Best Practice Models of Effective Vocational Rehabilitation Service Delivery in the Public Rehabilitation Program

Abstract

Rehabilitation counselors and practitioners are under increased pressure to adopt and pursue evidenced-based practices, and the rehabilitation counseling literature has been criticized for a lack of empirical work providing support for individual-level interventions. The purpose of this literature review was to examine the last 25 years of rehabilitation research with specific attention to empirical studies related to active employment-focused interventions and present models of best practices that already exist within the literature. Findings indicated that 35 empirical studies met the search criteria of presenting services or models with initial evidence of supporting employment outcomes. In the review process, studies were classified into seven categories based on topic, including interagency collaboration, counselor education and customer outcomes, services to a targeted group, supported employment and evidence-based practice (EBP), empowerment and customer self-concept, essential elements of service delivery, and miscellaneous vocational rehabilitation services and outcomes. A review and synthesis of studies within these topical areas are presented, along with implications within the context of the critical need for EBPs in rehabilitation counseling.

Keywords

evidence-based practices rehabilitation counseling vocational rehabilitation employment services

The state–federal vocational rehabilitation (VR) program is one of the most important vocational service programs in the United States, with a strong commitment to serving people with the widest range of disabilities (Saunders, 2005; U.S. Government Accountability Office [GAO], 2005). According to data gathered by the Rehabilitation Services Administration (RSA) for fiscal year 2005, a total of 1,402,291 individuals with disabilities were served by the VR program in the United States and U.S. territories. The total number of individuals with disabilities closed successfully earning at or above the federal minimum wage were 197,661 or 14% of the total served (RSA, 2005). Nationwide, approximately 55.8% of individuals who exit the VR program after receiving services go to work (RSA, 2005). Originating with passage of the Smith-Fess Act in 1920 and authorized by the Rehabilitation Act of 1973 as amended in 1998, the state–federal VR program provides grants to states to support a wide range of services designed to help individuals with disabilities prepare for and engage in gainful employment consistent with their strengths, resources, priorities, concerns, abilities, capabilities, interests, and utilizing informed choice.

Although the effectiveness of the VR counseling has been empirically demonstrated (Pruett, Swett, Chan, & Rosenthal, 2008), there is a serious lack of evidence-based practices (EBPs) that accurately define what specific VR service(s) and interventions produce employment outcomes for individuals with disabilities who participate in the state VR program (Leahy & Arokiasamy, 2010). Little is known about the type of services that might contribute differentially to improve employment rates of subpopulations with low employment outcomes. In addition, we still do not have an answer to the question raised by Paul (1967), “What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances?” (p. 111). Answers to this question will provide VR counselors with information regarding what services and interventions have a high probability of predicting successful outcomes for VR customers.

In addition to determining which approach works best for whom, how, and under what conditions, there are internal and external pressures for rehabilitation counselors in VR programs to demonstrate that they are using an array of evidence-based interventions in their practice to improve employment outcomes for customers with significant disabilities (Rubin, Chan, & Thomas, 2003). For example, the Work Incentives Improvement Act of 1999 and the Workforce Investment Act of 1998 require the state–federal VR program to demonstrate service efficacy to maintain and expand program funding and services (Koscuilek, 2004). Given current budget deficits at the national and state levels, along with increasing health care costs and shrinking public funding, budget-minded employers and government agencies are asking hard questions about expected outcomes of rehabilitation methods and demanding objective evidence to justify their support of rehabilitation services (Chan, Rosenthal, & Pruett, 2008). The public rehabilitation program is at a crossroads and must now develop EBPs that demonstrate the effectiveness of the VR services provided to individuals with disabilities leading to competitive employment outcomes.

The VR process typically involves a range of personal and environmental processes and the interactions thereof. This makes determining the relationship between specific aspects of service delivery and the outcome very complex (Saunders, Leahy, McGlynn, & Estrada-Hernández, 2006). There is considerable variation in VR agency outcomes that can be attributed to individual differences at the customer level, environmental and economic characteristics of the state, and differences in performance of the VR agencies themselves (Chan, Wang, Muller, & Fitzgerald, 2011; GAO, 2005, 2007). Although it is impossible to isolate all of the reasons for the variation, it is useful to examine different practices and approaches that appear in the literature. These findings can provide direction for future research, specifically, highlighting existing practices that are considered promising or effective over time that can be replicated, expanded, and evaluated to the point where they may be considered evidence based.

The purpose of this integrative review is to examine the literature to select studies describing best VR service practices by state VR agencies. The following section of this review provides background on EBP and its relevance to rehabilitation research and service provision. Following this background, the methodology for the literature review is presented along with a discussion of articles describing best service practices in the VR setting.

EBP and Rehabilitation Counseling

EBP in medicine and health care is not a new concept. The need for EBP originated in the medical and allied health disciplines in the 1950s when physicians argued for randomized controlled trials to improve health care services. A hierarchy of evidence obtained from empirical study has been established, with the highest levels of evidence coming from a systematic review of several randomized controlled trials of an intervention to lower levels of evidence obtained from expert opinion (Pruett, Rosenthal, Swett, Lee, & Chan, 2008). The EBP model requires the practitioner pose important and relevant questions regarding the provision of service and to use research to answer them, resulting in effective service provision based on sound evidence (Chan et al., 2008; Chan et al., 2011). Although the medical and other health care fields such as psychology have embraced EBP models of practice, the field of rehabilitation counseling has yet to fully adopt EBP in rehabilitation counseling education programs, field practice, or research (Tarvydas, Addy, & Fleming, 2010).

