Abstract
BACKGROUND:
The SGA Model Demonstration tested a coordinated team approach to determine whether a combination of vocational rehabilitation practices improve earnings outcomes of clients who also receive Social Security Disability Insurance.
OBJECTIVE:
This paper describes Phase II of the development of the intervention.
METHODS:
Researchers and policy fellows conducted site visits, interviewed personnel from 8 State Vocational Rehabilitation agencies and related partners, drafted a proposed intervention and submitted it for review to a Delphi panel.
RESULTS:
Delphi ratings supported the proposed intervention as likely leading to improved earnings outcomes and recommended that the SGA Project develop training, technical assistance, and capacity building activities to support implementation.
CONCLUSION:
The SGA Project invested 2 years developing an intervention by examining administrative data, consulting national experts, interviewing SVRAs directors and more than 100 practitioners across eight SVRAs. Pacing metrics were built into a team approach that included a vocational counselor, work incentives counselor, and a job development/job placement specialist with a business relations focus.
Keywords
Introduction
This paper is a companion to a previous article in this Special Issue describing the effort to develop an intervention that could be fully implemented by a state vocational rehabilitation agency (SVRA), subjected to a randomized controlled trial, and improve earnings outcomes of SSDI only beneficiaries. Foley and colleagues (2020) reported on Phase I that identified three key components likely related to earnings outcomes, are under the control of an SVRA, and vary across SVRAs. These components included pacing, capacities in providing work incentives counseling, and employment services delivery.
The SGA Project team determined that most SVRAs were not offering a unique set of services to SSDI only beneficiaries. Some SVRA directors reported investing heavily in infrastructure and systems to identify Social Security Administration beneficiaries, track outcomes, seek cost reimbursement and support work incentives counseling capacities internally or in partnership with other entities. Others focused on developing business relations functions and enhancing capacity to identify high paying jobs. Both types of capacities were difficult to measure with publicly available administrative data at the time of intervention development. Haines et al. (2018) documented the increase in business relations capacities. The Rehabilitation Services Administration funded several large national technical assistance centers and innovative training projects to advance dual customer strategies and approaches (c.f. the Job Driven Vocational Rehabilitation Technical Assistance Center (ExploreVR.org) and the Workforce Innovation Technical Assistance Center (WINTAC.org)).
During the development of the intervention, the Social Security Administration (SSA) was redesigning its work incentive counseling awards and considering changes in implementation. Many SVRA directors interviewed or participating in a Delphi Panel described how critical these services were and had started to identify strategies to deliver work incentive counseling through cost reimbursement funds or through contracts with vendors. We found no public data source that was tracking this capacity but considered it a highly critical component for the model demonstration intervention. SSA has invested heavily in model demonstrations testing incentives (Social Security Administration, 2019) but had not examined how SVRAs integrate work incentives counseling into the vocational rehabilitation process.
Counselors and clients work cooperatively to choose from a menu of services to reach an agreed upon employment goal. The menu of available services may also depend upon state level capacities, partnerships, and characteristics of the client. Multiple researchers document that counseling techniques and strategies may be related to positive outcome. Iwanaga and colleagues (2019) report the working alliance between a counselor and client may be predictive of engagement and motivation. Manthey et al. (2011) reported motivational interviewing techniques dovetail well with the vocational rehabilitation counseling philosophy and process. Team approaches have been on the rise as one way to create dual-customer cross-functional units that tailor membership based upon client needs (c.f., Moore et al., 2018).
In preliminary analyses, we found that pacing between eligibility and IPE development may be related to outcomes of SSDI beneficiaries (Foley et al., 2020) and that increased waiting time was detrimental to earnings of SSDI clients and for SVRA program income (Honeycutt & Stapleton, 2013). Higher performing SVRAs had a faster pace between eligibility and plan development suggesting that there were likely differences in practices, policies and procedures and not just differences in individual counselor behavior. Montana Rural Institute had similar findings in its investigation of VR clients that exited VR services prematurely and estimated costs to the nationwide program to be approximately $365 million annually. Ipsen & Goe (2016) found that a substantial number of clients who left in early phases perceived services as slow. They also reported that client engagement was related to frequent communication and satisfaction with the counselor relationship (Ipsen & Goe, 2016). Time and how it is perceived factors into federal, agency, and client outcomes.
