DOCUMENT RESUME

ED 368 860 CE 065 745

AUTHOR Perlman, Leonard G., Ed.; Hansen, Carl E., Ed.TITLE Private Sector Rehabilitation: Insurance, Trends &

Issues for the 21st Century. A Report on the Mary E.Switzer Memorial Seminar (17th, Washington, D.C.,June 2-4, 1993).

INSTITUTION National Rehabilitation Association, Alexandria,Va.

PUB DATE Oct 93NOTE 82p.; Switzer Seminar Series.AVAILABLE FROM National Rehabilitation Association, 633 South

Washington Street, Alexandria, VA 22314 ($15).PUB TYPE Collected Works Conference Proceedings (021)

Reports Research/Technical (143)

EDRS PRICE MF01/PC04 Plus Postage.DESCRIPTORS Adult Vocational Education; Business; *Disabilities;

*Health Insurance; *Private Sector; *VocationalRehabilitation; *Workers Compensation

ABSTRACTThis monograph reflects the writings, discussions,

and recommendations of the Switzer Scholars at the 16th annualMemorial Seminar. Introductory materials include the following: "ATribute to Mary E. Switzer"; "Welcome from the NationalRehabilitation Association" (Spencer L. Mosley, Ann Ward TourignY);list of seminar sponsors; "Introduction" (Leonard G. Perlman, Carl E.Hansen); and photographs of the 1993 Switzer Scholars. The fivepapers written expressly for the seminar follow: "Development ofRehabilitation in Business and Industry: Implications forRehabilitation Counselor Training" (Ralph M. Crystal); "EducatingPractitioners for Work in the Private Sector" (Dennis DavidGilbride); "Insurance Issues and Trends: A Focus on DisabilityManagement including Rehabilitation" (Patricia M. Owens); "Trends andInnovations in Private Sector Rehabilitation for the 21st Century"(John W. Lui); and "Ethical Issues in the Private Sector" (Edward P.Steffan) . Four special invited papers are included: "The History ofPrivate Sector Rehabilitation" (Lloyd M. Holt); "Choice, Autonomy,and Individual Provider Selection" (Stephen A. Zanskas);"Rehabilitation in Workers' Compensation: A Growth Potential" (BruceGrow:ck); and "Rehabilitation in the 90's and Beyond" (BarbaraGrenstein). A brief biography of Mary E. Switzer concludes themonograph. (YLB)

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Reproductions supplied by EDRS are the best that can be madefrom the original document. *

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EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

This document has been reproduced asrece.ved Porn the person or organizatronorigmating

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Points of view or opinions stated .n this docernent do not necessarily represent ofhcralOEM positron or pohcy

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TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)."

4

AveBEST CM MILANI

A Tribute To Me:ey E. Switzerby a Friend & Colleague

We are pleased to report that Col. Mc Cahill received anHonorary Switzer Scholar award at the reception hon-

oring the Scholars at this year's seminar. He was honoredfor his 50 years of sers ice and dedication to persons withdisabilities. He was also on the original planning committeeto set up the Mary E. Switzer Memorial Committee of NRAin the early 1970's. and of course. he was a long time friendand colleague of Ms. Switzer.

The following are Col. McCahill's thoughts of Ms. Switzer.which he titled, To an International Pilgrim in Rehabilitation. In

the December. 1971 issue of Performance. then the monthlymagazine of the President's Committee on Employment of theHandicapped (PCEH ), I wrote an In Memoriam of my friend and

long-time co-worker, "Queen Mary."

II> Col. William P. MeCahill. Former (and first)Director of the President's Committee on

Employment of the Handicapped, ExecutiveCommittee member and past Chairman.

People-to-People Committee for the Handicapped.

I said in part that Mary was a familiar participant ingatherings abroad and near to home. and the Switzer Memo-rial Committee more than two decades later, is continuingthese "gatherings" in her memory. serving persons withdisabilities worldwide as she did for so long.

I also quoted her pastor in my article as saying in hiseulop . May the good work begun in her be continued inthose of wm who remain. As one of those who "remain"from 1946 to the present. I can testify that the SwitzerMemorial Committee and NRA have nobly obeyed thecharge of Mary's Minister in Alexandria. In my last shortparagraph I said in part. "She has been all things to allpeople. serving those who served...She will stand out as apilgrim of the last quarter century of rehabilitation." Thatshe is indeed, and the Switzer Scholars and NRA leaderscontinue her pilgrim's progress.

But I want to emphasize her great and lasting contribu-tions to international rehabilitation around the globe. Sheand I worked together at several Rehab International WorldCongresses where she would sit in the seats reserved for the

USA. doing her perpetual knitting. When she left. I (forPCEH would sit in her place. sans knitting.

Her Pl. 480 foreign research grants served as a wo- waciosstertilization program. henefitting hoth the U.S. ani. Ioverseas persons with disabilities.

She received the highest honors around the workl wherever

she went, including Rehab International's Winged VictorStatue. and the President's Committee Distinguished Sers icePlaque signed hy a U.S. President. She brought countless foreign

leadeN to the U.S.. in cooperation with the World RehabilitationFund and Dr. Howard Rusk, Rehabilitation International andmany other international organizations. She was naturally ingreat demand as a keynote speaker. At one international meeting

Col. William P. McCahill talks to Switzer Scholarsand guests atter receiving the Switzer Scholar award

at the reception in Washington, D.0

in Canada she had to send regrets the day before her presentation

and I went to my hotel room with a borrowed typewriter andcrafted a reasonable substitute speech. I was first a journalistbefore becoming a marine, a bureaucrat and, at present at age 77.

the newest Switzer Scholar.Our international trips weren't all business, but provided

fun and games and a chance to exchange ideas and to cement

friendships with peers. And.at each PCEH annual meeting.our dias, both tiers, was filled with distinguished foreignleaders who utilized opportunities while in the U.S. to meetwith Mary both socially and professionally. I never saw themany letters that poured in from abroad after her death. butthen RSA Commissioner Joseph Hunt and friend IsabelDiamond answered most of them.

During the 50's and 60's Washington and the U.S. Con-gress were male dominated, but she strode the Halls ofCongress getting her way with hardly a murmur of dissentfrom Sen. Lister Hill and Rep. John Fogerty who chaired theAppropriations Sub-committees. Like those who remain.and too many who are missing. we all had wonderful storiesof Marv. But, that's another article.

One last quote from my Performance Memoriam: 'Eachot us who knew her w ill cherish her memon . for manreasons. for things said and unsaid, deeds done and undone.This the Switzer Memorial Committee. the NRA and thcSwitzer Scholars are doing in keeping her memory alive.And. tor that. a Marine Colonel's salute ot gratitude andpraise. She too. was Semper Fidelis.

1993 Switzer Monograph 17th Edition

Private Sector Rehabilitation: Insurance,Trends & Issues for the 21st Century

National RehabilitationAssociation

633 South Washington StreetAlexandria, Virginia 22314

VOICE (703) 836-0850TDD (703) 836-0849FAX (703) 836-0848

EditorsLeonard G. Perlman

Carl E. Hansen

Director of CommunicationsRonald J. Acquavita

1993 Switzer ScholarsCatherine C. Bennett

Phillip BusseyRalph M. Crystal

Estelle DavisThm DavisTim Field

Juliet H. FriedDennis Gilbride

Barbara GreensteinBruce GrowickJeanine Johnson

John W. LuiPatricia Nunez

Patricia M. OwensJeffrey J. Peterson

Ed SteffanDora Teimouri

Daniel M. Thomas D.C.Mary VencillJackie Wilson

Stephen Zanskas

Tic Switzer Monograph reflects the writings.discussions and recommendations of theSwitzer Scholars at thc 16th Annual MaryS% 'tier Memorial Seminar, held June 2-4,1993.at the President's Committee on Employment ofPeople with Disabilities in Washington, D.C.Opinions expressed in the Switzer Monographare those of the writers and do not necessarilyreflect policy of the National Rehabilitation As-sociation or any othcr organization.

The National Rehabilitation Association is anon-profit organization dedicated to improvingthe quality of life for people with disabilities.

Published October 1993. Toorderprevionseditions

of the Switzer Monogtnith, ccriact the NationalRehabilitation Asscciadon at (703)715-9090.

Welcome Spencer L. Mosley. Ann Ward Tourigny 1

Seminar Sponsors 2

Seminar Host Richard Douglas 3

Introduction Leonard G. Perlman. Carl E. Hansen

The 1993 Switzer Scholars 7

ChaptersDevelopment of Rehabilitation inBusiness and Industry: Implications forRehabilitation Counselor TrainingRalph M. Crystal

Educating Practitionersfor Work in the Private SectorDennis David Gilbride 20

Insurance Issues and Trends: A Focuson Disability Management including RehabilitationPatricia M. Owens 31

Trends & Innovations In Private SectorRehabilitation For The 21st CenturyJohn W. Lui 47

Ethical Issues In The Private SectorEdward P. Steffan 55

Special Invited PapersThe History ofPrivate Sector RehabilitationLloyd M. Holt 63

Choice, Autonomy andIndividual Provider SelectionStephen A. Zanskas 66

Rehabilitation in Workers' Compensation:A Growth PotentialBruce Growick 68

Rehabilitation in the 90'S and BeyondBarbara Greenstein 70

NRA Board of Directors/Staff Directors 71

Monograph order form 72

Mary E. Switzer (Brief Biography) 73

CM!. n chi 1402 Reproduction pi:mimed %%idiom pernu.mon (live credit to theNauonal Rehabilitation Associauon and ...end a copy to the Asociatton

4

Welcome from the National Rehabilitation Association

Spencer L. MosleyPresident,

National Rehabilitation Assn

1993's Seventeenth Mary Switzer Memorial Seminar Topic

1 "private Rehabilitation", continues this Seminar's tradition ofaddressing important contemporary subjects within the rehabilita-tion arena. Representative of the change that is constant in ourfield, private practitioners can provide options for people withdisabilities that offer a unique alternative, or solution, to theirrehabilitation problems.

As a comparatively new partner within the rehabilitation com-munity, private rehabilitation shares in the increasingly morecomplex business of providing evaluative assistance, vocationaldirection and employment alternatives to persons with disabilitiesseeking jobs and independence.

We know that the creative and insightful effort: characterizedby the developments and products of private rehabilitation willfurther expand the array of services available to assist all of us in

"enhancing the lives of persons with disabilities"!

Spencer L. Mosley

The Mary E. Switzer Memorial Seminar holds a special placein the history and tradition of the National Rehabilitation

Association. First, the Seminar honors a "grand lady" of rehabili-

tation. I wish I had known Mary Switzer. From her writings.biography, and stories relayed by those who did know her: I havedeveloped a deep respect for both who she was and what she did.Second, the seminar serves as the leading edge of rehabilitation

,owe. knowledge, policy, and practice. In addition. the Switzer Schol-

ars represent the best minds in the field, and this monographsynthesizes the current state of the art on private sector rehabili-

tation.

The National Rehabilitation Association is proud to sponsor

the seminar. I was honored and pleased to participate in this, the

seventeenth seminar. I pledge my personal support, and that ofthe organization, to transferring the knowledge brought forth in

Ann Ward Tourigny this document into practice.Executive Director,

National Rehabilitation Assn Sincerely.

COM Artiaiii

Ann Ward Tourigny, P1LD. CAF

5National Reludnlaaaon Assorsanon I493 Swa:er Monograph

The Seminar Sponsors

17th Mary E. Switzer Memorial Seminar and Monograph

The support of the following sponsors is deeply appreciated:

The Dole Foundation for Persons with DisabilitiesWashington. D.C.

E.I. DuPont de Nemours and CompanyWilmington, Delaware

National Association of Service Providers in Private RehabilitationAlexandria. Virginia

Nationpl Rehabilitation Counseling AssociationReston. Virginia

President's Committee on Employment of People with DisabilitiesWashington. D.C.