Multiple barriers to adopting EBP in rehabilitation counseling have been identified in the literature (Chan et al., 2011; Johnston et al., 2009; Leahy & Arokiasamy, 2010; Tarvydas et al., 2010). One of the major barriers to EBP implementation in rehabilitation counseling is the challenge of training practitioners to utilize research and results appropriately in practice (Chan et al., 2008). In addition, rehabilitation counselors work in many different practice environments (e.g., State–federal VR program, private, community rehabilitation organizations, and school systems), with many different roles, responsibilities, and customers to serve. The spread of rehabilitation counseling in multiple service settings has lead to not only specialty areas of rehabilitation counseling practice, such as transition, but has made rehabilitation research very complex. Additional barriers are inherent in the nature of rehabilitation research, as explained by Johnston et al. (2009), including the emphasis on empowering people with disabilities, small sample sizes, difficulty achieving internal and external controlled conditions, ethical challenges to including a control group, funding, and the need to include multiple social and environmental factors (Tarvydas et al., 2010). As Bellini and Rumrill (1999) observed, as rehabilitation research focuses on more complex phenomena, investigating interactions among multiple independent and dependent variables, research models must become more complex as well. In addition, as rehabilitation programs experience increased pressure to provide services that are supported by best scientific evidence, rehabilitation researchers must become increasingly concerned with the need to provide data that clearly documents that consumer gains can be attributed to rehabilitation interventions (Chan et al., 2011; Rubin et al., 2003).

Although barriers to implementing EBP in rehabilitation counseling have been well documented, there continues to be a call for research with a focus on how to develop empirically based EBP models that examine and demonstrate the effectiveness of VR services provided to individuals with disabilities. Developing EBP has been recently been emphasized by the National Institute of Disability and Rehabilitation Research (NIDRR) in all research projects publicly funded through NIDRR (Brannon, 2010). As Leahy, Thielsen, Millington, Austin, and Fleming (2009) stated, the emphasis in the future will be on the meaning of research findings to practitioners and consumers in improving services and employment outcomes, and translating and disseminating EBPs so they affect and inform practice and policy.

NIDRR and RSA, as the major funding sources of rehabilitation research, are working to close the gap between practice and EBP. Specifically, RSA is concerned about developing EBP that will provide evidence of effectiveness or efficacy of a practice that will potentially increase the likelihood of its adoption by practitioners, improving its chances of impacting employment outcomes of individuals with disabilities. In a resource-limited environment, the evidence of efficacy and effectiveness can help make programmatic funding decisions more rational and, hopefully, more equitable (Brannon, 2010). It is quite clear that RSA and NIDRR are calling for researchers to develop proven EBPs to enhance VR customer employment outcomes and provide data supporting the effectiveness of the VR program.

Given the emphasis by NIDRR and RSA to develop, implement, and disseminate EBPs in rehabilitation counseling, researchers have taken steps to address the need for EBP within the rehabilitation counseling profession. Authors have suggested methods for practitioners, educators, and researchers to adopt, engage with, and implement EBP in rehabilitation counseling (Hergenrather, Geishecker, McGuire-Kuletz, Gitlin, & Rhodes, 2010; Kosciulek, 2010; Leahy & Arokiasamy, 2010; Strauser & Wong, 2010). Contextually, Tarvydas et al. (2010) addressed the challenges EBP presents to the rehabilitation counseling field in the areas of rehabilitation philosophy, ethics, and the relationship between research and practice. Chan et al. (2011) presented EBP as an opportunity for rehabilitation counselors to use empirically validated interventions to ensure that their customers are getting the best possible services. As is pointed out by the authors, the continually low rates of employment for persons with disabilities, the changing demographics of the United States, and our increased understanding of the experience and impact of disability provide practitioners with multiple challenges that they must address through services, and they may do so more effectively and efficiently when practice is supported with research-based evidence.

Literature Review Overview and Method

To carry out this integrative review, the article selection criteria focused on identifying “active VR services” at the state VR agency level published in the last 25 years. “Active services” was defined as actual state VR agency services delivery practices that are considered “best practices” leading to competitive employment outcomes for individuals with disabilities, receiving VR services through the state VR agency. The exclusive emphasis on “active services” led to a decision not to include articles where the research methodology relied solely on using the RSA 911 or other secondary database. To locate relevant articles, the research team consulted other efforts to review literature pertinent to practices in the public VR program (e.g., Institute for Community Inclusion, 2010) and searched independently for additional articles published during the time period 1986–2011. The research team located a total of 561 articles during this search. Reviewers independently read the articles and evaluated them for appropriateness for inclusion in the sample, based on whether the article was an empirical evaluation of an active service related to the VR setting.

Of the 561 articles reviewed by the research team, 35 articles that matched the selection criteria were identified as “active service” examples of best practices in state VR agencies. As part of the review process, the 35 articles were classified into seven categories based on the content review. Articles were thematically analyzed and sorted by the research team based on the purpose, goals, and intended audience of the intervention, and categorized according to best fit. This was accomplished through an iterative group process of reading articles for content, suggesting possible themes, and then reaching a final decision based on group discussion until agreement was reached. Although some articles could have been classified into multiple categories, we decided to make the categories mutually exclusive. The categories were as follows:

Interagency collaboration (n = 10),

Counselor education and customer outcomes (n = 5),

Services to a targeted group (n = 5),

Supported employment and EBP (n = 5),

Empowerment and customer self-concept (n = 3),

Essential elements of service delivery (n = 3), and

Miscellaneous VR services and outcomes (n = 4).