Work incentives counseling and employment services delivery were identified as key components for the model. These have been widely studied as contributing to employment outcomes for many populations served by SVRAs. Yet, we found very limited knowledge about how services advance earnings outcomes sufficiently to lead to economic independence. Giesen and Hierholzer Lang (2018) reported that earnings outcomes were higher for SSDI clients who had visual impairments if they received services in a separate blind agency rather than in a combined agency. Dean et al. (2014) reported that receipt of VR services had a positive and complex relationship with employment, earnings, and SSDI receipt concluding that outcomes may be specific to types of clients and to specific services.
This paper describes case studies of 8 SVRAs and a second set of Delphi Panel rounds to design an intervention that focuses on higher earnings outcomes for SSDI only clients.
Methods
We combined extensive document review, analysis of publicly available data, site visits, and follow-up interviews of SVRA personnel and key partners into eight case studies of SVRAs selected based upon findings in Phase I. The case studies provided data to sculpt an intervention that was then presented to a Delphi Panel for review.
Research questions
The task was to understand pacing, work incentives counseling capacities and employment services delivery in SVRAs and how those decisions influence service provision for SSDI only clients. What policies, procedures and practices enhance or interfere with rapid pacing between eligibility and IPE? How does the SVRA deliver, vend or refer SSDI clients to work incentives counseling? What types of employment services are offered to SSDI clients? How are employment services provided and coordinated for SSDI only clients? How are SVRAs determining whether or not an applicant is an SSDI beneficiary?
Sample
Case study sites were selected based upon Phase I findings performance rankings, key informant interviews, and administrative data analysis. We eliminated 7 SVRAs (CO, FL, MD, TX, UT, VT, and WV) participating in a case study on efficient and effective VR services for a different project to lower research burden on SVRAs. We prioritized sampling from high performing and low performing groups of SVRAs rather than those consistently ranked as average performing. Two SVRAs had reported intensive efforts to build work incentive counseling in key informant interviews and were inconsistently ranked across models. We included both in the sample. We sent invitation letters and scheduled calls inviting participation. ICI received approval from the Institutional Review Board (IRB) at the University of Massachusetts Boston. Eight SVRAs agreed to participate.
Data collection
Prior to each site visit, the SGA Project curated available information on each SVRA and state system to create briefing books for the site visit team. Briefing books followed a template and provided a reference guide. This created a baseline of knowledge for interviewers and allowed for a more efficient site visit. The site visit team included at least three and up to five team members including at least one representative from Mathematica Policy Research, at least one ICI Senior Policy Fellow, and at least one research technician responsible for coordination, tape recording, obtaining additional documents and logistics, and for most site visits the Co-Principal Investigator. ICI Senior Policy Fellows were senior personnel who had extensive leadership experience as Directors or high-level management personnel in SVRAs. This expertise became invaluable to understand operational issues, implementation differences across states, rules and regulations, and relationships between the Designated State Unit, the Designated State Agency, partners, and vendors. After the site visits, we conducted short follow-up interviews or sent emails requesting clarification.
Interview protocol
The purpose was to understand pacing, work incentives counseling capacities, and employment services delivery for SSDI only clients. Site visit teams were guided by an open-ended interview protocol that prioritized those components and gave discretion to probe further as relevant to the location. We were particularly interested in how SVRAs created efficiencies in the early eligibility and planning phases of the rehabilitation process and how they identified SSDI only clients. Discussions focused on technical operational, policy, capacity and procedural issues in pacing, work incentives counseling, and employment services delivery.
Data analysis
We created an in-depth summary that compiled implementation variations and transferable strategies across the key components. A summary report is available from the first author (Foley, 2012). The summary report was submitted to the Rehabilitation Services Administration for review and input, shared across partners and reviewed, analyzed and discussed by the Delphi Panel.
Delphi Panel review
The Delphi Panel membership from Rounds 1 and 2 are described in Foley et al. (2020). We reconvened the panel for Rounds 3 (review and scoring of summary report) and Round 4 (discussion of the proposed intervention). Panel members were provided the summary report, an accompanying survey that included a set of scoring questions and open-ended questions. The survey asked whether the intervention overall and each component was likely (1 = not likely to 4 = very likely) to improve earnings outcome and if SVRAs had control over most features of the intervention (1 = not under VR control to 5 = complete control) Open-ended questions included: What should we improve and what policies or procedures might get in the way at the office level? Round 4 discussion included a summary of Round 3 and open discussion on challenges and recommendations.
Results
Findings from the site visits resulted in an expansion of the key components to include strategies related to rehabilitation counseling. Results are summarized by component, and then conclude with responses from the Delphi Panel.