The Principal Financial Group Foundatioo, Inc.Des Moines. Iowa

Vocational Evaluation and Work Adjustment AssociationAlexandria. Virginia

UNUM Life Insurance Company of AmericaPortland. Maine

Rehabilitation Consultants, Inc., John W. Lui, PresidentBedford. New Hampshire

Jeffrey J. Peterson, CIRS, CRCSulphur. Louisiana

Dr. Carl E. Hansen, Past President, National Rehabilitation AssociationAustin. Texas

Charlotte Cohen & AssociatesBrooklyn. Minnesota

RJR Nabisco, inc.New York. New York

Elliott & Fitzpatrick, Inc.Athens. Georgia

/vv.? Sts wer Alonovraph Vatumai Reludnhtanon ANwn latto,6

The Seminar Host

Dear Reader:

Once again. the President's Committee on Employment of People withDisabilities is proud to have been able to support another edition of the

Switzer program.

This year's subject is especially important to all concerned withdisability policy. The papers presented and the discussion thatensued on worker's compensation and issues of insurance offertremendous insight into an area that needs to be better understoodand managed. My compliments to both the planners and partici-pants of this. the 17th edition of the Switzer Memorial Seminar,for a job "well done".

But, the story must not end here. The Switzer scholars workrepresents a departure point, not an end result. It's up to the restof us to take advantage of their scholarship and the scholarship ofothers and get involved in positive ways to help move the systemfoRvard so that people with disabilities are better served. Read thereport and better define how you can play a part in this importantchallenge.

Rick Douglas

The President'sCommittee onEmployment ofPeoplewith Disabilities

Richard DouglasExecutive Director,

President's Committee onEmployment of People

with Disabilties

Acknowledgements

The 17th Mary E. Switzer Memorial Seminar and monograph of the proceedings were made possible by a numberof people and organizations dedicated to the independence ofpeople with disabilities.

Appreciation is expressed to the following; Rick Douglas, Executive Director, and Justin Dart, Jr. Chairman,President's Committee on Employment of People with Disabilities (PCEPD), the host of this year's Seminar, PaulHippolitus, Director of Program (PCEPD); Spencer Mosley, President, NRA, Ann W. Tourigny, Executive Director,NRA, Ron Acquavita, Director of Communications (NRA), and the NRA staff who who assisted with the many

details of the Seminar and Monograph.

Gratitude is expressed to the Sponsors of the Seminar who helped make this memorial event a reality through their

generosity.

Finally, our appreciation goes to the Switzer Scholars for giving so freely of their time and expertise and whose ideas

are presented in this monograph. They have our admiration and thanks.

7National Rehabilitation Association 1993 Switzer illonovapli

At the Seminar

The 1993 Mary E. Switzer Memorial Seminar Scholars

if 4 MI VA.,-

1

taa.

Carl E. Hansen, Chairperson, Switzer Memorial Committee, Ann W.Tourigny, NRA Executive Director, and Mark Shoob, Deputy Corn-

missioner of RSA provide a welcome for the Scholars.

_111John Lui debates the issues on his paper Trends and Innovations for

Private Sector Rehabilitation. Len Perlman, Switzer SeminarCoordinator is in the background

Stt Alotio L;raph N(111011(11 RI /la bl tall(01 taflon

Committed to !Enhancingthe Lives oj Persons

with Disakilitiqs

BEST COPY AVAILABLE 4

Introduction

Carl E. Hansen

Chairperson,

Mary E. Switzer MemorialSeminar Committee

Leonard G. Perlman

Coordinator,

Mary E. Switzer MemorialSeminar Committee

As I look back over the colorinl. exciting. and productive vear.siiirehalnlitation. I tend to see the inspiranon and accomplishments in tetinc

tlw kinds of people. First the pioneers, the leaders, those whomic.eived of a national, and, in.fact. an international program that woulddeal with disability as a Indio,. cause of dependency and were pledged to

do something about it. Awl second, the group of gallant individualsgo)wing in numbers each year who thmugh their own aided by

the coullselor.s and often by services of rehabilitation agencies (nutlacildies, were able to conquer their disability, rise abore it. and in

instances turn it into an asset or opportunity to ,I;() beyond where theywould hare been had they not had this tremendous victory to achieve.

Mary E. Switzer

For the past eighteen y ears the NiaryE. Switier Memorial Seminars hio.e

kept the name of Ms. Switzer alive andhave also become synonymous with in-novati e rehabilitation practices. "rhcSwitier Seminar\ have pro\ ided a forumand think-tank approach to review ingtopics of major imp(wtance to the field ofrehabilitation and the persons set's ed bythis profession. Each year a small num-ber of persons I 8-21) are draw n fromeverts and consumers w ith interests andacciwriplishments in the topic under con-sideration for the seminar.

The 17th Sw itier focused on Reha-bilitation in the Pris ate Sector along w ithissues such as in \ urance. orkers com-pensation. etc.

The follow ing e cerpts of com-ment s/reco m men dot ions made bySss it/er Scholar, help to set the tone lotthe seminar and indicate the scope of thety pes of issues generated by the chapters

ritten e pressly for the seminar.

"Counselors entering tile pris ate secfiw!oust understand the pressure that w ill be imit

upon them by purchaser\ of their serv ices...Situations in real life issues impl that coun-selors must has e the con ict ion to stand up

fiwtheirethical beliefs. With regard to train-ing. not only should ethical standards be part

of counsekw training programs.cunicull1111design should allow students of counselingto know themsel ves and their ahility to with-

stand pressures from outside influences.

Estelle Davis

"Rehabilitation in the pis ate sectorhas indeed e perienced enormousgrow th and e pansion since its ineeptiim

Natowal Re hilbillhaleM 11,14 egifle,11

in the late 1960's. The foundation forsuch a mos ement has clearly found itsroots in the state-Weral programs thathad been in place for nearly' seventyyears. New funding sources. primarilythe insurance companies for compensa-tion programs. have required rehabilita-tion professionals to deliver sers ices innew and innovative ways for returningthe injured worker to jobs."

Tim Field

"Rehabilitation education appears tohe geared to prod LI ce professUmalsthe public sector. We need to ensure thatss e have a SLIPPI) of qualified profes-sionals for the pri5 ate sector and need toaddress the funding of rehabilitationeducation and curricula to achieve this...We w ill see increasing disersitv in thess ork force. One issue for rehabilitationw ill he the increasing need for bilingualor multilingual counselors. The agingss ork kwee will also create additionalchallenges terms of the range as \\ ellas the nature of disabilities."

Catherine C. Bennett

-It is s nal that rehabilitation profes-sionals pay particular attention to dis-ability managemetu. The effectivenessof rehabilitation programs depends onhow well the rehabilitation conn se lop,can pros ide set's ices. State legislaturesmay not he inclined to continite workercoinpensat ion rehahilitation pMgrams itthe public is not heing adequatelysers ed."

Ralph M. Crystal

inn ci., I Ilon,i;taph

Leonard G. Perlman, Carl E. Hansen

"The chapter by Dr. Gilbride discussesle various opport Lin ities that are avai abl. to

rehabilitation personnel, experts in disabilityand work as it relates to the Anierican's WithDisabilities Act t ADA ). life care planning.expert w itness testimony, li.wensic work and'disability management.' With these newroles and current changes. the roles of theparaprofessional and the rehabilitation pro-essional needs to be clearly defined. The"ail-ling needs of those working or planning) work in the private sector need to beIcorporated into rehabilitation educationwograms."

Jeanine C. Johnson

"Ms. Owens in chapter three suggeststhat there is an important role for rehabili-tation professionals in disability manage-ment. Clearly. there is overlap betweenthe mission of vocational rehabilitationand purpose of disability managenlent.The field of rehabilitation needs to lookclosely at thL type of skills and expertiseit can provide to employers and insurersto facilitate reductions in injuries. promptand effective medical and vocational re-habilitation, and swift return to work."

Dennis Gilbride

Citing the ADA, Health Care Reform,Twenty-four hour coverage and SocialSecurity Reform as four change-agentsinfluencing disability management. Ms.Owens (in chapter three) identifies anunstable, concentrated and turbulent or-ganizational environment. She correctlystates that rehabilitation professionalscan shape the field and the field of reha-bilitation will be shaped by these agentsof change...Perceptive rehabi 1 itat ion pro-fessionals that efficiently observe. ana-lyze. and process the changes in theirenvironment will prosper. In a field al-ready recognized for demands of ac-countability. the documeination of both"hard" and "soft" case managenient sav-ings appears crucial."

Stephen A. Zanskas

The above excerpts pros ide a richcross-section or the ideas and criticalissues discussed ond debated at thethree-day seminar. It is obx ions that the

debate of these issues will continue.hopefully stimulated by the informationcontained in this monograph of the 17thSwitzer Memorial Seminar.

Our inuuduction ends with a quote by oneof the Switzer Scholars. It is both a wzullingand a challenge with a strong suggestion orwhat the field of rehabilitation needs to do as

we prepare for the 21st Century.

Our first task in phutning for aw nextcentury should be to find out if we are atriNk fen. evelt laTiring, (Ind if 50, 10 what

deg ree:' Our planning. ethu.ation, serv-ice delivery, and all the other elenumtsthat comprise what we presently think ofas rehabilitation counseling as a proles-Sion will Imre to take these findings into«mcidel:Ition. btu hopefully in a proac-tive and coordinated .Ishim in ways thatwill be nett. to us all... We are the bene-ficiaries of the work ql flu' giants of ()In-field, like Mary Switzer, persons who didnot wait jOr the bemfit of rehabilitation,That is our challenge, and one which Ibelieve we must meet to assure our sur-viral in the years to come.

Phillip Bussey

It is the hope of the Switzer Scholarsthat the ideas and recommendationsfound in this report will be used to stimu-late thinking and action as we strive toimprove services to persons with dis-abilities.

Background andPurposes of The Switzer

Memorial Seminars

The Mary Switzer memorial semi-nars, a program of the National Rehabili-tation Association (NRA ). is designed tobring together a small number of expertsin the area of rehabilitation that is thefocus of each year's seminar. The expertsare designated as SWITZER SCHOL-ARS by certificate, and this recognitionhas become a significant and prestigiousachie ement for persons interested in vo-cational rehabilitation, both nationallyand internationally. The end-product ofthe three-day program is a publishednlonograph of the pn)ceedings. includingrecommendations and iinplications foraction ill areas such as research. program

NV" Sti Wel Abinot;mrli Nallonal Rellabilthilton .111Ih talton

1 0

and policy development, training andlegislative needs. The format of themonograph is designed for ease of use bycounselors. consumers. educators. pol-icy-makers or anyone interested in theindependence of people s ith disabilities.

The seminars are a living memorial tothe late Mary E. Switzer. one of Amer-ica's foremost leaders and trailblazer forinnovative programs at the national.state, local and international levels forthose persons with a disability.

The Switzer Memorial Committee ofNRA was started by colleagues and friendsof Mary Switzer. including key members ofthe U.S. Congress. Secretaries of the U.S.Department of Health. Education and Wel-fare. the Department ot labor. private citi-zens and of course. NRA members.

The CurrentSwitzer Seminar

The 17th Mary N. Switzer MemorialSeminar was held in Washington. D.C.on June 2-4. 1993, and was hosted thisyear by the President's Committee onPeople with Disabilities (PCEPD). Wel-comes were provided by Justin W. Dart.Jr. Chairman, (PCEPD):Ann W.Tourigny. N R A Executive Director, CarlE. Hansen, Chairperson. Switzer Memo-rial Committee (NRA ) & Mark Shoot).Acting Deputy Commissioner. Rehabili-tation Services Administration (RSA ).