The following is a discussion of the findings of the integrative literature review by category.

Interagency Collaboration

Interagency collaboration articles focused on intera gency agreements involving one-stop centers, supported employment/customized employment, VR and mental health agencies, and community colleges and universities (see Table 1). These studies included a variety of methodologies, such as a case study methodology to examine practices in one-stop career centers designed to engage employers and develop jobs for customers with disabilities (Timmons, Boeltzig, Hall, Hamner, & Fesko, 2006). Other studies within this category focused on interagency collaboration for services to individuals with developmental disabilities and psychiatric disabilities (Borgeson & Cusick, 1994) and a seamless transition model (Certo et al., 2003). Specifically, Cohen, Butterworth, Gilmore, and Metzel (2003) outlined seven themes that highlighted “high performing” states that included interagency collaboration, and Metzel, Foley, and Butterworth (2005) identified crucial characteristics that resulted in agency collaborations and successful employment outcomes for supported employment programs. Several studies in this category explored collaboration between community colleges, universities, and VR agencies as a “best practice.” Flannery, Yovanoff, Benz, and McGrath Kato (2008) noted that collaboration between a community college and VR for short-term training programs improved employment outcomes. Balcazar, Keys, Davis, Lardon, and Jones (2005) examined an intervention designed to promote goal attainment as part of a university–VR agency collaboration leading to increased goal achievement. The remaining studies examined formal agreements and procedures between VR and a mental health agency (Rogers, Anthony, & Danley, 1989), a multisite transition grant program (Brewer et al., 2011), and a “customized employment” program, the Tennessee Customized Employment Partnership (TCEP), designed to assist individuals who require intensive support into employment (Luecking & Luecking, 2006).

Table 1.

Interagency Collaboration.

Study	Purpose	Results
Balcazar, Keys, Davis, Lardon, and Jones (2005)	Tested following hypotheses: (a) Trained participants will demonstrate more help recruiting skills than those who do not receive training, (b) participants who receive training follow-along support from their counselors will experience significantly more goal attainment than those who receive either training or supervision alone as well as participants in the active-treatment control group, (c) participants who receive either training or follow-along support from their counselors will attain more goals than participants in active-treatment control, and (d) participants who receive training and/or follow-up support from their counselors will experience more employment success than participants in active-treatment control group.	Participants who received combination of training and follow-along support attained more goals than participants in other three groups, particularly control group.
Borgeson and Cusick (1994)	Tested hypothesis that VR consumers w/ severe mental illness served by a “personal touch” of outreach, interagency collaboration, and support would exhibit less attrition from rehabilitation process between referral and delivery of service than consumers not receiving this approach.	Findings suggest a combination of personalized outreach and close interagency collaboration of service providers to keep persons w/ severe mental disabilities from dropping out of VR system before receiving services.
Brewer et al. (2011)	Evaluated New York State multisite transition grant program; objectives were to (a) strengthen partnerships between the NYS Vocational Rehabilitation (VR) system and high schools, (b) increase participation of youth in employment, VR-related services, and postsecondary partners, including postsecondary education and businesses.	Findings indicated that students with greater involvement in career development activities, measurable postsecondary goals in their Individualized Education Programs, and services from community partners were more likely to engage in work-related experiences and state–federal VR program.
Certo et al. (2003)	Tested hypothesis that joint investment and joint responsibility (a) facilitates a seamless transition from school to competitive employment and (b) enables better access to typical adult lifestyle for a diverse group of graduates with significant support needs.	63% competitive employment at the point of graduation; 71% competitive employment up to 3 years after graduation
Cohen, Butterworth, Gilmore, and Metzel (2003)	Highlighted successful practices of states identified as “high-performers” in integrated employment for people served by state MR/DD agencies.	Seven criteria were identified as contributing to increased employment outcomes: (a) clearly defined goals and data collection, (b) strong agency leadership, (c) interagency collaboration, (d) ongoing training and outreach, (e) communication through relationships, (f) local control, and (g) flexibility and respect for innovation.
Flannery, Yovanoff, Benz, and McGrath Kato (2008)	Described a continuous improvement process used in a partnership between VR and community college short-term training programs that was adapted in partnership w/ VR to meet needs of VR consumers attending these programs.	Results varied across the four colleges, reflecting regional preferences based on staff perception of importance and priority of needs in local region
Luecking and Luecking (2006)	Reviewed employment outcomes for individuals w/ most significant disabilities who participated in “customized employment” program designed to assist persons unlikely to compete for jobs w/ standardized job descriptions due to intensive support/accommodation needs.	71 individuals had been assisted w/ obtaining customized job in variety of employment settings.
Metzel, Foley, and Butterworth (2005)	Investigated the following questions: (a) What is necessary for development of potentially good interagency agreement for supported employment? (b) What is necessary for implementation of potentially good interagency agreement? and (c) What are positive outcomes of interagency agreements for supported employment?	Findings confirmed that for written interagency agreement to be effective, minimal elements to be included are (a) specific population to be served, (b) resources to be committed, (c) assignment of roles and responsibilities, and (d) reporting requirements.
Rogers, Anthony, and Danley (1989)	Investigated development of system of mental health and vocational rehabilitation service delivery that would positively affect client outcomes	Results of pretest and posttest interagency questionnaires among administrators indicated changes in collaboration occurred; however, results for practitioners indicated no change.
Timmons, Boeltzig, Hall, Hamner, and Fesko (2006)	Investigated the following questions: (a) What strategies have one-stop career centers used to increase employer awareness of one-stops? and (b) How have these strategies supported employer investment in hiring people w/ disabilities?	Employers hesitant to hire individuals w/ disabilities; authors recommended strategies needed to raise employer awareness of one-stop services leading to recruitment of individuals w/ disabilities for employment.

