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Investigation of Wisconsin's Family Care Policy: Research and Recommendations Concerning Employment Outcomes for People with Disabilities

by Matthew J. Pesko[1], Department of Social Work, University of Wisconsin-Madison

Abstract

Fair access to community employment has yet to become a reality for people with disabilities in the state of Wisconsin. Research has shown that integrated employment for individuals with disabilities can benefit both people with disabilities and employers. The literature also points to a relationship between employer outreach methods by disability service agencies and subsequent employer attitudes and, even further, employment outcomes. In Wisconsin, a new long-term care system for people with developmental and physical disabilities and the elderly, called Family Care, is being implemented in many of the counties throughout the state. This programmme allows for care management organizations to provide services related to vocational acquisition and retention for individuals with disabilities. The purpose of this study is, firstly, to explore the relationship between employer outreach efforts, employer attitudes and employment outcomes; and, secondly, to understand the differences, if any, between Wisconsin counties using the Family Care model and counties using the traditional model with regard to these three pieces of employment acquisition for people with disabilities.

A static-group comparison design was used as a way to generate exploratory and descriptive information on these topics. A mail survey, to which 101 care managers and employers in Wisconsin responded, measured perceptions of the level of employer outreach, attitudes of area employers, and hiring rates for people with disabilities in their counties. Results indicate that disability employment professionals and employers regard the current integrated employment status as neither completely closed-off nor readily conducive for acquisition, but rather somewhere in the middle. This exploratory look at the effect of Family Care on employment outcomes for people with disabilities reveals equivalent employment expectations as compared to the traditional system that will slowly be phased out.

KEYWORDS: Family Care, adults with disabilities, employment, employer attitudes

Introduction

Despite the implementation of promising disability legislation over the last two decades, including the Americans with Disabilities Act in 1990, few actual gains have been made in the employment of people with disabilities in the United States. In fact, data from the Current Population Survey show that employment outcomes have actually decreased over this span of time (Houtenville et al., 2005). Conversely, two-thirds of these non-working individuals with disabilities have the desire to work (National Organization on Disability/Harris, 2004). The benefits for businesses in employing individuals with disabilities are numerous but rarely taken advantage of and many times not even known. Rigorous research needs to be continued to understand mechanisms that may improve partnerships between consumers with disabilities, employers, and disability service providers, in an effort to heighten economic inclusion of individuals with disabilities.


Wisconsin's Family Care Policy

A new long-term care (LTC) programme is currently being established across Wisconsin called Family Care. This system of providing long-term care for individuals with developmental and physical disabilities, along with the elderly, was first proposed in 1998 by Governor Tommy Thompson. The goal of the new system is to 'emphasise independence and quality of life while recognizing the need for interdependence and support' (Wisconsin DHFS, 1998: i). The centrepieces of the legislation are the implementation of Aging and Disability Resource Centres and Care Management Organizations in all areas of the state (county by county). The Aging and Disability Resource Centres will be a one-stop source of information and referral for people with disabilities. Once enrolled, Care Management Organizations will provide the fiscal means for individuals with disabilities to obtain services related to their long-term care options. Vocational development and placement are part of the guaranteed services offered through the CMOs and driven by consumer demand.

Due to positive findings from a number of studies and the ensuing momentum of the Family Care programme in the state capital and the Department of Health Services, a large expansion has taken place over the last couple of years beginning in 2006. Family Care is now available in 33 counties, each having commenced the functions of their Aging and Disability Resource Centres (ADRCs) and Care Management Organizations (CMOs): essential parts of the Family Care programme. These 33 counties are served by seven separate CMOs, many of them as part of a consortium of nearby counties. Fifteen more counties will introduce Family Care by the end of 2009. Approximately 67.3 percent of Wisconsin's eligible population will be covered by Family Care by the end of the year from this expansion (Wisconsin DHFS, 2009: personal calculation).