Planning For Tile Seminar

The Switzer Planning Committee metin Washington. D.C. in early January .1993 and developed the objectives of the17th Switzer Memorial Seminar and pro-vided the format and subtopics to serveas a foundation for the seminar. The sub-topics served as M basis for the discussionand debate that have become the hall-mark of the Switzer Memorial Seminars.The subtopics are now listed in the tableof contents as chapters in this mono-graph. The chapters were sent in advanceto the Switzer Scholars for their review.critique and preparatitm prior to theseminar. Selected comments and recom-mendations made by the Switzer Schol-ars are also found ill this text. In addition,"Special In ited papers" are in the Mono-graph following the main chapters.

The Switzer Scholars

Catherine C. Bennett Phillip Bussey Ralph M. Crystal Estelle DavisPrincipal Financial Group Bussey, Davis and Assoc. University of Kentucky Bussey, Davis and Assoc.

Des Moines, Iowa Lanham, Maryland Lexington, Kentucky Lanham, Maryland

4-44111111pv

Toi,, Davis Tim Field Juliet H. Fried Dennis GilbrideCharlotte Cohen & Assoc. E & F Vocational Services Associate Professor- Drake UniversityBrooklyn Park, Minnesota Athens, Georgia Greeley, Colorado Des Moines, Iowa

Barbara Greenstein Bruce Growick Jeanine C. Johnson John W. LuiUNUM Insurance Company

Tarrytown, New YorkOhio State University

Columbus, OhioIntracorp

Itasca, IllinoisRehabilitation Consultants,

Inc.,Bedford, New Hampshire

.\atnnial Rehabilitation A 1 co, nmon

11NO \II It. et It011m:lapil

1993

I.

, 9 S r

Patricia NunezContinental Rehab.

Resources. Inc..Piscataway. New Jersey

Patricia M. OwensUNUM Insurance Company

Brooklyn, New York

Jeffrey J. PetersonSuiphur. Louisiana

Ed SteffanEPS Rehabilitation Inc.

Tinley Park, Illinois

Daniel M. Thomas Mary Vencill Jackie Wilson Stephen A. Zanskas

Health Ins. Assn. of Amer.Washington. D.C.

Berkeley Planning Assoc.Berkeley, California

Wilson Associates,Montclair. New Jersey

Crawford & Co.Green Bay. Wisconsin

Dora TeimouriRSNOSERS

U.S. Dept. of EducationWashington. D.C.

Pov Stt it.. wri,vr.iph

17th Mary E. Switzer Memorial SeminarPlanning Committee

Phillip Bussey, Bussey, Davis & Associates, Lanham. MD

Ronald Conley, Pelavin Associates, Inc. Washington, DC

Estelle Davis, Bussey, Davis & Associates, Lanham, MD

Wesley Geigel, Electronic Industries Foundation, Washinton. DC

Barbara Greenstein, UNUM Insurance Company, Tarrytown. NYRichard Lawrence, University of Maryland, College Park. MD

John Nelson. Rehabilitation Services Administration, Wash..DC

Patricia Nunez. Continental Rehabilitation Resources, Inc.Carl E. Hansen, Chairperson, Switzer Memorial Committee, Austin, TX

Leonard G. Perlman, Coordinator, Switzer Memorial Seminars. Rockville, MD

Ann W. Tourigny, Executive Director, NRA

Vattoruil Rehabili (anon .1% 0( hits(111 1 2 al COM MIAMI

Chapter One

Development of Rehabilitation inBusiness and Industry: Implications forRehabilitation Counselor TrainingRalph M. Crystal

The focus of the paper will encompass the devel-opment and growth of rehabilitation in businessand industry with a particular emphasis on theimplications for the training of rehabilitation

counselors. "Ihe first part of this manuscript includes anoverview of the development of rehabilitation in businessand industry. The second part of the paper will present anexamination of issues regarding worker compensation andbusiness and industry as these relate to the training ofrehabilitation counselors.

Historical Origins

Pressures to develop worker compensation programsincreased with the shift from an agrarian to an industrialsociety in the late I 800s. Prior to this time the family andthe extended family were viewed as the social supportnetwork. With the move from farms and rural areas to cities.the family structure was less able to provide for the needsof its members, particulatly those who became incapacitatedthrough injury, disease, or disability. The growth of indus-tries and cities led to urbanization and a shift in the supportsystem from the family to the community at large.

Before worker compensation laws were passed an in-jured worker had to prove employer negligence before beingable to ohtain medical services and financial relief. A cis illawsuit could he an expensive and drawn out process for aninjured worker. The ability of an employee to win a civillaw suit was reduced because of (a) possible contributorynegligence. h) negligence of a Co-worker, and (c) theassumption of inherent risks in a job. However. ultimately

Rolnh . . Rob11)1111,1110n Loonsehm: Pc

ol kentock. I e Ington. hentuck

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the social concern for an injured worker lead to the passageof worker compensation legislation.

The legal principle of worker compensation is liabilitywithout fault. The costs of work related injuries were to heallocated to the employer not because of presumed fault. butbecause of the inherent risks in industrial employment.White (1983) describes the purpose of worker compensationto "help workers survive the economic effects of workaccidents and at the same time limit the financial liabi litv ofemployers for those accidents" (p.59). Sink and Field ( 1981)

state that worker compensation laws were designed to pro-vide employers Immunity from prosecution.

Workers compensation evolved as a program developedand administered by individual states. The federal govern-ment has also des eloped a rehabilitation program w hichcovers federal employees. This is in contrast to the publicrehabilitation program which is supported by national leg-islation and public tax monies, and is similar throughout thenation. Worker compensation developed as an indiviuualstate program and is viewed as a program that is bestmanaged at the state level to respond to individual circum-stances in each state. For example. differences in states callfor different types of worker compensation programs.

States that have large populations and industrial baseshave different needs than do states with small populationsand an agrarian and service industry base. Therefore, workercompensation rehabilitation developed in response to localstate issues. Alsc at the state level local industries, busi-nesses. and labor unions can have a greater voice in workercompensation legislation than at the national level.

Despite differences in worker compensation programsall have certain common themes. According to Weed andField (1986) these include the following: (a) to provideprompt and reammable income and medical benefits for

Natumal Rehabditalum i c sac mum 1 3 /(19? Sit 11,:cr ifimoeraph

work related accidents regardless of fault. (h) provide asingle remedy and reduce court delays, costs, and workloads arising out of personal injury litigation, (c) relievepublic and i)i'k ate resources Of financial drains, ((1) elimi-nate payment of fees to lawyers and w itnesses as ss ell astime consuming trials and appeals. (e) encourage ma \ imum employer interest in safety and rehabilitation, and (1)prompt the study of causes of accidents rather than con-cealment of fault.

Rehabilitation is included among the intentions of workercompensation legislation. White (1983) describes this benefit as

designed to aid the partially disabled employee in Finding a new

trade or %ocation so that he/she can again be a productive citizen.

Although \ ocational rehabilitation is among the original goals of

worker compensation. many states still do not mandate or pro-

% ide for the % ocational rehabilitation of injured workers (Weedand Field. I986).

Another lino tilde\ elopment in proprietary rehabilitationprograms to the inclusion of long term disabilitypro\ isions as a benefit of employ ment. With only a fewe \ceptions. all employers are required to maintain workercompensation co% erage for their employees. With longterms disability there is no such requirement. Typically .larger employ ers ale 'none likely to oiler a long termsdisability benefit as a past of the employee benefit. package.

..ong term disability co\ erage is for non-w ork related dis-

ahling health problems.

With thk tspe of Polie. the in-'enti e to return a "orkerto employ mem is to minimize the costs asswiated ith

lid\ Mein', for disabi lit \ \\ hen the cos ered indis idual is notorking. This is especially the case if the individual is

unable to perfOrm his/her prior \\ ork because of the Innitations resulting from the impairment. From the perspectis eof the in.nrance company it is to their ads antage to returnthe ssorker to employ ment so benefits can be discontinued.The benefits and cos erage of this ty pc of insurance ss ill sar'ruin policy to policy . Although Insurance of this kind is

regulated in general by each state, the specific benelits andlimits of the cos erage is not.

Another area of disability benefits relates to personalinjuries such as might occur through automobile accidentsand slip and fall injuries. In many instances obtainiq2 reha-bilitation beneljts requires the injured indis idual to gothrough a litigation process. With hoth personal injury andlong term disability the ad\ antage returning the injuredperson to employ ment can result in reduced costs w ithregard to lost \sages and lin UR' 110550 of the Unpairment to

earn money . Flic defense in a litigation can make a strongercase 1.01 nnnimal s% age and es en future medical damages if

the injured indis idual is ssoiking rather than sitting at home.

The Development ofProprietary Rehabilitation Programs

the rise of proprietary rehabilitation program. is closely

linked to the concept of return to ss ork programs. In the late19W. insurance companie. began deselopnw and utilizingtins ate rehabilitation companies to assist ss ith medical case

management imd ocational rehabilitation programs. Insur-ance companies discovered that these private firms couklreduce costs to the company because of their emphasis ongetting the employee back to work as soon as possible. Areturn to the same job. or short term retraining and direct joltplacement in the same or similar job was emphasized.

In 1970 the Federal Occupational S lety and Health Act(Pt ,-596 ) V, as passed. In addition to its other pro% isions, this

legislation called for the creation ()la National C'onunissionon State Worker's Compensation laws. Several recommen-dations related to emphasizing vocational rehabilitationwere included. Conley and Noble (1978) note that a federalinterdepartmental po..cy group ss as formed to study thereconnnendations. Again, vocational rehabilitation wasgis en a strong emphasis.

l.ynch, I nch. and Beck 11992) obsers ed that sks rock-

eting medical and compensation costs to injuredzind expenses related to catastrophic injuries ha se spurredinsurance companies and employers to re\ less possibleway s to contain costs and to has e more connol user reha-bilitation outcomes ( particularly return to w ork ). St nue largecorporations has e responded w ith extensise safety pro-grams, employ ee support sers ices, on site medical manage-ment, health promotion. and case management sers ices.

'llese same Ixtors have led to the des elopment of proprietary

praetice in other areas of insurance. Thus. rehabilitation profes-

sionals now work in personal injury case. automobile accidents.

and long term disability. It is itot uncomnion for rehabilitationprofessionals to be ins-Ns ed with a variety clients front differentty pes of insurance. In fact. any time an issue of a peNons'employability is raised the rehabilitation professional may becalla! upon to render an opinion.

Another factor that has led to the growth of the pHs aterehabilitation sector has been the emphasis in the publicrehabilitation program on clients ss ith se..erePublic programs emphasize developmental disabilities.transition. supported employ Mem. and independent li% Mg.While the goals of public and private programs are similar.the procedures and techniques utilized are different. ln fact.in many instances these two pnigrams work uigether tosers c clients. This cooperati \ c planning has been utilized tofacilitate the ultimate return to ss ork potential kir the client.

In public rehabilitation programs many clients ha\ e de-s elopmental disabilities or disabilities that de% clop ss ith agradual onset. 'Ms is in contrast to \stinker compensationrehabilitation ss here the primary disabilities relate to back.hand. and knee impairments. Pain is frequently a componentof an injured workers' disabling condition. These types orinjuries are alO common in personal injuries and On occa-sion with king term disability .

Similarities and DifferencesBetween Proprietary and Public Rehabilitation

In general Ille goal of proprietary rehabilitation programsis to help the intik idual return to a prior or related les el ofmational. phy sical and/or mental functioning. This may

also include monetary pay ments to compensate for lost

Reh,1011,111,4,1 haw/ 4 If,

phy steal function and lost w ages. This is similar to theinsurance concept of' replacement of \ alue as occurs in otherfonus of insurance such as automobile. hotneow ners. andbusineY, policies. The person who incurs a loss', in eitherworker compensation or other forms of' insurance is entit ledto a tvplacement for that loss either through a similar item(another car if one w as totaled in an accident, or a job in

orker compensation I. or a cash pay men( (ii an item cannothe replaced such as stolen jew elry ).