Note. NYS = New York State; VR = vocational rehabilitation; MR/DD = mental retardation/developmental disability.

The interagency collaboration studies were the most numerous among “best practices” in VR service delivery. The “best practices” described in these works included strategies to engage employers in the job-seeking process at one-stop service centers and interagency agreements for services to specific populations in the form of supported employment services and partners involving VR agencies, community colleges, and universities that result in positive outcomes for customers. As noted by the authors, the advantage of interagency collaborations is the pooling of funding sources, sharing of staff expertise, and coordination of service delivery to targeted populations. On a systems-level, interagency collaborations offer a consistent service delivery method leading to employment outcomes. On the practitioner level, interagency collaborations provide access to resources and services that might not be available without an interagency agreement. For customers, interagency collaborations offer choice in training and employment options for VR plan development.

Impact of Counselor Education on Customer Outcomes

Studies related to counselor education and customer outcomes took two different approaches to investigating the relationship (see Table 2). In a series of four studies, Szymanski and Parker (1989a, 1989b), Szymanski (1991), and Szymanski and Danek (1992) utilized case data and information on counselor preparation and education to determine whether there was a relationship between type of education (e.g., bachelor’s degree, master’s degree) and rehabilitation-specific training and employment outcomes of customers. Researchers evaluated effectiveness and cost-efficiency with customers with severe and nonsevere disabilities. Across studies, authors found that counselors with a master’s degree in rehabilitation counseling performed significantly better with clients with severe disabilities than counselors who had a bachelor’s degree or an unrelated master’s degree; however, no differences were found in success with customers with nonsevere disabilities. When time in position was also included, results indicated that the differences in performance were not found among counselors with more than 6 years of experience.

Table 2.

Impact of Counselor Education and Customer Outcomes.

Study	Purpose	Results
Szymanski (1991)	Sought to determine relationship of counselor performance w/ type of educational preparation; years of experience used as a moderator.	Combination of level of counselor education and years’ DVR experience accounted for 10% of variance of competitive closure rate for clients w/ severe disabilities and 13% of variance of number of rehabilitated clients w/ severe disabilities; counselors with MA in rehabilitation counseling or related MA demonstrated better rehabilitation outcomes w/ clients w/ severe disabilities than colleagues w/ unrelated BA or MA or less than a BA.
Szymanski and Danek (1992)	Examined relationship between counselor educational preparation and performance in state VR program.	No differences found in number of closures for persons w/ severe disabilities and persons w/ nonsevere disabilities; however, counselors with MA in rehabilitation counseling (RC) were more cost-effective and achieved higher competitive employment outcomes w/ clients w/ severe disabilities. Counselors w/ MA in RC or related MA more cost-efficient.
Szymanski and Parker (1989a)	Looked at performance of counselors w/ respect to educational background, certification, caseload, and work experience.	Counselors w/ MA in RC were significantly more successful in competitive closure rates w/ persons w/ severe disabilities than counselors w/ other degrees, through 6 years of service; after 6 years, differences were no longer significant.
Szymanski and Parker (1989b)	Examined relationship between counselor preservice education, years of rehabilitation counseling experience, and success w/ VR clients w/ severe disabilities.	No differences found in success rate for clients w/ nonsevere disabilities; no differences between counselors w/ MA in RC versus related MA found; counselors w/ MA in RC who spent less on nonsuccessful closures had better successful closure rates and fewer unsuccessful closures than those w/ BA or unrelated MA; counselors w/ MA in RC more effective and cost-efficient in serving customers w/ severe disabilities than counselors w/ a BA or unrelated MA for a substantial portion of agency tenure.
Wheaton and Berven (1994)	Investigated relationship between level of professional education completed by counselors and caseload management profiles; authors developed profiles based on commonalities in case management practices.	Clusters of counselors demonstrating more positive client outcomes tended to have higher levels of professional education specific to RC; that is, Efficiency Experts and SD Specialists clusters (two clusters w/ most positive performance profiles) had higher levels of professional education than worrisome cluster. Counselors with MA in RC more effective, particularly serving individuals w/ significant disabilities.

Note. VR = vocational rehabilitation; DVR = Division of Vocational Rehabilitation.

Using a different approach, Wheaton and Berven (1994) used case performance data to rate counselors in case management performance and then performed a cluster analysis to determine distinct types of case management practice. Six distinct clusters were created, and correlations were calculated between cluster, customer outcomes, and level of education (MA in rehab counseling, MA in related field, MA in unrelated field or BA). Results indicated that clusters of counselors demonstrating more positive client outcomes tended to have higher levels of professional education in rehabilitation counseling. Findings from the studies within this category provide empirical evidence that could affect agency-hiring practices, particularly concerning service to and performance with individuals with significant disabilities.

