. This section suggests 

ways to increase the supply of disability services infrastructure workers using promising 

recruiting and retention practices such as increasing salaries and benefits, training to 

upgrade worker skills, recruiting workers from underutilized populations, and leveraging 

transferable skills. By developing the discussion of the supply-demand gap and 

exploring best practices to reduce the gap, this section lays the foundation for a supply 

management discipline. Such a discipline is mandatory to formulate disability services 

policy, especially on the national level, where supply management has been 

conspicuous in its absence. 

Section 4 explores recruiting and retention strategies used in the private sector. Public 

policy affecting the disability services infrastructure cannot be developed in isolation 

from the private sector. When employers explore current and future workforce 

demographics to develop workforce management strategies, they are engaging in the 

private sector version of disability services supply management. Using their data and 

tools, employers can better identify and target appropriate candidates for disability 

service positions. These private sector practices provide models and strategies that the 

public sector can apply as well. In fact, as employers implement workforce 

management, they may interface with parallel public sector programs. Employers can 

work with community-based rehabilitation programs and vocational rehabilitation 

agencies to develop and tap underutilized populations. Such partnerships offer 

employers a large pool of potential job candidates that can receive job training through 

9
vocational services. Another useful strategy employers can explore relates to the 

successful return to work of injured/ill workers and the prevention of disabilities. Some 

employers, for example, may develop or hire return-to-work coordinators and case 

managers to facilitate return to work. Such private sector efforts offer a laboratory for 

disability services strategies and can provide some of the needed infrastructure that 

must be addressed through public policy. 

Section 5 explores ways in which the public sector can work with the private sector to 

provide a suitable workforce infrastructure for people with disabilities. Public agencies 

and programs can establish practices that promote an adequate supply of qualified 

frontline workers. These public agencies and programs include the State-federal 

vocational rehabilitation services system, the Department of Veterans Affairs, the 

Workforce Investment Act and One-Stop Centers, and the Ticket to Work Program. This 

section also examines how new technologies and Web-enabled tools can improve 

access to services and information for people with disabilities. In another important 

discussion, this section identifies problems in health care supply and access for people 

with disabilities. Proposed solutions in health care reform include the medical home 

model, with primary care physicians coordinating all care, and electronic medical 

records to improve efficiency of delivery. In another strategic discussion, the section 

explores the need for transition services for youth with disabilities that could be met 

through the postsecondary education system. U.S. community colleges can provide an 

efficient and accessible link between students and their careers through career and 

technical education. 

Section 6 highlights the recommendations that flow from the discussions in the previous 

sections. These recommendations include how private sector employers can improve 

their hiring and retention practices to ensure an adequate supply of workers; how 

federal and State agencies can target service strategies to enhance the supply of 

workers; how we can redirect resources in our educational and training establishments 

to focus on infrastructure occupations; and what we can do to monitor workforce supply 

10
and demand so that planning can accommodate unexpected events and redirect 

resources accordingly. 

The appendices provide detailed evidence that supports the findings in each of the 

sections and the recommendations. An extensive search of the literature was 

conducted, and many of the documents that provided an empirical basis for this report 

have been abstracted and placed in appendix A. Readers who wish to have more 

detailed information can review these abstracts, which are grouped according to report 

section. Appendix B contains detailed information and charts on many disability services 

infrastructure occupations. This information provided the basis for section 3; it is also 

useful for program planning and as guidance for schools and training programs that 

offer career and vocational counseling for their students. 

All these discussions identify opportunities for public-private sector partnerships to help 

implement public policy to better manage the nation’s disability services infrastructure. 

Given the overlap between private and public goals and programs, such partnerships 

are inevitable. This public-private overlap is significant for policy formulation and 

implementation, because it is based on an even more significant underlying connection. 

People with disabilities have a shared interest with their nation and government in 

resolving challenges to disability services infrastructure management; in fact, this 

population contains an untapped resource to realize a solution to this policy challenge. 

11
12
SECTION 1. Introduction and Background 

In many important ways, Americans with disabilities depend on the disability services 

infrastructure, which consists of health and human services programs. The availability 

and quality of the services delivered through this important infrastructure affect the 

health, employment, and social participation of people with disabilities, who number 

approximately 50 million people, about one-sixth of the overall U.S. population. In fact, 

this infrastructure is critical to their quality of life. Conversely, barriers and gaps in 

services, supports, and accommodations negatively affect the lives of people with 

disabilities. 

To maintain the desired levels of service quality, now and in the future, policymakers 

and planners must anticipate labor market changes as well as the future needs of 

people with disabilities for services. New service delivery models must be explored and 

investments made in the infrastructure that supports disability services. The massive 

baby boom generation is beginning to leave the workforce. Nearly 7 million people in 

key managerial, professional, and technical jobs will likely retire in the next 10 years. At 

the same time, owing to declining birthrates, the U.S. economy is about to experience a 

shortage of young workers. As the baby boomers retire, the “brain drain” of skilled and 

experienced workers is creating another problem: The new workforce entrants are 

replacing experience with inexperience. The combination of these trends will create 

unprecedented competition for talent across all industries, which will further reduce 

available talent needed to support people with disabilities. In addition, mismatches 

between available skills and job requirements will continue to widen. Manpower Inc. 

surveyed nearly 43,000 employers in 32 countries and territories in late January 2008 to 

determine the extent to which talent shortages are affecting today’s labor markets.1

 The 

results of the third annual Talent Shortage Survey revealed that 31 percent of 

employers worldwide are having difficulty filling positions because of the lack of suitable 

talent in their markets. 

Today’s forecasts predict a long-term shortage of qualified workers throughout the 

disability services infrastructure. Even more important, a high percentage of this 

13
shortage will involve a lack of skills rather than an insufficient number of workers. 

Therefore, it is essential to examine whether existing competencies and skills in today’s 

occupations are sufficient to address future needs. Skill and competency deficiencies 

will negatively affect the lives of people with disabilities as much as or even more than a 

physical shortage of workers. Both shortfalls are critical, and it is imperative to address 

them in the very near future. 

Around the world, Manpower Inc.—in partnership with community organizations and 

education, business, and government entities—engages in workforce development 

programs that put people to work. Manpower Inc. has developed a business strategy for 

dealing with labor shortages. In the current context, this strategy focuses on addressing 

the short- and long-term labor and talent shortfalls facing the disability services support 

infrastructure. Manpower Inc. and NCD are seeking ways to correct the imbalance 

between supply and demand that, if not quickly addressed, will exacerbate the gaps in 

social and vocational participation of people with disabilities in our society and 

economy. 

Of many potential approaches, one is to ensure that our society fully taps the 

underutilized pool of workers with disabilities. The agencies and companies serving 

people with disabilities must begin planning strategically to hire more workers from the 

very population they serve. The more equitably people with disabilities participate 

throughout these service programs, the more sensitive and responsive the infrastructure 

will become to their needs. Their active participation will help alleviate the overall 

shortages and improve the economy’s use of people with disabilities. The nation must 

tap this pool of talented people. 

Before we proceed, it is important to clarify the terms used in this report. This will 

enhance understanding and facilitate actions needed to overcome the gaps and barriers 

discussed here. 

14
Disability Services Infrastructure 

“Disability services infrastructure” refers to the full range of support services available to 

people with disabilities, including education; health care; vocational, social, and 

recreational programs; and other human service programs that affect the quality of life 

and independent living of people with disabilities of all ages and their families. These 

programs can be either public or private. They may be developed specifically for people 

with disabilities or modified for use by people with disabilities. These programs address 

needs that people with disabilities experience from infancy to old age. The infrastructure 

supporting these programs is the primary concern in this report: It is currently 

insufficient to meet the needs of people with disabilities and will likely be even less 

responsive in the future, as a result of the trends described in the report. 

Gaps and Barriers 

Regardless of funding source or intended target audience, all services and their 

resulting outcomes should be engineered to support participation in education, 

employment, and health care opportunities by people with disabilities to the same extent 

that other people participate. The gaps and barriers experienced by people with 

disabilities and their families are documented in the sections that follow; they include 

environmental, procedural, organizational, legal, social, and political barriers. 

Purpose of the Report 

The purpose of this NCD report is to reveal the current and future supply and demand 

associated with labor markets in the disability services infrastructure; to review existing 

strategies for maintaining balance between needs and services; and to suggest how to 

transform management and human resources practices for attracting, engaging, and 

retaining the workers needed in critical occupations. The report also calls for an 

examination for how the proliferation of new technologies and Web-enabled tools, such 

as the social networking platforms, can improve access to services and information for 

people with disabilities. These new technologies have the potential to empower people 

15
with disabilities and provide them with opportunities for informed decision making in 

their lives and careers. Finally, this report reviews how current public and private 

initiatives and policies affect the soundness of the disability services infrastructure and 

what can be done to use public resources more effectively. 

The current focus of the Obama Administration on economic stimulus and health care 

reform has created much legislative activity and many policy discussions on these 

interrelated and very complex issues. Although many factors must be considered to 

understand the future needs of people with disabilities and the resources available to 

address them, a firm understanding of health care and economic trends is an important 

aspect of the discussion if we want to make the most of the opportunities that will result 

from stimulus legislation and health care reform. The future quality of life for people with 

disabilities is at stake. 

Methodology 

NCD took a multifaceted approach to identify the sources that provide the foundation for 

this report’s findings and recommendations. The scope of this innovative project was 

comprehensive and unique. No clear body of information existed on which to build; 

therefore, from the outset, it was necessary to cast a wide net and identify as many 

sources of insight, information, and data as possible. 

NCD began by locating organizations related to both the disability and the workforce 

communities, including government agencies at all levels. We identified contact people 

and Web sites. Contact people provided information to update print documentation. 

These contacts informed us of other people and organizations that could provide 

additional information, so our list of organizations continued to grow through this 

“snowball” sampling process. These contacts also made important suggestions 

regarding which occupations in the disability services infrastructure we should include. 

NCD compiled a list of key words and phrases that provided a thorough description of 

the disability services program components. We used the word list to do an extensive 

16
literature search to identify the needs of people with disabilities and the service gaps 

and barriers that prevent them from achieving the same quality of life as people without 

disabilities. NCD searched for foreign documents as well as those from the United 

States, as it is likely that solutions discovered elsewhere may be suitable for replication 

here. The documents obtained through the literature searches were reviewed, 

summarized, and sorted into appropriate categories corresponding to services provided 

through the disability services infrastructure, national trends, needs of people with 

disabilities, gaps and barriers associated with service delivery, and occupational 

forecasts related to the disability services infrastructure. The literature search was 

designed to go beyond disability and explore how solutions that have worked with other 

population sectors might be considered for people with disabilities. NCD was looking 

specifically for solutions that had a supporting evidence base. 

The most useful documents had not only good descriptions of solutions but also data 

collected through fairly rigorous research designs. Studies with a more rigorous design 

were accorded more weight in our use of data. We used systematic reviews when they 

were available (which was infrequently), because they typically provide comprehensive 

overviews of the highest quality empirical research available. To reveal more detail than 

is usually captured in an overview of this nature, NCD abstracted documents of 

particular significance to a topic area, These abstracts are organized by topic in 

appendix A. 

Finally, NCD used published data from the Bureau of Labor Statistics (BLS) of the U.S. 

Department of Labor to compile forecasts of the occupations identified as part of the 

disability services infrastructure. This is the most comprehensive and up-to-date source 

of occupational information available. To supplement the BLS information, which 

focuses on demand for workers, NCD contacted associations and organizations 

affiliated with these occupations to obtain more information, particularly additional 

forecasts associated with the supply of workers. Appendix B includes charts that show 

the projected future demand for workers. 

17
18
SECTION 2. National Trends, Gaps and Barriers, and 

Their Implications for People with 

Disabilities and the Disability Services 

Industry 

Manpower Inc. has addressed issues associated with skill shortages for many years as 

part of its core business of providing human resources infrastructure support to 

companies and governments throughout the world. The company describes the timetested strategies and tactics it uses in its recently published study Confronting the 

Talent Crunch: 2008.

2

 Manpower is aware of the trends contributing to the imbalances 

in the human resources infrastructure that will further limit opportunities for people with 

disabilities to experience the same quality of life and independence as people without 

disabilities. Data systematically collected over 50 years indicates that people with 

disabilities have lower high school and college graduation rates, experience greater 

levels of unemployment and underemployment, have income levels that fall 

disproportionately below the poverty line, are frequently without any medical insurance, 

and experience less integration into community life than others. It is also clear that 

current labor shortages will become worse in the near term unless new approaches are 

applied. Driving these increasingly critical shortages are the following demographic 

shifts: 

1. Baby boomers are entering their retirement years and will need a variety of 

medical and social supports to maintain their quality of life, further burdening 

the supports available for people with disabilities. As a result of medical 

advances and scientific developments, boomers will have an increasingly 

longer lifespan and thus will be competing with people with disabilities for 

services already in short supply. 

2. At the same time, the falling U.S. birthrate means fewer younger workers to 

replace the boomers. The late Frank Bowe characterized the baby boom 

generation as “the pig in the python.”3

 The children of this generation constitute 

a smaller population cohort immediately behind the boomers, which means 

19
that the supply of workers will be further weakened and the burden on younger 

generations to produce the wealth needed to support the retirement lives of 

boomers will become greater, further straining the ability to adequately meet 

the needs of people with disabilities of all ages. 

Both long-term and short-term solutions are needed. The current disability services 

infrastructure, already strained, is configured to serve a smaller group while drawing on 

the large labor pool the baby boom formerly provided. In the future, the burdens on the 

health care and social support systems will grow, while resources and labor supplies will 

be stretched ever more thinly. It will take a combined public-private initiative to provide 

the strategic planning to fully fund and provide for the social and health care needs of all 

citizens, not just those of older people or people with disabilities. Our society cannot 

take from one group to meet the needs of others. 

Bowe foretells the convergence of interests of the disability and aging constituencies as 

the first wave of the postwar baby boom generation turns 60 and experiences the 

gradually (sometimes not so gradually) disabling effects of aging.4

 He makes the point 

that disability is our common destiny, if we live long enough. Usually, hearing begins to 

go first, then vision, and then mobility. 

A larger proportion of older people will result in a larger percentage of people with 

limitations and disabilities in the population at large. Bowe says, “The disability 

community is about to become a lot more central in American life.”5 He notes that in 15 

years, 40 percent more Americans will have some degree of hearing loss and vision 

impairment, and the current 14 percent of adult Americans with moderate to severe 

mobility limitations will increase dramatically. 

As the baby boomers age, Bowe notes, “Accessibility issues will be, for these people, 

no longer someone else’s problems but rather our concern.”6 Seniors are much more 

likely to exercise their right to vote than younger people. The baby boom generation 

gave America its first child consumer market (think Davy Crockett coonskin caps and 

20
the Mouseketeers) and will continue to drive markets to respond to their changing 

needs as they age. 

In our geographically mobile society, few aging parents can count on their offspring to 

care for them in old age. Adult children commonly live far from their parents and are 

already overcommitted, with demanding careers, obligations to merged families, 

grandchildren of their own, and lives complicated by multiple marriages and two-career 

couples. And easy access to birth control has made the post-baby boom generation 

smaller. So who will help the boomers cope with the effects of aging? Today’s seniors—

and presumably the coming wave—want to remain as active and independent as 

circumstances permit, preferably aging in place in their own homes. 

What we are seeing is a coalescence of the need for help by both seniors and people 

living with disabilities. People with disabilities already enjoy some community access 

features and in-home supportive services that enable them to be active citizens 

engaged in community life and aspiring to or achieving full-time competitive 

employment. These services, if preserved and extended, will also sustain the baby 

boom generation as it ages. It is critically important to see how these mutual needs and 

supports can be integrated even better, so that none of our citizens in either group 

misses out on the quality of life that people who are younger and free of disabilities 

enjoy. 

Recent data, primarily from the Census Bureau, can be used to forecast the expanding 

population of people with disabilities over the next 20 years. Any staff shortages or gaps 

in the disability services infrastructure that exist now will be exacerbated not only by the 

aging of the population but also by the increase in the number of people with disabilities. 

Population Growth. The U.S. Census Bureau estimated the U.S. population at 

306 million on March 1, 2009,7

 and projects an increase to 336 million by 2020 and 

364 million by 2030.8

 In other words, the population is expected to increase by 

35 million (10.4%) from 2007 to 2020 and by 63 million (17.3%) from 2007 to 2030. 

According to the Census Bureau’s 2006 American Community Survey (ACS),9

21
15.7 percent of the population reported a disability. Applying this percentage to the 

population projections suggests that the population with disabilities will be 53 million by 

2020 and 57 million by 2030. (This estimate is for people ages 5 years and older, but 

the exercise assumes that the percentage is the same for all ages and constant over 

time.) 

Disability, Age, and the Baby Boom 

The baby boom generation, born between 1946 and 1964, has created a demand for 

increased government services at each stage; for example, the need to build more 

public schools in the 1950s and 1960s. Figure 1 shows the U.S. population by age 

group in 2006, when the boomers were 42–60 years old. As this generation continues to 

age, the demand for disability services will increase. 

Figure 1. 

2006 U.S. Population, by Age Group

Source: U.S. Census Bureau (see note 7). 

The connection between age and disability is well known and is graphed in Figure 2. 

For example, the disability prevalence rate among the youngest baby boomers (42-

year-olds) was 11.9 percent, while the rate among the oldest boomers (60-year-olds) 

was 25.2 percent. As the boomers age, the population with disabilities will increase. 

22
Figure 2. 

2006 Disability Prevalence Rate, by Age Group

Source: U.S. Census Bureau (see note 7). 

Institutions 

It is important to note that a portion of the population with disabilities lives in institutions. 

As shown in table 1, in 2006, 5.7 percent of people ages five and older with disabilities 

lived in institutions, compared with 0.7 percent of people without disabilities. And the 

percentage of people with disabilities living in institutions increased with age: 

2.3 percent for those aged 5–20; 3.6 percent for those aged 21–64; and 9.8 percent for 

those aged 65 and older. The degree of institutionalization will likely affect the demand 

for social services. Unfortunately, current data does not distinguish between privately 

and publicly funded institutional care. 

Type of Disability 

Disability is a complex concept and includes numerous types. The American 

Community Survey (ACS) collects data in several broad disability categories: sensory, 

physical, mental, self-care, go-outside-home, and employment. (Survey respondents 

may report more than one category). These categories are useful to understand the 

23
Table 1. 

2006 U.S. Population, by Age, Residence Type, and Disability Status 

Disability Status 

Age/Residence Type Total Disability No Disability 

Ages 5 and older 279,019,603 43,755,805 235,263,798 

 Living in the community 274,896,047 41,247,284 233,648,763 

 Living in an Institution 4,123,556 2,508,521 1,615,035 

 Percentage living in an institution 1.5 5.7 0.7 

Ages 5–20 66,645,996 4,411,409 62,234,587 

 Living in the community 66,361,958 4,311,751 62,050,207 

 Living in an institution 284,038 99,658 184,380 

 Percentage living in an institution 0.4 2.3 0.3 

Ages 21–64 175,179,720 23,217,180 151,962,540 

 Living in the community 172,961,160 22,381,523 150,579,637 

 Living in an institution 2,218,560 835,657 1,382,903 

 Percentage living in an institution 1.3 3.6 0.9 

Ages 65 and older 37,193,887 16,127,216 21,066,671 

 Living in the community 35,572,929 14,554,010 21,018,919 

 Living in an institution 1,620,958 1,573,206 47,752 

 Percentage living in an institution 4.4 9.8 0.2 

Note: “Living in the community” refers to households and noninstitutional group quarters. 

Source: American Community Survey 2006 

24
types of disability services needed. According to the 2006 ACS, among people with 

disabilities ages 5 years and older, 28.9 percent had a sensory disability, 63.3 percent 

reported a physical disability, 40.2 percent reported a mental disability, 22.5 percent 

reported a self-care disability, 32.6 percent reported a go-outside-home disability, and 

59.3 percent reported an employment disability. 

Needs, Gaps, and Service Barriers 

Appendix A provides abstracts highlighting the needs of people with disabilities in 

critical areas: education, employment, health care, independent living, and quality of life. 

Our focus is this report was to identify broad issues affecting the entire population of 

people with disabilities. The major issues in each need area are summarized below. 

Education 

Students with disabilities at all levels of education have experienced greater degrees of 

integration and opportunity. Yet difficulties and inequities still exist: 

● Graduation rates for students with disabilities lag behind those for other 

students. 

● Younger students with disabilities experience more behavior problems and 

have less developed social skills than other students. 

● Older students with disabilities tend to have lower self-esteem, to participate 

less in school activities, to feel somewhat isolated, and to be fearful about their 

future prospects, including employment, than other students. 

● More students with disabilities are enrolled in postsecondary schools than in the 

past, but the numbers are still comparatively low and support services are 

frequently lacking at colleges and universities. 

● Students with disabilities who are part of immigrant families face additional 

difficulties. Cultural differences may lead to misunderstanding, and parents 

25
often do not know how to navigate the educational system and or how to 

access available supports. 

Employment 

● Across the board, people with disabilities have lower employment rates and 

earnings. 

● Transition-age youth with disabilities are getting greater access to employment 

support services, but they need more work experience opportunities while in 

school. 

● Although corporate America is offering more opportunities for workers with 

disabilities, many companies have not yet developed corporate cultures that are 

open to disability and diversity. 

● The employment success rates of people served by vocational rehabilitation 

agencies have not improved appreciably. 

Health Care 

● Funding for specialized health care services for people with disabilities is not 

adequate to meet the need. 

● Treatment services are often inaccessible or not adapted to the special needs 

of people with disabilities. 

● Health care burdens and costs are greater for families of people with disabilities 

than for families that do not have a member with a disability. 

● There is a growing gap of unmet need for care providers in the workforce. 

Independent Living and Quality of Life 

● Physical accessibility to transportation, recreation, and other important venues 

remains a problem, particularly in minority communities. 

● Recreational opportunities are limited for people with disabilities. 

26
● Accessible housing and transportation are limited almost everywhere in the 

nation. 

● Income supports for people with disabilities are falling behind the growth of 

income of other population sectors. 

● A greater proportion of people with disabilities falls below the poverty line. 

Summary 

The number of people with disabilities will increase over the next 10 years, and many of 

them will be over 60 years of age. The double impact of age and disability will strain the 

service infrastructure for older people and siphon off services for younger people unless 

additional resources are directed at the increased needs. The current needs of people 

with disabilities, although receiving increasing attention, are multifaceted and often 

unmet. Existing shortfalls and expected increases in demand for services require 

immediate consideration if service gains are to be sustained and needs properly 

addressed. 

27
28
SECTION 3. Disability Services Infrastructure 

Occupations: Supply and Demand 

This section summarizes information about current and future supply and demand 

associated with disability services infrastructure occupations. 

The data comes primarily from the Employment Outlook Projections of the Bureau of 

Labor Statistics (BLS) of the U.S. Department of Labor.10,11,12,13 Appendix B provides 

detailed information about these occupations, including workforce estimates, future 

demand, educational requirements, salary levels, and competencies that may be 

transferable among disability services infrastructure occupations. The BLS uses 

available data to estimate current supply (i.e., the number of people employed at the 

time the study was completed) and to project demand 10 years into the future. Where 

possible, the BLS projections incorporate expectations about future supply from other 

sources, primarily professional and industry associations. These projections can help 

policymakers, administrators of education and training programs, employers, and the 

counseling profession make decisions that will ensure an adequate future supply of 

workers for these occupations, which are critical to the well-being of people with 

disabilities. 

The projections consider both expected growth in demand and replacement needs 

owing to workers retiring or leaving their jobs. Education and training pipelines are not 

systematically tracked, but the best estimates assume that occupations with the largest 

gap between current supply and future demand will require special attention. This is a 

central concern: to manage supply over time to ensure that it is sufficient to meet the 

future needs of people with disabilities. 

This discussion of supply and demand is based on research that extrapolates data from 

the past into the future. The biennial BLS study encompasses a 10-year period; its 

projections assume that current trends will likely continue as the future unfolds.14

However, the prediction models used in 2006, for example, did not anticipate the 

protracted economic downturn that began in late 2007 and continued through 2009. 

29
Likewise, the comprehensive stimulus plan proposed by President Barack Obama and 

enacted by Congress may alter current trends that affect projections. In fact, some 

components of the stimulus plan are directed at supply-demand imbalances, particularly 

in health care occupations, so the future reality may bear little resemblance to current 

projections. In addition, other unforeseen events and forces might affect the balance 

between supply and demand, such as natural disasters, flu pandemics, terrorist acts, 

expanded or new wars, and prolonged economic turmoil. This section will highlight 

stimulus plan provisions intended to address future shortfalls. 

However conditional the predictions are, they are still useful. The current balance 

between supply and demand points the way to what should be given the most attention 

moving forward, with a careful eye on events that might require a corrective response. 

These projections provide a baseline for a capacity-planning process that can be 

modified and improved on a continuing basis in future years as services infrastructure 

leaders learn more about planning for the future. In this initial effort, both the private 

sector and all levels of government must focus on how education and training 

resources, including those of employers, should be aligned for the future. 

Occupations with Future High Demand 

The BLS projects that certain occupations will require at least a 15 percent rate of 

growth over the next 10 years to respond to increases in demand. These occupations 

will require the most additional support through policy, publicity, and resource allocation. 

Table 2 organizes these occupations into four areas of need for people with disabilities: 

employment, health care, quality of life, and education. 

Workers in the health and medical services will be in greatest demand over the next 10 

years, and the extent of the demand is very strong. The three occupations in which 

demand is projected to increase most are all in health care. The single highest increase 

in demand—for home health aides—directly affects the quality of life of people with 

disabilities. 

30
Table 2. 

Occupations Projected To Be in High Demand Over the Next 10 Years 

Area of Need Occupation 

Projected Increase 

in Demand 

Employment Rehabilitation counselor 23% 

Home health aide 48.7% 

Medical assistant 35.4% 

Substance abuse counselor 34.3% 

Mental health counselor 30% 

Physical therapy aide 28.9% 

Occupational therapy aide 27.9% 

Physical therapist 27.1% 

Physician assistant 27% 

Registered nurse 23.5% 

Occupational therapist 23.1% 

Respiratory therapist 22.6% 

Pharmacist 21.7% 

Health Care 

Massage therapist 20.3% 

Emergency medical technician 19.2% 

Medical records technician 17.8% 

Medical and health services manager 16.4% 

Psychologist 15.3% 

Health Care 

(cont’d) 

Radiology technician 15.1% 

Social and human service assistant 33.6% 

Social and community service manager 24.7% 

Social worker 22.2% 

Quality of life 

Child care worker 17.8% 

Sign language interpreter 23.6% 

Clinical, counseling, school psychologist 15.8% 

Education 

Special education teacher 15.4% 

Source: Author 

31
Employment opportunities will be plentiful in the high-demand fields listed in table 2. 

Schools, colleges, community organizations, and employers should expand their 

offerings accordingly, and guidance counselors might encourage youth to consider 

careers in these fields. Vocational rehabilitation agencies and programs should inform 

consumers about opportunities in these high-demand occupations. 

Supply Issues 

There are no general surveys or studies of trends in supply as there are for trends in 

demand. In the absence of hard data, we can look at the principles driving supply 

trends. One driving principle, as long as the economic climate remains difficult, is that 

people are likely to hold on to the jobs they have. Therefore, one might expect 

replacement needs to be lower than currently projected. The economic downturn and 

the higher Social Security retirement age mean that older workers are likely to stay 

employed longer. These trends may provide a “softer landing” from projected shortfalls 

in supply, especially in the higher skill jobs held by many older workers. But supply 

shortfalls are already appearing and will be felt especially in new occupations and entrylevel occupations, such as home health aide. 

Labor markets are not static. Organizations react to changing conditions by responding 

to the reality confronting them. When employers feel the pressure of a shrinking supply 

of workers to meet increasing demand for services, they will create training and career 

development opportunities to keep existing workers on the job and improve their 

capabilities. Employers are also likely to increase wages in these occupations to entice 

workers to remain and to attract new hires to fill vacancies. It is uncertain to what extent 

such employer efforts will narrow the supply-demand gap, because they may be offset 

by the impact of extended or enhanced unemployment benefits currently under 

consideration. Enhanced benefits could influence unemployed people to stay on the 

rolls rather than seek or accept new employment. It is hard to estimate the relative 

strength of countervailing trends such as these, but identifying them is a starting point. 

32
The health care sector has a history of high turnover among long-term personal care 

workers and aides. Over a 6-year period from 2000 to 2006, the actual wages of these 

workers decreased when adjusted for inflation.15 This situation will only worsen as the 

trends mentioned above become stronger. To keep these workers on the job and 

provide daily care for older people and those with disabilities, employers will have to 

increase salaries and benefits, and provide training to upgrade skills.16 A recent fourState demonstration project sponsored by the Department of Health and Human 

Services using these and related strategies showed a significant decrease in turnover 

among these important caregivers. 17 But while this demonstration shows how to 

increase employee retention in a high-demand occupation, it does not address the 

challenge of recruiting new workers to reduce the supply-demand gap. 

Employers must adopt new recruitment strategies, including recruitment among 

underutilized populations. People with disabilities, who are often consumers of 

vocational rehabilitation (VR) programs, can be valuable recruits for companies 

experiencing worker shortages. VR programs should seize this opportunity and help 

people enter these occupations at whatever level possible. Because they are wellversed in many disability issues as a result of their own experience, these people are 

ideal recruits. The list of high-demand occupations includes some for which people with 

disabilities could be trained quickly, such as the medical records technician and aide 

occupations. People with disabilities have long been an underutilized sector of the labor 

market. Section 5 will describe more strategies to increase the supply of workers in 

these critical occupations. 

Graduates of training and education programs constitute a large proportion of the 

workforce supply in the disability services infrastructure, and this area of the supply 

channel is at risk. It is expensive to expand education and training capacity. A recent 

study of the supply of general surgeons indicates that no increase is occurring in 

medical school enrollment, and physician shortages are predicted through the mid-21st

century.18 Similarly, a study sponsored by the American Association of Colleges of 

Nursing indicates that a lack of funds to hire adequate numbers of faculty is limiting 

33
enrollment of nursing students.19 A recent study found that the current supply channel 

for rehabilitation counselors is inadequate to meet retirement replacement demands, let 

alone the additional demand from increasing caseloads.20 State VR agencies expected 

to hire more than 3,700 counselors between 2002 and 2007, but the graduation rate 

from rehabilitation counselor programs over the period was only a little more than a third 

of that total. It is not yet clear how distance learning technologies might mitigate the lack 

of resources inhibiting growth in traditional education and training facilities. 

Finally, the federal and State governments need to act quickly to increase the flow of 

money to move the economy out of the recession that began in December 2007. 

Stimulus money includes funds directed at jobs in the disability services infrastructure, 

such as primary care physicians and frontline caregivers, and will most certainly 

influence the supply of workers for these jobs. It is difficult to anticipate what will happen 

to the supply-demand balance as a result of these funds and later, when the funds are 

spent. 

American Recovery and Reinvestment Act (ARRA) of 2009 

The stimulus package introduced by the Obama Administration in 2009 includes a timelimited infusion of new funding that responds to the projected limited supply of service 

providers in the areas of health, education, employment, and quality of life. In addition, 

Congress has introduced numerous bills and passed legislation designed to enhance 

education, recruitment, and hiring in key infrastructure occupations, thus making them 

more attractive and worthwhile for prospective students and workers. Most of these new 

and proposed laws focus on increasing funding for education, or recruiting and retaining 

workers in needed areas. Although the goal of the stimulus funds is to increase 

employment in the near term, the longer term impact is much less certain. Some bills 

are unlikely to make it out of Congress, but enough have been proposed in both the 

House and the Senate to indicate that Congress is aware of workforce shortage 

concerns. 

34
The Obama Administration has said it will address specific disability issues germane to 

the needs described here. In education, the focus is on early screening, transition from 

school to work, and expanded higher education opportunities. Regarding employment, 

the emphasis is on enforcing the provisions of the Americans with Disabilities Act (ADA) 

and providing resources to help employers accommodate workers with disabilities. In 

health care, the goal is to require insurance plans to cover preexisting conditions and 

improve mental health care. 

What the Administration and Congress will be able to accomplish is unknown, but 

whatever they implement will affect the supply-demand balance in the disability services 

infrastructure. Some current initiatives in Congress are listed in table 3, to illustrate what 

Congress and the Administration are considering. 

Table 3. Legislative Initiatives 

Needs of People with Disabilities 

Legislation 

Occupation, Field, 

or Population 

Impacted Employment

Health, 

Safety, 

Wellbeing Education 

Independent 

Living 

Passed 

S.AJMDT.799 Medical professionals X 

S.AJMDT.802 Medical professionals 

(veterans) 

X 

Title I Pt. A of 

IDEA 

Teachers X 

Proposed 

S.750 Gerontology X X 

S.811, HR2066 Psychology X 

S.790, HR1946 Health professionals X 

S.502 Older workers X 

35
Table 3 (cont’d) 

Needs of People with Disabilities 

Legislation 

Occupation, Field, 

or Population 

Impacted Employment

Health, 

Safety, 

Wellbeing Education 

Independent 

Living 

Proposed (cont’d) 

S.999, HR1932 Child mental health X X 

HR 1928 Nursing X 

HR 1457 Geriatric X 

S.497, HR2043 Nursing X 

HR 2273 Nursing X 

HR 1581 Health professionals X 

HR 1011 Mental health X 

HR 724 Nursing X 

HR 795 Social work X 

HR 1930 Dentists X 

HR 1161 Teachers X 

HR 2350 Physicians X 

HR 349 Autism X X 

S.2933 Older workers X 

HR 468 Geriatric X 

HR 2832 Nursing X 

HR 2388 Physicians X 

Source: Author 

One of the two passed Senate bills, S.AJMDT 799, establishes a reserve fund to 

address systemic inequities of Medicare and Medicaid reimbursement that lead to 

access problems in rural areas. The second, S.AJMDT. 802, provides a Veterans 

36
Health Administration reserve fund to ensure that the supply of professionals serving 

veterans is appropriately prepared to meet their needs. 