The concept of worker compensation is similar to otherforms of insurance in that a person is not entitled to an itemof greater (or lesser) value than the one that was lost. So ifa person has an automobile accident, that indix idual isentitled to an automobile of a similar value. If a person hasa work injury he/she is entitled to another job (comparableto the prior job). or if that does not not occur than monetarypay ment to compensate for the value of the function that w aslost is provided.

This is in contrast to the puhlic rehabilitation program.Clients served by public rehabilitation programs are ex al u-;fled to determine the most appropriate rehabilitation out-come regardless of past employment or experience. This hasbeen translated to mean asssiting the client to attain hk/herfull potential considering the resources of the agency and areasonahle expectation for success.

Although not intended. worker con ipensation programscan become adversarial. For example, there can be disagree-ments regarding the entent of disability of an injured workeras w ell as the contribution of pre-existing factors to thedisablinucondition. In public programs there is not typicallydisagreeinent reagrding the medical and psycholt)gical con-dition. In worker compensation program it is typical to haveseveral medical. psychological, or vocational reports. ()nenthese has e contradictory conclusions. It is unusual in publicrehabilitation to have a diversity of reports.

In many instances clients in public programs do nothas e a work history. In all instances clients in workercompensation and long term disability programs havebeen employed. It is not uncommon for a worker compen-sation client to ha e worked for many years at a manuallahor occupation. When the injury occurs it may be diffi-cult for the person to return to the job because of a senseof being worn out, even after the person has recov eredmedically to the injury.

Worker compensation clients frequently w ant to hecompensated for their injuries and loss of function prior toparticipating in a rehabiltation program. In some instancesthe injured worker feels that he/she is disabled and unableto w ink and is uncertain why vocational rehabilitation isbeing undertaken. It is the exception in the public rehabili-tation program not to w ant the sers ices being offered. Thisis not to he confused with resistence on the part of theclient. At times there are even ironic situations in workerconpen sat ion . As an example, a self employed w orker mayhave to file a worker compensation claim against him orher self through the insurance carrier for benefits. Theperson may even experience difficulty collecting.

The nature of the disahility causes different issues whichthe rehabilitation counselor must address in a counselingcontext. In v, orker coinpensation the counselor deals withthe client and the nature of his/her injury. Feelings relatedto the employer and the nature of the job are often the focusof counseling. In public rehabilitation programs there is notalw ay s a specific incident or situation 5; hich led to thedisability . With developmental disabilities the client has hadthe disability since birth or during the dev elopment al years.

Disability in proprietary rehabilitation can cause tremen-dous dysfunction and dislocation. This also becomes an areafor the rehabilitation counselor to focus on in counseling fora return to work. The injured and disabled worker may' hemarginally literate. At the time of the disability that personmay he earning a salary that Ile/she would be Unable to earnwithout the physical ability to perform the work. Thus.issues of self-esteem come into plav. The injured workerinay be reluctant to enter a joh that pays at the minimumwage. He/she may feel (and rightly so) that this is not enoughmoney to support a family. School may not he appropriatebecause the individual may not he prepared for the demandsand expectations of an academic program.

Rehabilitation counselot., in proprietary programs face anumber of ethical issues. One issue that comes up on afrequent basis is who is the client? Is it the person with thedisability who is being served or the person paying the fee.Counselors are taught to advocate for their clients. How ever.the extent of advocacy maybe limited if the counselor is tolddint the case will be assigned elsewhere if the requestedservice is not provided. The insiirance adjustor is not anotherrehabilitation professional. Many times the rehabilitationcounselor expects that individual to have a human SCI's iceorientation. The reality is that the adjustor has been trainedin insurance. not counseling.

AS is evident the source of fiinding in public and rropnetaryprograms differs. The public program is financed by tax dollars

hereas proprietary programs are financed by tut mey fromworker compensation. long term disability. and other forms ofinsurance. However, public and ptoprietary rehabilitation WW1-

selors are encouraged to identify third party sources of fundingto pay for services. In some instances this can include insurance

or public rehabilitation programs.The public program is an eligibility prognun. All persons are

entitled to an evaluation of rehabilitation potential and possiblyservices. In contrast, proprietary rehahilitation programs amentitlement programs. A person has to have a work related injury

or other injury covemd by the insurance policy in order to receive

services. This set-ves to limit the persollti ho can be sersed by

insurance rehabilitation progrants.Insurance rehabilitation typically has two types of pro-

fessional providers. Although different, their roles may attimes overlap. Rehabilitation nurses are used as an extensionof the insurance company for medical management and totnonitor the persons recovery from the injury or disability.Rehabilitation counselors have a role similar to that whichthey have in public rehabilitation programs. That is to pro-s ide vocational rehabilitation services. Thus, the rehabilita-

15Notional I?,/um/',I, tmi, 1 %Am tatom Sit A/WWI:tap/1

t ion counselor takes the medical and phy sical functioning ot'the client and relates this inicwination to educational and

ocational data and then recommends a rehabilitation pri)-iiram for the client within the guidelines of the 1k orkercompensation legislation.

An emphasis is placed in proprietary rehabilitation inplacing the disabled or injured worker hack with the samecompany and a similar or related job. This may not hepossible in the public rehabilitation program if there is notan employ, er for the person to return. The rehabilitationcounselor v. orks closely with the employer in the return towork process in proprietary rehabilitation programs. Thereis usually a reliance on work hardening and conditioningprograms to help the injured worker regain the stamina andphysical conditioning necessary for a return to the job. Thecounselor relies on an assessment of residual and transfer-able vocational and work skills. Job placement is empha-sized in both public and proprietary programs.

The public rehabilitation program is a national program.Although there are some variations in different parts of thecountry to accommodate differences in client populationsand geographic needs, the program is essentially similar inall states. I3y contrast, worker compensation, long term

ity. and ot her insurance rehabilitation programs differby stale and ek en within states. As pre\ iously indicated.worker compensation programs are supported by legislationin individual states. In addition, with only a handful ofexceptions. the worker compensation program within a statewill differ depending on the interpretation of the workercompensation carriers in the state. Consequently. eachworker compensation carrier may have a different perspec-

e on the worker compensation legislation in the state. Itis difficult for states to monitor these differences because ofthe large number of cases and the relatively small workercompensation staffs maintained by states. Also. frequentchanges in legislation make enforcement difficult. Withlong term disability and other forms of insurance the natureof the particular policy dictates the services offered.

The Americans With Disabilities Act (ADA) may havea positive impact on the return to work of persons withworker compensation injuries. By specifying the essentialfUnctions of a job the injured worker can determine whetherhe/she is qualified to perform a particular job. This will bebeneficial for workers who have physical work restrictions.Employers may view the ADA as an avenue to employ theinjured worker without the fear of the person being reinj tiredif he/she is given a task beyond his/her physical capabilities.

Future Developmentsin Proprietary Rehabilitation

A common denominator of all rehabilitation programs isthe fact that they have some kind of medical coverageattached to the services provided. In public rehabilitationthat medical provision can extend to all areas in which theindividual may need assistance with in order to enter the

orkplace. In proprietary rehabilitation the coverage relatesto the specific problem for which the insurance is to cos er.

Flow both public and proprietary rehabilitation programsfunction may change in the future if national health insur-ance provides cm erage for conditions otherwise covered bythe medical benefits of public and proprietary rehabilitat ion.At least two directions are possible. one of which NA ill haveproknind effects on rehabilitation service in all areas. Onedirection would be a continuation of the present proceduresof medical coverage which are dictated by the first dollarconcept. For example. in a worker compensation situationif a medical service is provided by national health insurancethere may be an attempt made to recover the cost of theservice from the worker compensation carrier. A publicrehabilitation counselor may attempt to recover moniesspent on medical services if the individual is a long termdisability client. This is the familiar concept of utilizingsiinilar benefits.

The more dramatic approach would he a second option.In this option all medical coverage from all sources wouldbe folded into the national health insurance umbrella. Thus.medical benefits available through public and all forms ofproprietary rehabilitation would be provided through na-tional health insurance. This may even be extended to themedical provisions of social security, public assistance.medicare. and medicaid. The impetus for this would be tohave a greater pool of' funds available to provide medicalcm erage. Another advantage would he to place under one"policy" all of a persons medical needs and eliminate costsand duplication of services.

Such a move would have a major impact and a redirectionof the dollars allocated for the medical provisions of publicand insurance rehabilitation programs. It would minimizethe need for rehabilitation programs to determine the natureof the medical services required for clients and consumers.That function woukl be separate and distinct from the reha-hi itat ion program.

Another outcome would he a blurring of the lines be-tween public and proprietary rehabilitation. With it nolonger necessary for the rehabilitation counselor to deter-mine the appropriate rehabilitation medical services forwhich the individual is entitled, the counselor would be freeto concentrate on vocational rehabilitation efforts. An ex-tension of the concept whereby medical benefits are foldedunder the umbrella of national health insurance would be tochange the nature of how rehabilitation counseling servicesare provided. In public rehabilitation programs the coun-selor is an employee of the state. For the most part in privaterehabilitation the counselor is an independent contractor. Amerging of these two positions would place all rehabilitationcounselors on a contractual basis as in the usual case withother professions. The certified, qualified. or licensed coun-selors would then be free to provide service to a client fromany rehabilitation area. Some might choose to specialize inpublic rehabilitation. Others might select to specialize inpRiprietary rehabilitation. Still others might serve all clients.

This would be a radical approach to rehabilitition coun-seling service provision. However, it may be a logical ex-tension and e,.olution to the role of the rehabilitation coun-

/9)t Sti II:cp Mottot,',Orif .k 1,18 12

selor if the medical henetits for all rehabilitation programsare placed under national health insurance. 1:\ en if cuninsel-ors do not become independent contractors in all areas ofrehabilitation, changes brought about 11., national healthinsurance may have profound effects on how rehabilitationserviees are provided.

Implementation of CurriculumComponents Related toBusiness and Industry

Me second part of this paper %k I focus on rehab; I; tanoncounselor education curriculum issues related to workerc()inpensati(m rehabilitation.

Several suggestions for the inclusion of worker compensation information in the curriculum will be ided. I ler-shenson i988) noted lhat rehabilitation counselor educa-tion has shiked its curriculum and focus to conform tochanges in federal policy as a means of gaining lederaltraining funds. I le states that these changes have jeopardi/edthe identity and status of rehabilitation counseling as anindependent pmfessio

labeck and Ellien 1988i suggested that a \ ariety of trend\ha\ e contributed to the de\ elopnlent of disability managenientpn)grams in indusny In a review of the task force recommenda-tions for rehabilitation counselor education made by the NationalCouncil on Rehabilitation l'.ducation and the National Associa-tion of Rehabilitation Professionals in Pulsate Practice. \lc la-lion and Nlatkin I 98.1i noted substantial medal-) and agreementcurt ke \ issues.'lliese include philosophy placement medical andpsychosoeial aspects. and \ ocational and personal adjustmenttraining.

Rehabilitation CounselorEducation Curriculum Issues

lershenson (1988) noted curriculum de \ elopment nirehabilitation counselor trainiii z.. pmgranis has been shaped

espectations for practice in public progruns. This hasbeen a function ot" training monie \ being made asthe lederal go\ eminent to unk ersit \ rehabilitation educa-tion programs. I le questions w het her this places in jeopardythe independence of the rehabilitation counseling pi-tires-sion. I Icusseser. a, McNIalion and Matkin I 983i note theseis nurch Os erlap in the training needs tOr counselors w hoobtain employ went in public and proprietary rehabilitationprograms. Although the clients may has e different disabili-ties, the basic concepts. approaches. theories. and met Rini-°logics are si nilai Ihe basic goal. the return to w ork andeconomic self-sullicienc \ of persons w ith disabilities isshared lw both pnigrams.

Curriculum areas such as medical and psy chologicalaspects of disability . \ ocational assessment. case manage-ment. job des elopment and placement. counseling skills,and independent i \ ing arc required for practice III all aspectsol rehabilitation counseling. Where there are differencesthese can be accounted for hy different disabilik groupsbeing sersed and diflerent strategies bring practiced. The

underlying know ledge and skill competencies reinaM thesame wherever the rehabilitation counselor practices.

