Launching and supporting the SGA Project in Kentucky and Minnesota: Experiences and perspectives of the Senior Technical Assistance Team

3.1 Why get involved

The initial impetus for Minnesota Department of Employment and Economic Development/Vocational Rehabilitation Services (DEED/VRS) was twofold. Prior to SGA, the VRS Director had stressed to staff the need for increasing the pace at which services were delivered. She and her Senior Management Team felt that it was important for vocational rehabilitation counselors (VRCs) to engage clients more quickly into services, which presumably would lead to fewer drop-outs and more efficient IPE intervention delivery. VRS had started this process and the SGA Project offered an opportunity to buttress it through increased funding and enhanced emphasis. Some members of the Senior Management Team were interested in confronting barriers to SSDI clients’ successful employment and eventual financial stability without SSA fiscal support.

Minnesota DEED/VRS had been involved in several quality improvement and innovation projects. VRS had a multi-year project adopting Motivational Interviewing techniques and saw participation in the SGA Project as a way to build further. The Next Generation Placement enhanced business engagement using active business outreach and standardized, coordinated training between SVRA staff and community rehabilitation providers. VRS also embraced the Individual Placement and Support (IPS) evidence-based model of supported employment for people with serious mental illness and had more local sites than any other state. Adoption of IPS included a faster pace at eligibility and a team approach. VRS saw an alignment between these efforts and the SGA Model.

The Minnesota Department of Human Services (DHS) Linkage Line (a statewide disability resource information and referral service) saw the SGA Project as a way to gather additional evidence about the effectiveness of their model of benefits counseling and financial coaching. The DHS personnel invested in tools for client assistance such as DB 101, a nationally recognized decision support software for SSDI benefits counseling, and the creation of the Linkage Line itself. Participation in the SGA Project provided an opportunity to demonstrate the continued utility of this approach to VRS and its clients. Both the DHS and VRS staff resonated with the fact that the SGA Model included financial coaching beyond benefits counseling and incorporating empowerment and taking control of one’s life through use of personal financial improvements. ICI TA staff had fostered the connection between VRS and the Linkage Line as a solution to a capacity issue in work incentives counseling.

3.2 Gaining VRS staff buy-in

To generate interest and “buy-in” from VRS staff, VRS and ICI hosted a series of meetings to discuss the SGA. These meetings involved central office and local team personnel and were designed to present information and answer questions about the SGA, its genesis, its purpose, its structure, and its individual components. Meetings were held before any randomization and were constructed to allay some generalized fears about engagement and potential consequences for clients. The major concern was that some clients in intervention offices would get something special while those in the control offices would have less comprehensive services. In contrast, others worried that clients in the intervention offices would be “forced into” a service model (especially faster pacing and use of a team) that they were not comfortable with or desired. Questions emanating included:

Why couldn’t we have the agency select offices it knew provided effective services overall rather than through randomization?

After initial meetings, the VR administrative staff expressed more comfort in proceeding and met with ICI SGA research and TA teams to plan for implementation. Planning discussed the intervention in more detail, creating a design that stayed true to the research model yet was flexible enough to meet the operational requirements, structure, and culture of VRS. Mathematica Policy Research’s interim evaluation report of Minnesota’s SGA Demonstration described the negotiation between VRS and ICI about the balance between TA to ensure fidelity to a model and VRS goals to align any training and TA with existing training investments (Kehn et al., 2017).

The ICI and VRS Senior, Regional and Supervisory staff embarked upon an 18-month planning phase which included contract negotiations, creation of training and TA strategies, data system modifications, operational and policy solutions to procedural challenges, bidding process for contractors, and an expanded partnership with DHS Linkage Line. In September 2015, VRS and ICI launched the SGA Project and hosted two multi-day trainings for offices randomized into the intervention. Randomization procedures for each state are detailed in the impact analyses articles in this Special Issue.