The Family Care programme is based on principles of efficiency and entitlement. Therefore, it has already been seen that people with disabilities in Family Care counties are coming off the "waiting lists" for services (Wisconsin Managed Care and Employment Task Force, 2008b). Conversely, as indicated above, the state is experiencing a lack of economic resources to invest into the Family Care system because of the recent economic crisis and increased enrolment in the programme. Therefore, this author wished to consider what will be the fate of the services offered to people with disabilities. Vocational services may be one of the first areas to be trimmed from a service plan because of the presumed non-essential role that work plays in the life of a person with a disability (contrary to community living and personal care services, for example). In Family Care counties in 2006, only 2.6 percent of funding was being used for supported employment, with an additional 7.9 percent being used for pre-vocational/sheltered employment (Wisconsin Managed Care and Employment Task Force, 2008b: slide 13). Conversely, surveys of care managers from Family Care pilot counties by Robert (2001; 2003) found that employment services were perceived not to be difficult to access or provide and that the Family Care system allowed more flexibility to access those services. A lack of integrated vocational services could detrimentally affect the population of adults with disabilities in Wisconsin by taking away a sense of empowerment and independence and decreasing their feelings of social inclusion in the community, leading to an overall lower quality of life (Kober and Eggleton, 2005; Freedman and Fesko, 1996). The rest of the community would suffer as well as a decline in labour participation would decrease both business productivity and government tax revenues.

Method

A static-group comparison design was used as a way to generate exploratory and descriptive information on these topics. Mail surveys were sent to individuals in eleven counties: four counties that represent the "intervention group", having already established the Family Care programme, and seven counties that represent the "comparison group", having not yet established the Family Care programme. Within each of the eleven counties, mail surveys were sent to two groups of respondents. The first group consisted of care managers, individuals who work for disability service agencies (including CMOs) and who implement the service plans of the consumers with disabilities in their counties. The second group consisted of local employers. These two groups were included in the research because of the unique role that each plays in the employment acquisition and retention process.


Participants

Participants in these two groups were recruited using targeted convenience sampling methods. The names and addresses of care managers were either (1) found on county or managed care organization websites, or (2) found by establishing contact with administrative personnel within the county or managed care organization to garner a list of their care manager employees. All care managers from these lists were included except one county whose administrator limited the list to consenting employees.

Contact information for local employers in each of the counties was found on the "WORKnet Wisconsin" website (http://worknet.wisconsin.gov/worknet/). This website gives a county-by-county snapshot of the 25 largest local employers and contact information for these employers. Included employers were selected by starting with the largest employers, going down the list, and choosing each employer that was considered to have (1) the potential to hire people with disabilities, and (2) the potential for a manager/human resource administrator who could fill out the survey. For each county, no more than 2 school districts, 2 universities, or 2 city administrations were included in the sample.

These approaches led to the inclusion of 127 care managers (56 in Family Care counties and 71 in traditional service counties) and 165 employers (60 in Family Care counties and 105 in traditional service counties) in the sample. Those who responded to the survey included 101 care managers and employers for a response rate of 34.6%. One survey was excluded from the data because the individual completed less than half of the questions, and four surveys were returned by the postal service because of a faulty address.


Procedures

Cover letters and surveys were distributed to individuals from each of the groups. The participants were issued a two-page survey (4-point Likert-type) to measure their perceptions of employer outreach, attitudes of area employers, and hiring rates in their counties. The survey remained anonymous as only the county of employment was collected for demographic information. These materials were mailed individually to the potential participants using names and work address information that was garnered from either their employer organization (for care managers) or the WORKnet Wisconsin website (for employers). Exactly one week before these materials were mailed to the care managers, a letter explaining the purpose of the project was sent to the manager/director of the agency so they could understand the intent of the project. The surveys were collected via a self-addressed, stamped envelope.