Pacing
Sites placed a different value on speed with some linking pace to a sense of urgency and client responsiveness. Others believed that moving too quickly creates a “factory like” environment in which people are placed in any job without regard to interests, growth, or long-term career options. We focused on the difference between bureaucratic pacing and counseling pacing. Bureaucratic pacing is the time it takes to advance through the paperwork, data entry, referrals, reporting requirements and necessary documentation to move forward. Counseling pacing is the interaction between a client and the counselor (or team) providing services. Every SVRA indicated they were trying to improve responsiveness and attend to bureaucratic hurdles that burdened counselors or caused delays for clients. Each had unique challenges attributable to the design of their program, the nature of purchased services, budgetary constraints, and human resource issues. At least two states talked about a shortage of master’s level rehabilitation counselors and that recent retirements and continued vacancies had a major impact on their ability to efficiently serve all applicants in a timely way. Quotes from the interviewees reflect the conscious effort to consider pace as a feature of client responsiveness:
“We thought it was always better to move people along pretty quickly. Our concern was we were too slow about getting people engaged and how much time it took. Our general notion is that its better if you can get someone moving when they’re engaged. If there’s really nothing happening and you just move into a work plan, that’s not what we’re talking about.”
“When I think about 150 days [the average time in status between eligibility and IPE], I think that’s 5 months from when I sit down and say, ok good I am in a program, 5 months to go from here to a plan. I am thinking that is crazy ... I’m thinking holy smokes, how are we ever going to get better? How can we step it up and be a more agile system?”
“We’re seeing people coming in that right now they want a job, any job, because they need to make a payment, keep the car, buy food, given the economy has been an issue. So, we’re trying to respond to that.. so talk about a career path for the individual. I want to be honest. It’s a little difficult to keep the person engaged once they have a job.”
Monitoring key indicators of efficiency
Many were using or about to adopt electronic case management systems. Both Alabama and Nebraska were early adopters with advanced use of data to understand efficiency and pacing. Alabama reported they were training supervisors on how to use efficiency indicators for problem solving, performance monitoring and systems corrections. Nebraska used tracking data for team efficiency and provided guest access to key vendors. Nevada and Pennsylvania had developed their own systems. Nevada was also using paper forms and case files as rural counselors could not access the system reliably. Missouri was at the start of adopting an electronic case management system. Other SVRAs that did not have electronic case management systems were monitoring time between key VR process steps but did not appear to have access to data as quickly or routinely as those with data systems.
Efficiency of IPE development
There was wide variability in how SVRAs described the time between eligibility and IPE development. Some states typified the IPE as a modifiable or “living IPE” as the client’s job search proceeded. Modifications were acceptable and considered a positive. Other SVRAs typified the IPE as a contract and defined modifications as exceptions requiring performance review. Counselors indicated that IPE modification would trigger a quality case file review or a “ding” in their performance. This approach appeared more common in SVRAs that purchased services and considered a written plan as a mechanism to hold vendors accountable. SVRAs that had an IPE as contract approach also appeared to use more external assessment in the pre-plan phase. SVRAs with a living document approach often phrased assessment as a process that combined formal assessment with observing how clients proceeded with the job search. Universally, SVRA personnel reported that the wait for medical documentation was a challenge. Some SVRAs relied more heavily on counselors to assess client needs and others required formal medical documentation prior to IPE.
Limited staff incentive for improved pacing
Several SVRAs spoke about the pressures on counselors to be both a good counselor and a good data manager. Alabama had reported a previous wave of counselor retirements and a cohort of new counselors had started after the adoption of the electronic case management system. This was phrased as a cultural shift that enabled more data-based performance reviews. Nebraska had a team approach and appeared to divide up administrative duties such as data entry across the team rather than as a responsibility of counselors alone. However, across SVRA sites, there were few rewards for efficiency at the counselor level. Some SVRAs set pacing metrics based upon RSA regulations and standards. About half of the SVRAs set pacing metrics faster than required. None of the agencies described any incentives for counselors or teams to move more rapidly. Monitoring appeared to use disincentives for non-compliance rather than rewards for a more rapid pace.
Pacing processes specific to SSDI clients
Multiple SVRAs were enhancing capacities to interact with the Social Security Administration (SSA) and its local offices to identify SSDI beneficiaries more effectively. At the time of the site visits, SVRAs described challenging relationships indicating that the flow of information was variable, frequently inaccurate, and that data systems were nascent. Minnesota was the most advanced in identifying SSDI clients at application.
