Phase II of the SGA Project: Development of the coordinated team approach intervention

3.1.1 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.

3.1.2 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.

3.1.3 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.

3.1.4 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.

3.1.5 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.

3.3.1 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.

3.3.2 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.

3.4.1 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.

3.4.2 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.

3.4.3 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.

3.4.4 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.

3.5.1 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).

3.5.3 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.

3.5.4 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.

3.5.5 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.

3.5.6 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.

3.5.7 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.