3.3 Launching the SGA Project

The SGA launch training highlighted a practical conundrum whereby SGA Project goals and VRS goal were not exactly aligned (Kehn, et al., 2016). ICI and VRS reached a compromise to integrate a Motivational Interviewing TA provider into the launch training. One ongoing issue for researchers using randomized controlled trials is that implementing a specific model is not in isolation to other innovations/practices in which that agency participates. In MN, there was a major philosophical and financial investment in Motivational Interviewing prior to ICI involvement. The VRS team wanted Motivational Interviewing included in the SGA launch to build on the existing effort. ICI did include this section through a contractual arrangement with a private training contractor. ICI focused on the concepts, implementation, and essential elements of the SGA Model.

This initial introductory session (held one week prior to beginning of the implementation period) was designed as a multi- day event that brought together the counseling and supervisory staff of all the study sites. Given the amount of time and personnel involved the SGA introduction was conducted twice with half the intervention offices participating each time. The agenda for this 3-day meeting was designed in collaboration with a VRS planning group as noted above. As an addendum to the presentations, attendee exercises were built in as well as small group discussions with each intervention office to identify questions, concerns, and any specific relevant issues that might impact SGA implementation. The SGA TA team followed up with each office individually for an onsite meeting that quickly followed this general meeting.

3.4 Regular on-site meetings

The ICI TA team set up regular on - site visits to meet with each of the local office study sites as well as convening meetings with the VR senior leadership periodically. Each local office received at least two visits with some receiving 1-2 more either because of staff turnover or office specific issues that occurred. Some sites welcomed these visits as a chance to process information, get feedback, share ideas, and highlight successes/problems. Others clearly saw these as more intrusive and less relevant to their day to day work. The purpose of the periodic local office visits was to offer consultation and support to the VR staff engaged in the SGA services to clients. Some of the office visits involved more technical information relating to ensure data integrity for the management information system set up for the project. Onsite TA visits uncovered some discrepancies on how and when and what information was entered despite the earlier discussions. After this information emerged, procedures were implemented to ensure that project data was accurately captured.

3.5 Modified work incentive counseling strategy

During the planning phase, VRS had a bidding process to recruit work incentives counseling services. The bidding process resulted in no awardees. ICI TA identified the Linkage Line had not bid though eligible and worked with VRS and the Linkage Line to establish a partnership. VRS had difficulty recruiting and identifying fully trained benefits counselors. VRS decided to build existing relationships Rehabilitation Counseling graduate programs and train graduate students as paid financial specialist interns. The SGA ICI team and the external partner created intensive training and a mechanism for the Linkage Line to oversee the work of the graduate students. The ICI SGA TA staff partnered with an external subject matter expert who had been involved in similar training on benefits counseling in Minnesota. Thus, the financial specialists received intensive training and support.

3.6 Role of counselors

The original design had a more active role for counselors in the individual client teams. However, it quickly became evident that many counselors might have very few SGA participants on their caseload, some as low as less than 10 a year. The work incentive counselors and job placement personnel tended to work together across counselors and had a substantial numbers of SGA participants often representing the majority of their caseload. This created a very different approach to case management than business as usual and an unexpected natural flow to building a team without a counselor specialist strategy. As mentioned in Foley, Haines, and Mock (2020) in this special issue, designated counselors as SSDI specialists was widely rejected by all SVRAs in Phase II of the intervention development. As implemented in Minnesota, many of the counselors had very few clients that participated in the SGA intervention.

3.7 Challenges and perspectives

Overall, the SGA was seen positively by both VRS staff and clients but nonetheless, there were issues that arose during the project, which the TA staff attempted to address with varying degrees of success, both at office meetings and with individual meetings with SGA team members. Some of the items that came up at various times throughout the SGA in Minnesota were:

Logistical problems in setting up the individual client team meetings.

3.8 Minnesota VRS assessment of the TA provided

Overall the feedback from all levels of staff and partners at DHS regarding the SGA TA provided was positive, communicated both to ICI SGA staff itself and the external evaluator (Kehn et al., 2016). Staff appreciated the attention and visibility of the TA staff. They also enjoyed the chance to discuss the theoretical underpinnings of the SGA as well as some practical information about data recording and program implementation. The office staff commented very favorably on the flexibility built into the SGA Model that allowed for local variation while keeping within the overall design.