Several states had adopted presumptive eligibility. Presumptive eligibility allows an SVRA to immediately determine eligibility if an applicant provides documentation of status as an SSDI or SSI beneficiary. Some interviewees countered that what is lost in adopting presumptive eligibility as a policy is that it lessens the opportunity for more nuanced conversations between counselors and applicants about work disability. An example offered was that a person might qualify for SSDI benefits for a medical condition causing disability but that their vocational rehabilitation need was related to a different condition. SVRAs seemed to vary in whether eligibility determination was a bureaucratic step to access services or a counseling phase that helped counselors understand client needs. Some interviewees stated that presumptive eligibility would not allow them to categorize priority status sufficiently to meet their SVRAs definition of most significant disability. Having SSDI makes an applicant eligible but it does not guarantee priority for service delivery. It was described as a technical glitch and a challenge to describe to clients who were told they were eligible.
Rapid process improvement initiatives
Several SVRAs discussed rapid process improvement initiatives and had undertaken formal efforts to speed up a process. Minnesota provided an example and was successful in reducing time from eligibility to plan. Alabama leadership reported multiple examples of streamlining processes as part of a larger business intelligence and agency transparency effort. Missouri personnel spoke about creating a shared vision across all staff and encouraging local problem solving. They had recently moved assessments internally rather than as a purchased service due to a concern about wait times and length of an assessment period. Nebraska was the most technologically advanced and provided mobile technology to counselors who were expected to be off-site. It prioritized rapid communication as both a client engagement strategy and to reduce administrative challenges for highly mobile teams. Nevada adopted the use of video conferencing among staff and reported that counselors spend a lot of time out of the office going to clients. It was suggested this approach might be quicker as it was easier for counselors to get to clients than for clients to find transportation into an office. Many SVRA leadership personnel talked about financial efficiencies and how to provide services with insufficient case service dollars. The focus appeared to be what to do post IPE rather than between eligibility and IPE.
Table 1 provides a snapshot of strategies and challenges SVRAs linked to pacing which gives some suggestion that use of technology, early identification and leadership attention to streamlining processes might be assisting high performing SVRAs to achieve a faster pace for SSDI only clients and possibly all clients.
Strategies linked to pacing by SVRA by performance ranking based on RSA 911 analysis
Strategies linked to pacing by SVRA by performance ranking based on RSA 911 analysis
Even in high performing states, SVRA leadership stated that capacity for providing expert financial and benefits planning was precarious given the changes in funding SSA Work Incentive Planning and Assistance (WIPA) programs. At the time, SSA was reconsidering the design of work incentive projects and it was unclear what the future programs would provide as a service. Most SVRAs mentioned they were considering options about how to access work incentive counseling for clients. However, there were significant differences in opinion about whether or not VR should take on financial planning roles. Multiple SVRAs felt that financial expertise was out of its scope, highly specialized, and should be under the governance of the SSA. There was a concern that VR counselors may give inaccurate information particularly about highly complicated financial matters and these inaccuracies could have dire consequences for clients. Other SVRAs were actively embarking upon contracting with vendors who employed certified work incentive counselors (CWICs), considering hiring CWICs internally, investing heavily in counselor training, or looking into computer-based systems that could automate some aspects of financial and benefits planning.
Few sites had an integrated or continuum approach to financial planning, although Alabama, Nebraska, and Virginia had the most capacity and had expressed an interest in integrating work incentive counseling into the rehabilitation process. Nearly universally, SVRAs indicated that there were significant disparities by population in the availability of work incentives counseling. Most notably, deaf clients and clients in rural areas were reported to have very limited access. Many state WIPA program interviewees and SVRA personnel indicated that clients with mental illnesses particularly those jointly served by state mental health authorities often were advised by other entities to enroll onto SSI due to the vagaries of state Medicaid coverage, social services, and pharmacy costs. Mixed messages to a significant subpopulation of SSDI clients was a stated concern of every SVRA visited.
Several states reported lengthy waiting lists (90 days or more) or that only clients with job offers were eligible. Nebraska had a unique relationship with Easter Seals to contract for consultation, client services, and post-placement follow-up. Easter Seals was given guest access into the electronic case management system so that they could communicate with counselors and the team about progress, recommendations, and status. Nebraska and Easter Seals staff reported that a key feature of their partnership was the availability of Easter Seals CWICs to VR counselors and team members for consultation about client-specific issues as they arose. Alabama employed a staff member who had developed a VR counselor training on benefits and financial planning. Alabama expected that counselors become well versed and comfortable in discussing benefits. Alabama also operated the WIPA program in the southern half of the state, while another contractor covered the north. Implementation differences indicated that internal capacity allowed for more integration with the VR process.