Survey

An instrument was developed to assess attitudes of care managers and employers with regard to employer outreach efforts, changing employer attitudes, and employment outcomes for people with disabilities in their counties. A particular emphasis was made in the questionnaire to inquire about the attitudes pertaining to sheltered employment (defined in the survey as "employment for a group of people with disabilities in the same location") versus integrated employment ("employment setting that enables an individual to interact with persons without disabilities to the fullest extent possible"). A preliminary draft of the questionnaire was developed and subsequently reviewed by a panel of four experts with extensive experience in research and practice on behalf of people with disabilities to establish content validity. After making revisions, 18 closed-ended questions and one open-ended question were included for each group. In addition, three questions were added to the survey for care managers, specifically, to determine how much of their caseload consisted of people with disabilities with vocational goals. Of the 18 questions common to both the care manager and employer survey, 6 were related to each of the aims of the survey: employer outreach efforts, changing employer attitudes, and employment outcomes. These items were interspersed randomly throughout the questionnaire. Ratings for each of the 18 questions were provided on a 4-point Likert-type scale which included strongly disagree (1), somewhat disagree (2), somewhat agree (3), and strongly agree (4).

Cronbach's alpha for these 18 items was considered good (α = .831) On the other hand, factor analysis yielded five factors with questions that were not in line with the preconceived three-factor structure of the survey (Factor 1 = Questions 6, 7, 8, 9, 10, 11, 12, 13, 14; Factor 2 = Questions 1, 3, 8, 15, 17; Factor 3 = Questions 6, 16, 18; Factor 4 = Questions 2, 4; Factor 5 = Question 5). However, when questions 1-6 are removed from the factor analysis, only two factors remain: questions 7-12, 14 and questions 13, 15-18. Therefore, it can be reasonably concluded that the survey was able to measure opinions of the respondents with regard to employer attitudes and employment outcomes, but not as well with questions related to outreach to employers. This is most likely due to confusion of the participants about integrated and sheltered employment questions and the poor wording of question 6 in the employer survey which prevented thirteen employers from responding.


Data analysis

SPSS software was used to store and analyze the data. All ratings of the even-numbered questions were reversed because they were worded negatively in the survey. Questions 1-6, 7-12, and 13-18 were each summed together to best represent respondents' perceptions of outreach to employers, employer attitudes, and employment outcomes. If a participant did not answer one of the questions (N = 20), a value of 2.5 was used for that question to represent an average score. Descriptive statistics were then used to summarise ratings for those groups of questions. Two-factor analyses of variance (ANOVAs) were conducted to compare the three groups of questions with regard to the two independent variables: system – whether the respondent was from a Family Care county or traditionally-run county; and group – whether the respondent was a care manager or employer. A Pearson correlation was completed to determine if there was a positive relationship between outreach to employers, employer attitudes, and employment outcomes, as hypothesised.

Results

The mean and standard deviations for the three groups of questions with regard to system and group of the respondents are shown in Table 1.

    Family Care Traditional Both Systems
Outreach to Employers (Questions 1-6) Care Managers M = 15.39
SD = 1.65
N = 26
M = 15.33
SD = 2.33
N = 35
M = 15.35
SD = 2.05
N = 61
Employers M = 17.00
SD = 1.58
N = 15
M = 15.86
SD = 1.83
N = 25
M = 16.29
SD = 1.81
N = 40
Both Groups M = 15.98
SD = 1.79
N = 41
M = 15.55
SD = 2.14
N = 60
M = 15.72
SD = 2.00
N = 101
Employer Attitudes (Questions 7-12) Care Managers M = 13.48
SD = 2.32
N = 26
M = 13.33
SD = 2.70
N = 35
M = 13.39
SD = 2.53
N = 61
Employers M = 17.10
SD = 3.23
N = 15
M = 18.36
SD = 3.13
N = 25
M = 17.89
SD = 3.19
N = 40
Both Groups M = 14.81
SD = 3.18
N = 41
M = 15.43
SD = 3.80
N = 60
M = 15.17
SD = 3.56
N = 101
Employment Outcomes (Questions 13-18) Care Managers M = 17.08
SD = 3.03
N = 26
M = 16.51
SD = 3.10
N = 35
M = 16.75
SD = 3.06
N = 61
Employers M = 18.57
SD = 2.84
N = 15
M = 18.82
SD = 2.43
N = 25
M = 18.73
SD = 2.56
N = 40
Both Groups M = 17.62
SD = 3.02
N = 41
M = 17.48
SD = 3.04
N = 60
M = 17.54
SD = 3.02
N = 101