3.9 TA experience differed by team role

The job placement staff did not receive specialized training beyond the initial launch training. VRS was already embarking on a quality improvement project for Next Generation Placement. Further training was seen by VRS both as redundant and potentially confusing to staff. Most offices considered themselves quite competent on integrating job placement specialists into client services as they had already had a long history of doing this well in their view. Financial specialists felt that the TA was extremely useful to them and some on-going efforts have been continuing beyond the SGA Project.

3.10 Initial launch training

What was missing from the initial launch training was clear expectations and operational parameters. The participants felt that the focus did not assist them to understand and be ready to implement the SGA Model. Almost all observed that the Motivational Interviewing segment was extraneous and redundant from previous intensive training. Feedback indicated that the SGA TA team spent too much time on philosophy and background and not enough on requirements, expectations and role definition.

3.11 Focus on specialists

Many counselors expressed concern that TA was targeted to the needs of the specialists and not enough on the VR counselor. ICI TA staff observed the intermittent involvement of counselors given caseload distribution. Where counselors were involved more directly, many felt the need for more training and instruction on creating, leading, and managing team functions. The SGA Project intentionally created a flexible team structure. Any team member could take the lead in organizing activities on behalf of clients, especially given involvement of financial specialists and job placement specialists prior to IPE development. VR counselors felt this as more of an acute problem on teams where the Financial Specialist was a graduate student. Veteran counselors felt that their role was potentially usurped by trainees without relevant experience.

4.1 Why get involved

Kentucky leadership decided to participate for multiple reasons. There was a large population of individuals receiving SSDI in Kentucky and OVR executive leadership felt that this was an opportunity to improve staff skills to serve the population. It also provided a focus on a higher proportion of clients’ seeking and obtaining full time competitive integrated employment compared to historical trends. The SGA Model was a different approach that executive leadership felt introduced new components of engaging SSDI recipients in employment and would work better than historical interventions.

At the time, OVR was in the early stages of a strategic plan to integrate Social Security benefits planning services into the panoply of services provided by the agency. The SGA Project was in alignment with this strategic goal. District level leadership saw project participation as a way to engage not only the SSDI client, but family to gain a full understanding of return to work and its impact on the family economy. The possibility of increased Social Security reimbursements was a significant motivator for participation. A significant reason OVR decided to participate was to engage staff in new ideas, promote additional skills for serving this population, and expand resources to gain external TA. The OVR director at the time stated at the initiation: “It provided a way for us to become part of national leadership for changing the way VR business is done.”

4.2 Planning phase

Similar to Minnesota VRS, OVR engaged in an 18-month planning phase that included contract negotiations, capacity assessment for each of the components, data system modifications, policy and procedural changes, and human resource issues. OVR recruited, hired, and trained work incentives counselors and job placement staff. OVR designated a subgroup for each component of the model to identify policy and procedural issues that may facilitate or hinder adoption. One area of concern was how to adopt presumptive eligibility when quality case review required every counselor to acquire medical documentation of disability. OVR had significant difficulty obtaining timely information from the SSA and created an internal process to coordinate requests.

4.3 Initial training

ICI and OVR developed an initial launch training that assembled all OVR staff in offices randomized to the intervention. ICI TA staff partnered with an external subject matter expert on work incentives counseling to provide instruction on the implementation and to introduce the ongoing TA available. OVR leadership team co-presented and addressed such issues as use of the case management system and identification of beneficiary status.

4.4 Yearly training

OVR organized and hosted a yearly training of all staff. SGA intervention sites had pre-training meetings that included discussions of implementation challenges, cross-site training needs, and policy and procedural adaptations that applied across sites.