The ARRA has specific implications for people with disabilities that parallel the goals of 

the Administration: 

● States: enhanced funding for the Individuals with Disabilities Education Act 

(IDEA). 

● Social Security Administration: funding to reduce the backlog of disability 

claims. 

● State-federal vocational rehabilitation program: $540 million for services. 

● Centers for Independent Living: $140 million to enable people with disabilities 

to live in their communities. 

● Public Housing Capital Fund: $250 million for energy retrofits to supportive 

housing for people with disabilities, making these units more energy-efficient. 

Numerous bills are proposed and awaiting action. They are categorized below, although 

bills often include multiple funding vehicles that spill over categories. The largest 

category funds training and education programs to increase the supply of qualified 

professionals in the disability services infrastructure (primarily health care). 

S. 750 – Caring for an Aging America Act. Geriatric and Gerontology Loan 

Repayment Program; nursing education grants for those who complete specialty 

training in geriatrics or gerontology and elect to provide nursing services to older 

adults. 

S. 811, H.R. 2066 – Graduate Psychology Education Act. School grants to 

encourage specialized training, including services to veterans with posttraumatic 

stress disorder (PTSD). 

37
S. 790 – Health Access and Health Professions Supply Act of 2009. Expansion 

of loan repayment programs; matching State grants for the operation of State 

Health Workforce Centers; National Health Service Corps Scholarship Program for 

Medical, Dental, Physician Assistant, Pharmacy, Behavioral and Mental Health, 

Public Health, and Nursing Students in the United States Public Health Sciences 

Track in Affiliated Schools. 

H.R. 1928 – Home Health Care Nurse Promotion Act of 2009. Training grants to 

nursing schools and associations; scholarship and loan support for home health 

care nurses. 

H.R. 1457 – Geriatric Loan Forgiveness Act of 2009. Considers each year a 

person is enrolled in a geriatric training program as a year of obligated service 

under the National Health Service Corps Loan Repayment Program. 

H.R. 724 – America’s Partnership for Nursing Education Act of 2009. Grants 

for States experiencing explosive population growth with a significant projected 

shortage of nurses to increase the number of qualified nursing faculty in college 

and university nursing programs. 

S. 497, H.R. 2043 – Nurse Education, Expansion, and Development Act of 

2009. Grants to schools with nursing programs that promote accelerated degrees in 

nursing. 

H.R. 1930 – Primary Care Dental Academic Workforce Development Act of 

2009. Loan repayment for full-time faculty of dentistry programs. 

H.R. 1185 – Primary Care Volunteer Incentive Act of 2009. Limited loan 

repayment for part-time primary care volunteer doctors at community health 

centers. 

38
Other bills, including the following, focus on retention or career enhancement of 

professionals already in the disability services infrastructure: 

H.R. 1161 – Keep Teachers Teaching Act of 2009. Grants aimed at teacher 

retention, to be applied toward professional development, teacher mentoring, 

advanced certification, research or travel opportunities, and pairing teachers with 

industry professionals. 

H.R. 795 – Dorothy I. Height and Whitney M. Young, Jr. Social Work 

Reinvestment Act. A commission to advise Congress on recruitment and retention 

in the field of social work. 

S. 502 – Older Worker Opportunity Act of 2009. Employer tax credits to employ 

persons 62 years and older. 

Other bills, including the following, pursue alternative methods of increasing the 

capacity or quality of the service delivery channel: 

H.R. 1581 – Patient-Focused Critical Care Enhancement Act. Appropriations for 

augmented delivery of critical care services to rural settings via 

telecommunications; National Health Service Corps Loan Repayment Program

recruitment efforts for providers of critical care services. 

H.R. 1011 – Community Mental Health Services Improvement Act. Funding for 

technical support and personnel training in the National Health Information 

Infrastructure to address the needs of providers of mental health and substance 

abuse treatment services; grants to address behavioral and mental health 

workforce needs in professional shortage areas. 

Table 3 shows how the legislative priorities of the Administration and Congress intersect 

with the disability services infrastructure, especially the health care occupations. If 

several of these bills were passed, signed into law, and fully funded, the supply of 

39
health care workers, such as nurses and physicians, would come into better balance 

with demand, as would the supply of workers in education-related occupations. 

Passage of these bills would address workforce shortages in fields that affect the lives 

of people with disabilities, with substantial effect on supply shortages in the mental 

health profession. However, the legislative intent is primarily targeted to broader 

concerns of the overall population or of groups such as older people and veterans, 

which include significant numbers of people with disabilities. In one example of 

legislation directly intended to provide resources to the disability services infrastructure, 

the ARRA included funding for State VR agencies to build infrastructure that will 

enhance the VR system’s ability to help people with disabilities become employed. It is 

not known as of this writing which bills will become law, so it is important to track them 

to anticipate the impact on supply and demand, and plan accordingly. 

Competencies in Demand 

Employers rely on transferability of skills to ensure that they can quickly develop an 

adequate supply of workers by recruiting those with similar skills to workers in 

occupations that are experiencing shortages. Typically, on-the-job programs can quickly 

train these workers to levels of competence. However, specialization is becoming 

increasingly prevalent, and with it comes credentialing standards that require licensure 

by a regulating State agency or certification by a professional association. To obtain 

these gate-keeping credentials, people must have specific degrees and experiences 

that cannot be attained on the job. Unfortunately, many of the disability infrastructure 

occupations with strong future demand characteristics have such credentialing 

requirements. Insofar as these requirements ensure a high level of service quality, they 

must not be weakened or compromised. However, developing new ways to achieve the 

proper competencies and credentials would turn transferable opportunities into viable 

solutions to shortages. Workers who have already demonstrated successful tenure in 

related occupations should not be discouraged from pursuing opportunities in 

infrastructure occupations. 

40
Many of the high-demand occupations have career tracks that permit workers to move 

up as they gain education and experience. Therapy aides and social services program 

aides, for instance, have skills related to credentialed therapy and social services, which 

are high-demand occupations in the health care sector. Facilitating career advancement 

for people in lower tier jobs will require creative approaches to overcoming credentialing 

barriers. Employers, credentialing agencies, and education and training programs 

should consider the development of creative alternative credentialing opportunities. 

Gaining credentials for higher level jobs through education and training while on the job 

would be one approach. Professions, schools, employers, and credentialing agencies 

will need to collaborate, and they may need to partner with State legislatures or 

Congress to ratify alternative credentialing ladders. 

The following abilities underlie many of the in-demand occupations in the disability 

services infrastructure. People who have gained these abilities from previous work 

experiences are likely to be good candidates for transferring their skills and assuming 

infrastructure jobs with proper on-the-job and learning experiences. 

Transferable skills include the ability to do the following: 

1. Work comfortably with people and put them at ease in difficult circumstances. 

2. Identify, evaluate, and address the needs of others through information and 

personal assistance, often by providing direct care. 

3. Obtain needed information by interviewing, assessing, and reviewing records. 

4. Assist people with decision making and problem solving. 

5. Recommend strategies and solutions for managing personal issues. 

6. Communicate well verbally and in writing. 

7. Provide information and education to individuals and to the public. 

8. Use equipment to provide diagnostic and treatment services. 

9. Collaborate with other service and treatment providers and organizations. 

41
10. Follow policies and prescribed procedures when providing treatment and 

services. 

11. Ensure privacy and confidentiality of personal information. 

12. Use electronic recordkeeping systems and equipment so that information is 

valid and secure. 

13. Maintain work areas in a safe, clean, and organized manner. 

14. Work as a member of a team to provide coordinated services and treatment. 

15. Refer individuals and families to appropriate service and treatment providers. 

In addition to these competencies, many experienced workers assume managerial and 

administrative responsibilities that entail the following additional abilities: 

1. Plan, direct, coordinate, and supervise the work of others in providing services. 

2. Ensure that all operations of the organization are done in compliance with laws 

and regulations. 

3. Manage budget and fiscal procedures to balance costs and revenues. 

4. Provide resources for needed operations involved in service provision. 

5. Ensure that staff have the necessary skills and knowledge to serve individuals 

and families. 

Many of these competencies are required by high-demand occupations, suggesting that 

transfer of skills can be a potential solution to balancing supply and demand in the 

future. Overcoming credentialing barriers that prohibit movement of skilled workers 

across infrastructure occupations should be a high priority. 

42
SECTION 4. Private Sector Strategies for Building 

and Maintaining a Sufficient Supply of 

Disability Infrastructure Occupations 

Given the likely shortfalls in the supply of workers in disability infrastructure occupations 

over the next 10 years, it is essential to distinguish long-term solutions from the policies 

and practices that look promising right now. Because of the shortages, infrastructure 

employers will have to work harder to attract and maintain the workers they need. 

Unless something is done quickly, citizens with disabilities will fall further behind 

economically and socially in spite of new policies, new legislation, and increased 

funding for services. This reality is crucial for the companies in the private sector that 

provide services as part of the disability services infrastructure. Without adequate 

staffing, many of these companies may fail, thus adding to the shortage of available 

resources. Many frontline infrastructure jobs are low-salary positions. Because of the 

impending shortages, wages will probably increase in these jobs. Higher pay will help 

attract new workers; then the focus will be on retaining them. In this section, we outline 

management strategies to improve retention over the next decade. 

The section explores efforts undertaken by the private sector to ensure an adequate 

workforce through recruitment and retention strategies. These initiatives hold promise 

for correcting supply-demand imbalances in the disability services infrastructure. NCD 

strongly believes that no source of talent can be ignored moving into the second decade 

of the 21st century. That means that workforce management strategies and practices will 

have to change. 

Workforce Management 

NCD partnered with Manpower Inc. to prepare this report. In a recent study, Manpower 

surveyed the status of the existing workforce and identified opportunities.21 NCD 

believes that the findings of the Manpower survey are particularly relevant with respect 

to the disability services infrastructure. The current difficult economic climate, which has 

persisted since the end of 2007 and is likely to continue for some time, might actually 

43
help the situation in the short term. Workers who are close to retiring or have already 

retired might decide that the uncertain times require a delay of retirement or a return to 

work. This will mean that more workers than previously expected are still on the job, at 

least initially, and will allow more time to put new strategies in place to address the 

longer term shortfalls. In any case, employers need to recognize that encouraging early 

retirement and offloading older workers because of their higher salaries are no longer 

viable business strategies. In fact, salary increases and benefits that promote flexibility 

(which are as important to older workers as they are to workers with young children) 

should be considered as part of the new mindset of keeping older workers as long as 

possible, well beyond traditional retirement years. 

NCD and Manpower do not believe that a strategy of importing workers from other 

countries is likely to work. For many years, our economy has turned to immigration to 

ensure adequate numbers of workers in certain jobs. However, supply shortages of 

critical disability infrastructure occupations are occurring globally, not just in the United 

States. These workers will find opportunities in their home countries, and the increasing 

demand will likely drive up wages, reducing the allure of working in the United States. 

U.S. employers should focus on training, not only for new employees but for longer term 

employees as well, to improve productivity and provide opportunities for career 

advancement. 

Figure 3 summarizes a general strategy for dealing with shortages through a 

multifaceted approach that NCD believes will also benefit disability services 

infrastructure companies. The strategy involves identifying the current demographics of 

the workforce and forecasting how things will change over the coming decade. 

44
Figure 3. 

Forecasting and Planning for Future Retirement-Related Talent Deficits

Source: Manpower (2007). The New Agenda for an Older Workforce. Milwaukee, WI: 

Manpower, Inc. 

A demographic-based forecast will provide clues to help identify workers who are likely 

to consider retirement and those who will need to focus on elderly parents or young 

children. Tracking turnover trends will allow employers to understand replacement 

needs as well as the reasons workers leave. Inadequate pay is the reason for much of 

the turnover, but it is not the only reason. Family responsibilities are significant factors in 

different ways, depending on the employee’s age and gender. These assessments will 

suggest how employers can revamp benefit plans to attract and retain employees. 

Meanwhile, employers need to study their markets and forecast what the demands are 

likely to be—not just the number of workers but the skill sets employees must have to 

ensure that the company is competitive. Once these supply-and-demand projections are 

in place, employers can decide which recruiting, training, and retention strategies will be 

most successful. Too few employers engage in these strategic planning activities and 

thus are unprepared to deal with worker shortages. 

For employers that do plan strategically, the next task is to consistently recruit and 

prepare a competitive workforce. Figure 4 summarizes this process. 

45
Figure 4. 

Optimizing Talent Flow

Source: Manpower (2007). The New Agenda for an Older Workforce. Milwaukee, WI: 

Manpower, Inc. 

Proactive companies will partner with local schools and postsecondary education 

institutions to allow students to see firsthand what opportunities are available and to 

provide experiences for them to learn about the world of work. Students need to have 

realistic perceptions of careers early on so their career decisions are informed and 

aligned with their values, interests, and needs. Too few employers engage with schools, 

teachers, and students in their local communities. 

46
Career development should involve all employees. For new hires, employers need to 

demonstrate the long-term career potential and set them on a path to acquire skills through 

training and development. Employees should have individualized plans for developing their 

careers with their company, including internal and external learning opportunities for which 

they and their employers share responsibility. For employees in mid-career, the focus 

should be on ensuring that skills and knowledge are upgraded to mesh with changes in the 

marketplace. Workers should have a clear understanding that their companies do not want 

them to become obsolete; rather, the company wants them to remain as valuable as when 

they were first hired. Companies should collaborate with older workers to assess the needs 

of the company and the worker, and should offer flexible approaches that are mutually 

advantageous. The key to lowering turnover rates and keeping workers is to demonstrate 

to employees that they are valuable assets, and that the company wants to retain and 

promote them. Offering ongoing skill-building opportunities, accommodating employee 

needs, and rewarding workers according to their productivity are beneficial strategies for all. 

Employers can take many other steps to ensure that their employees become more 

productive and remain with the company. Employers need to establish an open and 

accepting corporate climate to ensure that workers from diverse cultures, including 

those with disabilities, feel welcome and have equal opportunities to fulfill their and their 

families’ needs. This includes the following: 

1. Offering performance-based compensation that rewards accomplishment, not 

just tenure. 

2. Treating employees with respect and expecting workers to treat each other 

with respect. 

3. Specifying expectations in a way that is clearly understood. This may require 

different approaches for different people. 

4. Ensuring that everyone has a sense of belonging and is welcomed. 

5. Treating all workers the same way. 

47
6. Providing access to equipment, tools, information, and other supports and 

resources to enable workers to efficiently accomplish their assigned tasks. 

7. Training workers to do their jobs and to adapt their skills and knowledge to 

changing circumstances; and using online technologies to provide training in a 

more timely and efficient way. 

8. Implementing a consistent, fair, and regular feedback system for workers, 

including two-way communication and flexible channels. The system should 

inform them about their strengths and weaknesses, and result in a plan they 

can implement to increase their productivity. 

9. Using teamwork approaches wherever possible so that workers understand 

how they fit in and contribute. 

10. Recognizing workers’ contributions in tangible ways. 

11. Providing opportunities for advancement. 

12. Helping workers plan a gradual transition to retirement. 

13. Keeping workers informed about the company’s progress and success in the 

marketplace. 

14. Giving workers as much assurance as possible about their job security. 

By demonstrating their will and skill in accommodating the needs of workers with 

disabilities, employers send an important message to all workers. Besides recognizing 

the potential of workers with disabilities, broadly disseminated guidelines about 

accommodations often become best practices, driving productivity enhancement for all 

workers. 

In the future, employers will face much greater challenges to ensure an adequate 

supply of qualified workers. Employers will have to provide proactive and flexible work 

arrangements for all employees and be much more sensitive to their needs. Flexible 

work schedules have already created some opportunities for women with children, but 

48
they are important for older workers and those with disabilities as well. Similarly, training 

should be a constant concern for workers at every stage of their careers. 

Recruitment Strategies 

The purpose of recruitment strategies is to identify and target the right people and bring 

them into the company. This requires a clear understanding of the skills and abilities 

that will be needed in the future to replace retiring workers and succeed in a changing 

marketplace. Figure 5 illustrates the strategy of balancing recruiting and retention to 

match future needs. 

Figure 5. 

Managing the Talent Pipeline

Source: Manpower (2007). The New Agenda for an Older Workforce. Milwaukee, WI: 

Manpower, Inc. 

49
It will become increasingly critical for employers to identify potential workers with the 

skills that will yield a competitive advantage. In addition to skills, however, infrastructure 

companies need to recruit workers who have the attitudes and values that are the 

hallmarks of those who serve people with disabilities. By practicing the proactive 

workforce management strategies outlined in this section, companies can solidify their 

reputations as employers of choice, and improve their recruiting and retention efforts. In 

light of the economic constraints most companies are experiencing, a good reputation 

can help overcome the inability to offer attractive financial packages to new recruits who 

have high potential. 

To link recruitment and workforce management, companies can partner with the 

education and training pipelines that provide entry-level and advanced skills to new and 

current workers. Partnering with these resources will help them equip students and 

trainees with appropriate skills, and provide connections for their graduates. Adding 

work experience and internships to the partnerships allows all parties to assess the 

quality of the fit between recruit and employer. This strategy can help eliminate trialand-error in the hiring process. 

Another partnership opportunity for employers exists with community-based 

rehabilitation programs and the State vocational rehabilitation agencies. These 

organizations and agencies are willing to train new workers with disabilities specifically 

for partner companies, often at no cost to the companies. The workers are then 

provided with ongoing assistance, as needed, to ensure their long-term success and 

retention. And employers can take advantage of tax credits for hiring these workers. 

This strategy can reduce labor shortages and employ people with disabilities at the 

same time. 

Companies must clearly define the skill sets needed by their infrastructure workers. For 

each job description, they need to specify essential job functions and list the 

experiences that typically provide opportunities to learn these skills. Clearly defining skill 

sets enables a company to assess whether applicants have the entry-level skills to 

begin productive service and what training they still need to gain increased productivity. 

50
Beside skills, companies need to have interview procedures in place that will reveal an 

applicant’s values and whether they are compatible with the company’s mission to serve 

people with disabilities. Without skills and values, the match is not likely to be 

successful. 

Successful Return-to-Work Strategies 

This section explores employer programs to prevent disabilities from occurring in their 

workforces and to manage the return to work of injured or disabled employees. These 

programs help retain good workers, minimize the long-term impact of injuries and 

illnesses, and demonstrate that the company values its workers with disabilities. When 

a disability infrastructure company uses these strategies, it contributes to the supply of 

infrastructure workers and provides employment for people with disabilities at the same 

time. 

Most employers have disability management (DM) programs to retain current 

employees who have suffered a disabling injury. Disability management is driven by the 

need to comply with government mandates, reduce the cost of providing employee 

benefits, and retain the skills and knowledge of valuable employees. 

DM programs are typically offered by external vendors for eligible employees as a 

benefit of employment. The process of verifying eligibility for benefits is usually much 

simpler than in public sector services. Compared with public sector services, the 

workers in these programs often have better prospects for successful return to work: 

They have been off work for only weeks or months and most still have jobs to return to. 

Consequently, these DM programs often use different staffing approaches and 

resources than public sector programs, reducing potential competition between the two 

systems over the supply of disability management occupations. 

DM programs, particularly those that are administered internally, may employ a master’s 

level professional with certification credentials who oversees programs for large work 

sites or multiple sites, or is used on a contract basis. A lean staff performs a reduced set 

51
of functions in-house; many functions are outsourced to insurance companies or other 

vendors. Two functions, however, are frequently part of an employer’s in-house staff: 

the return-to-work coordinator and the case manager. 

● Return-to-work (RTW) coordinators work with all stakeholders (medical, 

insurance, supervisors, co-workers) to develop and implement an RTW plan for 

an employee after an injury or the onset of a temporary disability. RTW 

coordinators are most common in manufacturing, utilities, construction, and 

other industries where employees perform physical work. RTW coordinators 

may have earned specialized credentials through a professional association 

with continuing education requirements. They may be experienced employees 

who have no formal rehabilitation credentials but have returned to work 

themselves after a significant disability event and have received on-the-job 

training in the RTW process. 

● Case managers orchestrate compliance with insurance or medical requirements 

during the RTW process and facilitate information exchange between the 

employer and medical providers. Case managers are used in virtually all 

industries and professions. Most medical case managers are registered nurses 

with an additional credential; those who manage insurance cases may need 

only the case manager credential. 

Research has found that successful DM programs usually include the following 

components: 

● A strong commitment throughout the workplace to health and safety. 

● An employer who makes early, considerate contact with injured/ill workers. 

● An employer who offers work accommodation to facilitate RTW. 

● An RTW plan that supports returning workers without disadvantaging coworkers or supervisors. 

● Supervisors who are trained and included in RTW planning. 

52
● The use of an RTW coordinator or case manager. 

● Exchange of information between the employer and medical providers. 

This list does not explicitly include ergonomic evaluation because most ergonomics 

goals are achieved through the work accommodation offer, which often can be 

developed in an interactive process with the returning worker without incurring the 

expense of a master’s level ergonomist to perform a full evaluation. Employers typically 

focus on returning injured/ill employees to their original job, perhaps with a modification 

to accommodate temporary or permanent impairments. 

Most employers who are active in groups such as the Disability Management Employer 

Coalition (www.dmec.org) acknowledge that there is room for improvement in their DM 

programs, including efforts to identify employees at risk for disability and systematic 

early intervention to prevent disability. These efforts could reduce the number of 

disability claimants moving from the employment sector to social services. 

Private sector return-to-work and disability management programs are a useful 

complement to the public sector disability services infrastructure. Progressive 

employers actively seek to prevent or reduce disability claims, thus reducing the number 

of people who lose employment and apply to the public sector for services. The private 

sector does not aggressively compete with the public sector for disability services 

professionals. The private sector uses master’s level professionals conservatively and 

relies extensively on credentials or designations that have a commercial insurance 

focus that is not necessary in the public sector, where greater efforts are expended on 

verifying eligibility for benefits. NCD encourages the public sector to use the recruiting, 

retention, and workforce management strategies of private sector organizations to 

reduce the gap between supply and demand in the disability services infrastructure. 

53
54
SECTION 5. Public Sector Strategies for Building 

and Maintaining a Sufficient Supply of 

Disability Infrastructure Occupations 

In this section, we describe how the public sector, in partnership with the private sector, 

can support the nation’s efforts to provide a suitable workforce infrastructure for people 

with disabilities over the next 10 years. “Public sector” refers to the tax-supported 

federal, State, and local education, health care, and employment programs that serve 

people with disabilities. The term also includes programs and systems that serve the 

overall population, including people with disabilities. All these service providers must 

ensure that they have an adequate supply of qualified personnel to help people with 

disabilities become labor market participants, improve their overall quality of life, and 

gain greater access to opportunity. 

Publicly funded programs not only require a suitable workforce to meet the increasing 

demand for their services, they also can lead by example by hiring people with 

disabilities. The Equal Employment Opportunity Commission, for example, employs 

people with disabilities at a rate that is nearly 2.5 times higher than the average for all 

federal agencies. The Social Security Administration has a “Schedule a Hiring” initiative 

with simplified hiring protocols that make it easier to hire people with disabilities. 

Public agencies and programs can establish practices and services that ensure an 

adequate supply of workers, hire qualified people with disabilities as part of their 

frontline workforce, and equip workers with the ability to provide high-quality services. 

These workforce goals can be approached using multiple strategies. First, public sector 

agencies can adopt the workforce planning management practices already in use in the 

private sector (outlined in the previous section) to recruit, hire, and retain a sufficient 

workforce. Second, the mission of many of these programs is to focus on the 

employment needs of people with disabilities and to provide them with competitive, 

marketable skills so they gain greater financial independence and improved quality of 

life. These programs can promote careers in the disability services infrastructure by 

providing information, education, skill training, connections, and on-the-job support to 

55
their consumers. People with disabilities are underemployed and, because of their 

knowledge and personal experience, are well-equipped to work in the disability services 

infrastructure. Publicly funded employment programs need to focus on the opportunities 

available to people with disabilities in their own services infrastructure. This section will 

provide an overview of potential opportunities in the public sector. Some of the data 

presented can be used as benchmarks or performance indicators of outcomes achieved 

in public sector programs. These measures can give us a sense of the quality of 

services provided, which we can then use as a baseline to assess improvements 

anticipated over the next 10 years. It is not enough to have an adequate number of 

workers; we need an adequate supply of qualified workers. 

Employment Services for People with Disabilities 

State-Federal Vocational Rehabilitation Services System 

The flagship of employment services for people with disabilities in the United States is 

the State-federal vocational rehabilitation (VR) program. Eighty programs, under the 

leadership of the Rehabilitation Services Administration (RSA) of the U.S. Department 

of Education, exist throughout the 50 States. Some States have two agencies: one to 

serve the general population of people with disabilities and a second to serve people 

with vision impairments. A primary goal of these agencies is to help people with 

disabilities become more independent through employment. 

Each year, these agencies serve more than 600,000 people with disabilities; more than 

200,000 of these people obtain jobs in the community. According to 2006 data, more 

than 205,000 people with disabilities were placed in jobs that year as a result of 

receiving services from the VR program. Of these, it is estimated that more than 28,000 

(14%) were placed in disability services infrastructure jobs. Although this is a fairly high 

proportion, it can be even higher, as the demand is likely to be much greater in the 

foreseeable future. 

VR agencies and programs need to focus on outreach strategies to infrastructure 

employers so that connections to jobs are more readily available to consumers of VR 

56
programs. Private-public partnerships for training and placing people with disabilities 

with infrastructure employers have been successful and should be expanded, and onthe-job training has been a consistently successful strategy for employing people with 

disabilities. Formal training and education programs for preparing people for 

infrastructure jobs funded through the VR system also need to be expanded to 

accommodate the increasing number of referrals from the VR. 

In June 2009, the unemployment rate for people with disabilities was 14.3 percent, while 

the overall rate was 9.5 percent. A month later, in July, the unemployment rate for people 

with disabilities jumped to 15.1 percent, while the rate for those without disabilities 

remained at 9.5 percent. Given the high demand for infrastructure positions, many 

employment and long-term career opportunities should be available in this sector for people 

with disabilities. Many people with disabilities are placed in entry-level jobs that pay low 

wages,22 but this is true for the population in general. However, these jobs need to have 

career potential so wages can increase and people can attain their desired quality of life. 

Studies point to the need to focus on services that build an employer-consumer 

connection before placement, so doors will open more readily for people with 

disabilities.23 Finding a job should not be left to chance; direct support services are 

needed to help a person get that first placement. Ongoing support and training during 

the early stages of holding a job also appear to be valuable contributing factors to longterm success. Developing services to help employers hire people with disabilities—such 

as accommodation support, job-matching, on-the-job support services, and disability 

management—can also benefit the employment prospects of people with disabilities. 

VR programs need to build their capacity to be direct intermediaries in the labor market 

so that many more people with disabilities obtain jobs with career potential. 

In 2007, the Government Accountability Office ( ) analyzed the State-federal VR 

system’s ability to serve beneficiaries of Social Service Disability Insurance (SSDI) who 

were seeking to return to work.24 The results were uneven, but the report identified 

certain factors that seemed to achieve desired outcomes. They included the following: 

57
1. Close ties to the business community. 

2. Collaboration with other agencies. 

3. Spending a greater proportion of their funding on training. 

Agencies with a higher proportion of certified counselors were more likely to help 

beneficiaries become employed and independent of SSDI income supports. 

NCD conducted a review of State VR agency programs for youth with disabilities 

transitioning from school to work and offered recommendations to improve services and 

outcomes (NCD 2008).25 The NCD report concluded that transition-age youth were 

definitely becoming more of a focus for the VR agencies and that programs should 

concentrate on the following: 

1. More rigorous research and evaluation are needed. It was not clear which 

services contributed to the desired outcomes, because the research base did not 

have adequate methodologies to establish evidence-based practice guidelines. 

2. VR agencies should establish specialized units of professionals dedicated to 

serve this population, and should devote training resources to this area. 

3. VR agencies should continue to build on their collaborations with schools and 

other community-based organizations to serve these youth. 

Finally, GAO conducted a review of the overall performance of the State-federal VR 

system.26 The review analyzed how well the system monitored its own performance so 

that ongoing improvements could be made on the basis of feedback. Conclusions 

included the following: 

1. Monitoring was not timely and needs to be speeded up. 

2. Outcomes for specific populations, including transition-age youth and SSDI 

beneficiaries, are not tracked; thus, it is difficult to measure the success of 

policy initiatives undertaken for various groups of people with disabilities. 

58
3. The extent to which the VR system meets the needs of the population it is 

intended to serve is not clear. Although the system serves a large number of 

people each year, it is not known how many more people need the service. 

4. No incentives or sanctions exist to help VR agencies focus efforts on improving 

their performance in desired directions. 

Department of Veterans Affairs 

The Department of Veterans Affairs (VA) offers a vocational rehabilitation program to 

veterans with disabilities. GAO conducted a review of this program in 2008 and 

prepared a report to Congress.27 The reported concluded that the VA VR program was 

improving by having service tracks tailored to the different needs of veterans but that 

the focus on employment services, as opposed to training and education, was lagging 

behind. The report recommended that incentives for veterans to attend schools and 

training programs be extended to veterans who were on track for direct placement into 

jobs. The VA was commended for collaborating with other programs in pursuit of direct 

employment, but GAO believed that more could be done. 

In particular, the VA VR program was encouraged to continue building on its 

collaboration with State VR agencies, primarily to take advantage of the employer 

networks these agencies have in place. The VA VR program was encouraged to build 

its own relationships with employers to improve direct employment opportunities for 

veterans with disabilities. Finally, GAO commented that the VA needed to engage in 

strategic planning to determine its workforce needs, because too many regional offices 

lack the necessary staff to fully implement the direct employment service program. This 

is increasingly important as the wars in Iraq and Afghanistan create increasing numbers 

of veterans with disabilities. 

Another significant workforce opportunity is the VA’s new Post 9/11 GI Bill of 2008, 

which took effect in August 2009, creating new education benefits for service members 

who have been on active duty for 90 or more days since September 10, 2001. These 

benefits are tiered on the basis of number of days of active duty, which gives currently 

59
and previously activated National Guard and Reserve members the same benefits as 

active duty service members. The benefits include the following: 

1. Up to 100 percent tuition and fee coverage. 

2. A monthly housing stipend. 

3. Up to $1,000 a year for books and supplies. 

4. A one-time relocation allowance. 

5. The option to transfer benefits to family members. 

It is hoped that the VA will use these generous benefits not only to assist veterans with 

their career needs but also to connect them to the vocational possibilities of the 

disability services infrastructure, including the workforce needs of the VA itself.

Ticket to Work of the Social Security Administration 

No discussion of employment programs for people with disabilities is complete without 

mentioning the Ticket to Work and Self-Sufficiency Program based in the Social 

Security Administration. The program has potential, but to date it has not met 

expectations as far as helping SSI and SSDI beneficiaries replace benefits with 

employment. 

Several trends offer hope that the Ticket program will improve on its past performance. 

In July 2008, SSA implemented new rules making the program much more attractive to 

private sector employment networks (ENs) that serve consumers. The new rules 

provide a much more favorable environment for collaboration between State VR 

agencies and ENs. These infrastructure improvements are expected to increase the 

number of ENs providing services from the 1,200 enrolled in 2008 to 5,000. 

The Ticket program is not based on a fee for service. Rather, providers are paid only if 

they generate employment outcomes leading to termination of SSDI benefits. Many EN 

providers are private sector nonprofits already participating in other government 

60
programs to serve people with disabilities. Some are for-profit companies that have 

streamlined methods to secure job placement, which is to be expected under an 

outcome-based program. 

The Ticket program and other SSA initiatives could change the economics of disability 

insurance and disability services in the United States. While State VR agencies have a 

mandate to serve people with significant disabilities, the Ticket program makes it more 

profitable for ENs to serve people with less significant disabilities. Ideally, the Ticket 

program can secure employment for these people and reduce the numbers of SSDI and 

SSI beneficiaries. In turn, this would reduce the demand on the Social Security Trust 

Fund, which is an important goal. 

In addition, private sector disability insurance carriers routinely seek to place their longterm disability beneficiaries on SSDI to reduce the carriers’ own costs. While many of 

these people are entitled to SSA disability benefits, the Ticket program could be 

modified in ways that would motivate insurance carriers to maintain a longer term 

commitment to help people return to work, thus reducing their own costs over time. SSA 

has an early intervention demonstration project that would essentially use a return-towork attempt as part of the disability determination process, with protocols aimed at 

both VR agencies and ENs. In addition to reducing the rate of approval for SSDI 

benefits, this program could change the disability culture at SSA into a more 

employment-focused culture. Many people in the insurance industry and the general 

public perceive SSDI as a “permanent and total” workers’ compensation claim, yet SSDI 

need not be a direct route to permanent disability status. 

Among the quality-monitoring improvements in the new rules, the Ticket program 

rewards EN providers that help people stay employed for 5 years or more. SSA is also 

researching other improvements to work incentives that could give beneficiaries a more 

favorable benefits scenario for seeking employment. 

Any public-private partnership of this magnitude—based in an agency as large as SSA, 

which has other primary goals—is bound to face challenges. But the new Ticket 

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program rules and other efforts at SSA, combined with private sector investment in 

serving people with disabilities, are beginning to address those challenges. 

Workforce Investment Act (WIA) and One-Stop Centers 

Another key program serving people with disabilities is the One-Stop Center created by 

the Workforce Investment Act of 1998 (WIA). The WIA is designed to integrate the 

entire workforce development system funded through the Federal Government in each 

of the States. One-Stop Centers are the hub of this effort—they provide comprehensive 

services to job-seekers and employers on a local basis throughout the nation. Included 

in this network of employment services are the Employment Service and the 

Unemployment Insurance program. The State-federal VR program is also a mandated 

partner. 