Virginia was pursuing funding options to bring CWICs into the agency and reported more capacity than other SVRAs. Virginia worked with CWICs at the WIPA program but also with Work Incentive Specialist Advocates (WISA) who offered more capacity (approximately 30 in the state) to provide financial and benefits planning. We found that Virginia was rated as an average performer if only including earnings outcomes data at VR closure but was an above average performer when matching RSA 911 with Social Security data tracking earnings outcomes post closure. One possible explanation was that Virginia’s work incentive capacity was having an impact on earnings outcomes a year or two after VR closure.
SVRAs reported that WIPA programs covered portions of states and that each program made different choices about eligibility, waiting list, service delivery (i.e., in-person, by telephone), and had different capacities for serving distinct populations (i.e., deaf clients). Very often the WIPA program was based in an Independent Living Center (ILCs). SVRAs also discussed how work incentives counseling conversations were often included as part of ILC peer counseling services. Table 2 provides an overview of implementation strategies for work incentive counseling. SVRAs ranked as above average appeared to use many strategies and build internal capacity. Below average SVRAs appeared to rely heavily on other partners as either SSA grantees or as purchased services.
Implementation strategies of work incentive counseling by SVRA performance ranking based on RSA 911 analysis
Implementation strategies of work incentive counseling by SVRA performance ranking based on RSA 911 analysis
X: Yes, implemented; C: Creating.
SVRA personnel were asked about what employment services capacities are critical to advancing earnings outcomes for SSDI clients. High performing SVRAs tended to point toward their investment in business relations functions in addition to job development and job placement capacities. Definitions and delivery of job development and job placement was highly variable across SVRAs and for some SVRAs, highly variable within the state. Vendor quality and capacity was often cited as the reason for the variability. Some SVRAs made significant distinction between development and placement and others used the terms interchangeably. All SVRAs had some investment in business relations personnel though Nebraska and Alabama had fully developed business relations units that were integrated into field services. In most other sites, the business relations functions were relatively new or were staffed by a small number of people with statewide responsibilities.
Purchasing versus providing job placement
Whether a service was purchased or delivered depended upon local capacity, union negotiations, vendor relationships, and the ability to hire public employees. In some SVRAs, vendors were often self-employed contractors providing a specific service such as job placement. In other states, vendors were a constellation of entities including large multi-state organizations. Missouri purchased most of its services beyond vocational rehabilitation counseling and assessment. Other SVRAs varied in the degree of delivery versus purchased service depending upon the type of service, geographic area, and type of client. All SVRAs contracted out supported employment services. This was particularly true for agencies that had heavy investment in partnerships with state mental health authorities. Minnesota and Missouri had decades of investment in building supported employment capacities. They both participated in funded research, had trained personnel on evidenced based models, and built vendor capacity. Missouri was advancing data sharing strategies with the MH agency. These efforts prioritized employment outcomes for VR clients with mental illness but tended to focus on job attainment rather than earnings above substantial gainful activity levels.
SVRAs that purchased services discussed the complexities of monitoring vendor service quality, contracting, and statewide capacity. Alabama employed job development and job placement personnel and also contracted out with vendors. Minnesota had recently moved internal job development services to a purchased service. It was described as an evolving change and a major change in relationships with vendors. Missouri indicated that job development and job placement were major portions of the purchased services budget. Nebraska embedded job placement staff in offices as part of a team and described as the team member that was “out knocking on doors.” Nebraska was intent on eliminating referral and avoid “hand-off” of clients to another unit. The electronic case management system kept each team member informed yet interviewees described team communication as rapid, informal, and on a day to day basis. Job placement staff created a “job search agreement” as a “contract” with clients and reviewed progress with the team every 90 days.
Nevada job placement specialists were VRCs with specialty caseloads of clients in job placement. This was an atypical model as most job placement personnel in other SVRAs were not VRCs by training or expertise. Leadership staff talked about hiring external job placement and job coaching services through purchased services. These tended to be self-employed job placement specialists rather than organizations and in geographic areas that had limited capacity. These job placement specialists were described as people who had former relationships with the agency (i.e., retired counselors) or were persons in communities known to the agency (i.e., high school teachers on summer break). The offices in Las Vegas were described as having multiple vendors including supported employment providers.