Rehabilitation CounselorEducation Practice Issues

The rehabilitation counselor does not need to make aneither or choice: Either you NA ork for a public program oryou work for a proprietary program. In fact in some statespublic and proprietary programs w ork cooperatively . In anumber of instances a special unit has been designated towork e clusis el ss ith worker compensation clients. Inother states each pflugrain uses the other as a similar benefitresource. In other e\amples. the state w orker compensationpr()grain recommends that injured \\ orkers he referred to thepuHic program for rehabilitation ser\ ice. The relationshipbetween the public and the proprietary prograin does notnee(.I to he adversarial.

Implications for Trainingof Rehabilitation Counselors

The literature reflects the finding that high les els ofeducation correlate w ith attainment and prolessionalcompetence. There is commonality in the training require-ments for rehabilitation counselors employed in public andproprietary rehabilitation programs. Thus. it does not appearthat an entirely new or es en a distinct curriculum needs tobe des eloped for the training of rehabilitation counselors to

ork iii pioprietary rehabilitation practice. Many rehabilitation education programs has e curriculum componenrsss Inch relate to proprietary rehabilitatiim. These includediscussions of worker compensation. disability manage-ment. occupational medicine, and disability areas whichincorporate head inj Ur\ . drug and ak ohol, and orthopedicinipairment s.

At the present time many graduate \ of rehabilitationeducation programs select to enter proprietary rehabilitationpractice. In other instances the career pattern of rehabilita-tion professionals reflects job change from and to public andproprietary practice. This implies that the basic trainingrecek ed Iu rehabifitation counselors in masters les el train-ing programs is adequate and appropriate for practice in a\\ ide range of professional setting :ind conte \is.

Recommendations forRehabilitation Counselor Training

The \ iabdity of a discipline depends. 111 part. on theprofessional training of practitioners and the commitmentof lick! personnel to employ skilled professionals. Publicehabil nation programs w hich are federally funded are able

to basically speak w Ulm one \ ()ice because (il the relatiselycentrali/ed nature of the source of funding for the majorityof public programs . liy contrast. proprietary programs arego\ erntAl by legislation in each \tale and by the independentnature of service priw iders. 'Illus, it ss mild appear to be moredifficult lot proprietary programs to articulate training needsand to pro \ ide incenfis es lo students for traminr and em-ploy els for hiring graduates.

17\an( .,111 16 /What/WPM t s HUN p).;: rt ci 1/0mq,./rh

Se \ cral approaches arc possible to enhance the trainingof rehabilitation c(mnselors for service in proprietary pro-grains. First. the competencies needed bx ctmnselors \\ hoenter this area of practice can he limiter refilled. This canhelp rehabilitation counselor education programs determinethe extent to \\ hich they train counselors l'or proprietarser\ ice. Second. scholarships for training and paid intern-ship, can be offered. Third. a national registry of emplo-ment opening and positions can he dex eloped and inain-tained. Fourth. chapters of professional organiiations at thelocal le \ el can communicate w ith rehabilitation educationprograms in their geographic region to discuss trainingneeds. These and other steps can enhance communicationand facilitate (he placement of rehabilitation educationgraduates in proprietary progranis.

The training of rehabilitation counselors for public andproprietary programs does not ha\ e to be a mutually exclu-sive acti UN.. Much similarity and 0\ crlap already existsbetxx een these tw 0 programs. It is the desire of rehabilitationeducation programs to maintain their independence andthere ftwe accominodate the training needs of all constitu-ents. This can be facilitated by communication and a sharingof ideas and information.

Implementing a Business-IndustryEmphasis in the Curriculum

'Me inclusion of material in the rehabilitation counseloreducation (RCE) pre-service curriculum on business andindustry has recei \ ed increased attention in recent sears.Roth the National Council on Rehabilitation Fducation(N('RF) and the National Association of RehabilitationProfessionals in the Prix ate Sector (NARPPS) establishedtask forces to explore the training needs for rehabilitationprofessionals xx orking i n proprietary rehabil itat ion. The Re-habilitation Serx ices Administration ( RSA) has expectedRCl . grant applicants to demonstrate how their programsi Iwo! porate training in business and industry . orkers' com-pensation and job placement w ithin the curriculum. In fact.RSA has encouraged programs to place students in businesssettings for their practicum.

s pre\ imsly described, ser\ ices offered in the public prograin ha \ e as their goal the maximi/ation of the client's potential.

In t he proprietary sector the goal is the return of the injured \\ orker

to employment at a loch commensurate \\ ith the pre-disabihtxloch of functioning ( Matkin. 1982). N1cMahon and Matkin

1953) indicate that the most persistent and strongest suggestitm

in the N('RF. and NARPPS reports cimcerns an increased em-phasis Oil job placement skills.

NleNlahon (1979! states that in addition to the tradi-tional curriculum. students interested in proprietary reha-bilitation should take elect i \ e courses co \ ermg labor inar-ket trends and job analy sis, Insurance contracts and pratlices, workeis' compensation legislation. and the manage-ment of ethical conflicts. Sales iind Risse \ 1979 rtcommended that the follow ing areas of know ledge needed tobe added to the RCh. curriculum: (at \\ orkers compensation. (b) basic concepts of instil ;ince. it.) the legal and tree

\ 11

enterprise sy stems. and (di legal and medical case man-agement.

I. itch and Martin ( I()82) reported the results or a sur\ eyof NARPPS members in which respondents were asked toidentify skill and know ledge areas considered imp(wtant lOreffecti \ e pro\ Rion of rehabilitation ser\ ices in the proprie-tary sector. The areas rated as most important tended to beof a tangible skill-based nat the and geared more towardasev,ment and outcome acti \ it ies such as placing a clientinto employment as opposed to process acti \ ities such ascoordination of services.

Developing Business andIndustry Curriculum Components

With regard to zuldressing the potential work ril cs, em-ploy mem sites, and expected cornpetencies or graduates.rehabilitation counselor education programs are confrontedxx ith the dilemma as to whether (a) the current curriculummeets this need. ( b ) the curriculum basically meets this need.

ith minor modifications to the coment and structure ofsonic courses, or (c) an entirely new couNe is !teethed toaddress these issues. In the Graduate Progmin in Rehabili-tation Counseling at the University of Kentucky the following actix it les ha\ c been undertaken to determine the needfor coursew ork related to business and industry .

After obtaining information from practitioners and pro-fessionals a determination was made of the core know ledg,:and 5kill competencies required to eliectively function a, arehabilitation counselor in business and industrx . The fac-ulty then reviewed the current course offerings to determine(a) \\ here there was oxerlap in course material. (h ) hen:

there .),, appropriate materials. but the emphasis ictightneed to be changed for business and industry. and (c) xx hetthere w as no material ()tiered in this area.

Ihe results of this process indicated that for the most partthe curiculum already contained material for business andimlustry practice. 'flue major difference xx as the emphasisgiven in class lectures and discussions. Not included. butneeded in the curriculum was information about workers'compensation legislation and philosophy . liability and autoinsurance. personal injury proprietary rehabilitation sy s-tems. orking xx ith other professionals. and pro \ iding ex-pert testimony . Course content related to medical aspects ofdisability . \ ocational e \ aluat ion. consultation w ith employ -ers, and job placement xx as pFeellti included in the

but w ould need to he modified to acconimodate prac-tice issues in business and industry rehabilitation.

t 'Pt in further review and reflection it xx as determined thatrather than modify and add new material to existing courses,a new course co\ ening business and industry related topicsshould be dex eloped. Such an appt oach would ha\ e theadded benefit of including a review of reports by treatingphy sicians. transcripts of depositions, and issues related toactual rehabilitation practice as part of a class that otild bedirected pi imarily to these topics. This course w ould be theprimary -home" ror curriculum components relaml to busi-ness and industry .

, 1 8.,.111411,11

Implementing a Course onBusiness and Industry Rehabilitation

The course on business and industry rehabilitation wasdesigned to incorporate issues in both public and proprietaryrehabilitation. The course includes the following topicalareas ( a) philosophy of business and industry rehabilitation.(h) review of different systems in proprietary rehabilitation.(c) overview of disabilities frequently encountered (d) as-sessment, planning. and process issues. le) residual andtransferrable skill assessment as well as the use of comput-erized joh matching programs. (f ) consultat ion with employ-ers and job placement, (g) working with claimants, insur-ance companies, attorneys, physicians, and nurses. (h) vo-cational expert testimony and (i ) ethical and legal issues.

Summary

The parallel de \ elopment of public and proprietary reha-hil itat ion programs has led to the utilization of rehabilitationcounselors in both sectors.

Traditionally rehabilitation education programs ha\ ebeen supported by the federal government. There has beensome concern that rehabilitation counselors trained in theseprograms have not worked in the public program. but havebeen recruited by proprietary rehabilitation programs. It isevident that both public and proprietary rehabilitation utilizesimilar techniques and approaches. There is overlap be-tween the expectations of public and proprietary rehabilita-tion practice. Changes resulting from national health insur-ance may ha\ e profound effects on how rehabilitatiou ,erv-ices are provided in all areas of prokssional practice.

References

Conley. R.. and Noble. .1., Jr. (1978). Worker's compensa-tion reform: Challenge for the 80's. American Rehabili-tation. 3(3), 19-28.

laback. R.V.. and El lien. V. (1986). Implications of work-site prw:tice for rehabilitation counselor e,!ucation and

training. Journal of Applied Rehabilitation Counseling.17(3), 49-54.

Hershenson, D.R. (1988). Along for the ride: The evolutionof rehabilitation counselor education. RehabilitationCounseling Bulletin. 31(3), 204-217.

Lsynch, R.K.. Lynch. R.T., and Beck, R. (1992) Rehabilita-tion Counseling in the Private Sector. In R.M. Parker andE.M. Szymanski (Eds.). Rehabilitation Counselin,g: Ba-sics and Beyond (pp. 73-101). Austin, Texas: Pro-Ed.

Lynch. R.K., and Martin, T. (1982). Rehabilitation counsel-ing in the private sector: A training needs survey. Journalof Rehabilitation 48(3. .51-53: 73.

Matkin, R. (1980). Rehabilitation counseling in pri \ atepractice: Perspectives for education and preparation.Journal of Rehabilitation. 46(2), 60-62.

Matkin. R.E. (1982). Rehabilitation education curricula:Pepaing counselors to enter the private fOr-profit sec-tor. Report of the Training and Research Committee,National Association of Rehabilitation Professionals inthe Private Sector.

McMahon. B.T. (1979 ). Private sector rehabilitation: Bene-fits. dangers. and implications for education. Journal ofRehabilitation, 45(3).56-58.

McMahon, B.F. and Matkin, R. (1983). Preservice graduateeducation for private sector rehabilitation counselors.Rehabilitation Counseling Bulletin. 27(1). 54-60.

Sales, A. and Bissey. L. (1979). Placement in rehabilitationeducation: Curriculum considerations. Monograph. Uni-versity of Arizona Press.

Sink. J.. and Field. T. (1981), Vocational Assessment Plan-ning and Johs. Athens. GA: VSI3. Inc.

Weed. R.O. and Field. T.F. (1986). The difkrences andsimilarities between public and private sector \ ocationalrehabilitation: A literature review. Journal of AppliedRehabilitation Counseling, 17(2).11-16.

White. L. (1983). Human Debris: The injured worker inAmerica. New York: Sea\ iew/Putnam.

19

Nanonal Rehobtithinou I In tallot1 Monovaph

Excerpts of Reviews and Comments Chapter One

Dr. Cry stal discusses the similari-ties and differences in rehabilita-

tion education needs for the rehabili-tation counselor practicing in the pri-vate sector versus the public sector.Ile stresses the need for certain funda-mental training on basic knowledgeneeded by counselors in both settings.and he discusses some additionaltraining that would be of benefit spe-cifically for rehabilitatic.n in the pri-vate sector.