State and local Workforce Investment Boards are in place to ensure that services 

address local needs. These boards must have a majority of private sector 

representatives as well as representatives from human services agencies, including 

educational systems. One-Stops are required to collaborate and integrate services with 

the local offices of the State-federal VR system. This can go as far as co-locating staff 

from the two systems to ensure coordinated planning and allocation of resources at 

both the organization and individual consumer levels. GAO studied exemplary One-Stop 

programs; the findings suggest that One-Stops need to incorporate the following 

components into their services:28

1. Seamless access to all services. 

2. Services for employers, with dedicated staff to ensure that employers’ needs 

are considered. 

3. Strong collaboration with other community-based programs that increase and 

focus resources on workforce development. 

However, in spite of the intention of the One-Stops to increase accessibility, a recent 

study indicates that access issues remain for people with disabilities.29 These issues 

62
include physical access, in that One-Stop locations are not within reasonable distance 

for many people with disabilities; inaccessible space; and difficult internal program 

referrals. A 2007 GAO study found that fewer States reported VR co-location sites than 

in an earlier study, although more reported having electronic referral capabilities.30

Another study identified the following limitations in One-Stop services for people with 

disabilities:31

1. Inaccessible locations. 

2. Inaccessible computer equipment, which WIA consumers are expected to use. 

3. Automatic referral of people with disabilities to the VR program without first 

providing WIA services. 

4. WIA outcome measures focused on employment, earnings, and credentials of 

those who exit the programs. This emphasis may be a disincentive for OneStops to serve people with disabilities, who, as a group, tend to have lower 

employment and earnings rates. However, this is one of the very issues WIA 

programs are designed to address. 

Given the problems in recognizing the service needs of people with disabilities, the WIA 

One-Stops are not likely to be sensitive to the disability services infrastructure. Although 

these issues may be alleviated to some extent as time goes on, a more deliberate 

emphasis and focus on the employment and service needs of people with disabilities 

seems warranted. 

New Technologies, New Opportunities 

VR and employment programs need to take advantage of new technologies to assist 

people with their employment needs. Using these technologies, it is possible to imagine 

new ways to empower people with disabilities to access many more labor market 

opportunities. VR agencies need to be on the cutting edge of how to use these 

technologies for the benefit of people with disabilities. Many innovations are being 

63
driven by Web 2.0 technologies, which hold great potential to improve work 

opportunities and quality of life for people with disabilities everywhere. 

New software and computer network technologies, and their broader acceptance and 

use in our daily lives, suggest a good business case for rehabilitation uses. The new 

breed of inexpensive, fast, reliable Web-based solutions is empowering persons of all 

backgrounds to take greater control over their lives, and they are environmentally 

friendly as well. 

The growth of Internet and other technologies, driven by the reduced costs of global 

communication, is changing how we think, socialize, shop, and learn, and influencing 

how we will work in the future. Technological innovation is driving change—behavioral 

change in particular. The change is good news for people with disabilities, and it is here 

to stay. Trends worth highlighting include social networks built on Web 2.0 technology, 

and SaaS (software-as-a-service) and Cloud Computing, which enable companies to 

bring transformative innovation to the world of work. 

Social networks are having a huge impact on how people socialize, gather information, 

stay informed, and solve problems. As this new medium gains wider acceptance and 

adoption in both personal and work environments, it can be further customized to focus 

on particular subsets of populations, targeting their specific needs and wants. We can 

explore new applications of social network platforms to create communities specific to 

people with disabilities, in which people with similar interests and needs can exchange 

volumes of useful information instantly and at minimal cost. 

To see how this might work in practice, consider www.myvetwork.com, a fast-growing 

social network platform, custom-designed for persons associated with the U.S. military 

(active duty or veterans) and their spouses, families, and friends. (Compliance is not 

required of nongovernment organization Web sites, but the Internet sites mentioned 

here should comply with Section 508 of the ADA. The degree of compliance may 

change at any site at any time.) Recognizing this group’s unique needs and challenges, 

64
MyVetwork is creating a unique, independent, trusted source of information driven by its 

members’ collective interests and desire to stay in touch. 

The second trend is the proliferation of technologies that hold the promise of changing 

how work is done or—even more important—where it is done. The advent of the 

Internet makes it possible for work to come to us. The barriers to flexible work have 

been removed, benefitting both workers and the companies they serve. People have the 

freedom to structure their time around family and other needs. Workers are empowered 

and new opportunities exist for those who have traditionally been left out of the 

workforce. People with disabilities, retirees, stay-at-home moms, dislocated workers 

from industries that permanently left local communities—these people have a vast array 

of skills, and now they can offer their services to companies that are increasingly 

looking for talent that may not be available in their local labor markets. 

The opportunity for cost savings and improved productivity for corporations is tremendous, 

and they are starting to adopt the new mindset. Industry leaders in SaaS and Cloud 

Computing are developing technologies that enable them to link corporations looking for 

talent with “virtual workers” and home-based workers who prefer to work flexible hours or 

work from a distance. It is all about options and choices benefiting both individuals and the 

corporations that employ them. People with disabilities can make those choices on a large 

scale for the very first time, as much as any other group of workers, and they can realize 

the benefits of working from home or from any other location they desire. 

A technology platform that provides services to both employers and teams of 

employees is called www.livework.com. LiveWork offers employers high-quality work 

and accountability, and independent workers (referred to as “experts”) gain an 

infrastructure and the option of working for multiple companies. Both the companies and 

the experts can count on efficiency and community. With LiveWork, companies can 

outsource work to communities of virtual workers without the need to sign lengthy 

contracts with outsourcers. Any business can advertise its need for virtual workers and 

workers can find projects, as well as promoting their own services. Each worker’s profile 

includes information about his or her work history, reputation, and so on. 

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LiveOps (www.liveopps.com) has developed the leading on-demand contact center 

platform, which it uses to operate a virtual work community of 20,000 independent 

agents in the call center space. LiveOps is in a unique position to take this concept to 

the next level and create the next-generation technology platform that could 

revolutionize the world of work: an online marketplace that enables teams of free agents 

to sell their expertise and services to buyers of labor. This networked community of 

workers is a central market where buyers and sellers can convene, create work teams, 

converge, and transact business. 

LiveOps intends to do for the world of work what eBay did for commerce, and 

technology has advanced to the point that such an endeavor is possible. At the same 

time, three worldwide trends are converging to create a perfect environment for a global 

labor market: ever-increasing productivity, globalization, and environmental 

stewardship. 

A nondiscriminatory virtual employment market is further supported by the corporate 

trend of using talent management and applicant tracking software (also delivered as 

SaaS) to automate recruitment, assessment, hiring, and on-boarding processes. The 

automation helps employers with compliance while at the same time having a positive 

effect on employment of special groups. It is a win-win situation for employees and 

employers. People with disabilities need to have access to these technologies so they 

can participate competitively in these new labor markets. 

Health Care for People with Disabilities 

Access to health care is a major concern of people with disabilities everywhere.32

Studies describe either the lack of access to appropriate treatment or the receipt of 

inappropriate or perhaps even harmful treatment as a result of the lack of knowledge 

and experience of treatment providers. 

One solution being considered in health care reform is the “medical home model,” built 

around the relationship between the primary care physician and the patient. The physician 

66
is expected to get to know the patient and his or her needs, and coordinate all needed care 

with other treatment providers. If this approach is successful, it will help ensure that people 

with disabilities get the treatment they need, at the right time and from the right provider. 

However, there are not enough primary care physicians to met current and future demand, 

especially if this model is introduced as part of health care reform. 

Electronic medical records are touted as a technology that can improve the quality of 

services and reduce costs at the same time. These systems have the potential to 

provide substantial benefits to physicians, clinic practices, and health care 

organizations. They can facilitate workflow and improve the quality of patient care and 

patient safety. The Institute of Medicine has identified the application of information 

technology as a primary means to improve the quality of health care. However, health 

care IT professionals are in short supply. Recognizing this, the Administration and 

Congress included the Health Information Technology for Economic and Clinical Health 

Act (HITECH) as part of the American Recovery and Reinvestment Act (ARRA), and 

provided $19 billion for health IT. Not only is this investment potentially significant for 

the health of people with disabilities, it presents career opportunities for them that the 

VR and education systems need to pursue. 

The current health care reform debate (fall of 2009) is of central importance to everyone 

who is concerned about the health of this significant population. The debate seems to 

focus primarily on the costs associated with various reform proposals rather than on the 

quality of care provided. Of course, cost is a factor in quality, but it is not the only factor. 

ARRA and the various health care bills being debated all include investments in the 

quantity and quality of health care personnel at all levels of the continuum. To illustrate, 

on July 28, 2009, the Department of Health and Human Services announced that 

$200 million in ARRA funding was available for the training and financial support of 

health care professionals. These funds will be used for scholarships, loans, grants, 

primary care training programs, and increasing the diversity of the professional 

workforce, among other purposes. Another $300 million in ARRA workforce funds will 

be used to expand and develop the Health Resources and Services Administration’s 

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(HRSA’s) National Health Service Corps. When health care reform becomes a reality, it 

is likely that more services will be needed to meet the increased demand. Given that a 

shortfall in personnel is projected under current scenarios, any increase in services will 

only increase the supply-demand gap. Using ARRA and health care reform funding not 

only to expand but also to improve the quality of services will be imperative, if costs are 

to be controlled and outcomes improved. 

It is not clear how the anemic economy will fare in the next few years; however, evidence 

exists of increasing demands on the Medicare system as applications for SSDI benefits 

rapidly escalate. This is to be expected, with many people nearing retirement age or being 

laid off. Under more favorable circumstances, they might continue working despite health 

conditions. But with no work available, these conditions can be used to obtain SSDI along 

with Medicare. Even before the economic downturn, it was clear that Medicare funding 

streams would not be sufficient for future needs. Now the recession is likely to bring more 

beneficiaries into the system, with a corresponding shortfall in tax revenue owing to high 

levels of unemployment, putting Medicare funding in a vise. 

A core issue in the current debate is that providing more services to more people will 

increase the pressure on the health care system and will continue to drive up costs, as 

demand outstrips supply. Depending how the issue of cost is resolved, many different 

things could happen. If more costs are shifted to employers, they might lay more people 

off or keep wages low, thus further reducing the supply of disability service workers. If 

costs are moderated by controls placed on what health care providers can charge, 

incentives to enter the field will be diminished, thus contributing to a future imbalance 

between supply and demand. Until health care reform becomes a reality, it will be 

difficult to anticipate and plan for sufficient infrastructure staffing. Many administrators of 

health care and social service programs hesitate to use stimulus money to hire staff, 

because the funding is only temporary and the means to maintain these new staffing 

levels are not likely to emerge in the current economy. Thus, whatever programming 

can be done in the short term with stimulus funds to train and upgrade the skills of 

current health care personnel would seem to be a wise investment. Similarly, reducing 

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the costs of entering the health care field by providing funds for tuition and related 

education/training costs, including improving access to needed credentials, would likely 

entice more people to pursue health care careers and mitigate the projection of an 

imbalance between supply and demand. 

Education and Youth with Disabilities 

The education system focuses on providing the foundation for students to become 

productive, independent citizens. For most, this means pursuing postsecondary education 

and training, or becoming employed. Employment for youth with disabilities is a concern for 

the VR system and for the schools, but in spite of efforts over the past decade to increase 

collaboration between VR agencies and schools, improvements in outcomes are lagging. In 

general, unemployment rates for youth ages 16 to 19 years are about three times higher 

than the rates for older workers. For those 19 to 24 years old, the rate improves somewhat 

but is still about double the rate of other age groups. Of course, employment rates are 

lower because many in these age groups are in educational and training programs. It is 

well known that early employment experiences and successful completion of academic and 

training programs translates into long-term gains in employment, financial independence, 

and quality of life. It is important that youth with disabilities become engaged in personally 

productive activities, such as further education and employment, to whatever extent 

possible after they leave secondary education. 

One national study presents an exceptionally robust and useful window on the impact of 

education on employment-related experience of youth with disabilities. Longitudinal 

research sponsored by the Department of Education and conducted by SRI International 

has followed a nationally representative sample of more than 11,000 special education 

students since 2000. A 2009 report presented findings describing the experiences of these 

youth, who had left high school by 2005.33 In some instances, data collected from them 

was comparable to data collected from youth in the general population. Comparisons of the 

data enable us to measure the similarities in the post-high school experiences of youth with 

and without disabilities. Much of the effort in policymaking and practice innovations over the 

past 30 years has been devoted to providing accommodations to youth with disabilities so 

69
they can compete with their peers when they reach adulthood. The following are some of 

the more salient peer comparison findings from the 2005 data (unless otherwise noted, 

these results refer to youth with disabilities): 

1. Forty-five percent of youth with disabilities continued on to some 

postsecondary education within 4 years of leaving high school, while 

53 percent of youth without disabilities did so. 

2. Fewer were likely to be attending 4-year institutions (8% vs. 29% of youth 

without disabilities). 

3. Fifty-five percent of those who were identified as having a disability during their 

secondary education did not consider themselves as having a disability during 

their postsecondary experiences. 

4. Of those who reported their disability status to their postsecondary institution 

(37%), fewer received accommodations than when they attended secondary 

schools (24% vs. 84%). 

5. A large majority who received accommodations believed that they were helpful 

and that they were getting the right assistance. 

6. Almost 90 percent of the students reported that they were pursuing a specific 

degree or certificate. 

7. Seventy-two percent reported having worked at some time since leaving high 

school, with some holding up to three jobs. Of the latter, 58 percent reported 

working full time at one of their jobs. 

8. Of those who held jobs, 19 percent reported that their employers were aware 

of their disabilities and 3 percent reported receiving accommodations. 

9. A majority of working youth reported liking their jobs (85%), being well treated 

(87%), and receiving good pay and advancement opportunities (67% and 78%, 

respectively). 

10. Eighty-five percent had been engaged in employment, postsecondary 

education. or training since leaving high school. 

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11. Approximately 20 percent did not complete high school. Differences between 

them and their counterparts who finished high school showed up almost 

immediately. 

12. Noncompleters were less likely to enroll in postsecondary education (51% 

vs.17%) and more likely to have engaged the criminal justice system. 

These findings show that a high proportion of youth with disabilities actively prepare for 

their futures in positive ways, in numbers that are comparable to those for youth without 

disabilities. However, certain evident disparities—in completing secondary education 

and moving on to postsecondary opportunities, particularly 4-year programs, and in 

access to accommodations during postsecondary education—require ongoing attention. 

Any gaps at this early stage of career building and community participation will be more 

difficult to make up as time goes on. 

Community Colleges 

The system of community colleges throughout the United States is the perfect resource 

to help youth with disabilities transition to productive adulthood. Community colleges are 

increasingly seen as the key link between students and their careers. One of their 

strengths is their focus on career and technical education (CTE), which often directly 

connects students with work experiences. 

The College and Careers Initiative, sponsored by the U.S. Department of Education, 

funds programs that link high school students with career tracks that extend to 

associate or bachelor’s degree programs, or certification programs. These programs 

make direct connections between high school and postsecondary curricula, eliminating 

the problem students often face of having to take courses that are irrelevant to their 

career pursuits. The programs also strive to eliminate the problem of transfer credits 

between 2-year and 4-year colleges. 

CTE programs include employers as partners to ensure that students acquire needed 

skills and experiences, and that job opportunities are available when students complete 

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their programs. The goal is to keep students involved all the way through to completion 

and to connect them with high-demand jobs. This is a highly promising approach to 

address the workforce imbalance in the disability services industry. The career 

pathways pioneered by community colleges should be adopted as a workforce 

development strategy. For example, in the health care industry, a career pathway would 

enable youth to become nurse aides, then practical nurses, and eventually registered 

nurses or even nurse practitioners. 

Summary 

In the three critical sectors of education, health care, and employment, major efforts to 

provide opportunities to people with disabilities are meeting with success. Many people 

with disabilities are participating in life arenas of their choice because they took 

advantage of a disability services infrastructure that offered a continuum of 

opportunities. And many businesses, educational institutions, and community-based 

organizations are providing needed accommodations, enabling all of society to benefit 

from the contributions of people with disabilities. But although many positive signs and 

trends are apparent, discrepancies in key quality-of-life areas remain to be overcome. 

Positive momentum is threatened by workforce shortages that were projected even 

before the current recession. 

Near-term efforts are needed to engage the political process to do the following: 

● Maintain current services. 

● Invest now in accommodating current and future workforces. 

● Strategically plan how public and private sectors will work together to engage all 

people with disabilities in economic and social infrastructures. 

This can be the era when the United States moves from a gaping patchwork of 

programs to a strategically driven disability services infrastructure, staffed by highly 

qualified workers. 

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SECTION 6. Recommendations 

This NCD review indicates that the disability services infrastructure has grown stronger 

over the past 20 years and has addressed serious deficiencies associated with the 

quality of life of people with disabilities. However, most of the indicators suggest that 

quality of life for these people still lags behind that of others in our society. The 

infrastructure must be enhanced, both in terms of the number of workers needed to fill 

the required positions and in terms of the skill levels, tenures, and organizational 

supports provided to them, including wages and benefits. Data indicates that the need 

for these services will increase, especially as the baby boomers age into their retirement 

years, increasing the demands on infrastructure resources. Couple the increased 

demand with the boomers’ withdrawal from the workforce, and the imbalance between 

supply and demand is inevitable. Knowing in advance that this will happen compels a 

proactive response as soon as possible. We should not let any difficulties deflect us 

from the goal of ensuring that all services and their expected outcomes support 

participation by people with disabilities to the same extent that they support the 

participation of other citizens in any social enterprise. The following recommendations 

focus on actions that should be considered in this light. 

Recommendation 1:

Establish a mechanism to track ongoing economic, social, labor market, and 

professional developments so that new information can be used to redirect 

planning and actions in support of the disability services infrastructure. The reality 

of the future workforce may bear little resemblance to the projections provided 

here, and unforeseen events and forces might change the balance between supply 

and demand. These events and forces must be identified and accounted for 

quickly. The Departments of Labor and Education should partner to provide 

leadership to the nation on this issue. 

Recommendation 2:

Currently, not all occupations specific to the disability services infrastructure are 

tracked by the Bureau of Labor Statistics (BLS), which makes it difficult to plan for 

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shortages. In addition, these occupations are not well known to the general public, 

because information about them is hard to find. More definitive coverage of these 

occupations in the BLS data system would be very useful in overcoming workforce 

supply and demand imbalances. 

Recommendation 3:

Among its many potential labor sources, our society needs to fully tap the 

underutilized pool of workers with disabilities. The infrastructure agencies—

including the State-federal vocational rehabilitation (VR) system, the Department of 

Veterans Affairs (VA), and private sector companies that serve people with 

disabilities—must begin planning strategically to hire more workers from the 

population they serve. Accommodations are critical to making this happen. 

Infrastructure buildings and transportation systems need to be fully accessible if 

significant employment gains are to be made by people with disabilities. The 

Department of Transportation should be in the forefront, leading the way to 

resolving transportation issues. 

Recommendation 4:

Ensure that partnership opportunities are encouraged between the public and 

private sectors. Combined public-private initiatives will be required to provide the 

strategic planning to fully fund and provide for the social, educational, and health 

care needs of all citizens, not just those of older people or people with disabilities. 

Given their presence in communities in each of the 50 States, VR agencies and 

Workforce Investment Act (WIA) One-Stops are ideally positioned to ramp up 

collaboration with each other and with local employers and education-training 

programs. 

Recommendation 5: 

Establish systematic efforts to acquire information on the supply of infrastructure 

workers. Collect data from universities, training programs, professional 

organizations, and unions to track current and future workforce supply. The private 

sector and all levels of government must pay attention to how education and 

74
training resources, including those of employers, should be realigned for the 

development of the future workforce. Supply pipelines for infrastructure occupations 

need resources to expand current education and training programs, and to create 

new ones. Facilities and faculty/trainers need to be available quickly and in 

sufficient numbers. The National Institute on Disability and Rehabilitation Research 

should establish appropriate data collection systems. 

Recommendation 6: 

Promote opportunities to encourage new entrants into critical infrastructure 

occupations, such as home health aide, personal care assistant, mental health 

worker, and rehabilitation counselor. Publicize career opportunities in these and 

related infrastructure occupations through a variety of media channels, including 

social networking media. Target school- and college-age youth, educational 

institutions, and community employment support agencies. Schools, colleges, 

community-based organizations, and employers should expand their offerings, and 

career counseling personnel should encourage youth to consider careers in these 

occupations. In particular, vocational rehabilitation agencies and programs need to 

inform consumers with disabilities about opportunities in these occupations. Again, 

the federal Departments of Labor and Education should share the lead in this effort. 

Recommendation 7:

Infrastructure employers will have to increase the salaries and benefits, and provide 

training to upgrade the skills and value of their employees if they are to attract and 

maintain a suitable infrastructure workforce. Providing greater flexibility in work 

schedules and hourly work arrangements would attract a greater diversity of 

workers. Employers need to offer incentives to older workers to keep them on the 

job longer. Professional and business associations should promote this effort with 

their memberships. 

Recommendation 8: 

Many of the disability infrastructure occupations with strong future demand 

characteristics have credentialing requirements. Because these requirements 

75
ensure a high level of service quality, they must not be weakened or compromised. 

However, developing new ways to achieve the necessary competencies and 

credentials would turn transferable opportunities into viable solutions to worker 

shortages. Workers who have already demonstrated successful tenure in related 

occupations should not be discouraged from pursuing opportunities in other 

infrastructure occupations. 

Facilitating career advancement for people in lower tier jobs will require creative 

approaches to overcoming credentialing barriers where they exist. Employers, 

credentialing agencies, and education and training programs should develop 

creative alternative credentialing opportunities. Gaining credentials for higher level 

jobs through education and training while on the job is one approach to developing 

these opportunities. Distance learning opportunities, coupled with on-the-job 

training, need to be tapped to create new credentialing avenues. Overcoming 

credentialing barriers that prohibit movement of skilled workers across 

infrastructure occupations should become a high priority. The Department of 

Education should partner with State and professional credentialing bodies to create 

smoother pathways to enter and advance in disability infrastructure careers. 

Recommendation 9: 

Programs that serve people with disabilities, including the State/federal vocational 

rehabilitation system, as well as Work Force Investment programs intended to 

assist the general population, need to work more closely with one another and 

partner more with infrastructure employers to ensure that an adequate flow of job 

candidates, with and without disabilities, is channeled to fill job openings. These 

programs need to be fully accessible, including facility and services accessibility. 

They also need to use new Internet technologies to support service delivery. 

Infrastructure employers need to see these programs as valued recruiting 

resources for the workers they need. The programs need to include performance 

measures that show their success at placing candidates into infrastructure jobs. 

Such indicators will be useful to achieve a better workforce supply and demand 

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77

balance. Leadership for this effort should rest with the Departments of Labor and 

Education, as well as the VA and the Social Security Administration. 

Recommendation 10: 

An ongoing, coordinated effort is required to systematically monitor how well the 

disability services infrastructure is responding to people’s needs. A consortium of 

federal agencies—each with responsibility for some aspect of quality of life for 

people with disabilities—should design a system to collect and share data. The 

agencies would include the Census Bureau, the Departments of Labor and 

Education, and the Centers for Medicare and Medicaid Services. 

Recommendation 11: 

Research must be funded to develop a strong evidence base for the services 

offered by employment, health care, and education support programs. Improved 

practice is needed to serve job candidates as well as employers, to ensure that 

properly trained workers are successfully hired, retained, and provided with career 

opportunities in infrastructure occupations. The Departments of Education and 

Labor and the National Institutes of Health have important roles to play in 

implementing this recommendation. 

People with disabilities from all walks of life and all backgrounds are a vital component 

of our society. It is time to implement these recommendations and commit resources to 

pursue opportunities for their full participation in all aspects of our society and economy.
78
APPENDIX A. Literature Abstracts 

79
80
Abstracts for Section 2: National Trends, Gaps and Barriers, and Their 

Implications for People with Disabilities and the Disability Services 

Industry 

Education Issues 

Carlson, E., Daley, T., Bitterman, A., Heinzen, H., Keller, B., Markowitz, J., Riley, J., & 

Westat (2009). Early School Transitions and the Social Behavior of Children with 

Disabilities: Selected Findings from the Pre-Elementary Education Longitudinal Study. 

Washington, DC: National Center for Special Education Research. 

Purpose: Reviews the 5-year Pre-Elementary Education Longitudinal Study 

(PEELS), which examines the characteristics of 3,104 children with disabilities ages 

3–5 who received special education services in preschool. 

Findings: 

● 70% of children between school years 2003–04 and 2004–05 transitioned to a 

new grade, school, or program. 

● There were no significant differences based on teacher’s reports relative to 

ease of transition. 

● There were some differences based on parent reports relative to ease of transition. 

● Many children who move from preschool to kindergarten are declassified. 

● School readiness plays an important role in ease of transition. 

● Teachers, especially special education teachers, used a variety of strategies to 

facilitate transition. 

● Teachers reported more behavioral issues than parents. 

● Males who received special education services for 3 years had more 

behavioral problems. 

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● Males and females who received special education services for 3 years had 

significantly lower social skills than those who received services for less than 3 

years. 

Kundu, M., & Dutta, A. (2003). Disability-related services: Needs and satisfaction of 

postsecondary students. Rehabilitation Education, 17(1), 45–54. 

Purpose: Determine university need for and satisfaction with disability-related 

support services. 

Findings: 

● Over the decade studied, there was a 90% increase in the number of colleges 

and universities admitting people with disabilities. 

● Proportion of postsecondary students with disabilities increased from 2.6% in 

1978 to 17% in 2000. 

● About 6% of all undergraduates and 4% of all graduates and first-professional 

students identified themselves as having a disability. 

● Institutions of higher education must enhance the size and diversity of disabilityrelated support services. However, many educational settings have not kept 

pace with the increases in the number of students enrolling in their institutions. 

● Accessibility and availability of support services have traditionally played a 

decisive role in the selection of a postsecondary institution by a student with a 

disability. 

● Of 3,680 institutions admitting students with disabilities from 1996 through 

1998, 98% provided at least one support service, 88% provided alternative testtaking formats or additional time, 77% offered tutorial services, 69% offered 

readers/note-takers, 62% provided registration assistance or priority class 

registration, 55% provided assistive listening devices or talking computers, 45% 

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offered sign language interpreters/translators, and 42% offered course 

substitutions or waivers. 

● Many of the hindrances encountered by students in obtaining support services 

are the direct result of unrecognized need rather than lack of institutional ability. 

● Men expressed a higher need for services than women; married and 

separated/divorced students had more need than single students; sophomores, 

graduate students, and those pursuing other degrees reported a higher level of 

need than other students. 

● Sophomores had more satisfaction with services, men had higher satisfaction 

than women, students with a good GPA (3.0–4.0) were more satisfied, and 

those who had never married or were separated/divorced expressed greater 

satisfaction. 

83
Torres-Burgo, N., Reyes-Wasson, P., & Brusca-Vega, R. (1999). Perceptions and 

needs of Hispanic and non-Hispanic parents of children receiving learning disability 

services. Bilingual Research Journal, 23(4), 319–333. 

Purpose: To (a) determine whether and how the reported involvement and 

perceptions of Hispanic and non-Hispanic parents of children with learning 

disabilities differed with respect to the special education process in a large, 

culturally diverse urban school district, and (b) suggest ways in which the 

involvement of parents from diverse cultural and linguistic backgrounds might be 

advanced by local school personnel. 

Findings: 

● Hispanic parents of children with disabilities are at risk for poor treatment in the 

public school system; for example, opportunity for meaningful dialogue with 

parents is compromised when special ed teachers speak only English. 

● Many urban parents, regardless of their cultural and linguistic backgrounds, are 

not adequately included in some of the most basic aspects of the special ed 

process in the public school system; for example, knowing what an 

Individualized Education Plan was and receiving a copy of their child’s IEP. 

● While Hispanic and non-Hispanic parents are relatively satisfied with the 

services provided, urban parents, particularly urban Hispanic parents, are often 

provided with superficial opportunities for involvement in the special ed process 

rather than the extensive parent-professional interaction necessary to form 

equal partnerships. 

● Strategies to enhance the quality of involvement were proposed (p. 330). 

84
Wagner, M., Newman, L., Cameto Renee, P., Levine, P., and Marder, C. (2007). 

Perceptions and Expectations of Youth with Disabilities: A Special Topic Report of 

Findings from the National Longitudinal Transition Study-2 (NLTS2). Washington, 

DC: National Center for Special Education Research. 

Purpose: Discusses the findings of a survey of youths with disabilities regarding 

their subjective experiences. 

Findings: 

● Between 59% and 89% responded favorably to attributes about themselves 

such as being nice, being proud of themselves, able to handle challenges, 

feeling useful and important, and feeling that life is full of interesting things to 

do. 

● 60% reported no recent feelings of depression, loneliness, or being disliked by 

others. 

● Three in five gave themselves high marks on self-realization. 

● One in 10 reported not feeling useful or important. 

● 12% rarely or never felt hopeful about the future. 

● More than half responded favorably regarding their performance in the arts, with 

computers, and in athletics. 

● Parents had more favorable views than the youths’ themselves of their 

children’s strengths. 

● More than half felt they could confront their peers when they upset them. 

● Two-thirds felt comfortable seeking help from adults. 

● Half scored high on personal autonomy. 

● Eight in 10 scored high on psychological empowerment. 

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● Receiving instruction in transition planning did not affect scores on personal 

autonomy and psychological empowerment. 

● Most had positive views of school. 

● Most had no problems with school. 

● Most felt school was pretty safe. 

● Most felt they were a part of their school. 

● Half felt they receive necessary supports/services. 

● 1–11% reported negative views of school. 

● Three out of 10 reported no involvement in school. 

● Most reported positive relationships with parents. 

● About half felt they had caring friends. 

● 3% reported negative views of personal relationships. 

● Most expected to graduate from high school; fewer expected to attend college. 

● Most expected to become employed but were not confident they would earn 

enough to be financially self-sufficient. 

● Most expected to live independently. 

● Youth with ADD/ADHD reported trouble paying attention in school. 

● Youth with orthopedic disabilities reported weal athletic and mechanical skill. 

● Youth with autism were less engaged in school activities and friendships. 

● Youth with sensory or orthopedic disabilities reported having a disability more 

than youth with learning or speech/language disabilities. 

● Youth with visual impairments reported a strong sense of being able to handle 

things and not feeling depressed. They also reported strong involvement in 

school and with peers/friends. 

● Youth with mental retardation reported not feeling cared about by adults at 

school, not feeling useful, and feeling less hopeful about the future. 

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● Girls were more likely to report being sensitive to others. 

● Boys were more likely to report being good athletes. 

● Adolescent girls were more likely to seek friend/sibling support. 

● White youth sought friend/sibling support more than African American youth. 

● Youth from middle income homes were more likely to seek friend/sibling 

support than those from lower income homes. 

● Older youths were less likely to participate in school activities that younger 

youths. 

87
Employment 

Capella, M. E. (2003). Comparing employment outcomes of vocational 

rehabilitation consumers with hearing loss to other consumers and the general 

labor force. Rehabilitation Counseling Bulletin, 47, 24–33. 

Purpose: Discusses a comparison study of four aspects of employment 

(occupational category, earnings, projected job growth, and transferable skill levels) 

that can be used to evaluate postclosure outcomes for vocational rehabilitation 

(VR) consumers with hearting loss, VR consumers with other disabilities, and the 

general population. 

Findings: 

● There were few differences between the two VR groups. 

● The general population had better outcomes across all four categories. 

● VR consumers are employed in lower skill jobs than those in the general 

population. 

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Crudden, A., Sansing, W., & Butler, S. (2005). Overcoming barriers to employment: 

Strategies of rehabilitation providers. Journal of Visual Impairment and Blindness, 

99, 325–335. 

Purpose: Summarizes focus groups with rehabilitation providers relative to 

attitudinal, transportation, and print barriers, and possible strategies for overcoming 

them in the area of employment of persons with visual impairments. 

Findings: 

● Employer education and increased exposure to persons with visual impairments 

was a strategy for overcoming attitudinal barriers. 

● Strategies for overcoming transportation barriers include developing a network 

of volunteer drivers and increasing efforts to improve the transportation systems 

for multiple clients via grant funds. 

● Strategies for overcoming print barriers include further research on the impact 

of assistive technology, identifying the key aspects of superior assistive 

technology training programs, and research that would identify better methods 

for streamlining paperwork for providers, which would result in more focused job 

development/placement efforts on behalf of clients. 

89
Fabian, E. (2007). Urban youth with disabilities: Factors affecting transition 

employment. Rehabilitation Counseling Bulletin, 50(3), 130–138. 

Purpose: To determine from a sample of predominately minority youth participating 

in a transition-to-work program (Bridges) what demographic, disability, and 

background factors and what individual characteristics and experiences distinguish 

students who get jobs from those who do not, as well as the nature of the jobs they 

obtain. 

Findings: 

● 68% of the youth participating in the Bridges program secured competitive jobs 

during high school, with average hourly earnings above the minimum wage. 

● Girls in the sample secured jobs at a significantly lower rate than boys (63% to 

69%), although there were no wage differences. 

● Previous vocational experience is a significant factor in predicting employment 

during school for these youth. 

● No significant relationship emerged between having a career goal and getting a 

job. 

● The majority of students obtained service-sector jobs in retail and food service 

businesses. 

Implications: 

● Rehabilitation counselors in urban areas should think and work more 

systematically to develop partnerships with school personnel who are designing 

vocationally related curriculum and career experiences for youth, even before 

they enter secondary school. 

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Kessler, R. C., Heeringa, S., Lakoma, M. D., Petukhova, M., Rupp, A. E., 

Schoenbaum, M., Wang, P. S., & Zaslavsky, A. M. (2008). Individual and societal 

effects of mental disorders on earnings in the United States: Results from the 

national comorbidity survey replication. American Journal of Psychiatry, 165(6), 

703–711. 

Purpose: The purpose of this report was to update previous estimates of the 

association between mental disorders and earnings (lost earnings owing to mental 

disorders). Estimates for 2002 are based on data from the National Comorbidity 

Survey Replication (NCS-R). 