4.5 Regular on-site training

The TA team met monthly telephonically with area office directors and provided on-site TA and training to each office conducting the intervention. Two subject matter experts provided intensive work incentive counseling training to the newly hired work incentives counselors brought on for the project. Two of the three were certified work incentives counselors (CWICs) and one was a CWIC in training.

4.6 Challenges and perspectives

Several levels of OVR agency staff (district managers, executive leadership, and past leadership engaged in the project) provided a plethora of feedback. Overall, the responses found TA to have impact for the project, but additionally for more general vocational rehabilitation application as well. However, a few less than ideal factors related to TA were articulated as well. What follows is a summary list of feedback from the agency regarding the TA provided.

4.7 Staff buy-in

Staff benefited from TA, and TA led discussion of issues related to the project. Agency staff at all levels indicated that the discussions with TA staff resulted in considerable benefit for conceptualizing and embracing the project dynamics given how different they were from the ways the agency had been operating. Counselors in the implementation sites eventually embraced the benefits of rapid engagement and saw the advantages of early benefits counseling and financial education in assisting consumers in making informed choice about their vocational goals. Through TA, counselors began to view the IPE as a dynamic document that could be amended as more information became available about the consumer.

4.8 Changes in early rehabilitation processes

OVR described change to the field, particularly at the implementation sites. Project related changes to the agency’s eligibility process were made, streamlining it significantly. Presumptive eligibility, which was previously underutilized, became consistently implemented. In order to expedite eligibility, counselors utilized fewer outside assessments and relied more heavily on their professional judgment. Prior to the project, agency counselors did not have timely, accurate, access to Social Security information. Through the SGA a relationship was established with SSA that enabled them to access this information for use in presumptive eligibility determinations. Job Placement Specialists were added in some offices and they began providing information to clients prior to IPE development, assisting clients in making informed choices about employment goals. Additionally, counselors began to view the IPE as a dynamic document that could be amended without considering the initial IPE as faulty.

4.9 Changing cultural norms

External TA provided new perspectives to standing cultural norms that resulted in operational adjustments. It supported local leadership, supervision, and counselors in not only changing their behavior, but also in changing attitudes and expectations. An example also described in Sevak et al. (2016) was the adoption of the “traffic light” concept to help counselors gauge client readiness for participation of each by ready (green light), ambivalent (yellow light), and not ready (red light) in discussions about achieving earnings above substantial gainful activity. This was a substantial departure from business as usual. OVR counselors had typically relied upon external assessments and tended not to engage in discussions about earnings above SGA directly. The traffic light approach was a “light touch” way of assessing a client’s readiness to entertain conversation and not whether or not a conversation would happen immediately or after more interaction with the client. This also led to a common language across a team that included counselors, job placement and work incentive specialists.

4.10 TA team as sounding boards

Staff said things to the TA providers that they would not say to leadership, which helped bring issues to the front that needed to be discussed. ICI TA staff partnered with leadership to address those items. For example, the agency has a lengthy eligibility form that counselors were required to complete prior to making the eligibility determination. Counselors shared with the TA providers that getting this form completed was preventing them from meeting the rapid eligibility determination standards for the SGA Project. The TA providers shared this with the administration. It was discussed at a yearly SGA training with staff and a work group was established to revise and streamline the form. Similarly, the agency held a longstanding philosophy that comprehensive assessment of rehabilitation needs for each client was necessary prior to IPE development. This, however, considerably delayed IPE creation. This was discussed at multiple levels of OVR. A significant impetus for change was that ICI TA hosted co-meetings with OVR and VRS. OVR learned about VRS’s approach to a dynamic IPE and revisited the option.

4.11 Rural location, remote teaming and capacity issues

The ICI TA team supported OVR and the intervention sites to address team capacities and implementation across rural locations. Kentucky experienced challenges in service provision particularly when it came to team meetings and availability of placement and financial specialists over geographically large rural territories. The ICI TA team supported OVR to consider and implement remote teaming via phone and video conferencing. OVR acquired video conferencing capabilities specifically to enable team interactions across large areas.