Services to a Target Group

Studies in this category reflect efforts to find what services are most important for people within a particular target groups (e.g., racial/ethnic group, age, disability type) given some common barriers to work (see Table 3). Findings indicate that a few models of service exist (e.g., the Program for Assertive Community Treatment [PACT] team approach, an employment readiness training) for which there is initial evidence of effectiveness with their target population (Becker, Meisler, Stormer, & Brondino, 1999; Spence, 2000). Becker et al. (1999) provided evaluation data from a psychosocial vocational program modeled after PACT that improved customer participation in services. Spence (2000) provided evaluation data for a community rehabilitation program focused on adults with mental disabilities. Results demonstrated that a specific service offered in a vocational preparation program was a significant predictor of successful employment.

Table 3.

Services to a Target Group.

Study	Purpose	Results
Becker, Meisler, Stormer, and Brondino (1999)	Reported retrospective evaluation findings of a model program over 10-year period (1984–1994).	184 clients participated, w/ 34% remaining for 1–4 years and 33% remaining for > 4 years; 64% of clients who stayed in program 1+ years attained employment. Program maintained average employment rate of 33% of all participating clients. More than half of clients who held jobs worked part-time and were employed more than half time they were in program. Results from program compare favorability w/ other service models utilized w/ this population, including other PACT models.
Flannery et al. (2008)	Do students who are successful in skills training program (occupational skills training program) have better employment outcomes than students who drop out of program? What student and program factors are associated w/ success in program?	Results demonstrated that successful participants had higher wages and worked more hours per quarter as well as more quarters during the first year after exit. Critical factors for positive results were receipt of financial support, career services, and vocational coursework.
Johnstone et al. (2003)	Sought to provide descriptive information on customers with TBI applying for VR services and to find relationships between demographic, injury-related, financial, neuropsychological, and vocational services and employment.	Among all predictor variables examined, only on-the-job training and counseling and guidance from the services block were significant predictors of employment outcome at closure. Results indicated that these VR services were stronger predictors of outcome than medical, psychological, and demographic variables that are often considered. Results support paradigm shift focusing on environmental factors that impact participation over more traditional medical and psychosocial factors.
Spence (2000)	Investigated outcome for individuals w/ significant mental disabilities receiving supported employment services from community rehabilitation provider in Columbus, Ohio. Specific research questions covered program status, significant variables predicting successful closure, and distinguishing factors leading to successful outcomes at rehabilitation center.	Job development and participation in job readiness program were related to successful outcomes; White customers more likely to be successfully employed at closure than African American customers. Results indicated that interventions should focus on job development and employment preparation, and specific attention should be paid to African American customers as they were less likely to be successful.
Stroup (1999)	Investigated relationship between patient competency ratings, locust of control, and neuropsychological assessments to successful VR outcomes among a sample of customers w/ traumatic brain injuries.	Results indicated that customers who fared worse vocationally were more likely to underestimate level of impairment on patient competency scale. Those w/ accurate self-measures of deficits had better employment outcomes. Cognitive function and locust of control not related to vocational outcome. Implications for practice: awareness/understanding of deficits associated w/ injury important for customers when setting job goals and locating employment.

Note. PACT = Program for Assertive Community Treatment; TBI = traumatic brain injury; VR = vocational rehabilitation.

For customers with traumatic brain injury (TBI), Johnstone et al. (2003) compared VR services for demographics, medical, financial, and neuropsychological impairment information with respect to employment outcomes using secondary data analysis. Findings indicated that VR services—specifically, counseling and guidance and on the job training—were better predictors of employment than the other factors. Another investigation of outcomes for VR customers with TBI explored the relationship between customer self-rated competency, locus of control, and performance on neuropsychological tests and employment outcomes (Stroup, 1999). The results indicate those who had more accurate self-measures fared better in terms of employment than those who underestimated their level of impairment.

Findings based on VR services indicate that several services are related to successful outcomes, including counseling to increase customer awareness of deficits, assessment, comprehensive approaches to providing community-based services, vocational preparation, counseling and guidance, and job placement. These initial results should be explored in more detail to determine specific aspects of services that are related to employment success for the particular population of interest.

Supported Employment and EBP

Supported employment provides individuals with the most significant disabilities an opportunity to engage in integrated employment through interagency collaborations and long-term supports needed to maintain employment. Several studies in the sample described supported employment and other evidence-based employment practices that have been empirically supported in the psychiatric rehabilitation literature (see Table 4). Bond (1998) introduced the effectiveness of the Individual Placement and Support model (IPS) of supported employment through comparing the traditional approaches in VR services. The IPS principles resonate with a larger body of research suggesting that direct methods of intervention are better than traditional VR service stepwise methods, that integrated approaches are better than a brokered purchasing of services approach, and that assisting people to adapt to specific environments, rather than providing generic training, is more effective. In addition, Bond and Campbell (2008) identified the effectiveness of a variety of strategies, including supported employment to attain EBP by introducing the Substance Abuse and Mental Health Services Administration (SAMHSA) National EBP project and the Texas Blazing New Trails Conference. Larson (2008) suggested that practitioners need to utilize Evidence-Based Supported Employment and Motivational Interviewing to improve employment outcomes. Larson also emphasized that financial support, professional training, and agency support are needed to effectively implement this service package. Rhodes and Drum (1989) offered several “best practices” related to hiring for public jobs that improve the ability of service organizations to successfully implement supported employment programs through job restructuring. Revell, West, and Cheng (1998) found vendors funding methods that incorporate negotiated rates at the individual provider level have significantly more positive response than statewide fixed rates for all vendors in terms of supported employment funding methods.

Table 4.

Supported Employment and Evidence-Based Practice.