Findings: 

● Serious mental illness was estimated to be associated with a loss of 

$193.2 billion in personal earnings in the total US population in 2002. 

● To put this number in perspective, it is larger than the $145 billion economic 

stimulus package proposed by President Bush in January 2008. 

● This estimate is much higher than earlier estimates ($44.1 billion in 1985, 

$77 billion in 1992). 

● These differences can be easily explained by two factors: (1) inflation (adjusting 

1985 data to 2002 dollars: $83.1 billion, adjusting 1992 data: $107.7), and (2) 

controlling for education, marital status, and household size. 

● Irrespective of the reasons for differences in estimates across the studies, all 

three studies found that mental disorders are associated with massive losses of 

productive human capital. 

● This finding adds to a growing body of evidence that impaired functioning 

associated with mental disorders carries an enormous societal burden. 

● Three-fourths of the total association between serious mental illness and 

earning in the NCS-R is due to lower earnings among employed persons with 

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serious mental illness; the remaining one-fourth is due to a lower probability of 

having any earnings at all among persons with serious mental illness. 

● Appropriate policy solutions might include increased job training and vocational 

rehabilitation for workers with serious mental illness and increased enforcement 

of the ADA. 

● Some interventions, such as those based on a social skills training model or an 

occupational rehabilitation model, might be effective in decreasing 

unemployment and improving job performance among people with serious 

mental illness without decreasing symptoms of mental illness. 

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Saunders, J. L., Leahy, M. J., McGlynn, C., & Estrada-Hernandez, N. (2006). 

Predictors of employment outcomes for persons with disabilities: An integrative 

review of potential evidenced-based factors. Journal of Applied Rehabilitation 

Counseling, 37(2), 3–20. 

Purpose: To review and compile the results of nearly a quarter century of 

rehabilitation research examining employment outcomes of people with disabilities. 

A discussion of implications, recommendations, and limitations is provided in the 

context of the need for evidenced-based practice in rehabilitation counseling and 

knowledge translation approaches in rehabilitation research. 

Findings: 

● Some research-based evidence suggests that the following variables are 

significant in relation to employment outcomes: number of months in the longest 

lasting job; rehabilitation background; transferable skills; attorney involvement; 

cultural opportunities; extent of reading and interests; family adjustment; social 

support; transportation source; valence; wages; personality or interpersonal 

skills; intelligence; aptitude; adaptability; satisfactoriness; manager RTW Scale; 

McCarron-Dial; attitudes toward self-employment outcomes; working alliance; 

consumer involvement; program intervention; vocational evaluation of 

assessment; client training; counselor training; VR services; college; financial 

variables. 

● The synthesis of these studies provided an opportunity to identify and review 

some of the problems that inhibit the ability to clearly identify what has been 

learned in the past 25 years and translate that knowledge into evidenced-based 

practices. (See summary on p. 17.) 

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Schur, L., Kruse, D., & Blanck, P. (2005). Corporate culture and the employment of 

persons with disabilities. Behavioral Sciences and the Law, 23, 3–20. 

Purpose: Examines the role of corporate culture in the employment of people with 

disabilities and how corporations can develop supportive cultures that benefit 

people with disabilities, nondisabled employees, and the organization as a whole. 

Findings: 

● Employment not only increases financial resources but helps incorporate 

people with disabilities fully into mainstream society by increasing their social 

networks, civic skills, independence, and sense of efficacy and inclusion from 

filling a valued social role. 

● Employment levels of people with disabilities remain well below those of 

nondisabled people, and the majority of nonemployed people with disabilities 

would prefer to be working. Only 28.6% of the working age people reporting a work 

limitation were employed in 2002, compared with 76.6% not reporting a disability. 

● Using an even broader definition of disability, the 2000 census found that 56.6% 

of the 30 million working age Americans who reported functional or activity 

limitations were employed, compared with 77.2% of those without such 

limitations. Employment rates are lowest among those with several functional or 

activity limitations, of whom only 25.4% were employed in 1999. 

● 67% want to work. 

● Low employment rates contribute to high rates of poverty. 

● Corporate culture can create attitudinal, behavioral, and physical barriers for 

workers and job applicants with disabilities. 

● While the different levels of culture often reinforce one another, incongruities 

and conflicts may exist among them. For example, the expressed commitment 

to hiring people with disabilities may be accepted at the second level of 

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organizational culture (the level of shared meaning) but not at the most basic 

level (the unstated and often unconscious assumptions of the organization). 

● This lack of acceptance may in turn be reflected in the third level of culture, so 

that the physical environment remains inaccessible, jobs are structured in ways 

that make it difficult for people with disabilities to work there, and coworker and 

supervisor attitudes remain unchanged. 

● 20% of employers said the greatest barrier to people with disabilities finding 

employment is discrimination, prejudice, or employer reluctance to hire them. 

● 22% of private sector employers reported that attitudes and stereotypes were 

barriers to employment of people with disabilities in their own firms. 

● 32% said it was difficult or very difficult to change supervisor and coworker 

attitudes, while only 17% said it was difficult to create flexibility or modify returnto-work policies. 

● 81% of private sector employers said visible top management commitment was 

effective or very effective for reducing barriers to employment for people with 

disabilities, while 62% said this about staff training, and 59% said this about 

mentoring efforts. 

● U.S. employers found a lower rate of lost time days due to illness and injury among 

companies that used (1) employee involvement programs (stress and participation 

in decisions are inversely related; (2) conflict resolution and grievance procedures; 

(3) workforce stabilization and continuity policies; and (4) early support and 

assistance programs for employees with chronic illness or injuries. 

● Supervisor and coworker attitudes toward employees with disabilities reflect 

several influences: stereotypes, negative affect or discomfort in being around 

people with disabilities, strain caused by communication difficulties, personality 

factors, and previous contact with people with disabilities. 

● Supervisor and coworker attitudes in turn affect: performance expectations, 

performance evaluations, willingness to work with a person with a disability, and 

hiring into jobs with discretionary work activities (more responsibility). 

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● Employees with disabilities use a number of strategies to shape expectations in 

the workforce: concealing the disability; communicating information about 

disability to reduce discomfort/clarify norms; requesting help to clarify expected 

behaviors; emphasizing similarity to others through shared interests, opinions, 

and values; and becoming a “superworker” to dispel stereotypes and modify 

others’ expectations. 

● The biggest problem with established job methodologies is not the unsuitability 

of jobs but rather finding an organization that is willing to break the mold and 

give people a chance to prove their capabilities. 

● Accommodations are likely to provoke a response (to be perceived as unfair) if 

they are salient and relevant to coworkers. 

● 31% of employers reported that a barrier to employing people with disabilities 

was the lack of supervisory knowledge about accommodations; only 16% said 

that the cost of accommodations was a barrier. 

● Many of the steps to change corporate culture for better employment for people 

with disabilities have potential benefits for all employees, not just those with 

disabilities (e.g., universal accommodation). 

● These factors contribute to the success of workplace diversity programs: 

commitment by top management, making diversity a part of company 

philosophy (not a PR tool), linking diversity goals to performance evaluations, 

involving employees at all levels, and ongoing education and outreach. 

● Effects of diversity programs depend greatly on the organizational context and 

the way in which they are implemented. 

● If employment prospects of people with disabilities are to be improved 

significantly, attention must be paid to the ways in which corporate culture 

creates or reinforces obstacles for employees with disabilities, and how those 

obstacles can be removed or overcome. 

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Health, Safety, Well-being 

Christensen, K. M., Blair, M. E., & Holt, J. M. (2007). The built environment, 

evacuations, and individuals with disabilities. Journal of Disability Policy Studies, 

17(4), 249–254. 

Purpose: To clarify assumptions associated with emergency evacuations through 

more informed understanding of the complexity of evacuation issues for people with 

disabilities and provide a framework for evaluation of the appropriateness of 

policies and planning initiatives. 

Findings: 

● There are four types of evacuations: protective, preventive, rescue, and 

reconstructive. (Also called preparedness, prevention, response, and recovery.) 

● These distinctions are important, as each phase requires different considerations. 

● Protective: Long-term preimpact response (e.g., regional relocation before a 

hurricane, individual preparation for a future event) 

● Preventive: Short-term preimpact response associated with less 

predictable/localized events without time for relocation (e.g., bomb threat) 

● Rescue: Short-term postimpact response immediately following emergency to 

achieve personal safety (e.g., exiting a burning building) 

● Reconstructive: Long-term postimpact response (e.g., camps or temporary 

housing because of continued safety or health concerns) 

● Three overlying factors affecting all evacuations: (1) behavior of the individual, 

(2) planned systems involved in event, and (3) environment (built environment) 

in which event occurs. 

● When the built environment properly accommodates evacuation, planned 

systems are not necessary. 

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● Developing a framework for policy and preparation allows for easier 

identification and understanding of related issues. 

● Use Americans with Disabilities Act Accessibility Guidelines (ADAAG) for 

Accessible Egress . 

● The current ADA design requirements for accessible egress are primarily 

focused on facilitating the planned system of rescue evacuation response. This 

is unfortunate, because the intent of ADAAG is to ensure an accessible built 

environment, which will not be achieved by planned systems in inaccessible 

environments. 

● To address this issue, the U.S. Access Board proposed adoption of ADAAG 

requirements for “hardened” evacuation elevators as well as horizontal exits. 

● Individuals are required to respond to multiple discrete/implied 

instructions/directions that may not be supportive of accessible evacuation 

programs, which places a disproportionate burden on the person with a 

disability to secure personal safety. 

● Emergency planning should include criteria for recognizing the various forms of 

evacuation and for evaluating proper response. ADAAG should not be applied 

regardless of the form of evacuation until appropriate response analysis is 

conducted, which could result in practices and policies more consistent with 

ADAAG intent 

● While preventive and rescue evacuations receive the most research attention, 

very little attention has been given to the behavior of people with disabilities in 

emergency situations. 

● There is a need for scholarly study, advocacy, and policy improvements related 

to the various forms of emergency evacuation response for people with 

disabilities, specifically with regard to the built environment factor. 

● Disaster planning and emergency response must recognize various factors at 

play in any evacuation. Policy and planning continues to emphasize helping the 

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person with a disability adjust and accept the existing environment rather than 

altering the environment to accommodate disability needs. 

● Until such a shift is realized, policies and planning measures intended to secure 

equal participation and safety of people with disabilities in emergency 

evacuations will continue to be less effective and put these people at greater 

risk of injury or death in emergency evacuation situations. 

Frain, M. P., Berven, N. L., Chan, F., & Tschopp, M. K. (2008). Family resiliency, 

uncertainty, optimism, and the quality of life of individuals with HIV/AIDS. 

Rehabilitation Counseling Bulletin, 52, 16–27. 

Purpose: To contribute to the understanding of quality of life issues experienced by 

a sample of persons with HIV/AIDS by applying theories of family resiliency and 

cognitive appraisal concepts of uncertainty and optimism using a Web-based 

questionnaire of 125 people with HIV/AIDS. 

Findings: 

● Disease progression (clinical) was not found to be related to quality of life. 

● Family resiliency variables were found to predict quality of life. 

● Cognitive appraisal variables were found to predict quality of life. 

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Mold, F. (2003). A review and commentary of the social factors which influence 

stroke care: Issues of inequality in qualitative literature. Health and Social Care in 

the Community, 11(5), 405–414. 

Purpose: Assess how well the processes that might lead to inequity in the delivery 

and uptake of stroke services are currently understood by reviewing the current 

qualitative literature. 

Findings: 

● Nurses who have a positive attitude toward stroke patients believe that they 

made a valuable contribution to stroke rehabilitation and that patients benefit 

from their care. 

● Nurses who held less positive views of stroke patients viewed them as 

uncooperative. 

● Patient motivation not only influenced clinicians’ perspectives of patients, but 

also constituted the basis through which clinical decisions were made. 

● Nurses, doctors, and rehabilitation therapists judge patients’ motivation on the 

basis of their demeanor and compliance with rehab therapies. 

● Older people encountered negative attitudes toward them, especially when 

interacting with health care professionals. These attitudes did not include direct 

rudeness but subtle indicators of ageism, including neglect or lack of equal 

consultation regarding their health care. 

● Health care professionals perpetuated age stereotypes. Loss of function in an 

older stroke patient affected the professionals’ decision to rehabilitate—they 

were making clinical judgments on the basis of age and perceived recovery 

potential. 

● Social workers also held negative misconceptions about age, resulting in less 

assistance to older patients in dealing with health and social issues. 

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● Acute difficulties exist in matching an individual’s needs with the realities of the 

social care system. Patients must conform, adapt, and be suited to criteria 

imposed by the health care system. 

● Four core factors affect access to services: (1) availability of certain health 

services and limited availability of services to some social groups; (2) varying 

quality of identical services provided to different social groups; (3) costs 

(financial or otherwise, such as time off from work) associated with accessing 

health care services; and (4) provision of information where there is a lack of 

clarity about available services for specific groups, such as minorities. 

● Three mechanisms related to socioeconomic status affect interaction between 

patients and clinicians: (1) socioeconomic distance between social classes and 

the influence of this on the quality of the doctor-patient interaction; (2) 

differences in health knowledge, beliefs, and behavior that are grounded in 

these class differences; and (3) professional control, whereby clinicians control 

the consultation process. 

● Ethnic minority patients have several barriers to stroke services: limited 

translation of printed information, cultural assumptions about the cause and 

recovery process of stroke, and differences in health knowledge. 

● Three aspects of resource allocation influence care delivery: distribution of 

resources at local levels, financial constraints, and application of eligibility 

criteria in providing medical and community services. 

● The individual’s portrayal of self influences the delivery and uptake of services. 

People give meaning to their illness according to socially constructed views 

based on their socioeconomic status, age, gender, or ethnic identity, and this 

influences how service users respond to professionals providing care. 

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Stone, R. I., & Wiener, J. M. (2001). Who Will Care for Us? Addressing the LongTerm Care Workforce Crisis. Washington, DC: The Urban Institute. 

Purpose: Provide a broad overview of long-term care frontline workforce issues. 

Findings: 

● Long-term care providers report unprecedented vacancies and turnover rates 

for paraprofessional workers as a result of low wages and benefits, hard 

working conditions, heavy workloads, and a job that has been stigmatized by 

society. 

● The overwhelming majority of frontline long-term care workers are women: 55% 

are white, 35% are black, and 10% are Hispanic. 

● Most workers are relatively disadvantaged economically and have low levels of 

educational attainment. 

● One source set the turnover rate at 45% for nursing homes and about 10% for 

home health programs. Other sources place nursing home turnover at over 

100% per year. 

● Personal and home care assistance is the fourth-fastest-growing occupation, 

with a dramatic 84.7% growth rate. The number of home health aides is 

expected to increase by 74.6% and that of nursing assistants by 25.4% 

● Recruiting and retaining frontline long-term care workers have become a priority 

for many States. State initiatives have included increasing fringe benefits, 

developing career ladders, increasing/improving training, and develop new 

worker pools (former welfare recipients). 

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White, G. W., Fox, M. H., Rooney, C., & Rowland, J. (2007). Final Report: Findings 

of the Nobody Left Behind: Preparedness for Persons with Mobility Impairments 

Research Project. Lawrence, KS: Research and Training Center on Independent 

Living. 

Purpose: The Nobody Left Behind (NLB): Disaster Preparedness for Persons with 

Mobility Impairments research project explored disability-related disaster and 

emergency response practices at local emergency management agencies. The 

project examined whether disaster plans and emergency response systems include 

health, safety, and survival needs for people with mobility impairments. The 

researchers also examined morbidity/mortality of such persons in emergency 

situations and any best practices to prevent injuries and save lives. 

Findings: 

● 43% of emergency managers had some idea of the number of people with 

mobility impairments; 27% used census or self-reported registries to identify this 

population. Frustration exists with volunteer self-registry, as only a small 

percentage of people who would need assistance actually register. 

● The majority of emergency managers are not trained in special needs 

populations, which includes those with mobility impairments.

● There is little or no representation of persons with mobility impairments at the 

planning or revision stages of the emergency plan.

● The majority of emergency managers did not know how many people with 

mobility impairments lived in their jurisdiction.

● Only 21% of emergency managers are planning to develop guidelines for 

assisting persons with disabilities. 

● Emergency managers would benefit from educational courses, reliable 

surveillance tools, and developing specific guidelines to address emergency 

management issues for people with disabilities. 

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● Members of the disability community should develop individual and disabilityspecific preparedness plans and get involved in local disaster planning. 

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Independent Living 

Brown, J. D., Moraes, S., & Mayhew, J. (2005). Service needs of foster families 

with children who have disabilities. Journal of Child and Family Studies, 14(3), 417–

429. 

Purpose: To examine the service needs of foster families with children who have 

disabilities in a large Canadian city. Literature suggests that foster parents 

emphasize the value of training regarding special needs, communication with 

professionals, counseling services, respite, peer support, and community 

resources. 

Findings: 

● Foster parents were asked one open-ended question: What services or 

supports would be helpful to you? 

● Foster parents indicated that there needed to be more support in the 

community; for example, support groups. 

● Better public awareness and education about disabilities was necessary, as 

well as more integrated recreational and education opportunities for children 

with disabilities. 

● Additional financial support would be helpful. 

● Schools that understand the child’s needs were helpful, as was good 

communication with the teachers. Specialized program availability and access 

in the local school were helpful. 

● An understanding and supportive social worker was seen as helpful. 

● Information about the child’s history—medical information, classes on aboriginal 

culture and information about community services, training, and workshops—is 

helpful. 

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● There is a need for more specific information on disabilities in general and the 

disabilities of the children in their care. 

● Community and health care were useful, as was specific medical equipment for 

their foster child to use. 

● Services including music therapy, occupational therapy, speech therapy, play 

therapy, access to private therapists for assessments, in-home therapies, 

counseling are helpful. 

● Services to support transitions of foster children into new school settings, home 

settings, and independent living situations are helpful. 

● Foster parents mentioned respite care and the need for public awareness and 

education on children with disabilities. 

Summary: Ten areas of services or supports identified by foster parents as helpful: 

support in the community, financial resources, accommodating school system, 

good relationships with social workers, information, comprehensive medical care, 

access to professionals, services for aboriginal children and families, and 

transitional services and respite. 

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Hernandez, B., McCollough, S., Balcazar, F. E., & Keys, C. (2008). Accessibility of 

public accommodations in three ethnic minority communities. Journal of Disability 

Policy Studies, 19(2), 80–85. 

Purpose: To assess compliance with public accommodations provisions (Title III) 

of the ADA, which require removal of physical, procedural, and attitudinal barriers 

that prohibit people with disabilities from entering public establishments and 

accessing their goods and services. Physical accessibility was assessed for 90 

establishments in three ethnic minority communities. 

Findings: 

● 25.6% were fully accessible; 47.8% were accessible with minor assistance; and 

26.7% were inaccessible with minor assistance. 

● Establishments identified as for-profit tended to be more accessible than 

nonprofit establishments (one reason is that for-profits tend to be franchises 

that are part of a larger corporation with more financial resources). 

● Findings indicate that much work remains to improve the ADA compliance of 

establishments that are open to the public. 

● Underserved communities may be in particular need of improving their 

compliance with Title III of the ADA. 

● 45% of the predominantly minority sample had not heard of ADA. 

● The top three accessibility issues were signage, doors, and entrances: 73% had 

signage issues, 50.1% had problems with doors not being wide enough or too 

heavy to open, and 46.6% had problems with entrances that persons with 

disabilities could not enter independently. 

● Businesses and establishments in older neighborhoods tend to have more 

physical barriers, because they were constructed prior to the ADA. 

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Minkler, M., Hammel, J., Gill, C. J., Magasi, S., Vasquez, V. B., Bristo, M., & 

Coleman, D. (2008). Community-based participatory research in disability and longterm care policy. Journal of Disability Policy Studies, 19(2), 114–126. 

Purpose: To analyze a Chicago-based research project that documented the 

experiences of 200 people with disabilities as they attempted to transition out of 

nursing homes to less restrictive community living. Participants were involved in an 

empowerment and systems and policy change partnership program called Social 

Action Group (SAG). 

Findings: 

● Participation in SAG by disabled persons and action on the part of the 

University of Chicago and two independent living centers was demonstrated. 

● The SAG model was successful in supporting the transition of disabled persons 

out of nursing homes. 

● Strong opposition exists among nursing homes and labor lobbies to rebalancing 

resources toward community living. 

● The project was successful in demonstrating the efficacy of consumer-directed 

choice and community living support. 

● In addition to service providers and persons with disabilities, the inclusion of 

academics in future projects was seen as extremely important. 

108
Pyke, J., & Atcheson, V. (1993). Social recreation services: Issues from a case 

management perspective. Psychosocial Rehabilitation Journal, 17(2), 121–130. 

Purpose: Identify barriers to accessing and using social recreation services by 

persons with psychiatric disabilities, as reported by case managers in Canada. 

Findings: 

● 43% of inpatients were identified as having unmet needs in the social 

recreational domain, but only 12% were referred to a resource to meet those 

needs upon discharge. 

● For those who were referred, satisfaction ratings were excellent (23%), good 

(36%), and satisfactory (27%). 

● 88% of case managers reported that they had one or more clients using a 

social recreation service. A total of 97 clients (33%) of 320 clients served by 24 

case managers were recruited for study. 

● In the judgment of case managers, on the basis of their knowledge of their 

clients, an additional 107 clients could potentially benefit from such a service. 

● The majority of case managers cited program accessibility (geographic 

location/transportation) and hours of operation as the two most significant 

barriers. The third barrier was the perception that clients did not want to attend 

programs with other mentally ill people. The fourth and fifth ranked barriers 

were money and attendance expectations. 

● Hours of operation were more problematic for women. 

● The three barriers most frequently cited by practitioners were lack of time to 

accompany clients to programs, lack of staff education or training about 

recreation/leisure, and lack of awareness of available resources. 

● Suggestions for improving access to social recreation services: advocating for 

lower user fees; providing a transportation subsidy; meeting with social rec 

services to discuss activities and support that would increase participation; 

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providing consultation/support to mainstream services to make them more user 

friendly; orienting staff to the value of recreation; incorporating leisure 

counseling into staff training; training staff members to facilitate the 

development and use of social skills; Identifying people who might assist with 

linking, escorting, and supporting clients to attend and use social recreation 

services; and assigning responsibility for maintaining an up-to-date inventory of 

social recreation services. 

● The disparity between the number of clients actually using social recreation 

services and those that could use such services is largely due to the poor fit 

between clients’ needs and the perceptions of providers. 

● Social recreation services tend to be overlooked or undervalued not only by 

providers but also by planners. 

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Abstracts for Section 3: Disability Services Infrastructure 

Occupations—Supply and Demand 

Harris-Kojetin, L., Lipson, D., Fielding, J., Kiefer, K., & Stone R. I. (2004). Recent 

Findings on Frontline Long-Term Care Workers: A Research Synthesis 1999–2003. 

Washington, DC: U.S. Department of Health and Human Services, Institute for the 

Future of Aging Services. 

Purpose: Discusses research findings since 1999 in home, community-based, and 

nursing home settings. 

Findings: 

● Evaluation is an important component to building the evidence base for what 

works to develop a qualified and stable LTC workforce 

● The following interventions have demonstrated positive effects on 

retention/turnover rates: peer mentoring for new CANs, an education and 

payment incentive program; and the Wellspring Model, which focuses on 

cultural and organizational change from top management 

Iglehart, J. K. (2008). Grassroots activism and the pursuit of an expanded physician 

supply. New England Journal of Medicine, 358(16), 1741–1749. 

Purpose: Health policy report on physician supply shortages in the United States 

predicted to occur around 2020 and issues related to accommodating a growing 

population with fewer physicians. 

Findings: 

● Although much focus is directed to providing health insurance for the 47 million 

Americans who do not have it, few raise the question of whether there will be 

enough doctors and nurses if everyone gains coverage. 

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● The total number of students enrolled in medical (allopathic) schools remained 

essentially the same from 1980 through 2000 (16,000 graduates), while the 

U.S. population increased by approximately 71 million. 

● Because of the time required to train a physician (8–15 years), the United 

States must plan well in advance of 2020, when the Council on Graduate 

Medical Education (COGME) estimates that the shortage will occur. 

● Other reasons to increase the supply of physicians: the growing population 

(25 million every decade); aging baby boomers with health needs; the pending 

retirement of a large cohort of physicians; and the increasing emphasis 

physicians under 50 years old are placing on lifestyle issues (more personal 

time, fewer responsibilities). 

● COGME estimates a shortage of 85,000 physicians by 2020, other estimates of 

shortage range from 55,000 to 200,000. The largest shortfall will be among 

specialists. 

● Questions about the supply of physicians are not on the radar screens of most 

federal policymakers, who tend to track physician supply according to whether 

or not Medicare payment rates to physicians are adequate to ensure beneficiary 

care. Physician access remains good for most people, with some notable 

problems finding a specialist.

● Who has the most trouble seeing a doctor? Those without insurance and those 

covered by Medicaid, which pays very low fees for services.

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Nevidjon, B., & Ives-Erickson, J. (2001). The Nursing Shortage: Solutions for the 

Short and Long Term. Silver Spring, MD: American Nurses Association. 

Purpose: Discusses the current nursing shortage and suggests solutions. 

Findings: 

● Nurses themselves are the most important recruiters for nurses. 

● Education settings need to target children for the nursing profession earlier than 

high school. 

● Organizations need to pay attention to the employee market to understand what 

people are looking for in the work environment.

● Nurses need to become more vocal in lobbying for increased federal funding.

Paraprofessional Healthcare Institute. (2008). State Chart Book on Wages for 

Personal and Home Care Aides, 1999–2006. San Francisco: Center for Personal 

Assistance Services, University of California. 

Purpose: Provides wage information for personal and home care aides in 50 

States over a 7-year period. 

Findings: 

● In a 7-year period, there was a 14% increase (nationally) in wages before the 

adjustment for inflation. The “real wage” declined 4%. 

● No wages were above the 25% federal poverty line. 

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Purcell, P. (2008). CRS Report for Congress: Older Workers: Employment and 

Retirement Trends. Washington, DC: Congressional Research Service. 

Purpose: Discusses the impact on the labor force as baby boomers approach 

retirement age. 

Findings: 

● As baby boomers reach retirement age, there will be fewer new entrants in the 

labor force. 

● As the labor force decreases, economic growth will decrease. 

● Because of poor economic conditions, many people are working past the age of 62. 

● Older Americans are increasingly working full time. 

● Employers are encouraging older workers to remain on the job because of the 

lack of new workers. 

Stone, R. I., & Weiner, J. M. (2001). Who Will Care for Us? Addressing the LongTerm Care Workforce Crisis. Washington, DC: The Urban Institute. 

Purpose: Discusses issues affecting long-term care frontline workers 

Findings: 

● Low wage and benefits, hard working conditions, heavy workloads, and 

stigmatization of workers in this field make recruitment and retention difficult. 

● There are unprecedented vacancies and turnover rates in the field. 

● Federal and State policymakers acknowledge that this issue needs to be 

addressed. 

● These issues will worsen over time as demand increases. 

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Center for Health Workforce Studies, School of Public Health. (2008). Healthcare 

Employment Projections: An Analysis of Bureau of Labor Statistics Occupational 

Projections, 2006–2016. Albany, NY: University at Albany. 

Purpose: Summarizes labor projections for health care occupations in health care 

settings for the period 2006–2016. 

Findings: 

● The health sector is the fastest growing employment sector. 

● One million registered nurses will be needed between 2006 and 2016. 

● Home health aides, health office staff, registered nurses, orderlies, and medical 

assistants are the fastest growing job categories. 

Paraprofessional Healthcare Institute. (2003). State-based Initiatives to Improve the 

Recruitment and Retention of the Paraprofessional Long-Term Care Workforce. 

Washington, DC: U.S. Department of Health and Human Services, Institute for the 

Future of Aging Services, Paraprofessional Healthcare Institute

Purpose: Discusses a nationwide initiative to improve recruitment and retention of 

direct care workers in the long-term care field. Focuses on five States: California, 

Wisconsin, North Carolina, Massachusetts, and Pennsylvania. 

Findings: 

● States and providers need reliable information on how to improve recruitment 

and retention in the long-term care workforce. State efforts to recruit and retain 

LTC workers were not evaluated, and information is not provided on which 

initiatives were most effective. 

● Policy and practice changes are needed to achieve change. 

● Providers need to share information. 

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U.S. Department of Health and Human Services. (2003).The Future Supply of 

Long-Term Workers in Relation to the Aging Baby Boom Generation: Report to 

Congress. Washington, DC: U.S. Department of Health and Human Services. 

Purpose: To analyze information about the causes of shortages of direct care 

workers in long-term care settings and develop recommendations for the future. 

Findings: 

● It is critical to retain existing long-term care workers and attract new ones. 

● Pay and working conditions will play a key role in attracting new workers. 

● Current and new employees will need to play a much bigger role in retaining 

and attracting new workers. 

U.S. Department of Health and Human Services, Department of Veterans Affairs 

and Department of Labor, Office of the Assistant Secretary for Planning and 

Evaluation. (2006). The Supply and Demand of Professional Social Workers 

Providing Long-Term Care Services: Report to Congress. 

Purpose: Discusses the potential for professional social workers to work in longterm care settings. 

Findings: 

● By 2050, 110,000 social workers will be needed in LTC settings. 

● Efforts are currently under way to incorporate age-related content into the social 

work curriculum. 

● Some services provided by social workers in LTC settings can be performed by 

other disciplines. 

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U.S. Department of Health and Human Services, Office of the Assistant Secretary 

for Planning and Evaluation. (2006).The Supply of Direct Support Professionals 

Serving Individuals with Intellectual Disabilities and Other Developmental 

Disabilities: Report to Congress. 

Purpose: Discusses the reasons for shortages of direct support professionals who 

work with persons with intellectual and other developmental disabilities. 

Findings: 

● There will be a need for more direct support workers as the family members who 

currently care for persons with intellectual and other developmental disabilities age. 

● It will be necessary to make these jobs as attractive as possible. as there will be 

competition with LTC jobs. 

Health Resources and Services Administration, Bureau of Health Professions. 

(2008). The Adequacy of Pharmacist Supply 2004 to 2030. Washington, DC: U.S. 

Department of Health and Human Services. 

Purpose: Discusses the results of the Pharmacist Supply and Requirements Model 

(PhSRM) to project the future adequacy of pharmacist supply in the United States. 

Findings: 

● The projected shortfall of pharmacists has diminished since HRSA’s 2000 

Report to Congress because of an increase in the number of pharmacy 

technicians (and their expanded scope of practice), increased wages, and 

improved technology. Also, more people are entering pharmacy schools, and 

the number of schools and programs has increased. 

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● There is still a need for the Pharmacist Loan Repayment Demonstration to 

encourage employment in rural and low-income areas, and in prisons. 

Steinwald, A. B. (2008). Primary Care Professionals: Recent Supply Trends, 

Projections, and Valuation of Services. Washington, DC: U. S. Government 

Accountability Office. 

Purpose: Examines recent trends for primary care professionals and projections 

for future supply. 

Findings: 

● The supply of nonphysician professionals is increasing faster than the number 

of physicians. 

● Physicians are entering specialty fields because of the undervaluing of primary 

care, including lower payment rates. 

The Lewin Group. (2006). Ensuring a Qualified Long-Term Care Workforce: From 

Pre-Employment Screens to On-the-Job Monitoring. Washington, DC: U.S. 

Department of Health and Human Services. 

Purpose: Discusses a study in four States that assessed the efficacy of different 

approaches to preemployment screening and on-the-job monitoring of nurse 

assistants to prevent resident abuse in nursing homes. 

Findings: 

● It is difficult to ascertain the efficacy of nurse aide registries and criminal 

background checks in preventing abuse, because different States have different 

processes for screening and tracking. 

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● Criminal background checks are necessary and are a valuable tool for 

employers, but they are only one element of preventing abuse. 

● There is a correlation between criminal history and incidents of abuse. 

● There are not enough policies in place that support postemployment strategies 

Williams, T. E., & Ellison, E. C. (2008). Population analysis predicts a future critical 

shortage of general surgeons. Surgery, 548–555. 

Purpose: As the U.S. population increases, there has been no similar increase in 

medical school enrollments, thus creating a future shortage of physicians, 

specifically general surgeons.

Findings: 

● By 2010, there may be a shortage of 1,300 surgeons. 

● By 2020, there may be a shortage of 1,875 surgeons. 

● By 2050, there may be a shortage of 6,000 surgeons. 

● The government must increase funding for surgery trainees to prevent shortages. 

119
Wilson, Eaton, & Kamanu (2002). Extended Care Career Ladder Initiative (ECCLI) 

Round 2: Evaluation Report. Cambridge, MA: John F. Kennedy School of 

Government, Harvard University Faculty Research Working Papers Series. 

Purpose: Discusses an evaluation of the first year of the ECCLI project in 

Massachusetts. ECCLI was a response to high staff turnover and job vacancies 

among paraprofessionals in long-term care. Long-term care providers were asked 

to create projects that focused on both quality care for consumers and good jobs 

and opportunities for workers by partnering with other providers and workforce 

development organizations. 

Findings: 

● More educational training is needed for all paraprofessionals. 

● Wages need to be increased and publicized. 

● A career ladder program should be implemented. 

● More formal structures need to be involved to implement culture and practice 

change. 

● Ninety percent of employees indicated that they were committed to their job. 

● Quality of care improvements were demonstrated. 

● The sharing of expertise was seen as important. 

● Providers should involve workforce partners early on. 

● Funding/reimbursement delays are harmful to providers. 

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Abstracts for Section 4: Private Sector Strategies for Building and 

Maintaining a Sufficient Supply of Disability Infrastructure Occupations 

Ball, P., Monaco, G., Schmeling, J., Schartz, H., & Blanck, P. (2005). Disability as 

diversity in Fortune 100 companies. Behavioral Sciences and the Law, 23, 97–121. 