4.12 Concerns about pacing and ethics

Some counselors saw rapid eligibility and plan development as potential unethical treatment and some had expressed concern that rapid engagement would create anxiety in consumers, causing them to drop-out of VR services or make poor decisions about their vocational goals. The ICI TA team emphasized that the priority was to “always do what is right for the consumer” and gave counselors the opportunity to discuss specific concerns with TA providers and their peers. This remained a concern for a subset of counselors despite intensive TA.

4.13 Executive leadership perspectives

Executive leadership cited that the amount of TA provided was more than expected, with a considerable amount provided at the local level. Intervention sites were visited in person (5) times each by a TA team. Though the ICI TA team felt that site visits would help improve fidelity, OVR was concerned about staff time and burden of participation. An alternative was the use of monthly conference calls for the first phase of implementation and then every other month subsequently. It was felt that TA provided in this manner dealt positively with local staff and meaningfully addressed pockets of resistance and facilitated integration of all components into office operations.

4.14 Sustainability of SGA practices

OVR had considered adopting team approaches and was most enthusiastic about having in-house Kentucky Work Incentive Coordinators. One regional manager reported that pacing between eligibility and IPE development were considerably faster than they were prior to the SGA Project. A district manager noted new counselors hired are being acclimated and acculturated to a new way of rehabilitation counseling and service provision including use of rapid engagement, early benefits counseling and counseling from a job placement specialist. Other comments regarding sustainability included improved telecommunications, interoffice networking, operational process improvements particularly at eligibility, an enhanced relationship with SSA, and a view of the IPE as a living plan.

5.1 More focus on counselor skills and knowledge needed

The initial TA roll-out should have been much more specific vis a vis what concrete counselor skills and actions were expected. The lack of clarity in this key time frame led to additional stress and confusion on the part of already overburdened line staff. The ICI TA team underestimated the help that VR counselors would need to fully function as team leads. In some cases, primarily in MN, the TA did not adequately highlight the importance of counselors to the whole intervention and contributed to some feeling like “5th wheels” rather than an integral part of the client’s rehabilitation process. For more effective future research interventions, it highlights the importance of clarity in expectation. What the research and TA team thought were obvious demands brought on by the design were not as clear to the human service personnel participants. VR counselors historically saw themselves as the lead directors of all the planning and services delivered. While the SGA Project did not change this basic institutional expectation, it did create a more collaborative cultural framework and gave enhanced credibility to the other staff on the team, i.e., the Placement Specialist and the Financial Specialist.

5.2 Multiple innovations at once

One issue that serves as a practical caution is it becomes somewhat problematic in instituting a defined research program intervention in an entity that is engaged in multiple levels of innovation. Whereas KY OVR was very concerned due to funding limitations with managing day-to-day traditional VR services, MN VRS had a long tradition of many on-going pilot projects and system change initiatives, despite its own on-going funding challenges. This posed a challenge to ensure that the stated SGA Model was created in the intervention sites without interfering with (or being interfered by) other innovations not otherwise connected to the SGA.

5.3 Relationship building at all levels

The TA provided was proactive and often initiated by the ICI TA team rather than as specific requests from local VR personnel. Both SGA TA teams conducted regularly scheduled visits to individual intervention offices (a minimum of 2 over the life of the project) and with central office administrative team overseeing the SGA. It was important for ICI TA personnel to connect with all levels of the organization from top management to line staff charged prior to and throughout the entire process. Relationship building with agency staff involved is a core, if underappreciated skill of such a TA approach. This was generally seen as a supportive style and not overly intrusive overall. Furthermore, the TA staff acted as resources for additional information not just about the SGA itself. Requests ranged from ancillary SGA data updates to non-SGA related questions. In a sense, the ICI TA team became readily available subject matter experts on a wide range of VR rehabilitation issues. The majority reported that they felt the ICI TA team was able to strike a balance between encouraging local office flexibility while informing staff about adhering to the integrity of the research design. This balancing skill is required of TA personnel to support implementation or research interventions within operating human service settings.