Table 1: Mean ratings for participants across variables of outreach to employers, employer attitudes, and employment outcomes


The two-factor analyses of variance indicated a main significant effect for the group of the participants with regard to the questions about outreach to employers, F(1, 99) = 6.99, p = .01; a main significant effect for the group of the participants with regard to the questions about employer attitudes, F(1, 99) = 54.69, p <.001; and a main significant effect for the group of the participants with regard to the questions about employment outcomes, F(1, 99) = 9.93, p = .002. These results show statistical significance, but are also considered substantively significant. However, there were no statistically significant differences found for the county service system of the respondent or for the interaction between the system and group of the respondent. The analyses of variance indicate that differences exist between employer and care managers with regard to each of the three employment acquisition processes, but contrary to expectations, no differences exist between the respondents in Family Care counties and traditionally-run counties. Employers tended to rate items in the three clusters of questions higher than the care managers, and their answers averaged around the "somewhat agree" marker while care managers' ratings fell between the "somewhat disagree" and "somewhat agree" markers. Participants in the Family Care counties and traditionally-run counties had average scores between the "somewhat disagree" and "somewhat agree" markers for all three categories of questions.

The one-tailed Pearson correlations for the data revealed that outreach to employers and employer attitudes were significantly related, r = +.28, p = .002; outreach to employers and employment outcomes were significantly related, r = +.29, p = .002; and employer attitudes and employment outcomes were significantly related, r = +.67, p <.001. These results show statistical significance and are also considered substantively significant because they reveal that a broad cross-section of Wisconsin care manager and employers feel that outreach to employers, employer attitudes, and employment outcomes are all positively correlated. Generally, the better the employer outreach method by a disability service provider, the better attitudes employers will have about hiring people with disabilities. Similarly, better employer outreach methods by a disability service provider may lead to increased employment outcomes for people with disabilities. The strongest relationship in this data is between employer attitudes and employment outcomes: the more positive the employer attitudes, the better the employment outcomes.

Discussion

On the whole, it appears that disability employment professionals and employers regard the current integrated employment status as neither completely closed-off nor readily conducive for acquisition, but rather somewhere in the middle. In other words, jobs in the community are perceived to be available for people with disabilities, but they remain difficult to acquire and/or hold down for an extended, productive career. Interestingly, employers believe more in the potential for businesses and other organizations to hire people with disabilities than do care managers. Finally, while the implementation of the Family Care system in counties in Wisconsin is still recent and ongoing, this initial glance at the effect of Family Care on employment outcomes for people with disabilities reveals equivalent employment expectations as compared to the traditional system that will slowly be phased out.


Limitations

This research cannot be generalised across all care managers and employers in Wisconsin because of the nature of the methodology. There was no pre-test of this survey before counties implemented Family Care; therefore, there is no way to determine if the groups are equivalent. This research only gives a "snapshot" of the current status of employment acquisition, and should, in turn, encourage these participating counties and others throughout the state to undertake better employer outreach strategies, increase employer attitudes, and allow for more people with disabilities in the workforce. A second limitation is that, as indicated earlier, question six was poorly worded in the employer survey which led to many employers not answering the question, and, as a result, a more average and less deviated score for the category of questions related to outreach to employers. Third, upon further review of the open-ended comments from the participants, the survey might have included questions that were inferred to be double-barrelled when participants were asked about opinions related to employment and/or integrated employment. For instance, care managers and employers completing question two ("the structure of the disability service agencies best support sheltered employment") might conclude that the disability service agencies in their county do a good job of supporting both sheltered and integrated work. But if they had marked "strongly agree" to the question, they would be analyzed as rating low in employer outreach strategies for integrated employment. Fourth, the nature of sampling was conducive to errors and bias but was selected because of the relatively fast and efficient way of obtaining lists of care managers and employers to complete the survey.