Purpose: Investigate the inclusion of people with disabilities in the diversity policies 

of the most successful businesses in the United States by examining the publicly 

available workforce and supplier diversity policies of the top 100 companies on 

Fortune Magazine’s list of the 500 most profitable companies in the nation. 

Findings: 

● 92 of the 100 most prosperous companies in the nation have policies that 

express a commitment to promoting diversity in the workplace. Many of these 

companies also have policies that support minority-owned suppliers. 

● Although many corporate diversity policies include racial, ethnic, cultural, and 

gender components, fewer than half have written diversity policies that 

expressly include people with disabilities, and even fewer have supplier 

diversity statements that do so. 

● A significant portion of Fortune 100 companies recognize the role of people with 

disabilities in a diverse workforce (42% expressly mention disability). 

● Technology sector employers are the most consistent in their inclusion of 

people with disabilities in the diversity policy statements, along with the few 

chemical companies on the list. 

● Diversity policies among financial companies tend to be less specific about the 

definition of diversity, and these companies were less likely to have such 

policies. 

● Many companies that recognize people with disabilities as an important element 

of a diverse workforce do not state this commitment with regard to efforts to 

recruit and retain people with disabilities. 

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● While it is encouraging that most successful companies show significant efforts 

to include people with disabilities, there is room for improvement. 

● There are three major types of diversity policy: (1) those that explicitly include 

people with disabilities in the definition of diversity; (2) those that are 

nonspecific as to what constitutes diversity; and (3) those that mention minority, 

gender, or other status but do not specifically mention disability. 

● Many companies fail to explicitly recognize the role of people with disabilities in 

building a diverse marketplace. 

● Even companies that include people with disabilities in their policies do not 

always support the policies with actions that actively promote inclusion. 

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Bricout, J.C. (2004). Using telework to enhance return-to-work outcomes for 

individuals with spinal cord injuries. NeuroRehabilitation, 19, 147–159. 

Purpose: Discusses strategies for successfully implementing telework as a returnto-work strategy for persons with spinal cord injuries, using a disability management 

program as a venue for examining and enhancing individual, workgroup, and 

organizational readiness. 

Findings: 

● Having telework as part of a formal disability management program can 

promote employer and personal decisions to support return to work for people 

who are temporarily sidelined by major disability events such as spinal cord 

injuries. 

● 7.5% of all workers with disabilities do home-based work with computers versus 

5.9% of the general population (source: 1991 and 1997 Current Population 

Survey). 

● Additional costs of equipment or software for teleworkers with significant 

disabilities can be partly borne by State vocational rehabilitation agencies. 

● Telework advantages: overcome mobility and scheduling challenges; reduce 

office space and overhead costs, improve productivity, and increase employee 

retention. 

● Telework disadvantages: employee productivity can decrease if employees are not 

well-matched to telework, and teleworkers can become isolated with reduced 

career advancement and mobility. When people with disabilities are not visible in 

the workplace, it is harder to reduce employer and employee biases against them. 

● Successful teleworkers have character traits such as independence and 

initiative, as well as computer literacy and self-management skills and 

aptitudes. 

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Franche, R., Cullen, K., Clarke, J., Irvin, E., Sinclair, S., Frank, J., & the Institute for Work 

and Health (IWH) Workplace-based RTW Intervention Literature Review Research 

Team. (2005). Workplace-based return-to-work interventions: A systematic review of the 

quantitative literature. Journal of Occupational Rehabilitation, 15(4), 607–631. 

Purpose: A systematic literature review located 10 higher quality quantitative studies 

among a total of 4,124 papers identified by search, to find the quantitative basis to justify 

common workplace practices supporting return to work (RTW) of injured/ill workers. 

Findings: 

● Strong evidence that work disability duration is significantly reduced by work 

accommodation offers and contact between the health care provider and the 

workplace. 

● Moderate evidence that disability duration is reduced by interventions that 

include early contact with the worker by the workplace, ergonomic worksite 

visits, and presence of an RTW coordinator. 

● Moderate evidence exists that the five intervention components listed in the first 

two bullet points reduce costs associated with work disability duration. 

● Evidence for sustainability of these effects over time was insufficient or limited. 

● Evidence was insufficient regarding the impact of supernumerary replacement. 

(Reviewer’s note: This was an attempt to quantify that the RTW plan doesn’t 

disadvantage coworkers and supervisors, an issue addressed more broadly by 

the IWH paper in 2006.) 

● Evidence levels regarding the impact of the intervention components on qualifyof-life outcomes was insufficient or mixed. (Reviewer’s note: Broader quality-oflife issues are usually not a concern in workplace-based interventions. Many 

government programs assume that maintaining employment and avoiding 

public assistance is itself a measure of quality-of-life.) 

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Helm, R. E., Powell, N. J., & Nieuwenhuijsen, E. R. (1999). A return-to-work 

program for injured workers: A reassignment model. Work 12, 123–131. 

Purpose: Present a strategy for preventing permanent disability in significant 

disability events requiring accommodation through reassignment to new job 

positions to keep a person in the workplace with the current employer. Such a 

strategy could ultimately help people with impairments enjoy greater independence 

and social engagement, and reduce demand for public assistance. 

Findings: The Americans with Disabilities Act requires employers to engage in an 

interactive process to accommodate employees with disabilities up to and including 

reassignment to vacant jobs with capacity requirements that match the capabilities 

of employees. 

This requirement exceeds the requirements of workers’ compensation, in which 

many employers typically either return employees to their former jobs or move them 

into permanent disability (where they may also use public assistance). 

Medical providers often justify the decision to place employees on permanent 

disability rather than reassign them to new positions, because providers focus on 

work restrictions rather than matching residual capabilities with requirements in 

other positions. 

Larger manufacturers are well-served by adding occupational therapists (OTs) to 

their staff to manage accommodations and reassignments and the associated 

program. 

This program includes the following elements: 

● OT performs job analyses, including functional capacity requirements of vacant 

positions available for reassignment. 

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● OT meets with supervisor and employee to understand perspective and needs 

of each in order to identify and negotiate mutually acceptable reassignments. 

● OT coaches employees in new job to ensure successful placement. 

● OT follows up with both supervisor and employee to ensure job retention. 

● OT participates in collective bargaining to secure broader support for 

reassignments. 

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Henry, A. D., & Lucca, A. M. (2004). Facilitators and barriers to employment: The 

perspectives of people with psychiatric disabilities and employment service 

providers. Work, 22, 169–182. 

Purpose: As they conducted 12 focus groups across Massachusetts with 44 adults 

with serious mental illness (SMI) and 30 providers, researchers examined the 

perspectives of people with SMI and employment service providers regarding factors 

that most directly help or hinder consumer efforts to obtain and maintain employment. 

Findings: 

● While SMI may restrict work participation, the impact of SMI can be moderated 

by environmental factors or by other non-SMI characteristics of the person.

● Factors that can be significant facilitators or barriers include individualized approach 

to matching jobs to consumer interests; supportive, mutual consumer-provider 

relationship; family support; transportation; access to trained benefit counselors; and 

a medical hierarchy that accords low status to rehabilitation goals and providers.

● Participants regarded other factors as more significant barriers to sustained 

employment than SMI, and these other factors (when positive) can be facilitators. 

● Consumers focused on how their SMI can amplify on-the-job stress. Even 

employment success could trigger anxiety and fear of relapse. 

● Consumers and providers alike noted that someone with poor symptom control 

might have difficulty working, but all emphasized the therapeutic value of work. 

● Overdependency on mental health and entitlement programs were viewed as 

barriers. Social Security work incentives were viewed as complex, confusing 

systems that create employment barriers despite their intended purpose of 

facilitating. No providers spoke of actively encouraging consumers to leave the 

disability rolls, and most knew only a handful of people who had successfully 

transitioned off disability. 

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Kant, J., Jansen, N.W.H., van Amelsvoort, L. G., Van Leusden, R., & Berkouwer, A. 

(2008). Structured early consultation with occupational physician reduces sickness 

absence among office workers at high risk for long-term sickness absence: A 

randomized controlled trial. Journal of Occupational Rehabilitation, 18, 79–86. 

Purpose: To examine the efficacy of structured early consultation in preventing or 

reducing sickness absence among employees at high risk for future long-term 

sickness. A 34-item screening questionnaire was used to identify employees at high 

risk for sickness absence greater than 28 days. Questions included demographic, 

workplace, health, and psychosocial factors. Subjects in the experimental group (n 

= 147) received a structured early consult with their occupational physician (OP), in 

some cases followed by targeted intervention. There were 152 in the control group. 

Findings: 

● Modified intention-to-treat analysis revealed substantial differences (p = 0.007) 

in total sickness absence duration over 1-year followup between the 

experimental (mean 18.98; SD 29.50) and control group (mean 31.13; SD 

55.47). 

● Per-protocol analysis showed the proportion of long-term sickness absences 

(>28 days) over 1-year followup was significantly (p = 0.048) lower in the 

experimental (9.1%) versus control group (18.3%). 

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Klein, D., Schmeling, J., & Blanck, P. (2005). Emerging technologies and corporate 

culture at Microsoft: A methodological note. Behavioral Sciences and the Law, 23, 

65–96. 

Purpose: Explores factors important in the study and examination of corporate 

culture and change with a focus on the technological methods used to conduct a 

study of accessible technology and corporate culture at Microsoft. Advantages and 

challenges of emerging technologies are reviewed. 

Findings: 

● Examined Microsoft’s efforts to enhance diversity, specifically toward inclusion 

of persons with disabilities in its workforce, and efforts to improve product and 

service accessibility for persons with disabilities for both its workforce and its 

customers. 

● Public at large and disability advocates influence corporate behavior and culture 

related to persons with disabilities. Technology, both at Microsoft and at other 

IT companies, plays a role. 

● Corporate culture is defined as a system of assumptions generally agreed upon 

in the organization. The major reason for having a corporate culture is that it 

motivates people to change their behavior in line with the corporate necessity 

without a direct tie to financial compensation. 

● What role corporate culture plays currently or will play in the future of increased 

employment for people with disabilities has yet to be determined. 

● Some diversity research includes disability as a category of interest, but the 

focus remains on gender, race, and sexual orientation. 

● Most existing research on disability has focused on supervisor and coworker 

attitudes and their effects on employees with disabilities. 

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● A better understanding of corporate culture may help expose ways to improve 

the employment status and lives of people with disability in a way that is 

supported within their cultures. 

● Both economic incentives and regulatory compliance have direct and indirect 

implications for corporate culture, as well as the employment rates of people 

with disabilities. 

● Technologies developed for and used by people with disabilities can have 

broader impacts for the workforce and can be adopted company-wide when 

they provide advantages for productivity. 

● Universal tools once considered assistive technology—such as screen readers, 

spell checkers, voice recognition software, and the like—have been 

implemented in companies and result in improved productivity for all workers. 

● Explored how employee personal experience, corporate leadership, and 

stakeholder feedback affected product development related to people with 

disabilities; how the company’s development of accessible technology and 

software changed; employee retention and career advancement; and external 

product demand and revenue. 

● Ultimately, a disability research agenda will include a goal to learn how 

corporate change improves the lives of people with disabilities. Current 

research is inconclusive about whether emerging technologies create change in 

organizations. 

● Digitizing work product has business benefits for improving processes in a 

corporation. One benefit is that it may provide greater flexibility for 

accommodating people with sensory and cognitive disabilities (e.g., through the 

use of screen readers and voice recognition). 

● Many other alternative methods for data input and output are available, and can 

be customized to meet the needs of individuals and their environments. 

● Ad hoc digital documents can be a rich source of information about corporate 

culture and people with disabilities. 

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● Many people with disabilities find unconventional ways to function within a 

system when the system is not flexible enough to allow them to work efficiently. 

● Electronic/digital research data have advantages over traditional types of data 

with regard to storage and portability (e.g., flash drives) 

● Ease of finding information, flexibility in storing and management, and ease of 

communications for digital information reduce problems with data collection, 

decrease data collection time, and ease the burden on respondents. 

● Collaboration and flexibility of management and peers has advantages for 

people with disabilities—responding to an email or marking up a digital 

document allows extra time for those who may have difficulty communicating 

orally or face to face. 

● This approach also fosters a peer-level support or mentoring system that could 

help people with certain types of disability polish their communications before 

sending them. 

● This system allows for greater use of assistive technology and may promote a 

greater level of parity with others in the organization. 

● The organization, mission, and personnel of the accessible technologies group 

at Microsoft changed many times during the study, and members of the group 

expressed frustration at the difficulty of creating long-term change in developing 

accessible software. 

● Many suggested that the most reliable way to ensure inclusion of accessibility 

would be to start with upper management, especially at the highest levels. 

● Technological changes affect how technology is used by people with 

disabilities, which opens up more and richer areas of exploration for 

researchers. 

● Software automation increases opportunities for people with disabilities. 

Technologies such as calendars and scheduling software, or just-in-time 

training, can be useful for persons who need prompting to do particular tasks or 

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to do them in a certain order. Handheld devices might replace job coaches in 

some instances. 

● Automation can eliminate or streamline repetitive tasks, which might reduce the 

need for input/output systems (such as keyboards) for persons with motor 

impairments, GPS systems for directions, and so on. 

● Potentially large amounts of information and innovative uses of technological 

solutions are two-sided coins: They offer the possibility of producing more rich 

data than can be accessed and organized with efficiency, as well as the 

likelihood of inefficiencies in identifying the best information in the data set. 

● Adapting to emerging technologies and understanding the underlying social 

systems will be an ongoing process. 

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Mitra, S., & Bruck, D. (2004). The early intervention project. Journal of Disability 

Policy Studies, 15(3), 159–167. 

Purpose: Describe the Social Security Administration’s Early Intervention research 

project to test a system of screening and incentives to divert SSDI disability 

applicants into a return-to-work program that may help some stay in the workplace 

and remain off benefits, thus reducing costs to the SSA Trust Fund. 

Findings: Currently, SSA offers to help beneficiaries return to work after they have 

expended great effort to prove they cannot work. This confusing offer is often 

viewed with distrust or fear. 

An eligibility screening process identifies applicants who have a high probability of 

eventual acceptance as claimants yet still have the potential to return to work. 

Incentives to participate include the following: 

● 12 months of temporary cash stipends equaling the disability benefit the 

participant might eventually have qualified for; 

● immediate Medicare coverage for 3 years (eliminating a 2-year waiting period); 

● access to State Medicaid buy-in programs, and 

● employment services under an Intensive Service and Barrier Removal Model 

with broader scope of services, or an Employment Services Market System 

Model based on savings projected from return to work. 

● The project relies on effectiveness and accuracy of eligibility screening, 

adequacy of incentives, and effectiveness of service delivery methods. Three 

State pilots will fine-tune the services and service delivery. The national 

demonstration of 5,000 treatment and 5,000 control group members provides a 

statistically valid test of the systems. 

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Molde, H., Grasdal, A., & Eriksen, H. R. (2003). Does early intervention with a light 

mobilization program reduce long-term sick leave for low back pain? A 3-year 

follow-up study. Spine, 15(28), 2309–2315. 

Purpose: This study explored the long-term impact of a light mobilization program 

on clinical and economic outcomes of patients with subacute low back pain. 

Patients placed on a sick list for 8 to 12 weeks for low back pain were randomized. 

Experimental subjects (n = 237) were treated at a spine clinic receiving information, 

reassurance, and encouragement to engage in physical activity as normally as 

possible. Control subjects (n = 220) received treatment in a primary care setting. 

Findings: 

● Initial results at the end of 12 months were as follows: 68.4% of the intervention 

group were off sick leave, compared with 56.4% of the control group. 

● The reduced sick days of the intervention group over 3 years (average 125.7 

days per person vs. 169.6 days for the control group) was caused primarily by 

more rapid return to work during the first year. There was no significant 

difference in sick days between the two groups in the second and third year. 

● The reduced sick days of the intervention group did not increase the risk of 

reoccurrence (Reviewer’s note: This invalidates one of the primary excuses for 

not pursuing early intervention). 

● At 6-month followup, intervention patients were less likely to use bed rest and 

more likely to use stretching and walking to cope with back pain, compared with 

the control group. At 12-month followup, the intervention group was significantly 

different from the control group only by increased use of stretching. 

● Economic returns of intervention: Reduced sick days and increased production 

led to a net benefit over 3 years of approximately $2,822 per person for treating 

the 237 intervention patients. 

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O’Connell, E. (2008). Telework: An Opportunity to Promote Employment of People 

with Disabilities: Review of Literature. Shrewsbury, MA: Center for Health Policy 

and Research, University of Massachusetts Medical School. 

Purpose: Introduces topic of telework and reviews the literature on the use of 

telework as an accommodation for supporting employment of people with 

disabilities. 

Findings: 

● Telework is an employment arrangement in which an employee or contractor 

works at a remote location and uses communications technology such as 

computers, telephones, videophones, and faxes to interact with other workers. 

● “Telecommuting” is often used interchangeably with “telework.” 

● Telework is most appropriate for jobs that involve much use of 

telecommunications equipment, that can be performed individually, and that 

allow flexibility in determining work hours. Jobs that are particularly suitable for 

telework include word processing, customer service, computer programming, 

accounting, billing, claims processing, data entry, dispatching, editing, filling 

orders, researching, report writing, scheduling, transcription, graphics, auditing, 

and record-keeping. 

● There were 11.5 million teleworkers in the United States in 1999; 45 million 

Americans worked remotely at least one day in 2006; including 28.7 million who 

teleworked at least once a month, up 10% from 2005 and 39% from 2002. Of 

these, 12.4 million were direct employees of companies, while 16.2 million were 

contract teleworkers. 

● Three out of five teleworkers were male, and most (79%) were married or living 

with a partner. Teleworkers were relatively high earners, with 40% living in 

households that earned more than $75,000 per year and 21% living in 

households that earned $40,000–$74,999. Only 20% lived in households that 

135
earned less than $40,000 per year. Teleworkers were well-educated, with 72% 

having graduated from college. 

● The teleworking population can be divided along occupational and gender lines, 

with a predominantly male professional segment and a largely female clerical 

segment. 

● Benefits to teleworkers: fewer distractions/interruptions; increased flexibility; 

reduced commuting time; reduced costs for fuel, car maintenance, tolls, public 

transportation, etc.; greater job satisfaction and morale; and reduced workrelated clothing and food costs. 

● Benefits to employers: reduced real estate costs, increased productivity, 

reduced absenteeism, greater employee loyalty and enthusiasm, enhanced 

ability to recruit new workers, continued operations during inclement 

weather/emergencies, improved quality of internal communications, and 

improved ability to retain employees who would otherwise leave because of life 

changes such as increased family responsibilities, relocation, or disabilityrelated illness. 

● It is estimated that telework results in $7,500 savings per employee per year. 

● Benefits to society: reduced production of vehicular carbon emissions and other 

pollutants that cause global climate change, reduced traffic congestion, less 

reliance on fossil fuels, reduced costs of road maintenance and transportation 

infrastructure. 

● From an employer’s perspective, one of the biggest barriers to telework is a 

lack of information about, and experience with, this work arrangement. Other 

concerns include data security, lack of technical support resources for 

teleworkers, and liability for home-based worksite injuries. 

● From an employee’s perspective, concerns include fear of feeling lonely, 

becoming isolated from the workgroup, and losing “social capital” at work. Also, 

worry about worse relationships with supervisors and the possibility of receiving 

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poorer performance ratings, which will cause them to be stuck in dead-end jobs 

without opportunity for career advancement. 

● Best practice: honest self-assessment to determine whether telework would be 

a satisfactory arrangement. Must be comfortable working independently and 

with reduced personal contact, must have good time management and 

written/oral communication skills, and must be technologically literate. The 

employer and/or employee must agree to and maintain a communication plan, 

clearly define responsibilities and expectations, provide training on teleworkrelated issues, schedule periodic in-person meetings, provide computer 

equipment to ensure compatibility, create signed employer/employee 

agreements regarding use of computers and data security, ensure compliance 

with OSHA and liability for accidents, and telework frequently enough to work 

out kinks. 

● Telework is of particular interest to people with disabilities, because it offers a 

way to expand work opportunities in situations in which it would otherwise be 

difficult to work. 

● For many people with disabilities, symptoms can fluctuate unpredictably—

telework can provide the flexibility needed to maintain long-term employment. 

● Disability-related discrimination is likely to be reduced—when the workplace is 

virtual (nonphysical), people with disabilities are completely integrated. 

● Increasing the availability of telework for unemployed persons in the United 

States alone would save employers between $48 and $96 billion dollars 

annually in reduced short- and long-term disability payments, workers’ 

compensation, and personnel replacement costs. 

● Offering telework as an accommodation is one way employers can comply with 

the ADA. 

● Most employers began offering telework in response to employee needs; only 

10% reported hiring new employees with disabilities into telework positions. 

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● Most companies approved telework on an “as needed” basis for current 

employees. Companies were more willing to allow employees with a work 

history to telework than to hire new employees into telework positions. 

● Most employers were not willing to provide technology-related home 

modifications such as Internet connections and communications equipment. 

● Almost half of employers reported that some jobs could be done by telework. 

● A major issue for people with disabilities is that telework requires a level of 

knowledge and skill using information technology; studies have found that 

computer use and Internet access are lower among people with disabilities than 

among the general population. 

● Technological barriers can restrict access to electronic information for many 

potential users with disabilities. Barriers may involve the availability of assistive 

technologies to enable people with disabilities to engage in telework or 

compatibility between an employee’s assistive technology and the hardware, 

software, applications, and interface used by the employer. Some of these 

barriers are the result of the emphasis on designing assistive technology rather 

than universally designed technology. 

● For people with disabilities, telework reduces the in-person interaction that 

would typically occur in a work environment; therefore, teleworkers must find 

ways outside work to meet their social and recreational needs, which may be 

difficult for people who are already socially isolated. 

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Olson, D. L. (1999). An onsite ergonomic program: A model for industry. Work, 13, 

229–238. 

Purpose: Ergonomics is the science of fitting the job to the worker. This article 

identifies key components of comprehensive ergonomic programs used to reduce 

the risk of cumulative trauma disorders and similar injuries, thus reducing injuries 

and costs. 

Findings: 

● A GAO literature review identified core elements of ergonomic programs: 

management commitment, employee involvement, hazard identification, hazard 

controls, training and education, and appropriate medical management. 

● Program startup begins with a thorough analysis of OSHA 300 logs 

documenting accidents and injuries, physician visits, work restrictions, and time 

off work. Other tools include worker complaints, health risk assessments, 

consultant or safety committee inspections, and confidential employee surveys. 

● Risk factors include repetition, static or awkward postures, vibration, tool 

design, extreme temperatures, stressors, lack of control over work, distractions, 

cognitive workload, and environmental issues such as perceived management 

hostility. 

● A program uses engineering, administrative, and work practice controls to 

correct or control exposure to workplace hazards present in workstations, tools, 

and the jobs themselves. 

● Modified duty programs provide early, gradual return to work from disability 

events. To prevent problems, an employee on restricted duty and the foreman 

should both sign a form each day verifying compliance with restrictions from 

both sides. 

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Rodger, S. A., & de Jonge, D. M. (2005). Integrating technology in the workplace 

for people with spinal cord injury. International Journal of Therapy and 

Rehabilitation,12, 14–20. 

Purpose: Discusses barriers and supports to effective use of technology at work 

from the perspective of 11 users of technology with spinal cord injuries. 

Findings: 

● It is important to identify the technology that is needed. 

● Acquiring technology can be challenging because of lack of control over 

decisions about what technology to purchase and issues with installation and 

servicing. 

● Customizing and learning how to use the technology can become an issue 

owing to factors such as lack of time, cost, and complexity of the technology.

● Often, users experience pain and discomfort when using technology in the 

workplace because of poor workstation design. 

● Self-advocacy skills are an important component of successfully using 

technology. 

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Schur, L., Kruse, D., & Blanck, P. (2005). Corporate culture and the employment of 

persons with disabilities. Behavioral Sciences and the Law, 23, 3–20. 

Purpose: Examines the role of corporate culture in the employment of people with 

disabilities and how corporations can develop supportive cultures that benefit 

people with disabilities, nondisabled employees, and the organization as a whole. 

Findings: 

● Employment not only increases financial resources but helps incorporate 

people with disabilities fully into mainstream society by increasing their social 

networks, civic skills, independence, and the sense of efficacy and inclusion 

they get from filling a valued social role. 

● Employment levels of people with disabilities remain well below those of nondisabled 

people, and the majority of nonemployed people with disabilities would prefer to be 

working. Only 28.6% of working-age people reporting a work limitation were 

employed in 2002, compared with 76.6% who did not report a disability. 

● Using an even broader definition of disability, the 2000 census found that 56.6% 

of the 30 million working-age Americans reporting functional or activity 

limitations were employed, compared with 77.2% of those without such 

limitations. Employment rates are lowest among those with several functional or 

activity limitations, of whom only 25.4% were employed in 1999. 

● 67% of people with disabilities want to work. 

● Low employment rates contribute to high rates of poverty. 

● Corporate culture can create attitudinal, behavioral, and physical barriers for 

workers and job applicants with disabilities. 

● While the different levels of culture often reinforce one another, incongruities and 

conflicts may exist among them. For example, there may be an expressed 

commitment to hiring people with disabilities at second level of organizational 

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culture (shared meaning), but this commitment may not be accepted at the most 

basic level – the unstated and often unconscious assumptions of the organization. 

● This lack of acceptance may in turn be reflected in the third level of culture, so 

that the physical environment remains inaccessible, jobs are structured in ways 

that make it difficult for people with disabilities to work there, and coworker and 

supervisor attitudes remain unchanged. 

● 20% of employers said the greatest barrier to people with disabilities finding 

employment is discrimination, prejudice, or employer reluctance to hire them. 

● 22% of private sector employers reported that attitudes and stereotypes were 

barriers to the employment of people with disabilities in their own firms. 

● 32% said it was difficult or very difficult to change supervisor and coworker 

attitudes, while only 17% said this about creating flexibility and modifying their 

return-to-work policies. 

● 81% of private sector employers said visible top management commitment was 

effective or very effective in reducing barriers to employment for people with 

disabilities, while 62% said this about staff training, and 59% said this about 

mentoring efforts. 

● U.S. employers found a lower rate of lost time days due to illness and injury among 

companies that used (1) employee involvement programs (stress and participation 

in decisions are inversely related), (2) conflict resolution and grievance procedures, 

(3) workforce stabilization and continuity policies, and (4) early support and 

assistance programs for employees with chronic illness or injuries. 

● Supervisor and coworker attitudes toward employees with disabilities reflect 

several influences: stereotypes, discomfort being around people with 

disabilities, strain caused by communication difficulties, personality factors, and 

previous contact with people with disabilities. 

● Supervisor and coworker attitudes affect performance expectations, 

performance evaluations, willingness to work with a person with a disability, and 

hiring into jobs with discretionary work activities (more responsibility). 

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● Employees with disabilities use a number of strategies to shape expectations in 

the workforce: concealing the disability; communicating information about the 

disability to reduce discomfort/clarify norms; requesting help to clarify expected 

behaviors; emphasizing similarity to others through shared interests, opinions, 

and values; and becoming a “superworker” to dispel stereotypes and modify 

others’ expectations. 

● Established job methodologies—the biggest problem is not the unsuitability of 

jobs but rather finding an organization that is willing to break the mold and allow 

people a chance to prove their capability. 

● Accommodations are likely to provoke a response (to be perceived as unfair) 

when they are salient and relevant to coworkers. 

● 31% of employers said that a barrier to employing people with disabilities was 

the lack of supervisor knowledge about accommodations; only 16% said that 

the cost of accommodations was a barrier. 

● Many of the steps to change corporate culture for better employment for people 

with disabilities have potential benefits for all employees, not just those with 

disabilities (e.g., universal design) 

● Factors that contribute to the success of workplace diversity programs are 

commitment by top management, making diversity part of the company 

philosophy (not a PR tool), linking diversity goals to performance evaluations, 

involving employees at all levels, ongoing education, and outreach. 

● The effects of diversity programs depend greatly on the organizational context 

and the way they are implemented. 

● If employment prospects of people with disabilities are to be improved 

significantly, attention must be paid to the ways in which corporate culture 

creates or reinforces obstacles for employees with disabilities, and how those 

obstacles can be removed or overcome. 

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Shaw, W. S. (2006). Controlled case study of supervisor training to optimize injury 

response in the food processing industry. Work, 26, 107–114. 

Purpose: Toward the goal of reducing disability claims or duration of claims, a 

group of supervisors at a food-processing plant received a four-hour training 

covering employee communication, RTW problem-solving skills, and ergonomics. A 

control group was held out of training for 7 months. Each group was responsible for 

400 employees. 

Findings: 

● The first group of supervisors to receive training showed a 47% reduction in the 

number of new workers’ compensation claims filed during the first 7 months. 

● Prior to training, the second group of supervisors showed a 19% reduction in 

claims during the 7-month period. 

● Following training, the second group of supervisors showed a further 19% 

reduction in new claims, for a total reduction of 38% over 12 months. 

● In both groups, the number of active claims remained fairly constant. 

● Supervisors expressed confidence in their increased ability to deal with claimsrelated issues. 

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Social Security As Part of an Integrated National Disability Policy, testimony to the 

Social Security Advisory Board Discussion Forum on the Definition of Disability, 

April 14, 2004. 

Purpose: Virginia Reno, vice president for income security policy of the National 

Academy of Social Insurance, was asked to present the view that the current Social 

Security disability program framework can be maintained (with modest changes) 

and be consistent with an integrated national disability policy. This testimony is 

based in large part on the findings of the Academy’s Disability Policy Panel. 

Findings: 

● The Social Security definition of disability is not in conflict with a 21st century 

view of disability. Wage replacement remains important and is not replaced by 

the Americans with Disabilities Act. Particular programs will have varying 

definitions of disability that are driven by their expressed purpose; the Social 

Security definition of disability is very strict. 

● Social Security Disability Insurance (SSDI) is not a strong deterrent to work 

because benefits and income replacement rates are modest, U.S. disability 

spending is low by international standards, and people turn to disability benefits 

only as a last resort. 

● It is argued that liberalized eligibility criteria and rising income replacement 

rates of the SSDI benefit have caused people to leave the labor force and turn 

to SSDI. But the 1984 expansion of SSDI eligibility criteria was only a return to 

“a responsible center” from extraordinarily restrictive policies in the Reagan 

years. The claim that replacement rates rose during the 1980s and 1990s is 

focused on older men at the bottom of the wage distribution. This is not a flaw in 

the SSDI benefit formula but the result of an aberration in the wage structure of 

the U.S. economy. 

● Why did the disability rolls grow in the 1990s? Three possible explanations: (1) 

restrictions on other disability benefits pushed people to SSDI; (2) global 

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changes in the competitive workforce have made the workplace more 

“unforgiving”; and (3) fewer early retirement options drive more work disability 

applications. 

● Recovery and return to work from SSDI may be better than the “fewer than 1% 

on the SSDI rolls return to work” statistic makes it appear. In the mid-1990s, the 

Academy’s Disability Policy Panel found that after 6 years on SSDI rolls, 3.5% 

had recovered or returned to work. When those who died or reached retirement 

age were excluded, 6.2% had recovered or returned to work. 

Thornton, Zeitzer, Bruyerre, Golden, & Houtenville. (2003). What Works and 

Looking Ahead: A Comparative Study of UK and US Policies and Practices 

Facilitating Return to Work for People with Disabilities. US/UK Pathways to Work in 

the 21st Century Seminar and Workshop, May 1–2, , Washington, DC. 

Purpose: Independent research organizations in the United States and the United 

Kingdom were commissioned to review the research on “what works” in facilitating 

return to work for people with disabilities, and to consider current developments in 

light of the evidence. 

Findings: 

● Demographics: Employment rates among people with disabilities are falling in 

the United States and remain relatively stable in the UK. There is a common 

trend of younger people coming onto the Social Security Disability Insurance 

(SSDI) rolls in the United States and onto incapacity benefits in the UK. Mental 

disorders are the most common primary condition in both systems. 

● Making work pay: Incentives to leave benefits for employment may be easier to 

use in the United States, while UK’s tax credit for people with disabilities is a 

more generous means-tested benefit than the U.S. earned income tax credit 

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and also schedules the benefit out during the year rather than forcing the 

taxpayer to wait for tax returns. 

● Access to health insurance for people with disabilities who want to work is a 

serious concern in the United States; it is not an issue in the UK, which has 

universal health insurance. 

● The UK does not link disability benefit entitlement with inability to work, as the 

United States does. This may explain why the UK has higher rates of disability, 

but it also may explain why disability entitlement is a dead end for many in the 

United States. The UK links employment support with disability benefits in an 

early intervention scenario through its Jobcentre Plus. 

● U.S. employer tax credits support initial accommodations, which helps with 

return to work or hiring but not longer term support. The UK’s Access to Work 

program provides 3 years of support, which can be extended, with employers 

often willing to pay for less expensive initial supports. 

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Tompa, E., de Oliveira, C., Dolinschi, R., & Irvin, E. (2008). A systematic review of 

disability management interventions with economic evaluations. Journal of 

Occupational Rehabilitation, 18, 16–26. 

Purpose: A systematic literature review of disability management interventions 

asks the question “What is the credible evidence that incremental investment in 

disability management interventions is worth undertaking?” Researchers found 17 

disability management interventions with economic analyses; 8 were of high or 

medium quality. The review notes the lack of studies providing high-quality, reliable 

economic data. 

Findings: 

● Insufficient evidence supporting the economic merits of disability management 

interventions in five specific industry sectors; only one study per sector. 

● Strong evidence supporting the economic merits of multisector disability 

management interventions based in a systems-level perspective (three of four 

studies; the fourth appeared to contain this also but didn’t clearly articulate this).

● By intervention components, the study found moderate evidence for 

interventions including education, physiotherapy and work/vocational 

rehabilitation, and limited evidence for a behavioral component. 