Study	Purpose	Results
Bond (1998)	Examine empirical support for guiding principles of Individual Placement and Support (IPS) model of supported employment (SE) for people w/ severe mental illness (SMI)	Direct methods of intervention better than stepwise methods, integrated approaches better than brokered approaches, and assisting people to adapt to specific environments, rather than providing generic training, more effective. Overall pattern of research addressing IPS principles is supportive.
Bond and Campbell (2008)	Review primary needs/aspirations of consumers w/ SMI, summarize EBP movement in psychiatric rehabilitation, map practices to areas of consumers’ needs to clarify outcome domains addressed by existing EBPs. Questions: Within field of psychiatric rehabilitation, which practices are regarded as evidence based? How confident are we that these are in fact evidence based, and on what bases do we assert these claims? Are there outcome domains for which there are no current EBPs?	Evidence very strong for assertive community treatment, supported employment, and family psycho-education; evidence weaker for integrated dual disorders treatment, illness management and recovery, and medication management, according to protocol. Need practices that help consumers in relationships, social functioning, and avoidance of incarceration.
Larson (2008)	Provide strategies for practitioners to assist individuals w/ ambivalence about working to either obtain or sustain jobs.	Implementation of service package needs financial support for ongoing training and consultation opportunities for practitioners and supervisors. Employment specialists require sufficient time for EBSE and MI training, practice sessions, opportunities to problem solve application barriers, and access to supportive supervisors w/ abilities to teach and utilize these tools. Dissemination requires collaboration among mental health agencies to share knowledge, skills, and resources related to employment services.
Revell, West, and Cheng (1998)	Investigate current approaches used by state agencies to fund time-limited supported employment services from the perspective of local supported employment provider agencies. Specifically, results of in-depth telephone interviews w/ 386 local provider agencies in 40 states to be reported in terms of (a) types of funding arrangement most frequently used; (b) relationship of various funding approaches to issues such as conversion, inclusion of individuals w/ most significant disabilities, consumer choice and self-determination, and career advancement; and (c) implications of findings for future efforts to improve supported employment time-limited funding arrangements.	Survey of 385 vendor-supported employment provider agencies regarding types of reimbursement method used, influence of different types of methods on key consumer outcomes, and recommendations for improving funding systems. Findings consistently pointed to significantly more positive response of vendors to funding methods incorporating negotiated rates at individual provider level as compared with statewide fixed rates for all vendors. Statewide fixed hourly rates discouraged both conversions to community integrated employment opportunities and reopening of supported employment cases after job loss. Same response pattern held true for respondents’ perceptions of reimbursements covering costs of services. Statewide rates for specified outcomes or for daily, weekly, or monthly service units found to cover cost of services at levels significantly lower than other funding methods.
Rhodes and Drum (1989)	Results from a qualitative study of how laws, regulations, and procedures such as civil service procedures, job classifications, and pay flexibility impact supported employment practices in a given state. State-supported employment administrators’ responses were consistent in that above categories served as barriers to supported employment outcomes.	Small sample size (10 state supported employment programs studied); findings thus only representative of members of sample, cannot generalize to other states operating supported employment program

Note. EBP = evidence-based practice.

The research suggests that supported employment and EBPs lead to competitive employment outcomes for individuals with severe, persistent mental illness by providing a range of intense supports developed around an individual’s unique employment needs.

Empowerment and Customer Self-Concept

Within the empowerment and customer self-concept category (see Table 5), studies indicated a positive relationship among empowerment, self-concept (Saunders, Leahy, & Frank, 2000), self-esteem (Ferris, 1999), consumer involvement, service satisfaction (Ferris, 1999), employment outcomes (Ferris, 1999; Saunders et al., 2000), community integration (Kosciulek, 2005), and quality of life (QOL; Kosciulek, 2005). Saunders et al. (2000) demonstrated that self-concept may be the most effective predictor of employment outcomes using a quasi-experimental design and a psycho-educational intervention in VR program. Ferris (1999) found that empowerment training increased consumer involvement and satisfaction with services. Finally, Kosciulek (2005) presented the Consumer-Directed Theory of Empowerment (CDTE) model to develop and evaluate disability policy and rehabilitation services and examined the direct relations among consumer direction, community integration, empowerment, and QOL using the Longitudinal Study of the Vocational Rehabilitation Services Program database.

Table 5.

Empowerment and Customer Self-Concept.