I agree ss ith Dr. Crystal's underls -ing premise that rehabilitation coun-seling dealing ill either a public orpris ate setting utili/es the : aineskills and approaches. How es er. asDr. Crystal acknoss ledges. there ismuch greater emphasis on promptpla,:ement as a successful outcome forrehabilitation in the private sector.

I3ecause of this, the rehabilitationcounselor who aspires to work in theprivate sector in the future needs to hewell-prepared to deal with current jobplacement issues. As we look at reha-bilitation education curriculum for they ear 2(1)0 and beyond, the followingareas are ones which may undergorapid change or ad \ ancement andneed to he incorporated fully into thecurriculum:

. Labor market information chang-ing occupational patterns and jobrequirements.

2. Work place teLhnology/assisti-etechnology advancements. as theyrelate to job accolminxIat km.

3. l'..rgonomics.4. Placement techniques and issues.

While these topics are extremelyiinportant to the rehabilitation coun-sekw practicing in the private sector.it appears public sector counselorswould benefit from more training inthese areas as well. Incorporatingthese may pro \ ide an overall strength-ening of rehabilitation counselor education.

Catherine C. Bennett

Dr. Crystal's paper. which empha-siies the des el opment of rehabili-

tation with particular attention toworker's compensation in the variousstates, reminds me that our fiekl is notour exclusive domain but rather issubjec. to control and influence bymany factors to which we can of ne-cessity only react. For example. wedon't have great influence over thelaws that sometimes mandate ourservices. but rather 'react' or deliverour services under their pros isions.

The degree to which rehabilitationis going to he perceived as as iable anduseful adjunct to the other helpingprofessions. however, is more underour control than not, and as a profes-sion the tiine has come for us to planour future and work for its achieve-ment. We has e models of successfulachies anent of similar activities thatwe can look to for our edification,such as the efforts of psychology as aprofession. which has planned andiohhied for its present position in theprovision of health care and similarservices in the United States of today.

Any such activity must stall Irm asolid foundation of practice. which Dr.Crystal alludes to in his paper. l'or exam-ple, s c expect our students and practitio-ners to he solidly grounded in the basicsof es aluating and understanding humanbehas ior in the context of mans differentsettings. It is still our obligation to use this

and many other areas of knowledge in theunique way that is compatible kw ourprofession's slnind practice. continuedgrowth. and for its reomgnition by otherprofessionals as a useful adjunct to theirjoint efforts in the overall rehabilitationof perNons with

Phillip Bussey

Dr. Cry stal provides an ewellentdiscussion of the historical devel

opulent of private sector rehabilitationss ith business and industry . 'Mc dis-c1155i011 (Ides an ovens iess of bothsimilarities and dissimilarities be-tween the public sector and private

20II. I %tonoossrh Relisibtlitsitton Isso latton

sector rehabilitation movement, espe-cially as it relates to issues in the fieldof A orkers compensation.

Central to Dr. Cr\ stab's discus-sion. however, is the issue of "Who isthe client"? Dr. Crystal identifies. "thebasic goal is the return to work andeconomic self-sufticiency of personsss ith disabilities as being shared byboth programs." In my opinion this isnot necessarily an assumption that isalss ays correct. II istorically the clienthas been the person with a disabilityor handicap as addressed by the stateand federal laws for the last fifty yearsin vocational rehabilitation. I wouldagree that private sector rehab hasalso identified the injured worker asthe primary client in the socationalrehabilitation process in the privatesector. I do not think this is the case.Quite frankly . the client in pi \ ate sec-tor rehab is really best represented bsattention given to all players or partiesin the process called "return to work"of that injured worker. For instance.the insurance company that hires therehabilitation client plays a very sub-qantial role in the process which inturn govented by state lass s andregulation for ss orkers compensationdelivery programs. Attorneys whorepresent either insurance or the in-jured worker feel that they have a verysignificant role in the process as doesthe employer who is being assaultedss ith spiraling compensation insur-ance premiums. Finally. the injuredss orker him or herself is obviously amajor player in the process althoughsometimes it may seem to this personthat the oserall goal is to save moneyfor both the insurance carrier 0110 theemployer and not necessarily the totalrehab il it at ion or the worker.

N,Vith respect to the academic ortechnical preparation of the rehabconsultant either in the public or pri-s ate sectors, Dr. Cry stal has arguedthat the know ledge and skill compe-tencies remain the same for bothgroups. Dr. Crystal argues furtherthat. "it does not appear that an en-tirely new or distinct curriculum

needs to he developed for the trainingof rehabilitation counselors to workprior to rehabilitation practice:

The accompanying paper by Dr.Gilbride clearly identifies a majorthorn in the side of private sector re-habil itat itut administrators and practi-tioners. Dr. Gilbride correctly oft-sems es, "Students recei \ ing a scholar-ship support front RSA to attend atraining program must w ork in a stateagency tw o ears for es ery y ear oftuition support received". And fur-ther. "financial dependence on RSAresults in training that is narrowly fo-cused on public rehabilitation:" I tendto he more in agreement with Dr. Gil-bride w Ito questions the RSA Link a-sides training programs capacity totrain students to enter proprietary re-habilitation. While a new area of cur-riculum does not necessarily need tobe de\ eloped. I ant in concurrent:ess ith Dr. Crystal's effort at the Uni \ er-sity of Kentucky to des elop special-lied courses and areas of expertisethat more full \ address the needs ofrehabilitation consultants entering thepris ate sector area.

Tim Field

Historical origins surrounding thedes elopment of w orkers' com-

pensation programs in the UnitedStates are presented well by Dr. Cry s-tal. Social issues and legal principalsare included in the discussion ss Inchlead up to the inclusion of rehabilita-tion in w orkers compensation legis-latitm and the rise of proprietary reha-bilitation progranis in the ss otters'coinpensation system. Similaritiesand differences between proprietaryand public rehabilitation programs arediscussed in tennis of goals. clientele.counseling context. ethical issues,funding sources. chgibihit s s. entitle-

ment programs. and national ss. stateprograms. Although the ty pes of pro-lessional pros iders in insurance ( pro-p ielary 1 rehabilitation ale also dis-cussed, exception is taken ss ith theidentification ol onls tss o suchpm\ rehabilitanon muses andrehabi: nation cmnselors. Among themany other ty pes of prof essiondl

providers are: vocational evaluators,occupational therapists, physicaltherapists. employee assistance pro-fessionals and medical doctors.

Rehabilitation counselor educa-tion curriculUM issues related toss orkers' colopensation rehabilitationare also presented-There appears to besome contradiction and confusion inthe discussion of training needs forcounselors who pursue employmentin the pris ate sector vs. the publicsector. It is true :hat there are somecommonalities bets\ een rehabilitationcounselors in by Crystal

both sectors such as the goal ofrehabilitation and the know ledge ofsuch c(mtent areas as \ ocationai as-sessment. case management. counsel-ing skills. medical and psychologicalaspects of disability. and job develop-ment and placement. However. theapproaches. methodologies and theo-ries are oftentimes dissimilar and may.reflect more than a difference in dis-abilities. It may be a reflection of leg-islative mandates. employment set-tings. and business theory and prac-tice. to name a few . This translatesinto a difference of some knowledgeand skill competencies for the reha-bilitation counselor employed in aproprietary program as opposed to thepublic program.

While the content of the trainingcurriculum for rehabilitation counsel-ors in public: and proprietary programsdoes not has e be a mutually exclu-si \ c activit \ . as the author points out.additional applications (e.g.. life careplanning. expert testimony.. transfer-able skill analysis) and theoreticalframes\ orks (e.g.. business. insur-ance. law ) are necessary to pro\ ideadequate preparation for employmentin the private sector. Rehabilitationeducators 'oust be willing to expandtheir frame tif relerence to and know l-edge base of rehabilitation pmactkebey mid the pub] ic sy stein.

The phrase "business and industms

rehabilitation" is mentioned seseraltimes in the text of this manuscript.particularly in the latter hall'. and ap-pears to be used sy nony mousl ss ith'ss orkers' compensation rehabilitation. It is nnportant to note that rehabilitation in business and industry

Vithuhil 1,111.,u

may involve the workers compensa-tion system but it also includes otherinsurance systems. ADA consult-ation. life care planning and employeeassistance programs.

Juliet H. Fried

rhis paper raises a number of inter-esting issues that have significant

nplications for understanding therole of proprietary services in the fieldof vocational rehabilitation. A funda-mental difference exists between thegoals of public and proprietary reha-bilitation. Crystal points out that thegoal of the proprietary rehabilitationsystem is returning the injured st orkerto their prior or related level of \ oca-tional. physical and/or mental func-tioning.

In contrast. public rehabilitationattempts to assist the client "to attainhisther full potential". This differencein the definition of outcome accountsfor many of the process contrasts he-tss een the two systems.

Proprietary rehabilitation tends toemphasiie early. and fast return to s\ ork.

taili/ation of transferable skills, andplacement services. Public rehabilita-tion tends to take longer and may include

more schooling. "work adjustinent."counseling, and other community re-source utiliiation. The field of rehabili-tation clearly needs more process andoutcome research to identify the dice-tiseness of the services and techniquesutiliied by both systems.

A second important issue raised byCrystal is the , tie cf pain in the reha-bilitation process with injured ss ork-ers. Training programs and servicepro\ iders need a clearer under-standing of the profound impact thatpain has on a consumer. and how itaffects rehabilitation planning and re-turn to work,

21

Dennis Gilbride

In an excellent ()sem\ less tit mehabili

tation and the role of rehabilitationcounselors in pubhc and pm ate set-tiags. the ititluw addresses the simi-larities and differences, as well as the

PP)

implications for training. for publicand private practice.

Two specific areas that I believewarrant further at tent kin and develop-ment. either by educational institu-tions or prot.essicmal associations. arethe concepts of a national registry andpaid internship,. Often times, reha-bilitation counselors that are not in the"prk ate arena", or who do not haveconnections into same, may wish toexplore opportunities in the privatesector but may not have resourcesadequate for a thorough exploration.A comprehensive registry of privateentities nal ionw ide. woukl enable per-sons to explore not only within theirown state. but also to see what's hap-pening in other areas of the country .w here they might not ha\ e contacts orknowledge of opportunities.

"I'he concept of paid internships isone that has been in existence forsome time. hut I ha\ e a feeling hasbeen underutili/ed in the insurancerehabilitation !i:ena. This is a greatw ay for students to experience appli-cation of their new ly -learned skills inan exciting. challenging setting, andfor the prix ate rehabilitation pn iderto work w ith someone w ho is fresh tothe field. typically motisated. en-thused. and full of new ideas andstrategies. The empk er also has aunique opportunik to "try -Out" a pro-

for a time-limited period.and if a good match is made. ha \ e amaster's loci counselor reads to hitthe ground running at the end of theinternship. Additionally . that intern

oukl be adding productk ity to thesetting, dui ing their learning period.w hich is a (lear. "bottom line" benefitto the r,..shal il i tat ion company .

Fi'iall I w ant to comment on onedistinction cited by the author relatkto in,.urance rehabilitation having twotypes of professional pro \ iders: reha-hilitation nurses and rehabilitationcounselors. While I do know that

statutes across the country malldate that certain "ty pes" of ieii,iiiifiti(ion set:\ ices must he pro\ tiled ht spe

Lille professionals. my experienceVt ith a pm ate rehab company )in New. Jerse\ is that a highly skilled,w ell trained rehabihtation counselor

can be an ellecti \ e medical case man-ager. Conversely. a highly-skilled,well-trained nurse can he extremelysuccessful in the vocational arena. Aproperly trained rehabilitation coun-selor has the basic medical knowledgeupon completion of their training, andhave the ability to seek out informa-tion on medical issues with w hichthey are unfamiliar. Likewise, thenurse with strong medical knowledgeand the ability to apply said know l-edge in a private rehabilitation setting.as well as the ability to interact w ith a

ide range of individuals (employersincluded) will ha \ e no problem inlearning the ocational issues relati \ e

to return to work.