● By intervention features, the study found moderate evidence for interventions 

including a work accommodation offer, contact between health care provider 

and workplace, early contact with worker by workplace, ergonomic worksite 

visits, and management by a return-to-work coordinator. 

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Wooten, L. P., & James, E. H. (2005). Challenges of organizational learning: 

Perpetuation of discrimination against employees with disabilities. Behavioral 

Sciences and the Law, 23, 123–141. 

Purpose: To examine why organizations struggle with learning how to prevent 

discrimination against their employees with disabilities. The authors contend that 

failures in eliminating disability discrimination reflect difficulties of organizational 

learning. 

With increased information about workforce diversity, organizations should have a 

better understanding of how to prevent discrimination and create a work 

environment that accommodates the needs of disabled employees. 

Organizational learning requires the organization to adapt continuously to a 

changing business environment by drawing on knowledge—a repertoire of skills 

and routines— that influences decision making. 

Findings: 

● One of the most frequent codes for barriers to learning was discriminatory 

organizational routines—harassment of disabled employees, unwillingness to 

provide reasonable accommodations, and negative images of disabled 

employees—where some organizations lacked routines to manage the 

challenges of discrimination. These discriminatory routines consciously 

perpetuate negative behavior. The institutionalization of discriminatory routines 

produces a work environment in which disabled employees are perceived as 

damaged goods or second class citizens. 

● Another barrier to learning was organizational defense routines—

management’s denial or justification of discrimination and disassociation from 

the discriminatory behaviors—to prevent the organizations from experiencing 

embarrassment. This tendency to cover up negative information may result in 

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missed learning opportunities and the continuation of the behavior that caused 

the initial problem. 

● Reliance on reactive learning was another barrier—the organization failed to 

address the underlying cause of discriminatory behavior or had a myopic focus 

on strategic goals while neglecting to develop an inclusive work environment. 

This led to a failure in learning what factors within the organization could be 

seen as the cause of the problem and failure to resolve those specific issues. 

● Window dressing—the organization focused on impression management or a 

surface-level commitment with regard to disabled employees—was also 

identified. Without a deep-seated change of managerial practices, 

organizational learning does not occur. 

● Lack of vicarious learning emerged as the last category—learning from the 

previous mistakes of other organizations and the pressure of interest groups. 

To engage in vicarious learning, organizations need a reference point. There 

are few reference points for successful ADA implementation. 

Summary: 

● Several organizationally based learning theories explain the difficulty 

organizations have with creating a disability-friendly work environment. These 

barriers to learning are embedded in complex defense mechanisms and 

discriminatory organizational routines. 

● Businesses can learn by partnering with nonprofit organizations and 

government agencies and by learning how to comply with the ADA. 

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Abstracts for Section 5: Public Sector Strategies for Building and 

Maintaining a Sufficient Supply of Disability Infrastructure Occupations 

Benz, M. R., Lindstrom, L., & Yovanoff, P. (2000). Improving graduation and 

employment outcomes of students with disabilities: Predictive factors and student 

perspectives. Exceptional Children, 66(4), 509–529. 

Purpose: The article reports on findings from two studies. The first study examined 

student and program factors that predicted participants’ graduation with a standard 

high school diploma and placement in employment or continuing education. The 

second study examined participants’ perceptions of the program and staff 

characteristics that were most important in helping them achieve their education 

and transition goals. 

Findings: 

● Career-related work experience and completion of student-identified transition 

goals were highly associated with improved graduation and employment 

outcomes. 

● Individualization of services around student goals and personalized attention 

from staff were highly valued by participants. 

● The percentage of youth with disabilities graduating with a high school diploma 

has remained constant at about 30% over the past 10 years. 

● Research suggests that the following programmatic factors contribute to better 

postsecondary employment and education outcomes for students with 

disabilities: 

o Participation in vocational education classes during the last 2 years of high 

school, especially classes that offer occupationally specific instruction. 

o Participation in paid work experience in the community during the last 2 

years of high school. 

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o Competence in functional academic skills (reading, math, writing, problem 

solving); community living skills (money management, community access); 

personal-social skills (getting along with others); vocational skills (career 

awareness, job search); and self-determination skills (self-advocacy, goalsetting). 

o Participation in transition planning. 

o Graduation from high school. 

o Lack of continuing instructional needs in functional academic, vocational, 

and personal-social areas after leaving school. 

● Several organizational factors also have been identified as associated with 

exemplary secondary and transition programs and better outcomes for 

students, including (a) the use of written interagency agreements between 

schools and adult agencies to structure provision of collaborative transition 

services, and (b) establishment of key positions funded jointly by schools and 

adult agencies, such as vocational rehabilitation to deliver direct services to 

students in transition. 

● Several student-related factors were negatively associated with school 

performance and completion, including (a) being identified as emotionally 

disturbed, (b) having a prior history of absenteeism or course failure, and (c) 

being 3 or more years behind grade level in reading and math. 

● Several school-related factors were positively associated with school 

performance and completion rates, including (a) direct, individualized tutoring 

and support to complete homework assignments, attend class, and stay 

focused on school; (b) participation in vocational education classes, particularly 

in grades 11 and 12; and (c) participation in community-based work experience 

programs during the last 2 years of high school. 

● The majority of high school students with learning and behavioral disabilities 

said their placement in special education had not helped them academically, 

and they objected to what they viewed as the low-level, irrelevant, and 

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duplicative (with regular education) instruction they received, though they 

acknowledged that they had not mastered basic academic skills and that 

special education was warranted. 

● These youth did not want to be supported by special education staff in the 

general education classroom, as that would draw attention to their academic 

difficulties. 

● What they wanted was instruction in a challenging and relevant curriculum that 

would prepare them for life after school without requiring the “special education” 

label to participate. 

● Graduation with a standard high school diploma and engagement in work or 

schooling activities were both strongly predicted by student participation in two 

or more career-related, paid jobs while in school and by completion of four or 

more student-identified transition goals. 

● Individualization of program services around student-identified goals, the 

accomplishment of personally meaningful activities, and the emergence of selfawareness and self-confidence as a foundation for future accomplishments 

were identified by students as important benefits of transition programs. 

● The participants also identified important roles of transition program staff: (a) 

discuss problems with school, family, and friends; (b) provide specific support 

for education and transition goals (one-to-one tutoring and counseling); (c) 

assist with other issues that affect success (accompanying youth to court to 

resolve legal problems); and (d) provide general support to solve the real-life 

problems that arose during the early transition years after leaving school. 

● Components and services associated with improved secondary performance 

and postschool outcomes included (a) direct support for students in general 

education classes delivered in a way that does not highlight affiliation with 

special education; (b) participation in paid work experiences that are related to 

students’ career interests; (c) instruction in vocational education, functional 

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academic, and other transition content; and (d) completion of student-identified 

transition goals. 

Implications for practice: 

● Focus secondary and transition services concurrently on the two goals of 

school completion and postschool preparation. 

● Promote curricular relevance and student self-determination through studentcentered planning and individualized services. 

● Expand the use of collaborative service delivery programs as a mechanism for 

delivering transition services. 

● Extend secondary school reform efforts to include career development, applied 

learning in the community, and transition planning as a central part of the 

regular curriculum for all students. 

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Bolton, B. F., Bellini, J. L., & Brookings, J. B. (2000). Predicting client outcomes 

from personal history, functional limitations, and rehabilitation services. 

Rehabilitation Counseling Bulletin, 44(1), 10–21. 

Purpose: How much variance in employment outcomes can be explained by three 

sets of predictor variables that represent the three phases of the vocational 

rehabilitation (VR) process? Which variables made the largest contributions to the 

explanation of employment outcomes? 

Findings: 

● The research sample included more than 4,000 VR clients from five disability 

categories: orthopedic, chronic medical, psychiatric, mental retardation, and 

learning disabilities. 

● If we understand the determinants of successful outcomes, we can intervene to 

increase the likelihood of success for VR clients. 

● Rehab outcomes have been extensively researched, but few studies have 

assessed the predictability of outcomes from variable sets that reflect the 

multiple phases of the VR process while controlling for effects of disability. 

● The optimal combination of personal history, functional limitations, and services 

received explained approximately a third of the variability in competitive 

employment for VR clients (range of 24–40% of the various disability groups). 

● The optimal combination of personal history, functional limitations, and services 

explained approximately one-eighth (12%) of the variability in salary among 

competitively employed VR clients (range of 9–17% across disability groups). 

● Personal history typically accounted for 5% of the variance in competitive 

employment and salary outcomes (range of 1–8%). 

● Counselor-rated functional limitations made almost no addition to the prediction 

of competitive employment and a very modest contribution (4%) to salary. 

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● Service variables contributed substantially to prediction of employment and 

explained an average of 26% of the variance beyond what was already 

explained by personal history and functional limitations. Service variables 

contributed only modestly to the explanation of variation in weekly salaries 

(2%). 

● Job placement was by far the most important single variable contributing to the 

prediction of competitive employment (bivariate correlation of .50). Job 

placement made virtually no contribution to prediction of weekly salary at 

closure. 

● Personal history was the second most important variable for predicting both 

competitive employment and salary at closure (with the exception of competitive 

employment for the mentally retarded sample and salary for the chronic medical 

sample). 

● Training had considerable variability in explanatory capability. Provision of 

training made a unique contribution to predicting competitive employment for all 

five disability groups but made relatively larger contributions for the orthopedic 

and mentally retarded (MR) samples. 

● Time in rehabilitation had virtually no effect on predicting competitive 

employment but was the second largest service variable in predicting salary for 

most disability groups; it contributed negatively to predicting employment for the 

MR sample but positively to predicting salary for the orthopedic, psychiatric, and 

learning disabled samples. 

● Total cost contributed to prediction of employment for the orthopedic, 

psychiatric, and MR groups, and to predicting salary for the chronic medical and 

psychiatric groups. 

● Provision of personal adjustment, restoration, and maintenance services had 

virtually no effect on predicting employment outcomes for the five disability 

groups. 

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● Functional limitations were generally unimportant in predicting employment, 

although the relationships between functional limitations and salary at closure 

were of slightly greater magnitude. 

● The following functional limitations contributed to the prediction of salary: 

adaptive behavior for the chronic medical and MR groups; cognition for the 

orthopedic and chronic medical groups; physical capacity for the orthopedic, 

chronic medical, and MR groups; and vocational qualifications for the 

orthopedic, psychiatric, and MR samples. 

● The overwhelming importance of job placement demonstrated in this 

investigation supports an increased emphasis on the topic in both rehabilitation 

counselor education progress and State VR agency training for counselors. 

Summary: 

● Competitive employment is more predictable and thus more susceptible to 

improvement than salary at closure. 

● Personal history information constitutes a quantitative basis for calculating an 

estimate of client case difficulty for use by VR counselors. 

● Job placement services should receive greater emphasis in VR counselor 

education services. 

● Functional limitations should continue to be evaluated by counselors in 

conjunction with the VR client diagnostic and service planning phase. 

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Disability Services Sector Workforce Development Strategy: A 5-Year Framework, 

2007–2011. Tasmania, Australia: Department of Health and Human Services. 

Purpose: Government and nongovernment disability service providers seek to 

develop a cross-sector workforce of creative, innovative, and highly skilled people 

who have the knowledge and attributes to provide effective and efficient services of 

Tasmanians with disabilities and their families, both now and into the future. The 

goal is effective, targeted workforce development initiatives that are aligned with 

business planning and meet the needs of the disability services sector. 

Findings: 

● Creation and sustainability of an efficient and productive workforce requires 

more than an adequate number of workers. It requires a flexible approach for 

workers, which helps people balance work and life, and aims to improve morale 

and job function. 

● The client must be at the center of professional learning programs. 

● Professional learning must be ongoing and intrinsic to the work of disability 

services officers. 

● Workplace learning raises the profile of the disability service sector and fosters 

professionalism. 

● Disability services is a profession of choice, and professional learning will make 

the sector attractive. 

● Links among vision, goals, operational plans, and learning development 

strategies are important. Such links do not currently exist. 

● Workforce development will be aligned with and address the needs of the three 

elements of the workforce: the system, the individual, and the workplace. 

● For the disability services sector to maintain a pathway of continuous service 

delivery enhancement to people with disabilities, a learning culture needs to be 

supported at the sector level. 

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● The disability services sector needs to focus on the acquisition, sharing, and 

use of knowledge to foster a learning sector culture through open 

communication. 

● Individual development in the sector will be supported and encouraged through 

the enhancement of skills, knowledge, and learning ability, which will ensure 

continued organizational as well as individual growth. 

Fishman, M. E., Barnow, B., Glosser, A., & Gardiner, K. (2004). Recruiting and 

Retaining a Quality Paraprofessional Long-Term Care Workforce: Building 

Collaboratives with the Nation’s Workforce Investment System. Washington, DC: 

The Lewin Group. 

Purpose: Describes both the long-term care sector and the workforce investment 

system in an effort to build understanding of both systems. 

Findings: 

● Collaboration between the two systems is mutually beneficial. 

● Collaboration should include advertising job openings at One-Stop Centers; 

participation of employers on Workforce Investment Boards (WIBs); 

encouraging local WIBs to make long-term training a priority; promoting on-thejob training; working with employer intermediary organizations to recruit, train, 

and support staff; and exploring ways to make jobs more attractive 

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Gervey, R., Ratemo, M., Halper, A., Brucker, D., & Berkowitz, M, (2007). Ticket-toWork project: Evaluation of an assertive outreach approach to increase ticket 

assignment and use of the One-Stop system by SSA beneficiaries in an urban 

county in New Jersey. Journal of Vocational Rehabilitation, 26, 79–88. 

Purpose: To evaluate the effectiveness of an assertive outreach effort to increase 

Ticket-to-Work (TTW) enrollment and use of the One-Stop Career Center System 

by SSA beneficiaries in a densely populated, urban county in New Jersey. 

SSA’s national and regional attempts to notify beneficiaries about the Ticket 

program have resulted in a very low enrollment of SSA beneficiaries in the new 

work incentives program. The current project was designed to determine whether 

the TTW program could be enhanced through a more assertive person-to-person, 

phone-initiated outreach marketing approach. 

Findings: 

● 6% (34/557) of SSA beneficiaries spoken to directly responded positively to the 

invitation to explore employment or training opportunities or to visit the OneStop Career Center. 

● Two-thirds (347/557) were successfully contacted for the 3-month followup. Of 

these, eight reported being employed, although none had used the ticket. Two 

who were not working reported assigning their ticket. 

● 61% of all beneficiaries contacted stated that they were too ill to work; 35% 

indicated no interest in working; and 4% were beyond the age of 65 and should 

not have been on the SS list to receive the Ticked to Work notice or were 

deceased. 

● The assertive outreach effort increased contact with SSA beneficiaries more 

than a standard mailing campaign, but there seemed to be little or no apparent 

cost benefit to assertive outreach efforts. 

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● Summary: The key element in the success of the Ticket to Work program was 

for the private sector to be able to identify and recruit highly qualified job 

seekers from the SSA rolls. Instead of being a program that targeted 

beneficiaries with the most successful education and work background, the 

program was marketing to all SSA beneficiaries, resulting in a less attractive 

pool of customers. 

Kauff, J., Kirby, G., & Pavetti, L. (2005). Linking TANF Recipients with 

Paraprofessional Long-Term Care Jobs. Washington DC: Mathematica Policy 

Research Inc. 

Purpose: To examine the suitability of Temporary Assistance for Needy Families 

(TANF) recipients for employment as certified nurse aides (CNAs) and home health 

aides, and the feasibility of training recipients for these paraprofessional jobs. 

Findings: 

● 56% of TANF recipients in Illinois, Maryland, South Carolina, and the District of 

Columbia had moderate to high potential for entry into long-term care (LTC) 

employment on the basis of their demographic and current job characteristics. 

● 12% of all recipients in the four sites have a criminal record or dependence on 

drugs or alcohol that would disqualify them from LTC employment. 

● 37% of recipients have poor English skills or poor physical and mental health, 

which would disqualify them from LTC employment. 

● The total potential pool of new LTC workers was 56% (40,000 TANF 

recipients)—people who have a high or average probability of substantial 

employment generally and no or moderate liabilities to LTC employment 

specifically. 

● Strong links between the providers of LTC training programs for TANF 

recipients and employers facilitate successful links to employment. 

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● Job shadowing or work experience components of LTC training are beneficial. 

● Tapping into multiple sources of funding to support training programs can 

reduce the risk of programs folding and expand the array of program services 

and target populations. 

● Links between the LTC training programs and the TANF system can provide 

funding for trainees (e.g., transportation stipends, child care subsidies) as well 

as access to supportive services, including staff who can provide case 

management services and help address personal issues. 

● Retention services, including such supportive services as case management 

and child care or transportation assistance, might help to reduce employee 

turnover and ensure more continuity in patient care. 

Challenges to implementing an LTC training program for TANF recipients: 

● Additional LTC training program selection criteria (e.g., proof of reliable child 

care or transportation) can limit the pool of trainees. 

● “Work first” (not allowing education and training as the principal activity) limits 

training opportunities. 

● Few take advantage of advanced training opportunities. Many people are not 

aware that these opportunities exist, and advanced training is often not 

accessible. 

Implications: Before policymakers and program administrators invest in linking 

TANF with the LTC industry, they should evaluate existing programs or design, 

implement, and evaluate smaller scale demonstration projects to answer questions 

about how programs affect participant outcomes or the costs relative to the 

benefits. 

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Kirby, G., Pevetti, L., Max, J., & Gregory, J. (2005). TANF Recipients As Potential 

Long-Term Care Workers: An Assessment of the Prospects in the District of 

Columbia, Illinois, Maryland, and South Carolina. Washington, DC: Mathematica 

Policy Research Inc. 

Purpose: Discusses the characteristics of long-term care jobs and individuals in 

these positions, as well as the characteristics of TANF recipients and the likelihood 

of attracting them to LTC training and jobs. 

Findings: 

● Barriers such as transportation and child care need to be considered in 

designing an LTC training program. 

● Trainees should be provided with assistance during training and after job 

placement. 

● Better marketing strategies are needed to encourage TANF recipients to 

consider the LTC field. 

● Welfare offices should be encouraged to support recipients’ choice of LTC 

training. 

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Luecking, R. G., & Fabian, E. S. (2000). Paid internships and employment success 

for youth in transition. Career Development for Exceptional Individuals, 23(2), 205–

221. 

Purpose: This article presents information on the characteristics and postschool 

outcomes of youth who participated in the Marriott Foundation’s Bridges from 

School to Work internship program at seven national sites from 1993 to 1997. This 

study specifically examined whether gender, race, or primary disability affected 

internship performance and completion, and to what extent demographic, work 

behavior, and work setting factors during the internship contributed to postschool 

employment success at 6-, 12-, and 18-month followup intervals. 

Findings: 

● There were uniformly high rates of internship placement and completion among 

all categories of primary disability, race, and gender. 

6 months after internship completion 

● Enrollment in postsecondary education was the most frequently cited reason for 

not working at all three intervals, followed by not being able to find work. 

● The two work behavior variables—completion of internship and whether a job 

offer occurred—were the strongest predictors of outcome. 

● The only demographic variable associated with employment outcome at six months 

was whether the student had a learning disability; students with an LD were slightly 

more likely than students in other disability groups to be working at six months. 

12 months after internship 

● Work behaviors were most predictive of outcome, with students who received a 

job offer after internship completion being three times more likely to be 

employed at 12 months. 

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● Students with emotional disabilities were about half as likely to be employed at 

12 months, and students with minority backgrounds also were less likely to be 

employed. 

18 months after internship 

● Work behaviors were no longer significant predictors of outcome. Instead, the 

strongest predictors were demographic factors, specifically type of disability and 

ethnicity. Students with emotional disabilities were almost three times less likely 

to be employed than others, and minority students were about half as likely to 

be working than nonminority students. 

Summary: 

● A structured internship experience is beneficial for students across 

demographic characteristics, disability factors, and educational placement data. 

● Data from the six-month postinternship group reveal that students who perform 

better during the internship experience will also be more likely to be working 

after they leave school. 

● The students who received a job offer were the most likely to be employed at 12 

months, emphasizing the importance of acquiring adequate work skills to 

sustain performance after leaving school. 

● There is need for ongoing postschool vocational and career support services to 

sustain performance gains achieved during school years. 

● Some youth (e.g., those with emotional disabilities) may need nonwork ancillary 

services (e.g., counseling and case management) in conjunction with the paid 

work experience to achieve better employment outcomes. 

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Liu, S., Ireys, H. T., & Thornton, C. (2008). Participants in the Medicaid Buy-In 

program, 2000–2004. Journal of Disability Policy Studies, 19(2), 95–102. 

Purpose: Provides a descriptive profile of enrollment, expenditures, and earnings 

for Buy-In participants in 27 States between 2000 and 2004. 

Findings: 

● As of December 2005, 31 States were operating a Medicaid Buy-In program, 

with total nationwide enrollment of approximately 70,000. 

● The Medicaid Buy-In program grew significantly during a period when most 

State Medicaid programs operated under severe budgetary pressure. 

● Cross-State comparisons suggest that program design shapes enrollment and 

outcomes. 

● Among 126,606 participants enrolled in the Buy-In program in 27 States from 

2000–2004, 49% were males and 77% were white. 

● Average age of Buy-In participants was nearly 45 years; 46% were between 21 

and 44, and 51% were between 45 and 64. 

● 31% of Buy-In participants between 2000 and 2004 had a mental illness or 

other mental disorder. Mental retardation and musculoskeletal conditions were 

the primary disabling conditions for 12% and 9%, respectively. Only 2% had a 

sensory disorder, including vision, hearing, and speech. 21% had an 

impairment other than these four conditions. 

● The States varied in the type of conditions that were most common in their 

enrolled populations, possibly owing to differences in outreach approaches, 

specific asset and income eligibility criteria, and eligibility criteria for other 

Medicaid options. For example, New Hampshire had the highest share of 

participants with mental illness (56%) and West Virginia had the lowest (5%). 

● Many persons had received other disability benefits, such as SSI or SSDI, 

before participating in the Buy-In. At the time of enrollment, nearly 69% 

166
received only SSDI benefits, 2% received only SSI benefits, and 3% received 

both SSI and SSDI. 

● Total annual earnings among the 62,528 Buy-In participants in 2004 who had 

reported earnings (only 66% reported earnings, as some did not have to report 

earnings for various reasons) were $453 million, with an average of $7,246 per 

person. This average amount was equivalent to 78% of the federal poverty level 

(FPL), which was $9,310 in for a single person. About one fourth had incomes 

above FPL, and 7% had incomes above 200% of FPL. 

● Younger and nonwhite persons were disproportionately represented in the topearner group. Individuals age 21–44 years accounted for 60% of the high 

earners but only 45% of the Buy-In participants. Nonwhite persons made up 

37% of the top earners but only 19% of overall participants. 

● Persons who received SSDI made up a large majority of the participants (70%) 

but only 20% of the top earners (possibly because of SGA (Substantial Gainful 

Employment)-related disincentives and possible loss of benefits). Participants 

with no involvement in SSDI or SSI accounted for 79% of top earners but only 

25% overall. 

● The majority of Buy-In participants had earnings below SGA, the limit at which 

SSDI benefits are terminated. Hence, although the program functions as a work 

incentive, it may not lead to large numbers of people exiting SSDI or SSI. 

● A disproportionate percentage of Buy-In participants with the highest earnings 

were those without SSDI/SSI, which suggests that the Buy-In could serve a 

preventive role by helping certain persons with disabilities avoid becoming 

dependent on cash assistance. 

167
Metzel, D. S., & Giordano, A. (2007). Locations of employment services and people 

with disabilities: A geographical analysis of accessibility. Journal of Disability Policy 

Studies, 18(2), 88–97. 

Purpose: As a first step in assessing the accessibility of the locations of 

employment services, this study compared the locations of VR and One-Stop 

services with areas that had high numbers of nonemployment among people with 

disabilities and high numbers of unemployment in the general population. The 

objective was to determine at the national and State levels how geographically 

accessible these services are to nonemployed people with disabilities. 

Guidelines established by the Rehabilitation Act of 1973 were not provided for 

determining sites for VR services; as a result, there is considerable variation in the 

number and location of field offices among and within the States. 

A body of knowledge has established how location and distance have been used to 

disadvantage particular groups of people who are already socially and 

economically disadvantaged. 

Findings: 

● Nonemployed people with disabilities (NEPWD) were more likely than 

unemployed people to live near one another. 

● Overall, employment services in the Northeast and in parts of the South were 

inadequately sited to meet the numbers and locations of people in need. 

● One-Stops appeared to be only slightly better located than VRs in California, 

Florida, Louisiana, Michigan, Missouri, New Jersey, and Oklahoma. 

● In Arkansas, Idaho, North Dakota, and Wyoming, VR services were better 

located than One-Stops. 

● Illinois, Louisiana, and Pennsylvania had no VRs in tracts with high numbers of 

NEPWD. 

168
Summary: 

● The study assumed that locations of VR and One-Stop services are critical for 

accessibility and the use of services. 

● VRs and One-Stops are not in the communities that have the strongest need for 

them. 

● There are no formal locational criteria to guide the siting of VRs and One-Stops. 

One-Stops should be located within a reasonable travel distance for job 

seekers, but there are no guidelines for determining reasonable distance. 

● Program designers should also consider alternative service delivery designs 

that bring the service to the person in need, such as online applications and 

staff who meet where it is convenient for the intended users. 

● The private sector has turned away from participating in the TTW program, 

leaving the State VR system as the primary provider of employment services for 

the Ticket. 

● For the TTW program to achieve its initial goal, it may be necessary to “cream” 

from the SSDI beneficiaries, selecting those with the highest education, most 

recent employment, and most extensive work and earnings history. 

U. S. Government Accountability Office. (2009).VA Vocational Rehabilitation and 

Employment: Better Incentives, Workforce Planning, and Performance Reporting 

Could Improve Program. Washington, DC: Government Accountability Office. 

Purpose: A review of a newly implemented five-track service delivery model for the 

Veterans Affairs’ Vocational Rehabilitation and Employment Program. 

Findings: 

● Veterans in most need of immediate employment services may be at a 

disadvantage owing to the current incentive structure. 

169
170

● There has been improved capacity to serve veterans owing to additional staff 

and collaborations with other organizations. 

● A lack of information relative to staffing needs may limit the ability to provide 

quality service to those returning from Afghanistan and Iraq, as well as veterans 

from past conflicts. 

● There is a need to develop a strategic workforce planning process with regard to 

collecting relevant data to plan for appropriate current and future staffing needs.
APPENDIX B. Supply-Demand Charts of Infrastructure 

Occupations 

171
172
Occupations: Employment 

(Occupational definitions and information about education and training are adapted from 

the Bureau of Labor Statistics Occupational Outlook Handbook, 2008–2009 edition.) 

Rehabilitation counselors help people deal with the personal, social, and vocational 

effects of disabilities. They counsel people with disabilities resulting from birth defects, 

illness or disease, accidents, or other causes. They evaluate their strengths and 

limitations; provide personal and vocational counseling; and arrange for medical care, 

vocational training, and job placement. Rehabilitation counselors interview persons with 

disabilities and their families; evaluate school and medical reports; and confer with 

physicians, psychologists, occupational therapists, and employers to determine the 

capabilities and skills of the individual. They develop rehabilitation programs by 

conferring with clients; these programs often include training to help clients develop job 

skills. Rehabilitation counselors also help clients increase their capacity to live 

independently. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth1

Total 

Replacement 

Needs 

2006–

20162

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

141,000 173,000 32,000 23 60,000 72.8 18.3 8.9 Yes Low 

1. The average projected increase in these occupations from 2006 to 2016 is 10.4%. 

Occupations that are growing at a faster rate will have a higher demand. 

2. “Total replacement needs” is the sum of employment needs caused by both growth and net 

replacements. 

Projected supply and demand: Although the supply has been growing, demand will 

continue to increase sharply. 

173
Education and training: A 

master’s degree is usually 

required to be licensed as a 

counselor. Some States 

require counselors in public 

employment to have a 

master’s degree; others 

accept a bachelor’s degree 

with appropriate counseling 

courses. Counselor 

education programs in colleges and universities are often found in departments of 

education or psychology. Courses are often grouped into eight core areas: human 

growth and development, social and cultural diversity, relationships, group work, career 

development, assessment, research and program evaluation, and professional identity. 

In an accredited master’s degree program, 48 to 60 semester hours of graduate study, 

including a period of supervised clinical experience in counseling, are required. 

Related fields: These include college student affairs, elementary or secondary school 

counseling, education, gerontological counseling, marriage and family therapy, 

substance abuse counseling, rehabilitation counseling, agency or community 

counseling, clinical mental health counseling, career counseling, and related fields. 

Counselors work in a wide variety of public and private establishments, including health 

care facilities; job training, career development, and vocational rehabilitation centers; 

social agencies; correctional institutions; and residential care facilities, such as halfway 

houses for criminal offenders and group homes for children, the elderly, and persons 

with disabilities. Some substance abuse and behavioral disorder counselors work in 

therapeutic communities where people with addictions live while undergoing treatment. 

Counselors also work in organizations engaged in community improvement and social 

change, drug and alcohol rehabilitation programs, and State and local government 

agencies. 

174
Occupations: Health 

Audiologists work with people who have hearing, balance, and related ear problems. 

They examine people of all ages and identify those with the symptoms of hearing loss 

and other auditory, balance, and related sensory and neural problems. They then 

assess the nature and extent of the problems and help the person manage them. Using 

audiometers, computers, and other testing devices, they measure the loudness at which 

a person begins to hear sounds, the ability to distinguish between sounds, and the 

impact of hearing loss on a person’s daily life. In addition, audiologists use computer 

equipment to evaluate and diagnose balance disorders. Audiologists interpret these 

results and may coordinate them with medical, educational, and psychological 

information to make a diagnosis and determine a course of treatment. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

12,000 13,000 1,000 9.8 1,000 91.2 Varies by 

State 

Very 

high 

Projected supply and 

demand: The projected 

supply will closely 

approximate the demand 

for audiologists through 

2016. 

Education and training: 

A person must have at least

a master’s degree in 

175
audiology to qualify for a job. However, a first professional or doctoral degree is 

becoming more common. As of early 2007, eight States required a doctoral degree or 

its equivalent. The professional doctorate in audiology (Au.D.) requires approximately 8 

years of university training and supervised professional experience. Audiologists

regulated by licensure or registration in all 50 States. Forty-one States have continuing

education requirements for licensure renewal, the number of hours required varies by 

State. Twenty States and the District of Columbia also require audiologists to have 

Hearing Aid Dispenser license to dispense hearing aids; for the remaining 30 States, an

audiologist license is sufficient to dis

 are 

a 

pense hearing aids. 

Related fields: These include college student affairs, elementary or secondary school 

counseling, education, gerontological counseling, marriage and family therapy, substance 

abuse counseling, rehabilitation counseling, agency or community counseling, clinical 

mental health counseling, career counseling, and related fields. Counselors work in a wide 

variety of public and private establishments, including health care facilities; job training, 

career development, and vocational rehabilitation centers; social agencies; correctional 

institutions; and residential care facilities, such as halfway houses for criminal offenders and 

group homes for children, the elderly, and persons with disabilities. Some substance abuse 

and behavioral disorder counselors work in therapeutic communities where people with 

addictions live while undergoing treatment. Counselors also work in organizations engaged 

in community improvement and social change, drug and alcohol rehabilitation programs, 

and State and local government agencies. 

Dieticians and nutritionists plan food and nutrition programs, supervise meal preparation, 

and oversee the serving of meals. They prevent and treat illnesses by promoting healthy 

eating habits and recommending dietary modifications. For example, dietitians might teach 

a patient with high blood pressure how to use less salt when preparing meals or create a 

diet reduced in fat and sugar for an overweight patient. Dietitians manage food service 

systems for institutions such as hospitals and schools, promote sound eating habits 

through education, and conduct research. A dietitian can specialize, becoming a clinical 

dietitian, community dietitian, management dietitian, or consultant. 

176
Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replace

ment 

Needs 

2006–

2016 

-

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

57,000 62,000 5,000 8.6 5 71.7 13.6 14.7 Varies by 

State 

Very 

high 

Projected supply and 

demand: The demand for 

dieticians through 2016 will

be light. 

Education and training: 

Dietitians and nutritionists 

need at least a bachelor’s 

degree. Licensure, 

certification, and registration 

requirements vary by State. 

Related fields: Workers in other occupations who may apply the principles of dietetics 

include food service managers, health educators, dietetic technicians, and registered 

nurses. 

Emergency medical technicians (EMTs) and paramedics attend to persons involved 

in incidents as varied as automobile accidents, heart attacks, slips and falls, childbirth, 

and gunshot wounds, all of which require immediate medical attention. EMTs provide 

this vital service as they care for and transport the sick or injured to a medical facility. In 

an emergency, EMTs are typically dispatched by a 911 operator, and they often work 

with police and firefighters. Once they arrive, EMTs or paramedics assess the nature of 

the patient’s condition while trying to determine whether the patient has any preexisting 

177
conditions. Following medical protocols, they provide appropriate care and, when 

necessary, transport the patient. Some are trained to treat patients with minor injuries 

on the scene, or they may treat them at their home without transporting them. 

Emergency treatment is carried out under the medical direction of physicians. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

201,000 240,000 39,000 19.2 20 13.9 68.1 18.0 Yes Low

Projected supply and 

demand: There will be a 

strong demand for EMTs 

through 2016. 

Education and training: 

Generally, a high school 

diploma is required to enter 

a training program to 

become an EMT or a 

paramedic. Workers must 

complete a formal training and certification process. 

Related fields: Other workers in occupations that require quick and level-headed 

reactions to life-or-death situations are air traffic controllers, firefighting occupations, 

physician assistants, police and detectives, and registered nurses. 

Home health aides help people who are elderly, disabled, ill, or mentally disabled live in 

their own homes or in residential care facilities instead of in health facilities or institutions. 