Oklahoma had a unique relationship to the workforce system as the VR director oversaw other divisions and not just VR. Oklahoma faced similar issues as Nevada in a geographically large state with few cities and many small communities highly dependent upon a narrow number of industries. A unique approach was that they identified VR employees to become career technicians in a specific local industry. Having career technicians who could develop relationships locally and become well-versed in an industry was one solution to staff deployment where a team approach may not be viable.
The Pennsylvania SVRA was within the workforce system. VR personnel were part of the larger workforce union and, at the time of the site visit, there were intensive union negotiations happening. Management had less latitude than in other states with redefining roles, shifting tasks from one job category to another, or implementing team approaches requiring role flexibility. Pennsylvania counselors reported that they referred clients to job placement counselors in their offices who “ran them through programs” such as resume writing workshops, mock interviews, online applications, and job club.
Virginia reported that more than 50% of their case service funds purchase situational assessments, job development, job placement, and job coaching services. In addition to purchased services, Virginia employed job placement staff in each local office. They reported a substantial investment in providing training and technical assistance directly to businesses including recruitment, tax credit information, universal design strategies and disability training.
Growth of business relations capacity
All sites had an interest and growing capacity in business relations functions and activities. Alabama and Nebraska stood out as having much more depth and breadth than others and had been building capacities for many years. Virginia was investing heavily in a Regional Economic strategy and was the only site that mentioned partnerships across disability, workforce, and poverty systems to align and address business needs. Virginia described five regional business teams in which the SVRA was a lead or had a key role and worked with other entities like corrections, welfare programs, and others.
Alabama had the most advanced effort in Business Relations and had been operating for years prior to the site visit. They had 14 dedicated Business Relations Counselors (BRCs) that were connected to local offices. BRCs carried a caseload of businesses (as opposed to jobseekers) and were responsible for developing those relationships and meet business needs. Alabama created multiple databases for its Business Relations unit including Mr. ED and SEA. Mr. ED tracked interactions with businesses and served as a communication tool across the group. For example, BRCs could find out if any BRC was interacting with a business in any part of the state. The SEA was embedded in the electronic case management system to sample out the skills and assets of clients. Alabama defined their approach as a dual customer strategy and were discussing ways to align business outreach with jobseeker skills, talents and abilities.
Nebraska had a major initiative on rapid middle skills training by creating certificate programs in partnership with businesses and community colleges. The focus was to identify occupations such as auto mechanics, electricians, mentioned as examples, that would require short-term training but offer improved economic opportunities for clients. They reported 13 FTEs that focused on business engagement and spread throughout the state.
In Minnesota, several staff were identified as serving in a business relations role including one person with statewide responsibility and 5 program specialists. Minnesota was prioritizing public employment options for clients and assisting Minnesota become a model employer. Missouri was rolling out a business development effort with a BRC in each local office. Each office was given discretion about how to proceed and it appeared implementation varied across offices. Rural offices were described as working with a few key employers such as a trailer plant in McDonald County while offices based in Saint Louis, Kansas City, and Central Missouri were working in partnership with vendors to engage a much larger number of businesses.
Nevada had just hired a BRC who was also a local business owner and was tasked with developing relationships and communication strategies with local businesses across the state. Nevada was also experimenting with business engagement strategies and exploring the possibility of creating an electronic case management system that allows job placement specialists to connect with an employer. At the time, Oklahoma had limited capacity in business relations but saw it as a potential growth area. The VR Director had launched an initiative to recruit business to be an Employer Network (EN) and had success working with Hertz Rental Car.
In Pennsylvania, leadership staff described an ongoing discussion about how they could coordinate with the larger workforce system on business engagement initiatives. Similar to Minnesota, Pennsylvania had a strong emphasis on public employment options for clients and was pursuing opportunities in federal agencies. Two managerial level Business Relations Specialists (BRS) were engaging businesses and provided on demand training and technical assistance to those businesses. The BRS were senior staff with one assigned to Eastern Pennsylvania (including Philadelphia) and the other to the Western part of the state. The BRS had links to the local offices through counselors designated as job placement specialists and as the single point of contact (SPOC) for that office.
Table 3 provides an overview of strategies mentioned across the sites. The most notable differences echo administrative data analysis findings in Phase I suggesting that above average agencies are less likely to purchase job placement services than below average agencies.
Business relations and job placement strategies by performance ranking on RSA 911
Business relations and job placement strategies by performance ranking on RSA 911
X: Yes, Implemented; C: Creating.