Patricia Nunez

Be-;ides pro\ id ing a historical per-spectk e of w orkers' compensa-

tion system in this country . Dr. Crys-tal touches upon tw o key issues: TheAmerican, w ith Disabilities Act(AI)r\ ) and its possible benefits toindustrially injured w orkers: and re-habilitation counselor education.

1'here is no doubt that ADA w illhave a "positive intpact on the returnto \\ ork of persons with worker com-pensatiOn injuries". The concept ofessential functions \\ill define deal \the requirements of the job thus allow -ing kir true job mtch and thereforeaddresses Dr. Crystal's comment on"employ er's fear of the person beingre-injured". ADA. as a matter of fact,cannot arrive at the most appropriatetinle to tackle the workers' compensa-tion tunintil. The application of essen-tial functions and reasonable accoilimodat ions w ill assist employers to re-tain and re-hire their ow n injured em-ploy ees thus reducing the exposure ofhigher premium due to experience rat-ing. In the long run, it w ill create aInin'h sal er en \ ironinent at the woikplace further reducing the frequencyof injuries. With lesser merhead cost,i.e. w orket s' compensation insurance.the employ er can become more competitk e in the market. can treat theemploy ees better in terms of V, ageincreases and employ ee benefits. and

\,m,m.t1 16 It.11.11thinott nitpqr

2 4,n

can better invest in their plant equip-ment and/or safety equipment, etc.Needless to say, the insurance indus-ny will benefit. It is a win-win-\\ insituation for all.

While it is true that the rehabilita-tion professionals in both the publicand private sector employ the sameunderlying skills and knowledtze.practicing rehabilitation within legalsystems does require different ap-proaches and methodologies. It is

therefore vital for rehabilitation coun-selor education programs to includecourses or minimally a course onBusiness and Industry Rehahilit ation"as outlined by Dr. Crystal. This willprovide an excellent introduction toall future rehahilitation counselors.kw the students who are going intothe public sector, this will gi \ e themsome understanding of the disabilitybenefit systems. industrial rehabilita-tion and forensic rehahilitation. Forthe ones entering the prk ate sector,this will gis e them an orientation tothe field of their choice. I. Iltimately

this w ill foster a better public/privatepartnership and relationship.

-John W. Lui

n this paper. Ralph Cry stal docu-ments the development of w orker's

compensation programs Vt ith ourcountry 's economic shifi front anagrarian to an industrial econonk

sOcial support w as re-quired to replace the declining sup-port once a \ ailable front predomi-nately rural extended families. Re-flecting a tradition of state's rights,each state responded w ith \lorker'scompensation programs designated toaddress their percek ed unique needs.Although the federal governinent alsodo eloped a \\ orker's compensationpmgram for 1 ederal employees. ciml-parisons are too frequently made he

een proprietary rehabilitation andthe traditional state/federal rehabilita-tion system rather than the moreanalogous federal w orker's compen-sation program.

Prk ate Sector rehabilitation de \ el-oped in ik.'sponsL. to the obser anon

1-s

that the cost of services could he re-duced while restoring an individual totheir pre-injury or similar le el of oe-dipat ional attainment. These cost sal,i ngs were primarily. a result "of theprivate practitioners goal to restore anindividual rather than maxiinize anindividual's employment potential.

Public vocational rehabilitationhas also traditionally blended humanwith economic values. This socioeco-nomic blend is reflected by rehabilita-tion advocates early ii se of" the concept

ith policymakers that there has beena la\ orable return for very tax dollarspent on rehabilitation services.

Acknowledging the existence ofdifferences associated w it h funding

sources. Cry stal correctly concludt..there are more similarities than differ-ences between the potential sectors ofemployipent for rehabilitation practi-tioners. At one point, Dr. Cr, stal evennotes 'hat employment in public orproprktary rehahiliRaion no longeran "eithei or cho,:e" for practitioners.

Emphasizing similarities encoun-tered by rehabilitation practitioners,while identifying differences requir-ing redress through curriculum ad-justments. has profound implicationsfor the training of rehabilitation pro-fessionals. First, it implies that suffi-cient identifiable techniques, ap-proaches and a fundamental knowl-edge base exist to warrant proles-

23

sional training of rehabilitation coun-selors. Secondly, it constructively ad-dresses the need for adjustments incurricullim to prepare individuals toenter a more diverse labor market

ithout the incessant need for spe-cialization which has divided reha-bilitation prolessit,nals in the recentpast. Finally. it emphasizes the needfor the prokssion to define itselfrather than allow revenue sources uidefine the profession.

Stephen A. Zanskas

Th'ilablIthli/011 .1\ WI hint ,11 pnr.? .S n:r r Monograph

Chapter Two

Educating Practitionersfor Work in the Private SectorDennis Da id ( ilbride

Vocational rehabilitation services in both not-for-profit and for-profit private rehabilitation ha \ echanged dramatically over the past ten to fifteeny ears (Cohen & Pelavin 1992; Gilbride. Con-

nolly & Stensrud, 1990: Mew, & Bordieri I 98b). While theft icus in private rehabilitation has traditionally been onemploy ability and placement of people with disabilities,non-profit and for-profit practitioners are increasingly ap-proaching these goals differently. Many non-profit agenciesare moving toward a supported employment model, (Bel-lamy. Rhodes. Malik. & Albin. 1988: Buckley. Albin. &N lank. 19)18: Wellman. & Moon. 1988). while for-profitrehabilitation is inoving into consulting and other disabilitymanagement ser ices ( l.ynch. Lynch. & Beck. 1992).

'Illis divergence in .ioh tasks and necessary skills raises sig-nificant and fundamental questions concerning the type of edu-cation required by personnel entering plivate iehabilitation set-tings. These questions indude delineation of appropriate trainingcontent and outcome competencies. and the most effective man-ner of providing training 0,ynch & Martin 1982: Matkin. 1987:Nlatkin & Riggar. 1986: Sales. 1979. )

The purpose of this paper is to expli we these tnnning-relatedissues. The first section willaddress the context in which pi\ atefor-profit rehabilitation professionals w ork. and the implicationsthese factors have for training. The second section will addressforensic and ethical issues in rehabilitation. The third section willbriefly discuss the training needs of non-profit rehabilitationprofessionals and pro\ ide an example of a market driven ap-proach to cuniculum development. The final section of the paperwill present some tentati\ e conclusions and issues requiringfurther explonition,

Demi], I Li% RI ( iiihtik Phphase i-111\ tome..

PIV Sty if. tlf.in,Qtaph

Private For-Profit Rehabilitation

Rehabilitation services in the for-profit sector have un-dergone profound growth and change during the past twodecades (Gilbride, Connolly & Stensrud, 1990: lAnch.1.ynch. & Beck. 1992: Taylor, Goiter. Goiter. & Backer.1985). Counselors are working in a wider range of contexts.with clients having different types of disabilities, and theyare employing new strategies and technologies (Lynch.L \ nch. & Beck. 1992: Ritter & [eclair, 1990; Williams &Fidanra. 1990). To understand the training needs of profes-sionals in the for-profit sector it is important to understandfis e aspects of the current environment: 1. Where private-for-profit professionals are likely to work. 2. The impor-tance of being a Certified Rehabilitation Counselor (CRC).3. The role of accreditation of training programs by theCouncil on Rehabilitation Education (CORE). 4. Rehabili-tation Services Administration (RSA) training grants andpay hack requirements. 5. Professionals against whom reha-bilitation personnel are in competition.

I It ltere are far-m*0'h rehabilitation profi,s.sionats tV(Wking!

The simple answer is everywhere. Using Drake Unker-sity as an example. alunini of the rehabilitation programwork as directors of personnel in business and industry; asADA consultants to employers: in private practice provid-ing expert testimony ; in medical settings as part of transdis-ciplinary teams; in psy chiatric club houses; at insurance

companies; in for-profit (insurance) rehabilitation agencies;and as career. mental health and substance abuse counselors.Research indicates that this is not an unusual or atypical list(Ly nch, 1.y nch. & Beck, 1992: Malkin, 1 983: Williams &

Fidania, 19901.The broad range of settings in w hich for-profit rehabili-

tation professionals are currently working creates signifi-cant challenges for de \ eloping appropriate training ap-

No:1,1,nd Rclhibilitativoi

2 4$11

proaches. For example, business consulting and personneldevelopment obviously require very different competenciesthan those necessary for providing job seeking skills toclients %% it h head injuries or substance abuse.

Development of appropriate curricular and training mod-els requires educators and other stakeholders to first identifywhat is basic and fundamental to vocational rehabilitation.Substantial disagreement exists among leaders and educa-tors in the field of rehabilitation concerning how broadly thisbasic core should be defined. This is clear from a review of'the literature (e.g. Matkin, 1987: Matkin & Riggar. 1986:Parker & S/y manski. 1992: Rubin, Matkin. Askhley, Beard-sley. May, , Onstott. & Pucket. 1984). and w as demonstrateda number of times in the National Training Conference onRehabilitation Education held during March of 1993, inWashington DC.

For the purpose of this paper the key area of expertisenecessary for all rehabilitation professionals will be nar-row ly defined as the knowledge and skills necessary tonegotiate the interface of disability and the world of work.The interplay between disahilit) and work is clear in suchrehabilitation ser\ ices as placement. employ er develop-ment. work accominodations. disability inanagement andADA coinpliance. Because rehabilitation professionals arethe primary group within the medical and helping profes-sions who use employ ment as an outc(ime measure, theyoffer the capacity to tie rehabilitati) e sers ices togetheracross the recover) process.

There are tw 0 ke% iinplications of this definition ofocational rehabilitation. First. employers are hiring i-eha-

bilitation professionals in all the capacities listed abo) ebecause they perceive the importance of this unique exper-tise. Second. successful training programs inust ensure thattheir curricula, teaching methods. projects. and fieklworkexperiences result in students des eloping quality skills Illthis disability/w ork relat ionship.

The el leen eness of the training currently pros ided topri ate for-profit professionals by existing programs is thesubject of some debate. Defenders of current educationalapproaches point to the success that rehabilitation profes-sionals has e in obtaining positions. Those w ho ()eine

ehange cite data indicating the questioning occurring inmany states regarding the effectiseness of s ocalional re-habilitation w ith workers' compensation clients. Whilethere are many complex financial and political reasonsw hi many state legislators are repealing the mandatoryrehabilitation pro) isions of their ss orkers compensationsY stems. pris ate rehabilitation pros iders' inadequatedocumentation of their effeetk eness. (along ss ith ethicaland conflict of interest questions) is at least partly to blame(Washburn, I 992).

2. The imporiamv hem t a

(.v11/fled Rehalnlinnum ('ounselor I (*W.).

In a res iew of all the rob openings listed iii NARPPSJoin nal and News (is cr the past tss o yt.ws, and ail of Metor profit rehabilitation position anninnicentents sent to

Drake University. two conclusions become apparent: Em-ploy ers want applicants with either a master's degree orBSN. and they want people who are certified. The majorityof employers require (or at least prefer) applicants to have aCRC'. w ith some employers also accepting Certified Insur-ance Rehabilitation Specialists (CIRS I. and a few recruitingCertified Vocational Evaluators (CVE).

This strong emphasis by for-profit employers on certifi-cation has significant implications for education and train-ing. On December I 5. 1992. the Bachelor's degree category.for CRC eligibility was phased out. along with the categoryfor master's degrees unrelated to rehabilitat km. Conse-quently, beginning this year, only people with master'sdegrees in rehabilitation counseling or related programs ss illbe eligible to sit for the CRC' examination. This tighteningof CRC requirements will have a significant impact on thelabor pool because os er one-third (tithe applicants for CRCprior to December of 1992 held bachelor's degrees (Com-mission on Rehabilitation Counselor Certification. 1992).