Further Research

This data cannot determine causal explanations for the relative stability of the employment prognosis for people with disabilities across the two service systems in Wisconsin because of the lack of an experimental design. Additionally, while research during this critical juncture in the implementation of the Family Care programme is exciting and important, continual changes in policy and practice throughout the time of the research project lent to difficulties in obtaining accurate perspectives on employment of people with disabilities. For instance, while the survey was in the hands of the participants, the governor's biennial budget was introduced that gave further direction regarding the expansion of Family Care. Longitudinal research is needed that looks at outreach to employers, employer attitudes, and employment outcomes before and after implementation of Family Care in a variety of counties in Wisconsin. One obvious stakeholder group was missing from this analysis: people with disabilities themselves. Their perspectives would unquestionably assist in understanding the real barriers that hinder their acquisition or retention of employment in Wisconsin. Also, it would be advantageous to include professionals who work for the Division of Vocational Rehabilitation in future analyses because of their effect on short-term employment goals and objectives for people with disabilities in Wisconsin, in contrast to the long-term care plans executed by care managers.


Recommendations

There is currently an opportunity during Wisconsin's transition to Family Care in which integrated employment should be promoted to help individuals obtain better social and economic outcomes. A number of recommendations should be implemented to achieve this goal.

1. An integrated employment priority needs to be implemented by the state administration for Family Care, and effectively carried through by care management organizations, individual care managers, and contracted providers (Mills, 2006; Managed Care and Employment Task Force, 2008a). The Department of Health Service's commitment to integrated employment outcomes is evident in their establishment of the Managed Care and Employment Task Force in conjunction with the Pathways to Employment programme. However, there is often little discussion of client-centred employment outcomes in any of the official Family Care literature, and money being directed towards supported employment is a tiny portion of the CMO budgets. As a long-term care service provision system, Family Care has the responsibility to ensure that people with disabilities are able to obtain lasting employment opportunities in the community that will lead to a higher quality of life. By setting the precedent at the level of the state administration, and by providing education and ongoing training of care management organizations and care managers to provide these services, Family Care will help Wisconsin retain its reputation as one of the leaders in providing supported employment opportunities to people with disabilities.

2. Bringing people with developmental and physical disabilities across all areas of the state off waiting lists and guaranteeing services is an important component of this programme that should be continued. Quality funding, though, of care management organizations and care plans of people with disabilities needs to be ensured so that people with disabilities are given the opportunity to receive supported employment services (Managed Care and Employment Task Force, 2008a). Full funding to reduce care managers' caseloads will serve to increase their productivity and retention. Costs in this area can be reduced by exploring and implementing new ways to fund supported employment services such as the use of natural supports, faded paid supports (Mills, 2006; Managed Care and Employment Task Force, 2008a) and performance-based contracts for providers (Block et al., 2002). Great caution is advised when considering implementation of a "franchise model" for Family Care because of its emphasis on cutting costs potentially to the demise of system flexibility and positive client-centreed outcomes.

3. Counties that currently have exemplary policies regarding integrated employment acquisition and that pay for additional vocational services from their own county funds should not be penalised for joining Family Care. This long-term care system has the laudable goal of providing parity across all counties in Wisconsin, which would be especially beneficial for individuals with disabilities in rural areas or low socio-economic communities. However, a situation in which individuals with disabilities might lose services that currently help them achieve a high quality of life is alarming. Special provisions should be made for such counties that choose to provide services above and beyond that entitled by Family Care.