All sites reported significant workforce issues such as a wave of retirements of senior counselors and the corresponding loss of expertise and relationships with external organizations. Several mentioned significant vacancy issues (NV, PA, MN), union-management negotiations (PA, MN), and a wave of new counselors that needed support (AL, NV). Many were experiencing or about to experience (within a year) loss of central office leadership staff due to retirement.
Increasing interest in team approaches
The case study sites differed in deployment of counselors and other SVRA personnel. Nebraska had a very unique team approach not found in other locations. Offices were defined as teams and the team carried a caseload. Counselors were responsible for required activities as defined by regulations. Teams were described as cohesive units interacting directly with clients and sharing actionable information quickly. Nebraska spent a number of years developing the team approach and adapted to case management systems to allow for rapid communication internally and with key external entities. Alabama appeared closest to the Nebraska team approach with most services provided internally with a “team orientation” using an advanced case management system. Oklahoma and Virginia were developing team approaches across counselors and specialty staff such as assistive technology specialists.
Use of specialty counselors
None of the SVRAs designated specialty counselors for SSDI or SSI clients. The specialist model was used for a wide range of populations including transitioning youth, Veterans, and by disability subpopulation (generally deaf clients, persons with significant mental health disabilities and persons with traumatic brain injury). Specialists were often connected with other key partners such as transition counselors and schools. Deaf clients received services from counselors with fluency in American Sign Language (ASL). When asked whether or not they would consider creating specialty counselors who served SSDI clients, nearly every interview considered it an untenable strategy. Some suggested that any counselor should be able to serve anyone receiving SSDI or SSI benefits. Others stated that it would be problematic as it would confuse counselor assignment if there were competing types of specialty counselors. Counselors indicated that it would be a challenging caseload and that the number of clients per counselor should be reduced.
Counselor incentives and earnings outcomes
Three SVRAs developed strategies for connecting earnings outcomes to counselor actions. Alabama required each counselor to meet earnings goals as part of annual performance reviews. Oklahoma created pay incentives for achieving earnings outcomes. Pennsylvania connected office level incentives to achievement of SSA reimbursement goals. Four SVRAs (AL, NE, NV, and VA) had developed strong capacity in business intelligence and were including counselor metrics linked to performance. These four SVRAs had advanced capacity in electronic case management.
Motivational interviewing techniques
Minnesota and Missouri described training investment in motivational interviewing techniques and had participated in extensive agency wide competency building initiatives. Other SVRAs indicated an interest in acquiring training. Several SVRAs were concerned that motivational interviewing training might overwhelm their training budgets and training staff.
Intervention development and Delphi Panel
Summary of intervention
Phase I and Phase II findings drew attention to the importance of efficiency in the early phases of rehabilitation processes. We also heard from interviewees that team approaches were showing promise. Descriptions of the living IPE were also instructive. The SGA Project team also posed that a true team approach should involve critical members prior to plan development so that a client had benefits and local labor market information before formulating an employment goal. We created metrics for an intervention that would formulate a team prior to plan development. Thus, the intervention was a very different team deployment of services typically available and under the control of an SVRA.
We found no support to operate an intervention with a select number of counselors who would have a specialty caseload of SSDI clients. We designed a coordinated team approach in which VR counselors (VRC), job development/job placement specialists (JDPS) and financial planning specialists (FPS) would work together prior to IPE completion for all SSDI clients applying to a VR office. Business relations capacities were an emerging innovation and we were uncertain if these capacities were transferrable or if as an organizational capacity it would be amenable to an experimental design. We included business relations activities as part of the role of a JDPS. We set rapid benchmarks for eligibility (2 days) and completion of an IPE (30 days) in line with evidence accumulated through Task 1 and Task 2. Table 4 provides the details of the intervention.
Twenty of the 25 Delphi Panel members described in Foley, et al (2020a) continued to participate in Rounds 3 and 4. Of the five that did not participate, three had represented state mental health systems and the other two had left their positions as an SVRA director and as a federal employee. Sixteen Delphi panel members answered the survey with 2 partially completing it and only contributing written responses. Fourteen scored the intervention and rated it as likely to lead to earnings outcomes (mean 3.2/4 high likely) and found most of the intervention to be under the control of an SVRA (mean 4/5 fully under the control). Members rated each of the components as Looks Great (4), It’s Ok (3), Missing Pieces (2) Not Good (1).