178
Most personal and home care aides work with elderly or physically or mentally disabled 

clients who need more extensive personal and home care than family or friends can 

provide. Some aides work with families in which a parent is incapacitated and small 

children need care. Others help discharged hospital patients who have relatively short-term 

needs. Personal and home care aides—also called homemakers, caregivers, companions, 

and personal attendants—provide housekeeping and routine personal care services. They 

clean clients’ houses, do laundry, and change bed linens. Aides may plan meals (including 

special diets), shop for food, and cook. Aides also may help clients get out of bed, bathe, 

dress, and groom. Some accompany clients to doctors’ appointments or on other errands. 

Personal and home care aides provide instruction and psychological support to their 

patients. They may advise families and patients on nutrition, cleanliness, and household 

tasks. Aides also may assist in toilet training a severely mentally handicapped child, or they 

may just listen to clients talk. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth 

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

787 1,171 384 48.7 221 7.4 37.3 55.3 Varies Very 

low 

Projected supply and demand: There will be an extremely strong demand for home 

health aides through 2016. 

Education and training: In some States, the only requirement for employment is on-thejob training, which generally is provided by employers. Other States may require formal 

training, which is available from community colleges, vocational schools, elder care 

programs, and home health care agencies. 

179
Related fields: Personal and 

home care aides combine 

the duties of caregivers and 

social service workers. 

Workers in related 

occupations that involve 

personal contact to help 

others include child care 

workers; nursing, psychiatric, 

and home health aides; 

occupational therapist 

assistants and aides; physical therapist assistants and aides; and social and human 

service assistants. 

Massage therapists provide a means of treating painful ailments; decompressing tired, 

overworked muscles; reducing stress; rehabilitating injuries; and promoting general 

health. This is done by manipulating the soft tissue muscles of the body to improve 

circulation and remove waste products from the muscles. Clients may seek massage for 

medical benefit or for relaxation purposes, and there is a wide range of massage 

treatment available to meet these distinct needs. Massage therapy that aims to improve 

physical health typically differs in duration and technique from massage that is intended 

to simply relax or rejuvenate clients. The training background of those who perform the 

two types of massage therapy differs as well. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

118,000 142,000 24,000 20.3 9 32.2 49.1 18.7 Varies High 

180
Projected supply and 

demand: Although supply 

has been increasing 

strongly, demand will 

continue to be strong as 

well through 2016. 

Education and training: 

In 2007, 38 States and the 

District of Columbia had 

laws regulating massage 

therapy in some way. Most of the boards governing massage therapy in these States 

require practicing massage therapists to complete a formal education program and pass 

a national certification examination or a State exam. It is best to check information on 

licensing, certification, and accreditation on a State-by-State basis. 

Related fields: Other workers associated with the health care industry who provide 

therapy to clients include athletic trainers, physical therapists, physical therapist 

assistants and aides, chiropractors, and workers in other occupations that use touch to 

aid healing or relieve stress. 

Medical assistants perform administrative and clinical tasks to keep the offices of 

physicians, podiatrists, chiropractors, and other health practitioners running smoothly. They 

should not be confused with physician assistants, who examine, diagnose, and treat 

patients under the direct supervision of a physician. The duties of medical assistants vary 

from office to office, depending on the location and size of the practice and the practitioner’s 

specialty. In small practices, medical assistants usually do many different kinds of tasks, 

handling both administrative and clinical duties, and reporting directly to an office manager, 

physician, or other health practitioner. Those in large practices tend to specialize in a 

particular area, under the supervision of department administrators. 

181
Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College 

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

417,000 565,000 148,000 35.4 93 10.4 58.9 30.6 Varies Low 

Projected supply and 

demand: The demand for 

medical assistants through 

2016 will be very strong. 

Education and training: 

Some medical assistants 

are trained on the job, but 

many complete 1-year or 

2-year programs. 

Related fields: Medical assistants perform work similar to that done by other workers in 

medical support occupations. Administrative medical assistants do work similar to that 

of medical secretaries, medical transcriptionists, and medical records and health 

information technicians. Clinical medical assistants perform duties similar to those of 

dental assistants; dental hygienists; occupational therapist assistants and aides; 

pharmacy aides; licensed practical and licensed vocational nurses; surgical 

technologists; physical therapist assistants and aides; and nursing, psychiatric, and 

home health aides. 

Medical and health services managers plan, direct, coordinate, and supervise the 

delivery of health care. These workers are either specialists in charge of a specific 

clinical department or generalists who manage an entire facility or system. Future 

medical and health services managers must be prepared to deal with the integration of 

182
health care delivery systems, technological innovations, an increasingly complex 

regulatory environment, restructuring of work, and an increased focus on preventive 

care. They will be called on to improve efficiency in health care facilities and the quality 

of the care provided. Administrators handle the details of daily operations, including the 

management of personnel, finances, facility operations, and admissions, while also 

providing resident care. Clinical managers have training or experience in a specific 

clinical area and, accordingly, have more specific responsibilities than do generalists. 

For example, directors of physical therapy are experienced physical therapists, and 

most health information and medical record administrators have a bachelor’s degree in 

health information or medical record administration. Clinical managers establish and 

implement policies, objectives, and procedures for their departments; evaluate 

personnel and work quality; develop reports and budgets; and coordinate activities with 

other managers. Health information managers are responsible for the maintenance and 

security of all patient records. Recent regulations enacted by the Federal Government 

require that all health care providers maintain electronic patient records and that these 

records be secure. As a result, health information managers must keep up with current 

computer and software technology, and with legislative requirements. In addition, as 

patient data is more frequently used for quality management and in medical research, 

health information managers will ensure that databases are complete, accurate, and 

available only to authorized personnel. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

262,000 305,000 43,000 16.4 92,000 56.6 32 11.4 

Yes, for 

some 

positions 

Very 

high 

183
Projected supply and 

demand: There will need 

to be an additional 40,000 

positions by 2016. 

Education and training: A 

master’s degree in one of a 

number of fields is the 

standard credential for most 

generalist positions as a 

medical or health care manager. A bachelor’s degree is sometimes adequate for entry-level 

positions in smaller facilities or departments. In physicians’ offices and other facilities, onthe-job experience may substitute for formal education. Medical and health services 

managers must be familiar with management principles and practices, including finance 

and information systems, and must be able to interpret data. Motivating others to 

implement decisions requires strong leadership abilities. Tact, diplomacy, flexibility, and 

communication skills are essential, because managers spend most of their time interacting 

with others. Licensure. All States and the District of Columbia require nursing care facility 

administrators to have a bachelor’s degree, pass a licensing examination, complete a 

State-approved training program, and pursue continuing education. Some States also 

require licenses for administrators in assisted living facilities. A license is not required in 

other areas of medical and health services management. 

Related fields: Medical and health services managers have training or experience in 

both health and management. Other occupations requiring knowledge of both fields 

are insurance underwriters and social and community service managers. 

Medical records technicians assemble patients’ health information, making sure that 

patients’ initial medical charts are complete, that all forms are completed and properly 

identified and authenticated, and that all necessary information is in the computer. They 

regularly communicate with physicians and other health care professionals to clarify 

diagnoses or to obtain additional information. Technicians regularly use computer 

184
programs to tabulate and analyze data to improve patient care, better control costs, and 

provide documentation for use in legal actions or research studies. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

170,000 200,000 30,000 17.8 39 11.8 51.4 36.8 No Low 

Projected supply and 

demand: The demand for 

records technicians 

through 2016 will be 

moderately strong. 

Education and training: 

Medical records and 

health information 

technicians entering the 

field usually have an 

associate degree from a community or junior college. Many employers favor technicians 

who have become registered health information technicians (RHITs). Advancement 

opportunities for medical record and health information technicians are typically 

achieved by specialization or promotion to a management position. 

Related fields: Medical records and health information technicians need a strong clinical 

background to analyze the contents of medical records. Medical secretaries and 

medical transcriptionists also must be knowledgeable about medical terminology, 

anatomy, and physiology, even though they have little or no direct contact with patients. 

185
Mental health counselors work with individuals, families, and groups to address and 

treat mental and emotional disorders and to promote mental health. They are trained in

a variety of therapeutic techniques used to address issues, including depression, 

addiction and substance abuse, suicidal impulses, stress, problems with self-esteem, 

and grief. They also help with job and career concerns; educational decisions; issues 

related to mental and emotional health; and family, parenting, marital, or other 

relationship problems. Mental health counselors often work closely with other mental 

health specialists, such as psychiatrists, psychologists, clinical social workers, 

psychiatric nurses, and school counselors. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

100,000 130,000 30,000 30 50,000 72.8 18.3 8.9 Usually High

Projected supply and 

demand: The demand for 

mental health counselors 

will remain very high 

through 2016. 

Education and training: 

Education requirements vary 

based on occupational 

specialty and State licensure 

and certification requirements. A master’s degree is usually required to be licensed as a 

counselor. Some counselors elect to be certified by the National Board for Certified 

Counselors, Inc., which grants a general practice credential of national certified counselor. 

186
To be certified, a counselor must hold a master’s degree with a concentration in counseling 

from a regionally accredited college or university; have at least 2 years of supervised field 

experience in a counseling setting (graduates from counselor education programs 

accredited by the Council for Accreditation of Counseling and Related Educational 

Programs are exempted); provide two professional endorsements, one of which must be 

from a recent supervisor; and have a passing score on the board’s examination. This 

national certification is voluntary and is distinct from State licensing. However, in some 

States, those who pass the national exam are exempted from taking a State certification 

exam. The board also offers specialty certifications in school, clinical mental health, and 

addiction counseling. These specialty certifications require passage of a supplemental 

exam. To maintain their certifications, counselors retake and pass the exam or complete 

100 credit hours of acceptable continuing education every 5 years. 

Related fields: These include college student affairs, elementary or secondary school 

counseling, education, gerontological counseling, marriage and family therapy, substance 

abuse counseling, rehabilitation counseling, agency or community counseling, clinical 

mental health counseling, and career counseling. Counselors work in a wide variety of 

public and private establishments, including health care facilities; job training, career 

development, and vocational rehabilitation centers; social agencies; correctional 

institutions; and residential care facilities, such as halfway houses for criminal offenders and 

group homes for children, the elderly, and persons with disabilities. Some substance abuse 

and behavioral disorder counselors work in therapeutic communities where people with 

addictions live while undergoing treatment. Counselors also work in organizations engaged 

in community improvement and social change, drug and alcohol rehabilitation programs, 

and State and local government agencies. 

Occupational therapists help patients improve their ability to perform tasks in living and 

working environments. They work with persons who suffer from a mentally, physically, 

developmentally, or emotionally disabling condition. Occupational therapists use treatments 

to help patients develop, recover, or maintain daily living and work skills. The therapist helps 

clients not only to improve their basic motor functions and reasoning abilities but also 

187
compensate for permanent loss of function. The goal is to help clients have independent, 

productive, and satisfying lives. Occupational therapists help clients to perform all types of 

activities, from using a computer to caring for daily needs such as dressing, cooking, and 

eating. Physical exercises may be used to increase strength and dexterity, while other 

activities may be chosen to improve visual acuity or the ability to discern patterns. For 

example, a client with short-term memory loss might be encouraged to make lists to aid 

recall, and a person with coordination problems might be assigned exercises to improve 

hand-eye coordination. Occupational therapists also use computer programs to help clients 

improve decision making, abstract reasoning, problem solving, and perceptual skills, as well 

as memory, sequencing, and coordination—all of which are important for independent living. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification 

Required 

Income

Level 

99,000 122,000 23,000 23.1 8 89.3 8.8 1.8 Yes Very

high 

Projected supply and 

demand: There will be 

strong demand through 

2016 for occupational 

therapists. 

Education and training: A 

master’s degree or higher 

in occupational therapy is 

the minimum requirement 

for entry into the field. In 

2007, 124 master’s degree programs offered entry-level education, 66 programs offered 

188
a combined bachelor’s and master’s degree, and 5 offered an entry-level doctoral 

degree. Most schools have full-time programs, although a growing number are offering 

weekend or part-time programs as well. Coursework in occupational therapy programs 

includes the physical, biological, and behavioral sciences as well as the application of 

occupational therapy theory and skills. Programs also require the completion of 6 

months of supervised fieldwork. 

Related fields: Occupational therapists use specialized knowledge to help people 

perform daily living skills and achieve maximum independence. Other workers who 

have similar duties include athletic trainers, audiologists, chiropractors, physical 

therapists, recreational therapists, rehabilitation counselors, respiratory therapists, and 

speech-language pathologists 

Occupational therapy assistants and aides work under the direction of occupational 

therapists to provide rehabilitative services to persons with mental, physical, emotional, 

or developmental impairments. The ultimate goal is to improve clients’ quality of life and 

ability to perform daily activities. For example, occupational therapist assistants help 

injured workers reenter the labor force by teaching them how to compensate for lost 

motor skills or help persons with learning disabilities increase their independence. 

Occupational therapist assistants, commonly known as occupational therapy assistants, 

help clients with rehabilitative activities and exercises outlined in a treatment plan 

developed in collaboration with an occupational therapist. Activities range from teaching 

the proper method of moving from a bed into a wheelchair to the best way to stretch and 

limber up the muscles of the hand. Assistants monitor the person’s activities to make 

sure that they are performed correctly and to provide encouragement. They also record 

their client’s progress for the occupational therapist. If the treatment is not having the 

intended effect or the client is not improving as expected, the therapist may alter the 

treatment program in hopes of obtaining better results. In addition, occupational 

therapist assistants document the billing of the client’s health insurance provider. 

Occupational therapist aides typically prepare materials and assemble equipment used 

during treatment. They are responsible for a range of clerical tasks, including scheduling 

189
appointments, answering the telephone, restocking or ordering depleted supplies, and 

filling out insurance forms or other paperwork. Aides are not licensed, so the law does 

not allow them to perform as wide a range of tasks as occupational therapist assistants. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College 

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification 

Required 

Income

Level 

140,000 179,000 39,000 27.9 14 13.3 85.6 Varies Low 

Projected supply and 

demand: There will be 

strong demand for therapy 

assistants through 2016. 

Education and training: An 

associate degree or a 

certificate from an 

accredited community 

college or technical school 

is generally required to 

qualify for occupational therapist assistant jobs. In contrast, occupational therapist aides 

usually receive most of their training on the job. 

Related fields: Occupational therapist assistants and aides work under the supervision 

and direction of occupational therapists. Other workers in the health care field who work 

under similar supervision include dental assistants; medical assistants; nursing, 

psychiatric, and home health aides; personal and home care aides; pharmacy aides; 

pharmacy technicians; and physical therapist assistants and aides. 

190
Optometrists, also known as doctors of optometry, or ODs, are the main providers of 

vision care. They examine people’s eyes to diagnose vision problems, such as 

nearsightedness and farsightedness, and they test patients’ depth and color perception and 

ability to focus and coordinate the eyes. Optometrists may prescribe eyeglasses or contact 

lenses, or they may prescribe or provide other treatments, such as vision therapy or lowvision rehabilitation. Optometrists also test for glaucoma and other eye diseases, and 

diagnose conditions caused by systemic diseases such as diabetes and high blood 

pressure, referring patients to other health practitioners as needed. They administer drugs 

to patients to aid in the diagnosis of vision problems and to treat eye diseases. 

Optometrists often provide preoperative and postoperative care to cataract patients, as well 

as to patients who have had laser vision correction or other eye surgery. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

33,000 36,000 4,000 11.3 2 100 Yes Very

high

Projected supply and 

demand: The demand for 

optometrists will be 

moderately strong through 

2016. 

Education and training: 

Optometrists need a doctor 

of optometry degree, which 

requires the completion of a 

191
4-year program at an accredited optometry school. In 2006, there were 16 colleges of 

optometry in the United States and 1 in Puerto Rico that offered programs accredited by 

the Accreditation Council on Optometric Education of the American Optometric 

Association. Requirements for admission to optometry schools include college courses 

in English, mathematics, physics, chemistry, and biology. Because a strong background 

in science is important, many applicants to optometry school major in a science such as 

biology or chemistry as undergraduates. Others major in another subject and take many 

science courses offering laboratory experience. 

Related fields: Other workers who apply scientific knowledge to prevent, diagnose, and 

treat disorders and injuries are chiropractors, dentists, physicians and surgeons, 

psychologists, podiatrists, and veterinarians. 

Pharmacists distribute prescription drugs to people. They also advise their patients, as 

well as physicians and other health practitioners, on the selection, dosages, 

interactions, and side effects of medications. Pharmacists monitor the health and 

progress of patients to ensure the safe and effective use of medication. Compounding—

the actual mixing of ingredients to form medications—is a small part of a pharmacist’s 

practice, because most medicines are produced by pharmaceutical companies in a 

standard dosage and drug delivery form. Most pharmacists work in a community setting 

(such as a retail drugstore) or a health care facility (such as a hospital, nursing home, 

mental health institution, or neighborhood health clinic). 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

243,000 296,000 53,000 21.7 16 97.0 2.9 Yes Very 

high 

192
Projected supply and 

demand: Demand will be 

strong through 2016. 

Education and training: 

Pharmacists must earn a 

Pharm.D. degree from an 

accredited college or school 

of pharmacy. The Pharm.D. 

degree has replaced the 

bachelor of pharmacy 

degree, which is no longer being awarded. To be admitted to a Pharm.D. program, an 

applicant must have completed at least 2 years of postsecondary study, although most 

applicants have completed 3 or more years. Other entry requirements usually include 

courses in mathematics and natural sciences, such as chemistry, biology, and physics, 

as well as courses in the humanities and social sciences. In 2007, 92 colleges and 

schools of pharmacy were accredited to confer degrees by the Accreditation Council for 

Pharmacy Education. About 70 percent of Pharm.D. programs require applicants to take 

the Pharmacy College Admissions Test . 

Related fields: Persons in other professions who may work with pharmaceutical 

compounds include pharmacy aides, pharmacy technicians, biological scientists, medical 

scientists, and chemists and materials scientists. Increasingly, pharmacists are involved in 

patient care and therapy, work that they have in common with physicians and surgeons. 

Physician assistants (PAs) are supervised by physicians and surgeons. PAs provide 

diagnostic, therapeutic, and preventive health care services as delegated by a 

physician. Working as members of the health care team, they take medical histories, 

examine and treat patients, order and interpret laboratory tests and x-rays, and make 

diagnoses. They also treat minor injuries by suturing, splinting, and casting. PAs record 

progress notes, instruct and counsel patients, and order or carry out therapy. In 48 

States and the District of Columbia, physician assistants may prescribe some 

193
medications. The PA may be responsible for managerial duties, such as ordering 

medical supplies or equipment and supervising technicians and assistants. PAs may be 

the principal care providers in rural or inner city clinics where a physician is present for 

only one or two days each week. In such cases, the PA confers with the supervising 

physician and other medical professionals as needed and as required by law. PAs also 

may make house calls or go to hospitals and nursing care facilities to check on patients. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

66,000 83,000 18,000 27.0 27,000 66.9 25.5 7.6 Yes Very 

high 

Projected supply and 

demand: The demand 

through 2016 for physician 

assistants will remain very 

high. 

Education and training: 

Physician assistant 

education programs usually

last at least 2 years and are

full time. Most programs are

in schools of allied health, academic health centers, medical schools, and 4-year 

colleges; a few are in community colleges, the military, and hospitals. Many accredited 

PA programs have clinical teaching affiliations with medical schools. Admission 

requirements vary, but many programs require two years of college and some work 

experience in the health care field. Students should take courses in biology, English, 

194
chemistry, mathematics, psychology, and the social sciences. Many PAs have previous 

experience as registered nurses; others come from varied backgrounds, including 

military corpsman or medics and allied health occupations such as respiratory 

therapists, physical therapists, and EMTs and paramedics. 

Related fields: Other health care workers who provide direct patient care that requires a 

similar level of skill and training include audiologists, occupational therapists, physical 

therapists, registered nurses, and speech-language pathologists. 

Physical therapists provide services that help restore function, improve mobility, 

relieve pain, and prevent or limit permanent physical disabilities for patients suffering 

from injuries or disease. They restore, maintain, and promote overall fitness and health. 

Their patients include accident victims and persons with disabling conditions such as 

low back pain, arthritis, heart disease, fractures, head injuries, and cerebral palsy. 

Therapists examine patients’ medical histories, then test and measure their strength, 

range of motion, balance and coordination, posture, muscle performance, respiration, 

and motor function. Next, physical therapists develop plans describing a treatment 

strategy and its anticipated outcome. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

173,000 220,000 47,000 27.1 12 89.3 8.8 1.8 Yes Very 

high 

195
Projected supply and 

demand: The demand for 

physical therapists will be 

very strong through 2016. 

Education and training: 

A person who pursues a 

career as a physical 

therapist usually need a 

master’s degree from an 

accredited physical therapy 

program and a State license, which requires passing scores on national and State 

examinations. According to the American Physical Therapy Association, there were 209 

accredited physical therapist education programs in 2007. Of the accredited programs, 

43 offered master’s degrees and 166 offered doctoral degrees. Only master’s and 

doctoral degree programs are accredited, in accordance with the Commission on 

Accreditation in Physical Therapy Education. In the future, a doctoral degree might be 

the required entry-level degree. Master’s degree programs typically last 2 years, and 

doctoral programs last 3 years. 

Related fields: Physical therapists rehabilitate people with physical disabilities. Others 

who work in the rehabilitation field include audiologists, chiropractors, occupational 

therapists, recreational therapists, rehabilitation counselors, respiratory therapists, and 

speech-language pathologists. 

Physical therapy assistants and aides help physical therapists provide treatment that 

improves patient mobility, relieves pain, and prevents or lessens physical disabilities. An 

assistant might help patients exercise or learn to use crutches, or gather and prepare 

therapy equipment. Patients include accident victims and those with disabling conditions 

such as lower back pain, arthritis, heart disease, fractures, and cerebral palsy. Physical 

therapist assistants perform a variety of tasks. Under the direction and supervision of 

physical therapists, they provide part of a patient’s treatment, such as exercises, 

196
massages, electrical stimulation, hot and cold packs, and ultrasound. Assistants record 

the patient’s responses to treatment and report the outcome of each treatment to the 

physical therapist. Physical therapist aides help make therapy sessions productive, 

under the direct supervision of a physical therapist or physical therapist assistant. They 

usually are responsible for keeping the treatment area clean and organized and for 

preparing for each patient’s therapy. When patients need assistance moving to or from 

a treatment area, aides push them in a wheelchair or provide them with a shoulder to 

lean on. Because they are not licensed, aides do not perform the clinical tasks of a 

physical therapist assistant in States where licensure is required. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification 

Required 

Income

Level 

107,000 137,000 31,000 28.9 10 22.9 65.4 11.7 Varies by 

State 

Low 

Projected supply and 

demand: There will be a 

very strong demand for 

physical therapy aides 

through 2016. 

Education and training: 

Employers typically require 

physical therapist aides to 

have a high school diploma. 

They are trained on the job, 

and most employers provide clinical on-the-job training. In many States, physical 

therapist assistants are required by law to hold at least an associate degree. According 

197
to the American Physical Therapy Association, there were 233 accredited physical 

therapist assistant programs in the United States as of 2006. Accredited programs 

usually last 2 years (four semesters) and culminate in an associate degree. 

Related fields: Physical therapist assistants and aides work under the supervision of 

physical therapists. Other workers in the health care field who work under similar 

supervision include dental assistants; medical assistants; occupational therapist assistants 

and aides; pharmacy aides; pharmacy technicians; nursing, psychiatric, and home health 

aides; personal and home care aides; and social and human service assistants. 

Physicians and surgeons diagnose illnesses and prescribe and administer treatment 

for people suffering from injury or disease. Physicians examine patients, obtain medical 

histories, and order, perform, and interpret diagnostic tests. They counsel patients on 

diet, hygiene, and preventive health care. There are two types of physicians: MD (doctor 

of medicine and DO (doctor of osteopathic medicine). MDs also are known as allopathic 

physicians. While both MDs and DOs may use all accepted methods of treatment, 

including drugs and surgery, DOs place special emphasis on the body’s 

musculoskeletal system, preventive medicine, and holistic patient care. DOs are most 

likely to be primary care specialists, although they can be found in all specialties. About 

half of DOs practice general or family medicine, general internal medicine, or general 

pediatrics. Physicians work in one or more of several specialties, including, but not 

limited to, anesthesiology, family and general medicine, general internal medicine, 

general pediatrics, obstetrics and gynecology, psychiatry, and surgery. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

633,000 723,000 90,000 14.2 38 100 Yes Very 

high 

198
Projected supply and 

demand: There is likely to 

be a moderate demand for 

physicians through 2016. 

Education and training: 

Formal education and 

training requirements for 

physicians are among the 

most demanding of any 

occupation—4 years of 

undergraduate school, 4 years of medical school, and 3 to 8 years of internship and 

residency, depending on the specialty selected. A few medical schools offer combined 

undergraduate and medical school programs that last 6 years rather than the customary 8 

years. 

Related fields: Physicians work to prevent, diagnose, and treat diseases, disorders, and 

injuries. Other health care practitioners who need similar skills and who exercise critical 

judgment include chiropractors, dentists, optometrists, physician assistants, podiatrists, 

registered nurses, and veterinarians. 

Licensed practical nurses (LPNs) and licensed vocational nurses (LVNs) care for 

people under the direction of physicians and registered nurses. The nature of the 

supervision required varies by State and job setting. LPNs care for patients in many 

ways. Often, they provide basic bedside care; measure and record patients’ vital signs, 

such as height, weight, temperature, blood pressure, pulse, and respiration; prepare 

and give injections and enemas; monitor catheters; dress wounds; and give alcohol 

rubs and massages. To help keep patients comfortable, they assist with bathing, 

dressing, and personal hygiene; moving in bed; standing; and walking. They might also 

feed patients. Experienced LPNs may supervise nursing assistants and aides. As part 

of their work, LPNs collect samples for testing, perform routine laboratory tests, and 

record food and fluid intake and output. They clean and monitor medical equipment. 

199
Sometimes, they help physicians and registered nurses perform tests and procedures. 

Some LPNs help to deliver, care for, and feed infants. LPNs also monitor their patients 

and report adverse reactions to medications or treatments. LPNs gather information 

from patients, including their health history and how they are currently feeling. They may 

use this information to complete insurance forms, preauthorizations, and referrals, and 

they share information with registered nurses and doctors to help determine the best 

course of care for a patient. LPNs often teach family members how to care for a relative 

or teach patients about good health habits. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

749,000 854,000 105,000 14.0 71 7.0 72.4 20.6 Yes High 

Projected Supply and 

Demand: There will be a 

moderate demand for 

practical nurses through 

2016. 

Education and training: All 

States and the District of 

Columbia require LPNs to 

pass a licensing 

examination, known as the 

NCLEX-PN, after completing a State-approved practical nursing program. A high school 

diploma or its equivalent usually is required for entry, although some programs accept 

candidates without a diploma, and some programs are part of a high school curriculum. 

200
Related fields: LPNs work closely with the people they are helping. So do EMTs and 

paramedics; medical assistants; nursing, psychiatric, and home health aides; registered 

nurses; athletic trainers; social and human service assistants; pharmacy technicians; 

pharmacy aides; and surgical technologists. 

Psychologists study the human mind and human behavior. Research psychologists 

investigate the physical, cognitive, emotional, or social aspects of human behavior. 

Psychologists in health service fields provide mental health care in hospitals, clinics, 

schools, or private settings. Psychologists employed in applied settings—such as business, 

industry, government, or nonprofit organizations—provide training, conduct research, 

design organizational systems, and act as advocates for their patients or clients. Like other 

social scientists, psychologists formulate hypotheses and collect data to test their validity. 

Research methods vary with the topic under study. Psychologists sometimes gather 

information through controlled laboratory experiments or by administering personality, 

performance, aptitude, or intelligence tests. Other methods include observation, interviews, 

questionnaires, clinical studies, and surveys. Psychologists apply their knowledge to a wide 

range of endeavors, including health and human services, management, education, law, 

and sports. They usually specialize in one of a number of different areas. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

166,000 191,000 25,000 15.3 9 99.3 0.0 0.0 Yes Very 

high 

Projected supply and demand: The demand for psychologists has fluctuated, but the 

expected future demand through 2016 is moderately strong. 

201
Education and training: 

A doctoral degree is usually 

required for independent 

practice as a psychologist. 

Psychologists with a Ph.D. 

or doctor of psychology 

(Psy.D.) qualify for a wide 

range of teaching, 

research, clinical, and 

counseling positions in 

universities, health care 

services, elementary and secondary schools, private industry, and government. 

Psychologists with a doctoral degree often work in clinical positions or in private 

practice, but they also sometimes teach, conduct research, or carry out administrative 

responsibilities. 

ers, 

dical 

d 

Related fields: Psychologists work with people, developing relationships and comforting

them. Other occupations with similar duties include counselors, social workers, clergy, 

sociologists, special education teachers, funeral directors, market and survey research

recreation workers, and human resources, training, and labor relations managers and 

specialists. Psychologists also sometimes diagnose and treat problems and help patients 

recover. These duties are similar to those of physicians and surgeons, radiation therapists, 

audiologists, dentists, optometrists, and speech-language pathologists. 

Radiology technicians take X-rays and administer nonradioactive materials into 

patients’ bloodstreams for diagnostic purposes. Radiologic technologists (also referred

to as radiographers) produce X-ray films (radiographs) for use in diagnosing me

problems. They prepare patients for radiologic examinations by explaining the 

procedure, removing jewelry and other articles through which X-rays cannot pass, an

positioning patients so that the body can be appropriately radiographed. To prevent 

unnecessary exposure to radiation, these technicians surround the exposed area with 

202
radiation protection devices, such as lead shields, or limit the size of the X-ray beam. 

Radiographers position equipment at the correct angle and height over the appropriate 

body area. They may measure the thickness of the section to be radiographed and set 

controls on the X-ray machine to produce radiographs of the appropriate density, detail, 

and contrast. They place the X-ray film under the part of the patient’s body to be 

examined and make the exposure; then they remove the film and develop it. 

Percentage with: 

Employment 

2006 2016

College

Plus 

Licensure 

or 

Certification

Required 

Income

Level 

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

Some 

College

High 

School 

Degree

196,000 226,000 30,000 15.1 13 24.9 67.9 7.2 Varies by 

State 

Very 

high 

Projected supply and 

demand: The demand for 

radiology technicians will 

be moderately strong 

through 2016. 

Education and training: 

Preparation for this 

profession is offered in 

hospitals, colleges and 

universities, and, less 

frequently, at vocational-technical institutes. Hospitals employ most radiologic 

technologists. Employers prefer to hire technologists with formal training. Formal training 

programs in radiography range in length from 1 to 4 years and lead to a certificate, an 

associate degree, or a bachelor’s degree. Two-year associate degree programs are most 

prevalent. Some 1-year certificate programs are available for experienced radiographers or 

203
persons from other health occupations, such as medical technologists and registered 

nurses, who want to change fields. A bachelor’s or master’s degree in one of the radiologic 

technologies is desirable for supervisory, administrative, or teaching positions. 

Related fields: Radiologic technologists operate sophisticated equipment to help 

physicians, dentists, and other health practitioners diagnose and treat patients. Workers 

in related occupations include cardiovascular technologists and technicians, clinical 

laboratory technologists and technicians, diagnostic medical sonographers, nuclear 

medicine technologists, radiation therapists, and respiratory therapists. 

Registered nurses (RNs), regardless of specialty or work setting, treat patients, educate 

patients and the public about various medical conditions, and provide advice and emotional 

support to patients’ family members. RNs record patients’ medical histories and symptoms, 

help perform diagnostic tests and analyze results, operate medical machinery, administer 

treatment and medications, and help with patient followup and rehabilitation. RNs teach 

patients and their families how to manage their illness or injury, explaining posttreatment 

home care needs; diet, nutrition, and exercise programs; and self-administration of 

medication and physical therapy. Some RNs work to promote general health by educating 

the public on warning signs and symptoms of disease. RNs also might run general health 

screening or immunization clinics, blood drives, and public seminars on various conditions. 

When caring for patients, RNs establish a plan of care or contribute to an existing plan. 

Plans may include numerous activities, such as administering medication, including careful 

checking of dosages and avoiding interactions; starting, maintaining, and discontinuing 

intravenous (IV) lines for fluid, medication, blood, or blood products; administering therapies 

and treatments; observing the patient and recording those observations; and consulting 

with physicians and other health care clinicians. Some RNs provide direction to licensed 

practical nurses and nursing aides regarding patient care. RNs with advanced educational 

preparation and training may perform diagnostic and therapeutic procedures and may have 

prescriptive authority. 

204
Percentage with: 

Employment

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College 

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

2,505 3,092 587 23.5 233 56.2 42.7 1.0 Yes Very 

high 

Projected supply and 

demand: The projected 

demand for nurses will 

remain very strong through 

2016. Most observers point 

out that the capacity of 

current preparation 

programs is insufficient to 

meet this demand, including 

a shortfall of faculty. 

Education and training: There are three major educational paths to registered nursing—

a bachelor of science degree in nursing (BSN), an associate degree in nursing (ADN), 

and a diploma. BSN programs, offered by colleges and universities, take about 4 years 

to complete. In 2006, 709 nursing programs offered degrees at the bachelor’s level. 

ADN programs, offered by community and junior colleges, take 2 to 3 years to 

complete. About 850 RN programs granted associate degrees. Diploma programs, 

administered in hospitals, last about 3 years. Only about 70 programs offered diplomas. 

Generally, licensed graduates of any of the three types of educational programs qualify 

for entry-level positions. 

Related fields: Because of the number of specialties for registered nurses and the 

variety of responsibilities and duties, many other health care occupations are similar in 

205
some aspect of the job. Other occupations that deal directly with patients when 

providing care include licensed practical and licensed vocational nurses, physicians and 

surgeons, athletic trainers, respiratory therapists, massage therapists, dietitians and 

nutritionists, occupational therapists, physical therapists, and EMTs and paramedics. 