Study	Purpose	Results
Ferris (1999)	Evaluated the following hypotheses w/ respect to participants: (a) obtain employment at a rate higher than group that does not receive empowerment training, (b) prematurely drop out or discontinue MJC/RS services at lower rate than participants not receiving empowerment training based on actuarial data, (c) case costs of both groups (empowerment training and control) will be equal and will not significantly differ from expected case cost based on actuarial data, (d) display a pattern of successful rehabilitation (employed for 120 days) superior to pattern of persons not receiving empowerment training at 1- and 2-year follow-ups, (e) report an increase sense of control and self-confidence as a result of empowerment training, (f) report feeling satisfied w/ content and quality of empowerment training program.	(a) Empowerment Training (ET) group had more successful closures than expected versus group w/out empowerment training, (b) ET group did not experience any dropouts, (c) no difference between consumers successfully closed versus consumers who dropped out, (d) consumers reported benefits from training and how it helped them maintain employment, (e) consumers reported more of a sense of control, (f) post–ET survey results indicated consumers very satisfied with training (5 out of 5 on Likert-type scale).
Kosciulek (2005)	Tested hypothesized structural model Consumer-Directed Theory of Empowerment (CDTE) in vocational rehabilitation context	Community integration would have substantial impact on QOL and consumer direction would improve QOL. QOL theory and research support hypothesis that direct and significant relationships exist among community integration, consumer direction, and QOL.
Saunders, Leahy, and Frank (2000)	Investigated the following research questions: (a) Is there positive change in participants’ self-concept after participating in CLEO Program, as measured by pre- and posttreatment measures of academic/work score from second edition of Tennessee Self-Concept Scale (TCSC:2)? (b) Is there positive change in clients’ overall self-concept after participating in CLEO Program, as measured by pre- and posttreatment measures of the TSCS:2 total self-concept score? (c) Is there difference in growth between treatment and control groups on employment self-concept, as measured by difference between pre- and postmeasures on the TSCS:2 academic/work self-concept scale? (d) Is there difference in growth between treatment and control groups on overall self-concept, as measured by difference in pre- and postmeasures of TSCS:2 total self-concept score?	(a) No significant difference between pre- and postmeasures, (b) statistically significant change in pre- and postmean scores on TSCS:2 total self-concept score, (c) not statistically significant, and (d) statistically significant for growth in overall self-concept as measured by TSCS:2 (ES = .77). Additional analysis of participant variables that may be of interest indicated statistically significant growth for treatment group versus control group on a total of eight scale.

Note. MJC/RS = Michigan Jobs Commission/Rehabilitation Services; QOL = quality of life.

The findings from the empowerment and self-concept studies provide empirical evidence that could impact VR service delivery practices, particularly that services addressing empowerment and self-concept increased consumer involved and satisfaction with services leading to enhanced employment outcomes.

Essential Elements of Service Delivery

Several studies in the sample related to essential elements of service delivery, and approached the topic using different conceptual frameworks and methodologies (see Table 6). Timmons, Schuster, Hamner, and Bose (2002) sought the view of adults with disabilities who had utilized state agency services to obtain employment. Participants indicated that the most effective aspects of agency services were related to feeling welcome and making a connection with agency staff. Shiffer (1994) explored aspects of agency culture and the impact on services, by analyzing the impact of a team-based approach in a VR agency. Findings indicated effective teamwork accounted for a higher proportion of placements. Silva Cardoso, Blalock, Allen, Chan, and Rubin (2004) explored elements of service delivery from the standpoint of the relationship between services targeted at improving functioning and well-being. Findings indicated that there was a moderate correlation between measured levels of functioning in self-direction, work tolerance, general employability, and self-care and physical, family and social, and financial well-being. In terms of implications for best practices, this finding can be applied to service selection; there is some initial evidence that improving function in those areas may also affect well-being. Considered together, findings from these three studies provide important information for service provision; the targets of the interventions (e.g., life skills) and the way the services are provided (e.g., teamwork, customer, and staff connection) appear critical to successful outcomes.

Table 6.

Essential Elements of Service Delivery.

Study	Purpose	Results
Shiffer (1994)	Evaluate the impact of implementation of team-based approach in VR agency in Anchorage, Alaska; specifically, measure impact on production (e.g., number of placements), work quality, employee morale, and organizational change	After controlling for factors such as cost, employment opportunities, customer characteristics, and benefits/compensation, results indicated no increase in production rate but substantial increases in morale and quality of work. Five of eight work teams scored as an “effective” team according to measure, and effectiveness rating was positively related to production.
Silva Cardoso, Blalock, Allen, Chan, and Rubin (2004)	Examine relationships between life functioning and subjective well-being in sample of adults w/ disabilities receiving services from state VR agency	Self-direction, work tolerance, general employability, and self-care related to physical, family and social, and financial well-being. VR services aimed at improving life functioning lead to improvement in subjective quality of life, including positive employment outcomes.
Timmons, Schuster, Hamner, and Bose (2002)	Investigate customer perspectives on essential elements of service delivery; specifically, participants who had sought assistance from state agency to obtain employment were asked about helpful supports provided and characteristics of agencies that served as barriers.	Customer satisfaction and reported effectiveness of services were most related to agency culture, consumer-directedness, access to resources, quality personnel, and coordination services. Agency culture was expressed as clients feeling welcome and connected with agency staff and other clients and having an overall positive experience w/ services. Quality personnel were reported by clients to be reliable and consistent, and provided emotional support throughout job search process.

Note. VR = vocational rehabilitation.

Miscellaneous VR Services and Customer Outcomes

Several studies found in the review pertained to aspects of services that are shown to have a relationship with improved outcomes in VR agencies. These studies investigated a variety of topics, including the working alliance (Lustig, Strauser, Rice, & Rucker, 2002), assistive technology (Noll, Owens, Smith, & Schwanke, 2006), family-focused services (Marshall & Johnson, 1996), and labor market analysis (Rose, Schacht, Lonetree, & Schwartz, 1994) as selected aspects of service provision within the VR setting (see Table 7). Findings of these studies demonstrate that particular aspects of VR services have the potential to positively affect customer outcomes. The relationship between the counselor and customer (Lustig et al., 2002) is related to not only better employment outcomes but also customer outlook on employment and job satisfaction. Noll et al. (2006) found that although assistive technology is an effective and cost-efficient service, counselors would benefit from additional training and preparation in this key area. Marshall and Johnson (1996) proposed a model of service to rehabilitation customers inclusive of family, which researchers suggest will lead to better outcomes. Finally, Rose et al. (1994) investigated the use of labor market analysis as a tool for developing employment plans and finding positions that match up with what is available in the customer’s geographic area, increasing the likelihood of preparing for a job that is attainable in the community. These studies provide initial support for services or approaches that are often available within VR agencies that may be beneficial to customers.