4. Special care needs to be taken with the eligibility of individuals with a secondary mental health concern to make sure that they do not "fall between the cracks" and not receive necessary services through either Family Care or a separate service programme such as the Community Mental Health Services division of the Department of Health Services. Also, once enrolled in Family Care, service provision should be carefully considered for those members who have a dual diagnosis. A consistent policy should be laid out by the Department of Health Services to oblige CMOs to cover mental health services as part of their benefits package.

5. Individuals currently in the traditional, waiver-based system must be carefully transitioned to the new Family Care system using the functional screen so their vocational goals are maintained at the highest level possible (Managed Care and Employment Task Force, 2008a). The use of self-directed supports has been cited as a beneficial way to maintain the same level of care. For instance, providers of supported employment used in the waiver programme could be contracted in the Family Care programme as a self-directed support even if that provider is not included on a provider list for that CMO. The functional screen tool also needs to be carefully modified in order to provide young individuals who are transitioning into the Family Care system high expectations of what they can accomplish through their care plans.

6. An alternative to Family Care, called IRIS, allows individuals to determine their own care plans and thus promotes self-determination. This IRIS alternative should be highly publicised and recruited for, but the Family Care programme itself should also attempt in its own context (Self-Directed Supports option) to establish these very important person-centred principles that emphasize individual quality-of-life outcomes for each participant. Attempts to freeze or cap the enrolment into these self-directed options should be strictly prohibited.

7. Lastly, continuous quality improvement and transparent data collection and dissemination should be engaged in by the state administration of Family Care to ensure that individuals with disabilities are continuing to increase their access to the labour market (Mills, 2006; Managed Care and Employment Task Force, 2008a). Frequent and up-to-date employment statistics should be disseminated to all stakeholders of the Family Care programme. Memorandums of agreement with the Division of Vocational Rehabilitation and local school districts should also be written and executed to provide a cohesive employment acquisition and retention plan for individuals with disabilities.

Conclusion

Individuals with disabilities in Wisconsin continue to face barriers to obtaining employment in the community. Aside from their own self-advocacy for employment, positive employer outreach strategies by disability service agencies have been shown to correlate with increased employer perspectives and increased employment outcomes. However, employers tend to rate outreach strategies, their own attitudes, and employment outcomes higher than do care managers that work for the disability service agencies (including CMOs). The implementation of Family Care, therefore, creates an opportunity for these agencies to execute new and innovative strategies in an effort to secure employment for their consumers with disabilities. Constraints of their occupation and system in which they work might hinder the progress that care managers are able to make to the consumer-employer-service provider relationship. Efforts need to be made by the individual professionals and organisations of which they are a part, to emphasise the importance of employment for people with disabilities and to make employment acquisition and retention interventions one of their largest priorities.


Acknowledgements

The participation of those who responded to the mail survey is greatly appreciated. The author would also like to thank mentor Donald J. Anderson for his invaluable advice and guidance; Dr. Stephanie A. Robert for her support of this project and precise feedback; and the College of Letters and Sciences Honors Programme/Trewartha and Mark Mensink Grant for the funding of this research.

List of Tables

Table 1: Mean ratings for participants across variables of outreach to employers, employer attitudes, and employment outcomes

Notes

[1] Matthew Pesko graduated with a BS from the University of Wisconsin-Madison in the Spring of 2009 with a degree in Rehabilitation Psychology and Social Welfare. He is currently serving for a year in the Jesuit Volunteer Corps in Portland, Maine, USA working on transitional housing for homeless with mental illness.

References

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To cite this paper please use the following details: Pesko, M. (2009), 'Investigation of Wisconsin's Family Care Policy: Research and Recommendations Concerning Employment Outcomes for People with Disabilities', Reinvention: a Journal of Undergraduate Research, Volume 2, Issue 2, http://www.warwick.ac.uk/go/reinventionjournal/archive/volume2issue2/pesko Date accessed [insert date]. If you cite this article or use it in any teaching or other related activities please let us know by e-mailing us at Reinventionjournal@warwick.ac.uk