Other occupations that use advanced medical equipment to treat patients include 

cardiovascular technologists and technicians, diagnostic medical sonographers, 

radiologic technologists and technicians, radiation therapists, and surgical technologists. 

Workers who also assist other health care professionals in providing care include 

nursing, psychiatric, and home health aides; physician assistants; and dental hygienists. 

Some nurses take on a management role, similar to medical and health services 

managers. 

Respiratory therapists and respiratory therapy technicians—also known as 

respiratory care practitioners—evaluate, treat, and care for patients with breathing or 

other cardiopulmonary disorders. Practicing under the direction of a physician, 

respiratory therapists assume primary responsibility for all respiratory care therapeutic 

treatments and diagnostic procedures, including the supervision of respiratory therapy 

technicians. Respiratory therapy technicians follow specific, well-defined respiratory 

care procedures under the direction of respiratory therapists and physicians. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

102,000 126,000 23 22.6 6 27.7 71.2 1.1 Yes Very 

high 

206
Projected supply and 

demand: There will be a 

steady and strong demand 

for respiratory therapists 

through 2016. 

Education and training: 

An associate degree is 

required to become a 

respiratory therapist. 

Training is offered at the 

postsecondary level by colleges and universities, medical schools, vocational-technical 

institutes, and the armed forces. Most programs award an associate or bachelor’s degree 

and prepare graduates for jobs as advanced respiratory therapists. A limited number of 

associate degree programs lead to jobs as entry-level respiratory therapists. According to 

the Commission on Accreditation of Allied Health Education Programs, 45 entry-level and 

334 advanced respiratory therapy programs were accredited in the United States in 2006. 

Related fields: Under the supervision of a physician, respiratory therapists administer 

respiratory care and life support to patients with heart and lung difficulties. Other workers who 

care for, treat, or train people to improve their physical condition include registered nurses, 

occupational therapists, physical therapists, radiation therapists, and athletic trainers. 

Respiratory care practitioners work with advanced medical technology, as do other health 

care technicians, including cardiovascular technologists and technicians, nuclear medicine 

technologists, radiologic technologists and technicians, and diagnostic medical sonographers. 

Substance abuse and behavioral disorder counselors help people who have problems 

with alcohol, drugs, gambling, or eating disorders. They counsel persons who are addicted 

to drugs, helping them identify behaviors and problems related to their addiction. 

Counseling can be done on an individual basis but is frequently done in a group setting. 

These counselors often work with family members who are affected by the addictions of 

their loved ones. Counselors also conduct programs aimed at preventing addiction. 

207
Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

83,000 112,000 29,000 34.3 45,000 72.8 18.3 809

Varies 

greatly High 

Projected supply and 

demand: There will be a 

very steep demand curve 

for substance abuse and 

behavior disorder 

counselors through 2016. 

Education and training: 

Education requirements vary 

based on occupational 

specialty and State licensure and certification requirements. A master’s degree is usually 

required to be licensed as a counselor. Some States require counselors in public 

employment to have a master’s degree; others accept a bachelor’s degree with appropriate 

counseling courses. Substance abuse and behavior disorder counselors are generally 

governed by a different State agency or board than other counselors. The criteria for their 

licensure vary greatly; in some cases, these counselors may only need a high school 

diploma and certification. Those interested in entering the field must research state and 

specialty requirements to determine what qualifications they must have. 

Related fields: These include college student affairs, elementary or secondary school 

counseling, education, gerontological counseling, marriage and family therapy, substance 

abuse counseling, rehabilitation counseling, agency or community counseling, clinical 

mental health counseling, and career counseling. Counselors work in a wide variety of 

208
public and private establishments, including health care facilities; job training, career 

development, and vocational rehabilitation centers; social agencies; correctional 

institutions; and residential care facilities, such as halfway houses for criminal offenders and 

group homes for children, the elderly, and persons with disabilities. Counselors also work in 

organizations engaged in community improvement and social change, drug and alcohol 

rehabilitation programs, and State and local government agencies. 

Occupations: Quality of Life 

Child care workers nurture and care for children who have not yet entered formal 

schooling. They also supervise older children before and after school. These workers 

play an important role in children’s development by caring for them when parents are at 

work or away for other reasons. In addition to attending to children’s basic needs, child 

care workers organize activities and implement curricula that stimulate children’s 

physical, emotional, intellectual, and social growth. They help children explore individual 

interests, develop talents and independence, build self-esteem, and learn how to get 

along with others. Child care workers generally are classified into three different groups 

on the basis of where they work: private household workers, who care for children at the 

children’s home; family child care providers, who care for children in the provider’s own 

home; and child care workers who work at child care centers. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification

Required 

Income

Level 

1,388 1,636 248 17.8 473 14.5 37.8 47.7 Varies by

State 

Very 

low 

209
Projected supply and 

demand: Although supply is 

increasing, the demand 

curve through 2016 is also 

going up steeply. The 

demand for child care 

workers will continue to be 

strong. 

Education and training: 

The training and 

qualifications required of child care workers vary widely. Each State has its own 

licensing requirements that regulate caregiver training. These requirements range from 

a high school diploma to a national child development associate (CDA) credential to 

community college courses or a college degree in child development or early childhood 

education. State requirements are generally higher for workers at child care centers 

than for family child care providers. Child care workers in private settings who care for 

only a few children often are not regulated by States at all. Child care workers generally 

can obtain some form of employment with a high school diploma and little or no 

experience, but certain private firms and publicly funded programs have more 

demanding training and education requirements. Some employers may prefer workers 

who have taken secondary or postsecondary courses in child development and early 

childhood education or who have work experience in a child care setting. Other 

employers require their own specialized training. An increasing number of employers 

require an associate degree in early childhood education. 

Related fields: Child care work requires patience; creativity; an ability to nurture, 

motivate, teach, and influence children; and leadership, organizational, and 

administrative skills. Others who work with children and need these qualities and skills 

include teacher assistants and teachers—preschool, kindergarten, elementary, middle, 

secondary and special education. 

210
Recreation therapists, also referred to as therapeutic recreation specialists, provide 

treatment services and recreation activities for persons with disabilities or illnesses. 

Using a variety of techniques—including arts and crafts, animals, sports, games, dance 

and movement, drama, music, and community outings—therapists improve and 

maintain the physical, mental, and emotional well-being of their clients. Therapists help 

people reduce depression, stress, and anxiety; recover basic motor functioning and 

reasoning abilities; build confidence; and socialize effectively so they can enjoy greater 

independence and reduce or eliminate the effects of their illness or disability. In 

addition, therapists help people with disabilities integrate into the community by 

teaching them how to use community resources and recreational activities. Recreational 

therapists are different from recreation workers, who organize recreational activities 

primarily for enjoyment. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

25,000 26,000 1,000 3.7 2,000 76.5 13.6 0.0 Varies by 

State High 

Projected supply and 

demand: Although a balance

currently exists, we will need 

another 2,000 recreation 

therapists to meet the 

demand through 2016. 

Education and training: Most

entry-level recreational 

211
therapists need a bachelor’s degree in therapeutic recreation, or a degree in recreation with 

a concentration in therapeutic recreation. People may qualify for paraprofessional positions 

with an associate degree in therapeutic recreation or another subject related to health care. 

An associate degree in recreational therapy; training in art, drama, or music therapy; or 

qualifying work experience may be sufficient for activity director positions in nursing homes. 

Related fields: Other workers who have similar jobs are occupational therapists, physical 

therapists, recreation workers, rehabilitation counselors, and special education teachers.

Social and community service managers plan, organize, and coordinate the activities of 

a social service or community outreach program. Mangers oversee the program or 

organization budget and policies regarding participant involvement, program requirements, 

and benefits. Work may involve directing social workers, counselors, or probation officers. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

130,000 162,000 32,000 24.7 57,000 71.5 19.6 8.9 Typically not Very 

high 

Projected supply and 

demand: There will be a 

strong demand for these 

managers through 2016. 

Education and training: A 

master’s degree in one of a 

number of fields is the 

standard credential for most 

212
generalist positions as a medical or health care manager. A bachelor’s degree is 

sometimes adequate for entry-level positions in smaller facilities and departments. 

Related fields: General management positions 

Social workers assist people by helping them cope with issues in their everyday lives, deal 

with their relationships, and solve personal and family problems. Some social workers help 

clients who face a disability or a life-threatening disease, or a social problem, such as 

inadequate housing, unemployment, or substance abuse. Social workers also assist 

families that have serious domestic conflicts, sometimes involving child or spousal abuse. 

Some social workers conduct research, advocate for improved services, engage in 

systems design, or are involved in planning or policy development. Many social workers 

specialize in serving a particular population or working in a specific setting. Child, family, 

and school social workers provide social services and assistance to improve the social and 

psychological functioning of children and their families, and to maximize the well-being of 

families and the academic functioning of children. They may assist single parents, arrange 

adoptions, or help find foster homes for neglected, abandoned, or abused children. Some 

specialize in services for senior citizens. These social workers may run support groups for 

the children of aging parents; advise elderly people or family members about housing, 

transportation, long-term care, and other services; and coordinate and monitor these 

services. In schools, social workers often serve as the link between students’ families and 

the school, working with parents, guardians, teachers, and other school officials to ensure 

that students reach their academic and personal potential. In addition, they address 

problems such as misbehavior, truancy, and teenage pregnancy, and advise teachers on 

how to cope with difficult students. 

Medical and public health social workers provide psychosocial support to people, families, 

or vulnerable populations so they can cope with chronic, acute, or terminal illnesses such 

as Alzheimer’s disease, cancer, or AIDS. They also advise family caregivers, counsel 

patients, and help plan for patients’ needs after discharge from hospitals. They may 

arrange for at-home services such as meals-on-wheels or home care. Mental health and 

substance abuse social workers assess and treat persons with mental illness or substance 

213
abuse problems, including abuse of alcohol, tobacco, or other drugs. Such services include 

individual and group therapy, outreach, crisis intervention, social rehabilitation, and 

teaching the skills needed for everyday living. They also may help plan for supportive 

services to ease clients’ return to the community. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

595,000 727,000 132,000 22.2 258,000 77.2 15.7 7.1 Yes High

Projected supply and 

demand: There will need to

be a steep increase in the 

number of social workers 

by 2016. 

Education and training: A 

bachelor’s degree in social 

work is the most common 

minimum requirement for a 

job as a social worker; 

however, majors in psychology, sociology, and related fields may qualify for some entrylevel jobs, especially in small community agencies. An advanced degree has become 

the standard for many positions. A master’s degree in social work is typically required 

for positions in health settings and is required for clinical work as well. Some jobs in 

public and private agencies also may require an advanced degree, such as a master’s 

degree in social services policy or administration. 

214
Related fields: Workers in occupations with similar duties include the clergy, counselors, 

probation officers and correctional treatment specialists, psychologists, and social and 

human services assistants. 

Social and human services assistants help social workers, health care workers, and 

other professionals provide services to people. Social and human services assistant is a 

generic term for workers with a wide array of job titles, including human services worker, 

case management aide, social work assistant, community support worker, mental health 

aide, community outreach worker, life skills counselor, or gerontology aide. They work in 

a variety of fields, such as nursing, psychiatry, psychology, rehabilitative or physical 

therapy, and social work. Some have little direct supervision—they may run a group 

home, for example. Others work under close direction. Social and human services 

assistants help clients improve their quality of life. They assess clients’ needs; 

investigate their eligibility for benefits and services such as food stamps, Medicaid, or 

welfare; and help clients obtain them. They also arrange for transportation and escorts, 

if necessary, and provide emotional support. Social and human services assistants 

monitor and keep case records on clients, and report progress to supervisors and case 

managers. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

339,000 453,000 114,000 33.6 153,000 58.1 26.3 15.6 No Low 

215
Projected supply and 

demand: A large increase in 

social and human services 

assistants will be needed. 

Education and 

training: Many employers 

prefer to hire people with 

some education beyond 

high school. Certificates or 

associate degrees in 

subjects such as human services, gerontology, or one of the social or behavioral 

sciences meet many employers’ requirements. Some jobs may require a bachelor’s or 

master’s degree in human services or a related field, such as counseling, rehabilitation, 

or social work. 

Related fields: Workers in other occupations that require skills similar to those of social 

and human services assistants include social workers, clergy, counselors, child care 

workers; occupational therapist assistants and aides, physical therapist assistants and 

aides, and nursing, psychiatric, and home health aides. 

Occupations: Education 

Clinical, counseling, and school psychologists diagnose and treat mental disorders; 

learning disabilities; and cognitive, behavioral, and emotional problems using individual, 

child, family, and group therapies. May design and implement behavior modification 

programs. Psychologists in health services fields provide mental health care in hospitals, 

clinics, schools, or private settings. School psychologists work with students in early 

childhood and elementary and secondary schools. They collaborate with teachers, parents, 

and school personnel to create safe, healthy, and supportive learning environments for all 

students. School psychologists address students’ learning and behavioral problems, 

suggest improvements to classroom management strategies or parenting techniques, and 

216
evaluate students with disabilities and gifted and talented students to help determine the 

best way to educate them. They improve teaching, learning, and socialization strategies 

based on their understanding of the psychology of learning environments. They also may 

evaluate the effectiveness of academic programs, prevention programs, behavior 

management procedures, and other services provided in the school setting. Counseling 

psychologists use various techniques, including interviewing and testing, to advise people 

on how to deal with problems of everyday living, including career or work problems and 

problems faced in different stages of life. They work in settings such as university 

counseling centers, hospitals, and individual or group practices. Clinical psychologists—

who constitute the largest specialty—work most often in counseling centers, independent or 

group practices, hospitals, or clinics. They help mentally and emotionally distressed clients 

adjust to life and may help medical and surgical patients deal with illnesses or injuries. 

Some clinical psychologists work in physical rehabilitation settings, treating patients with 

spinal cord injuries, chronic pain or illness, stroke, arthritis, or neurological conditions. 

Others help people deal with personal crises, such as divorce or the death of a loved one. 

Percentage with: 

Employment

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

152,000 176,000 24,000 15.8 47,000 99.3 0 0 Yes Very 

high 

Projected supply and demand: Estimates of actual and projected numbers of jobs has 

varied over the past 10 years. It appears that demand will be moderate by 2016. 

Education and training: A doctoral degree is usually required for independent practice as a 

psychologist. Psychologists with a Ph.D. or doctor of psychology (Psy.D.) qualify for a wide 

range of teaching, research, clinical, and counseling positions in universities, health care 

services, elementary and secondary schools, private industry, and government. 

217
Psychologists with a doctoral 

degree often work in clinical 

positions or in private 

practices, but they also 

sometimes teach, conduct 

research, or carry out 

administrative 

responsibilities. A specialist 

degree or its equivalent is 

required in most States for a 

person to work as a school psychologist, although a few States still credential school 

psychologists with master’s degrees. A specialist (Ed.S.) degree in school psychology 

requires a minimum of 3 years of full-time graduate study (at least 60 graduate semester 

hours) and a 1-year full-time internship. Because their professional practice addresses 

educational and mental health components of students’ development, school psychologists’ 

training includes coursework in both education and psychology. 

Related fields: Psychologists work with people, developing relationships and comforting 

them. Other occupations with similar duties include counselors, social 

workers, clergy, sociologists, special education teachers, funeral directors, market and 

survey researchers, recreation workers, and human resources, training, and labor 

relations managers and specialists. 

Educational, vocational, and school counselors provide individuals and groups with 

career and educational counseling. School counselors assist students of all levels, from 

elementary school to postsecondary education. They advocate for students and work with 

other persons and organizations to promote the academic, career, personal, and social 

development of children and youth. School counselors help students evaluate their abilities, 

interests, talents, and personalities to develop realistic academic and career goals. 

Counselors use interviews, counseling sessions, interest and aptitude assessment tests, 

and other methods to evaluate and advise students. They also operate career information 

218
centers and career education programs. Often, counselors work with students who have 

academic and social development problems or other special needs. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

260,000 292,000 33,000 12.6 84,000 72.8 18.3 8.9 Yes Very 

high 

Projected supply and 

demand: Although the 

demand through 2016 is 

growing, supply is not too 

far behind. 

Education and training: A 

master’s degree is usually 

required to be licensed as a 

counselor. Some States 

require counselors in public employment to have a master’s degree; others accept a 

bachelor’s degree with appropriate counseling courses. Many States require school 

counselors to hold a State school counseling certification and to have completed at 

least some graduate course work; most require the completion of a master’s degree. 

Some States require school counselors to be licensed, which generally requires 

continuing education credits. Some States require public school counselors to have 

both counseling and teaching certificates, and to have had some teaching experience. 

Related fields: Counselors help people evaluate their interests, abilities, and disabilities, 

and deal with personal, social, academic, and career problems. Others who help people 

219
in similar ways include teachers, social and human services assistants, social 

workers, psychologists, physicians and surgeons, registered nurses, occupational 

therapists, and human resources, training, and labor relations managers and 

specialists. 

Sign language interpreters facilitate communication between people who are deaf or 

hard-of-hearing and people who can hear. Sign language interpreters must be fluent in 

English and in American Sign Language (ASL), which combines signing, finger spelling, 

and specific body language. ASL has its own grammatical rules, sentence structure, 

idioms, historical contexts, and cultural nuances. Sign language interpreting, like foreign 

language interpreting, involves more than simply replacing a word of spoken English 

with a sign representing that word. Most sign language interpreters either interpret, 

aiding communication between English and ASL, or transliterate, facilitating 

communication between English and contact signing—a form of signing that uses a 

more English language-based word order. Some interpreters specialize in oral 

interpreting for deaf or hard-of-hearing people who lip-read instead of sign. Other 

specialties include tactile signing, which is interpreting for people who are blind as well 

as deaf by making manual signs into a person’s hands; cued speech; and signing exact 

English. Self-employed and freelance interpreters and translators need general 

business skills to successfully manage their finances and careers. They must set prices 

for their work, bill customers, keep financial records, and market their services to attract 

new business and build their client base. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

41,000 51,000 10,000 23.6 7 47.8 36.3 15.9 Varies High

220
Projected supply and 

demand: The demand for 

interpreters through 2016 

will be strong and growing. 

Education and training: The 

educational backgrounds of 

interpreters and translators 

vary. Knowing at least two 

languages is essential. 

Although it is not necessary 

to have been raised bilingual to succeed, many interpreters and translators grew up 

speaking two languages. In high school, students can prepare for these careers by 

taking a broad range of courses that include English writing and comprehension, foreign 

languages, and basic computer proficiency. Other helpful pursuits include spending time 

abroad, engaging in direct contact with foreign cultures, and reading extensively on a 

variety of subjects in English and at least one other language. Beyond high school, 

there are many educational options. Although a bachelor’s degree is often required, 

interpreters and translators note that it is acceptable to major in something other than a 

language. An educational background in a particular field of study provides a natural 

area of subject matter expertise. However, specialized training in how to do the work is 

generally required. Formal programs in interpreting and translation are available at 

colleges nationwide and through nonuniversity training programs, conferences, and 

courses. Many people who work as conference interpreters or in more technical areas—

such as localization, engineering, or finance—have master’s degrees, while those 

working in the community as court or medical interpreters or translators are more likely 

to complete job-specific training programs. 

Related fields: Interpreters and translators use their multilingual skills, as do teachers of 

languages. These include preschool, kindergarten, elementary, middle, and secondary 

school teachers; postsecondary school teachers; special education teachers; adult 

221
literacy and remedial education teachers; and self-enrichment education teachers. The 

work of interpreters, particularly guide or escort interpreters, is similar to that of tour 

guides and escorts, in that they accompany individuals or groups on tours or to places 

of interest. 

Special education teachers work with children and youths who have a variety of 

disabilities. A small number of special education teachers work with students with 

severe cases of mental retardation or autism, primarily teaching them life skills and 

basic literacy. However, the majority of special education teachers work with children 

with mild to moderate disabilities, using or modifying the general education curriculum to 

meet the child’s individual needs. Most special education teachers instruct students at 

the elementary, middle, and secondary school level, although some work with infants 

and toddlers. They diagnose and treat mental disorders; learning disabilities; and 

cognitive, behavioral, and emotional problems using individual, child, family, and group 

therapies, and may design and implement behavior modification programs. Special 

education teachers use various techniques to promote learning. Depending on the 

disability, teaching methods can include individualized instruction, problem solving 

assignments, and small-group work. When students need special accommodations to 

take a test, special education teachers see that they are provided, such as having the 

questions read orally or lengthening the time allowed to take the test. Special education 

teachers help develop an Individualized Education Program (IEP) for each student. The 

IEP sets personalized goals for the student and is tailored to that student’s needs and 

abilities. If appropriate, the program includes a transition plan outlining specific steps to 

prepare students with disabilities for middle school or high school or, in the case of older 

students, for a job or postsecondary study. Teachers review the IEP with the student’s 

parents, school administrators, and the student’s general education teachers. Teachers 

work closely with parents to inform them of their child’s progress and suggest 

techniques to promote learning at home. Special education teachers design and teach 

appropriate curricula, assign work geared toward each student’s needs and abilities, 

and grade papers and homework assignments. They are involved in the students’ 

behavioral, social, and academic development, helping them develop emotionally, feel 

222
comfortable in social situations, and be aware of socially acceptable behavior. 

Preparing special education students for daily life after graduation also is an important 

aspect of the job. Teachers provide students with career counseling or help them learn 

routine skills, such as balancing a checkbook. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

459,000 530,000 71,000 15.4 173,000 87.2 8.3 4.5 Yes Very 

high 

Projected supply and 

demand: There will be a 

moderate demand for 

special education teachers 

by 2016. 

Education and training: 

Many colleges and 

universities across the 

United States offer 

programs in special 

education at the undergraduate, master’s, and doctoral degree levels. Special education 

teachers usually undergo longer periods of training than do general education teachers. 

Most bachelor’s degree programs last 4 years and include general and specialized 

courses in special education. However, an increasing number of institutions require a 

5th year or other graduate-level preparation. Among the courses offered are educational 

psychology, legal issues of special education, child growth and development, and 

strategies for teaching students with disabilities. Some programs require specialization, 

223
while others offer generalized special education degrees or a course of study in several 

specialized areas. The last year of the program usually is spent student teaching in a 

classroom supervised by a certified teacher. 

Related fields: Other occupations involved with the identification, evaluation, and 

development of students with disabilities include psychologists, social workers, speechlanguage pathologists, audiologists, counselors, teacher assistants, occupational 

therapists, recreational therapists, and teachers—preschool, kindergarten, elementary, 

middle, and secondary. 

Speech-language pathologists, sometimes called speech therapists, assess, 

diagnose, treat, and help prevent disorders related to speech, language, cognitivecommunication, voice, swallowing, and fluency. Speech-language pathologists work 

with people who cannot produce speech sounds or cannot produce them clearly; those 

with speech rhythm and fluency problems, such as stuttering; people with voice 

disorders, such as inappropriate pitch or harsh voice; those with problems 

understanding and producing language; those who wish to improve their communication 

skills by modifying an accent; and those with cognitive communication impairments, 

such as attention, memory, and problem solving disorders. They also work with people 

who have swallowing difficulties. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected 

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School

Degree

Licensure 

or 

Certification

Required 

Income

Level 

110,000 121,000 12,000 10.6 11 97.9 0 0 Yes Very 

high 

224
Projected supply and 

demand: Demand will be 

moderate through 2016. 

Education and training: 

Most speech-language 

pathologist jobs require a 

master’s degree. In 2007, 

more than 230 colleges and 

universities offered 

graduate programs in 

speech-language pathology accredited by the Council on Academic Accreditation in 

Audiology and Speech-Language Pathology. While graduation from an accredited 

program is not always required to become a speech-language pathologist, it may be 

helpful to obtain a license or may be required to obtain a license in some States. 

Related fields: Workers in related occupations include audiologists, occupational 

therapists, optometrists, physical therapists, psychologists, and recreational therapists. 

Speech-language pathologists in school systems often work closely with special 

education teachers to assist students with disabilities. 

Teacher assistants—also called teacher aides or instructional aides— provide 

instructional and clerical support for classroom teachers, allowing teachers more time 

for lesson planning and teaching. They support and assist children in learning class 

material using the teacher’s lesson plans, providing students with individualized 

attention. Teacher assistants also supervise students in the cafeteria, schoolyard, and 

hallways, or on field trips; they record grades, set up equipment, and help prepare 

materials for instruction. Some assistants refer to themselves as paraeducators or 

paraprofessionals. 

Some teacher assistants perform exclusively noninstructional or clerical tasks, such as 

monitoring nonacademic settings. Playground and lunchroom attendants are examples 

225
of such assistants. Most teacher assistants, however, perform a combination of 

instructional and clerical duties. They generally provide instructional reinforcement to 

children, under the direction and guidance of teachers. They work with students 

individually or in small groups—listening while students read, reviewing or reinforcing 

class lessons, or helping them find information for reports. At the secondary school 

level, teacher assistants often specialize in a certain subject, such as math or science. 

Teacher assistants often take charge of special projects and prepare equipment or 

exhibits, such as for a science demonstration. Some assistants work in computer 

laboratories, helping students use computers and educational software programs. 

Percentage with: 

Employment 

2006 2016

Total 

Growth 

Projected

% 

Growth

Total 

Replacement 

Needs 

2006–

2016 

College

Plus 

Some 

College

High 

School 

Degree

Licensure 

or 

Certification 

Required 

Income

Level 

1,312 1,449 137,000 10.4 350 17.9 44.7 37.4 No Very 

Low 

Projected supply and 

demand: Future demand is 

less than previous 

projections, but there will 

still be a need for a sizable 

number of new teacher 

assistants by 2016. 

Education and training: 

Many teacher assistants 

need only a high school 

diploma and on-the-job training. A college degree or related coursework in child 

development improves job opportunities, however. In fact, teacher assistants who work 

226
in Title 1 schools—those with a large proportion of students from low-income 

households—must have college training or proven academic skills. As of 2006, federal 

regulations specified that assistants must hold a 2-year or higher degree, have a 

minimum of 2 years of college, or pass a rigorous State or local assessment. A number 

of colleges offer associate degrees or certificate programs that either prepare graduates 

to work as teacher assistants or provide additional training for current teacher 

assistants. All teacher assistants receive some on-the-job training. Teacher assistants 

need to become familiar with the school system and with the operation and rules of the 

school. Those who tutor and review lessons with students must learn and understand 

the class materials and instructional methods used by the teacher. Teacher assistants 

also must know how to operate audiovisual equipment, keep records, and prepare 

instructional materials, as well as have adequate computer skills. 

Related fields: The support activities of teacher assistants and their educational 

backgrounds are similar to those of child care workers, library technicians, and library 

assistants. Teacher assistants who work with children with disabilities perform many of 

the same functions as occupational therapist assistants and aides. 

227
228
APPENDIX C. Mission of the National Council on 

Disability 

Overview and Purpose 

The National Council on Disability (NCD) is an independent federal agency, composed 

of 15 members appointed by the President, by and with the consent of the U.S. Senate. 

The purpose of NCD is to promote policies, programs, practices, and procedures that 

guarantee equal opportunity for all individuals with disabilities, and that empower 

individuals with disabilities to achieve economic self-sufficiency, independent living, and 

inclusion and integration into all aspects of society. 

To carry out this mandate, we gather public and stakeholder input, including that 

received at our public meetings held around the country; review and evaluate federal 

programs and legislation; and provide the President, Congress, and federal agencies 

with advice and recommendations. 

Specific Duties 

The current statutory mandate of NCD includes the following: 

● Reviewing and evaluating, on a continuing basis, policies, programs, practices, 

and procedures concerning people with disabilities conducted or assisted by 

federal departments and agencies, including programs established or assisted 

under the Rehabilitation Act of 1973, as amended, or under the Developmental 

Disabilities Assistance and Bill of Rights Act, as well as all statutes and 

regulations pertaining to federal programs that assist such people with 

disabilities, to assess the effectiveness of such policies, programs, practices, 

procedures, statutes, and regulations in meeting the needs of people with 

disabilities. 

229
● Reviewing and evaluating, on a continuing basis, new and emerging disability 

policy issues affecting people with disabilities in the Federal Government, at the 

State and local government levels, and in the private sector, including the need 

for and coordination of adult services, access to personal assistance services, 

school reform efforts and the impact of such efforts on people with disabilities, 

access to health care, and policies that act as disincentives for people to seek 

and retain employment. 

● Making recommendations to the President, Congress, the Secretary of 

Education, the director of the National Institute on Disability and Rehabilitation 

Research, and other officials of federal agencies about ways to better promote 

equal opportunity, economic self-sufficiency, independent living, and inclusion 

and integration into all aspects of society for Americans with disabilities. 

● Providing Congress, on a continuing basis, with advice, recommendations, 

legislative proposals, and any additional information that NCD or Congress 

deems appropriate. 

● Gathering information about the implementation, effectiveness, and impact of 

the Americans with Disabilities Act of 1990 (ADA) (42 U.S.C. § 12101 et seq.). 

● Advising the President, Congress, the commissioner of the Rehabilitation 

Services Administration, the assistant secretary for Special Education and 

Rehabilitative Services in the Department of Education, and the director of the 

National Institute on Disability and Rehabilitation Research on the development 

of the programs to be carried out under the Rehabilitation Act of 1973, as 

amended. 

● Providing advice to the commissioner of the Rehabilitation Services 

Administration with respect to the policies and conduct of the administration. 

● Making recommendations to the director of the National Institute on Disability 

and Rehabilitation Research on ways to improve research, service, 

administration, and the collection, dissemination, and implementation of 

research findings affecting people with disabilities. 

230
● Providing advice regarding priorities for the activities of the Interagency 

Disability Coordinating Council and reviewing the recommendations of this 

council for legislative and administrative changes to ensure that such 

recommendations are consistent with NCD’s purpose of promoting the full 

integration, independence, and productivity of people with disabilities. 

● Preparing and submitting to the President and Congress an annual report titled 

National Disability Policy: A Progress Report. 

Statutory History 

NCD was established in 1978 as an advisory board within the Department of Education 

(P.L. 95-602). The Rehabilitation Act Amendments of 1984 (P.L. 98-221) transformed 

NCD into an independent agency. 

231
232
233

Endnotes 

1

 Manpower, Talent Shortage Survey: 2008 Global Results (Milwaukee, WI: Manpower, 

Inc., 2008). 

2

 Manpower, Confronting the Talent Crunch: 2008 (Milwaukee, WI: Manpower, Inc., 

2008). 

3

 Frank Bowe, Making Inclusion Work (Upper Saddle River, NJ: Prentiss Hall, 2005).

4

 Ibid. 

5

 Ibid. 

6

 Ibid. 

7

 U.S. Census Bureau, Population Estimates, Table 1: Monthly Population Estimates for 

the United States: April 1, 2000, to March 1, 2009. Accessed April 24, 2009, at 

www.census.gov/popest/national/tables/NA-EST2008-01.xls. 

8

 U.S. Census Bureau, 2005 Interim State Population Projections, Table 6. Internet 

release date: April 21, 2005. Accessed April 24, 2009, at www.census.gov/

population/projections/presstab6.xls. 

9

 American Community Survey, 2006. Accessed December 23, 2009, at 

http://www.census.gov/hhes/www/disability/2006acs.html. 

10 A. Dohm and L. Shniper, “Occupational Employment Projections to 2016,” Monthly 

Labor Review, 2007, 85–105. 

11 D. Hecker, “Occupational Employment Projections to 2014,” Monthly Labor Review, 

2006, 70–101. 

12 D. Hecker, “Occupational Employment Projections to 2012,” Monthly Labor Review, 

2004, 80–105. 

13 D. Hecker, “Occupational Employment Projections to 2010,” Monthly Labor Review, 

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14 J. C. Franklin, “An Overview of BLS Projections to 2016,” Monthly Labor Review, 

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15 Center for Personal Assistance Services, State Chart Book on Wages for Personal 

and Home Care Aides, 1999–2006 (San Francisco: University of California San 

Francisco, 2008). 

16 R. I. Stone and J. M. Weiner, Who Will Care for Us? Addressing the Long-Term Care 

Workforce Crisis (Washington, DC: Urban Institute, 2001). 

17 Department of Health and Human Services, Office of Evaluation and Planning, The 

Supply of Direct Support Professionals Serving Individuals with Intellectual Disabilities 

and Other Developmental Disabilities: Report to Congress, 2006. 
234

18 T. E. Williams and C. E. Ellison, “Population Analysis Predicts a Future Shortage of 

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19 P. I. Buerhaus, D. O. Staiger, and D. I. Auerbach, The Future of the Nursing 

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20 T. Chan and K. Ruedel, A National Report: The Demand for and the Supply of 

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21 Manpower 2007. 

22 Capella 2003. 

23 Bolton, Bellini & Brookings, 2000; Chapin & Kewman; Crewe, 2000. 

24 Government Accountability Office (GAO), 2007 http://www.gao.gov/new.items/d07332.pdf

25 NCD 2008 http://www.ncd.gov/newsroom/publications/2008/doc/Rehabilitation

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26 GAO 2005. 

27 GAO 2009. 

28 GAO, Workforce Investment Act One-Stop Centers Implemented Strategies to 

Strengthen Services and Partnerships, But More Research and Information Sharing Is 

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29 Metzel & Giordano, 2007 

30 GAO, Workforce Investment Act: One-Stop System Infrastructure Continues to 

Evolve, But Labor Should Take Action to Require That All Employment Service Offices 

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31 P. Holcomb and B. S Barnow, Serving People with Disabilities Through the Workforce 

Investment Act’s One-Stop Career Centers (Washington, DC: Urban Institute, 2004). 

32 A. Veltman, D. E. Stewart, G. S. Tardif, and M. Branigan, “Perceptions of Primary 

Healthcare Services Among People with Disabilities, Part 1: Access Issues,” Medscape 

General Medicine, 3 (2001); DeJong, Palsbo, Beatty, et.al. 2002; A. I. Batavia and M. 

Batavia, “Disability, Chronic Conditions, and Iatrogenic Illness,” Archives of Physical 

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33 Newman, Wagner, Cameto, and Knokey, 2009.