Table 7.

Miscellaneous VR Services and Outcomes.

Study	Purpose	Results
Lustig, Strauser, Rice, and Rucker (2002)	Investigate effect of working alliance on rehab outcomes: (a) difference between employed and unemployed clients on measured levels of working alliance, (b) employed clients—relationship between working alliance and satisfaction w/ current job, (c) employed clients—relationship between working alliance and clients’ view of future employment prospects, (d) unemployed clients—relationship between working alliance and clients’ view of future employment prospects.	Employed clients had stronger working alliance than unemployed clients; working alliance related to client’s perception of future employment prospects and satisfaction w/ current job.
Marshall and Johnson (1996)	Identify the extent to which American Indian vocational rehabilitation projects (a) provide services to family members when necessary to ensure successful vocational rehabilitation outcomes and (b) utilize family, as well as other natural support systems, to provide comprehensive rehabilitation services to transition-age adolescents and adults w/ disabilities.	Tribal vocational rehabilitation programs had better understanding of the extent to which they are utilizing families to achieve rehabilitation goals; suggested use of family-focused rehabilitation model.
Noll, Owens, Smith, and Schwanke (2006)	Investigate counselor views regarding their role and competence in providing assistive technology (AT) services and devices to people w/ disabilities in the Wisconsin.	Counselors found AT to be cost-effective service that can increase employment outcomes; counselors’ role in AT service delivery included coordinating, purchasing, and following up on services. Counselors indicated relatively high level of comfort w/ these roles, but minimal knowledge base in AT possibly indicates counselors are less comfortable in this area.
Rose, Schacht, Lonetree, and Schwartz (1994)	Analyze local labor markets as part of job development activities for American Indians with disabilities.	Analyzing local labor markets is potentially useful in helping counselors and customers develop IPE goals, as well as w/ placement (due to increased awareness of local labor market).

Note. VR = vocational rehabilitation; IPE = Individual Plan for Employment.

Summary

The purpose of this integrative review was to identify and summarize research in the rehabilitation counseling literature that highlighted effective practices within VR service delivery. As is consistent with previous reviews and literature synthesis, the results noted a few areas of strength and limitations of the current published knowledge base related to services that increase customer employment outcomes in VR agencies (Institute for Community Inclusion, 2010; Saunders et al., 2006).

Although there are several implications of this review on practice and future research efforts, the findings must be presented within the context of some study limitations. For one, although an exhaustive effort was made to locate all relevant articles, the research team may not have found every possible study that met the inclusion criteria. In addition, as the goal of the review was to highlight practices with some initial evidence of effectiveness, no effort was made to evaluate the quality or the rigor of the research. Authors have provided tables with the original citation and basic study details so that readers may make independent evaluations.

There are several published studies that present novel service models and provide initial evidence of effectiveness; however, many studies are still published using administrative data that only provide a broad view of practice. EBPs, although existing in specific areas of rehabilitation counseling and VR services delivery, are still not a common practice at the system or practitioner level, are inconsistent in application and scope, and lack a formal methodological approach on how to design, implement, and analyze results. Although not as well developed as other disciplines, for example, psychiatric rehabilitation, the literature does reflect attempts to develop and apply EBP at the system and practitioner level. These efforts are noted within several areas, with interagency collaborations and supported employment services being the most widely referenced “best practices” in the field. However, for a counselor or an agency who wants to be able to utilize research findings to guide day-to-day interventions, we still lack a substantive answer to the question of what services are most appropriate when, and under what circumstances (Paul, 1967).

The findings from this review provide a few areas where practices have been proposed and evaluated for initial effectiveness, as well as research methods and practices that deserve further attention. Consistent with other reviews (e.g., Saunders et al., 2006), authors observed that there were few efforts to replicate and expand on similar research efforts identified in this search. The series of studies by a common lead researcher (Szymanski, 1991; Szymanski & Danek, 1992; Szymanski & Parker, 1989a, 1989b) was the only example of studies that utilized similar methods and sources of information to ask a question across several samples. With few examples of these efforts in the literature, it is difficult to ascertain as a user of research whether the findings can be generalized beyond the sample and whether there is practical utility. A related criticism of rehabilitation research is that it is often not theory driven; at least one instance of a researcher proposing a theoretical model and then empirically testing it was identified in this review (Kosciulek, 1999, 2005); this level of empirical rigor and good research practice should be expanded. Future research should focus on replicating and expanding these initial findings, as well as developing quantitative and qualitative EBP methodologies that can be applied at multiple levels of VR service allowing for thorough analysis of results and dissemination of results to the field. Results could also be used to inform program administrators, field-level practitioners, and legislators as to what VR service delivery practice is effective in promoting employment outcomes for individuals with disabilities.

Footnotes

Authors’ Note

The contents of this article do not necessarily represent the policy of the Department of Education, and endorsement by the Federal Government should not be assumed

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The contents of this article were developed with support through the Rehabilitation Research and Training Center on Effective Vocational Rehabilitation Service Delivery Practices (EBP-VR-RRTC) established at both the University of Wisconsin–Madison and the University of Wisconsin–Stout under a grant from the Department of Education, National Institute on Disability and Rehabilitation Research (NIDRR) Grant Number PR# H133B100034.

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