Team approach: Challenges and recommendations
Delphi Panel Rating: 3.3 out of 4.0. Members recommended that the intervention include more clarity about how the SSDI client would take a leadership role on their team. Additional suggestions included expanding the team to include family, health care providers, and mental health care providers. Another concern was whether VR counselors, who often work independently, have the interest and ability to facilitate a team.
Work incentive counseling
Delphi Panel Rating: 3.3 out of 4.0. Discussion and written comments raised issues about work incentive counseling capacities across states. One recommendation was to assess quality and accuracy of the service and consider additional training and technical assistance needs. Several members recommended that the service should extend beyond job placement.
Business relations/job placement
Delphi Panel Rating 3.1 out of 4.0. Members raised more questions about the business relations/job development component including how the SVRA would connect with the Workforce System, whether SVRAs would hire personnel or contract, and to modernize job development and job placement services. Methodological issues were raised about randomizing vendors, client choice of vendor, and statewide capacity issues. Several Delphi panel members raised the issue of whether there was sufficient time and budget to attain the capacity for business relations and job placement capacity to operate an intervention in some SVRAs.
Pacing
Pacing was embedded in each of the above components and not scored as an independent component. The pacing was challenged by Delphi Panel members who indicated that staffing, bureaucratic procedures, geographic disparities, state budget issues, case flow, counselor willingness, and client comfort would need to be addressed. Members suggested that the cost of the intervention should include sufficient funding to retain adequate staffing. Other comments focused on the pressures of SVRAs who have implemented an order of selection process and whether SSDI clients will necessarily meet priority categories. An eligible SSDI client might be put on a waiting list for services with an extended time between eligibility and plan in SVRAs with an order of selection.
Summary
Round 4 discussions supported consensus that the intervention as designed was likely to lead to improved earnings outcomes and would require intensive technical assistance and capacity building for most SVRAs who may have interest. Methodological issues might be addressed as part of site selection if baseline capacities and OOS status were included as criteria. Most agreed that the success was more likely if an SVRA Director and Field Services personnel were fully supporting implementation, and combined that with support, training, and easy access to information.
Conclusions
Phase I and Phase II activities lead to the creation of a rapid coordinated team approach to encourage and support SSDI only clients to pursue employment with earnings above substantial gainful activity as defined by the Social Security Administration. The SGA Project Team noticed that SVRAs that had higher earnings outcomes were more rapid between eligibility and IPE, had developed internal capacities in work incentives counseling, had internal capacity in job placement and job development and were investing in business relations functions. Experts assembled as a Delphi Panel had been involved in both Phases of development and were in agreement that the intervention was likely to lead to increased earnings outcomes. Recommendations by the Panel included increasing the role of SSDI clients as leaders of their team, providing funds to SVRAs to build staffing capacity, addressing office and agency level policies and procedures that challenge implementation.
Discussion
The SGA Model Demonstration spent two years acquiring multiple sources of data, obtaining expert opinion, and interviewing approximately one hundred practitioners across eight SVRAs about how to create a testable intervention focused on earnings outcomes. Job placement and job development services have long been a core service of SVRAs. Work incentives counseling and business relations functions were deemed highly critical services universally. Pacing of services emerged as another major factor. Though it is simple to measure as days from one status to another, it is more nuanced in practice. Were delays related to counseling performance or to inefficiencies in bureaucratic procedures? During this time period, the nation was in recovery from the Great Recession of 2008. Some SVRAs were able to achieve higher earnings outcomes than their peers even in states with high unemployment rates. Administrative data and expert opinion support findings that leadership decisions and innovations make a difference on the earnings outcome achievement for SSDI only clients. But this is one angle on SVRA performance. Some SVRAs were focusing on job placement of persons with mental illnesses and building capacities to implement evidenced based supported employment. SVRAs and their partners may be making local decisions about which population and what outcome to prioritize. It appeared to the SGA team that all SVRAs were actively pursuing innovations, willing to participate in research, and seeking solutions to improving outcomes. In 2014, the Workforce Innovation and Opportunity Act included new measures for pacing, work incentives counseling, and business relations services. Multiple phases of the SGA Project suggest these innovations are in the right direction to promote earnings outcomes of SSDI clients.
Conflict of interest
None to report.
Footnotes
Acknowledgments
The Institute for Community Inclusion at the University of Massachusetts-Boston and Mathematica Policy Research led the Substantial Gainful Activity Project Demonstration through a grant received from the U.S. Department of Education, Rehabilitation Services Administration. The views and opinions expressed here are those of the authors and do not necessarily reflect the views, opinions, or policies of the Rehabilitation Services Administration. The authors are solely responsible for any errors.