A master's degree in rehabilitation. w ith certification,has almost unis ersally become the entry les el requirementin for-profit rehabilitation. People planning to enter thislabor inarket w ill increasingly be f(trced into attendinggraduate school at a university or college offering a rehabili-tation counseling degree program.

Further, CRC renew al requires I 00 hours of continuingeducation. This requirement has created an entire industryof continuing education providers. whieh has in turn createdan infrastructure by which new ideas, strategies and tech-nologies can be introduced into the field.

3. The role of accreilnation ol training progniins b1. an'Connril on RdnibilnanOn Edi/ConOn (COW.).

There are Lam ent ly 77 master's degree programs aecred-ited by CORE. A number of ads antages accrue for studentsgiaduating front a CORE. accredited program. includingtheir ability to sit for the CRC exannnation immediatekw hereas other students must wait betw een I to 3 \ ears).

CORE has s cry explicit and extensis c guidelines on curricu-lum. course content. fieldss ork requirements and programlength. Se) en years ago Mat kin and Riggar (1986) arguedthat C'ORE needed to Fees aluate its guidelines to bec(Htlemore sensitive to and reles ant for pris ate for-profit rehabili-tation. This has not occui red. la a more recent study. Gil-bride. Connolly and Stensrud (1990) ktund that most CoR1,.accredited plograms did not has c any cow ses related to thespecific application of )ocational rehabilitation in thi i-

s ate sector. The content. structure and process outlined byCORE is still focused on. and most appropriate for publicrehabil nal ion.

It is also important to note that CORE currently out\accredits master's degree programs in rehabilitation coun-seling. While CORE is considering certification of otherprograms the \ do not presently accredit undergraduate pro-grams. or other rehabilitation master's degree programsstICh as those in job placement. %ocational evaluation. orlaci lilies administration.

5 /9,/ 11,1p.vratai

With CRC and CORE accreditation of pmgrzulls becom-ing more important, much more attention must be paid toCORE standards and their impact em and ivies ance to prepa-ration of pHs ate-for-pront professionals.

4. Rehabililation Services ,1dminiArration (RS.11nuiaing grallt am! pay/hick requirz.men Li

There are currently 49 master's degree programs in reha-bilitation counseling that receise funding from RSA. Ofthese programs 45 ( )2' tare CORE accredited representing

of all CORE accredited schools. Further, for Cs er\ oneprogram funded by RSA. two to three programs apply fewfunding but are denied. This implies that almost all COREand many non-CORE accredited schools are either receivingor try ing to receie grant support from RSA.

In order to recei \ e funding from RSA. a degree program mustdemonstrate that it's mission matches that of the State/Fedend

(vational rehabilitation program, and that it has strong linkages\\ ith public and nein-profit rehabilitation. The mission, goals.ohjectis es. curriculum. course content, and fieldwork require-inent \ of the program must focus on public mhabilitation. Fur-ther, students receis ing scholarship support from RSA to attenda training program must work in a state agency (or a non-profitagency pros iding sers lees to state agency clients) Is\ 0 years fOres ery year of tuition support received. Usually this "pay back"work niu \I take place within the sk year period f011ow inggraduation.

There are tslo opposing impacts of RSA funding ofrehahi itat ion training programs on for-profit tehabifitation.First, this funding has resulted in a large number of highquality. ss ell supported rehabilitation degree programs dis-persed throughout the United States. However, financialdependeuce on RSA results in training that is narrow lyocused on public rehabilitation. Consequently . there is the

(Anis ersit\ capacity to train students to enter for-profit reha-bilitation. but no incentise for progrzuns to disersily intotraining designed to meet the needs of the for-profit sector.

5. Prolcsialnlis horn reluthilihition

comicelon are in compethion.

One reason rehabilitation training prognims are depend-ent on RS funding is that schools has e difficulty recmitingnon-scholarship supported students. Nlany students inter-ested in a career in rehabilitation find it \ ery difficult toreject grant support that ofien includes both tuition assis-tance and a monthly stipend. Gis en the financial and per-sonal ress ards of ssorking in the pri \ ate for-profll sector. itis important to address the reasons 55h training progralvisare not mem helmed by self-pay applicants.

To understand this issue w e must first ask \\ ho arerehabil itat ion prole \sionals? Holland ( 1990 ) 1 ists \ ocational

rehabilitation counseling as a Social I nterprising -Consen-tional (SEC) occupation. Other SEC occupations includeelementary scluiol teacher. probation officer, school social

orker, and psy chiatric aide. Itss c look just at the first twothemes (SE), occupations include detectis e. hospital adnnnistrator. school ps etiologist. director of special education.

and psy chiatric social w orker. An implication of these listsis the large number of well know n professional les el jobsthat people \A ith these \ ocational interests and personalityty pe might pursue.

Private for-profit rehabilitation is a relatisely new and un-known profession. Most of the occupations listed above am jobsabout w hich the average college age student has ample inf(inna-don. Students know what psychology is, but vocational rehabili-tation ofien makes students think of prisons, vocat:onal trainingschciols, or worse yetnothing. The National Council on Reha-bilitation I.:ducation (N('RE) has begun to address the need toincrease ass zueness of the profession to improse recruitment( Pacinelli & Stude, 1991 ).

Competition for jobs is another critica: J.actor. Rehabili-tation professionals are often competing for jobs with socialsc orkers or mental health, substance abuse, employ ee assis-tance. and fainily counselors. In order to be selectee!. reha-hil nation professionals must demonstrate the y. has e exper-tise in the disability/w ork relationship. and that this skill isnecessary for a specific job.

['here are three implications of these competitis C issuesfor rehabilitation education. First. training programs mustfocus recruitment on high school and undergraduate stu-dents who have personalities that match the \\ ork en \ iron-mein of rehabilitation and pro \ ide information to prospec-

\ e Students on all the options a rehabilitation degree offers.Second. rehabil it at ion graduates need to be trained to clearlymarket their expertise and to represent how they can do thework employers require. Third. rehabilitation educators(among others) must continuously demonstrate to the medi-cal and helping services the imponance of looking at s oca-t tonal issues. and assist business and industry to appreciatethe positive outcomes that dais e from understanding andaccommodating people w ith disabilities.

Forensic Issues in Private RehabilitationInsurance rehabilitation has traditionalk had a great deal of

interaction with the workers' compensation legal system (Nlat-kin. 1985).1-his experience has helped prepare professionals tounderstand the ty pe of dlivuinentation required'. aild the scrutinythat oxurs in forensic settings. Recently . rehabilitation profes-sionals ha\ e begun to expand their practices into life care plan-ning and expert socational testim()ny (131ackw ell. 1991: Deutsch

Sass \ cr. 1986: Vogenthaler & 'Herne:. 199(); Weed & Field.1990: Weed eK: Riddick. 1992i.

I it'e care plans delineate all the sers ices and products thatpersons with catastrophic injuries or illnesses may need overtheir lite time (Weed & Field. 19911 I. Because life care plansare often used as the basis of a settlement \\ ith an insurancecompan \ it is \ ital that the information be accurate andcomprehensive. 13ecause of the under!) Mg requirement forcomplex analy sis of economic trends, life care planning isoften done in conjunction w ith an economist (WeedRiddick. 1992 I. For example a life care plan may need toinclude the pitential cost of a \1/4 heelehair and routine phy

\ kit in the scar 20E1. hie care plans are oftenconducted by rehabilitation nurses how Cs rehahiljtanlin

/.),/ Ntt ihil,11111111,; how"6

counselors with L ,ensive experience and training in themedical needs and impact of specific disabilities (i.e. headinjury) are increasingly becoming ins olved in this work.

Expert vocational testimony is generally concerned w ith theimpact of a disability on labor market access and earningscapacity (Blackwell, 199 I; Vogenthaler & Tierney, 1990; Weed& FAL 1990). While some vocational testimon) does notinclude a disability (as in the case of marriage termination). thedisability/work relationship is usually central to this process. Asss ith life care planning, economic analysis is pivotal to experttestimony. Understanding the level of economic loss resultingfrom a specific injury. accident or disease, requires an in-depthunderstanding of worker characteristics, disability, and labormarkets, along with a decision making model that can he clezuiydeknded.

Although rehabilitation professionals are utilized as life careplanning and forensic testimony experts. traditional rehabilita-tion counseling training is generally not enough to qualify apractitioner for this work (Deutsch. 1985; Blackwell. 1991).Most expert witnesses obtain txmt-masters experience and train-

ing in techniques such as transferable skills analysis. wage losscalculation, labor market analysis, economic projections, medi-cal technologies. and .ega.1 1 processes.

Most training in forensic rehabilitation has occurred inspecialty workshops and at professional conferences spon-sored by private rehabilitation organizations such as theNational Association of Rehabilitation Professionals in thePris ate Sector ( NARPPS ). For a number of years fiwensicrehabilitation has been one of the specific training tracks atNARPPS national confer:races. Rehabilitation profession-als are also taking graduate cqurses outside of rehabilitationin departments of economics. business, law and psychol og .

Ethical Issues in Private RehabilitationThe need kw rehabilitation professionals to he trained in

et h k-al decision making began to receive attention in the mid1980's (Rubin. 1993). In 1987 the National Institute onDisability and Rehabilitation Research (N1DRR) funded agrant to des clop and es aluate an ethics training package.This grant resulted in a number of studies exploring thetypes of ethical dilemmas rehabilitation professionals ell-counter. and training material for ethics education. A sub-sequent NIDRR grant further SlIpported des elopment ofethics curricula.

A central focus of ethics trania.,: is assisting profession-als in the des elopment of analytical ethical decision makingskills (Fischer. Rollins, Rubin & McGinn. 1993). Mostethics training is based on the Code of Professional Ethicslor Rehabditotion Counselors' that has been adopted byCRC. t he American Rehabi litat ion Counsel ing Association.the Natitmal Rehabilitation Counseling Association and theNational Council on Rehabilitation Education.

There are three nhijor prohleins with the applicatnm ofethics research and trainin to the private sector. First. nu1stnon-profit rehabilitation professionals are not certified reha-bilitation counselors, an t! aro not members of one of thenational counseling associations. Second. NARPPS has a

different code of ethics for its membership. Third, ethicstraining has only been field tested in state/federal rehahili-tation agencies (Fischer, Rollins, Rubin & McGinn, 1993).Consequently. most ethics research and materials are fo-cused on the ethical dilemmas encountered hy public ratherthan private rehabilitation practitioners.

While the public rehabilitation focus of ethics researchand training is only a I imited concern for non-profit profes-sionals. serious differences exist between appropriate pro-fessional behaviors in public and for-profit settings. Thesignificant ethical differences between public and for-profitrehabilitation have been noted for a numher of years (Kaiser& Brown, 1988; Nadolsky. 1986), and they include the"Who is the client?" question, and the "cost containment"focus of rehabilitation services in some situations.

Both public and non-profit rehabilitation professionalsclearly view the person with the disability as their centralcustomer, and the needs of consumers as primary. Thesituation is not as clear in for-profit rehabilitation. and infact may be the exact opposite. Many for-profit rehabilita-tion professionals are hired by employers or defense attor-neys with the explicit intent of reducing that employer'sexposure and containing the cost of a claim.

The NARPPS code of ethics specifically allows for ob-jective expert testimony. and states that "When there is aconflict of interest between the disabled client and theNARPPS member's employing party. the member mustclarify the nature and direction of his/her loyalty and respon-sibilities and keep all parties informed of that commit nient"(NARPPS, 1992. p.22). Thus. NARPPS only requires themember to disclose who their primary client is. it does notrequire. as does the CRC code of' ethics, that the needs ofthe person with a disahility always come first.

Consequently, rehabilitation professionals in the kw-profit sector find themselves continuously in complex ethi-cal dii 'units. The for-profit sector recogniies this andfrequently has workshops or entire training tracks devotedto ethics at its national convention. The problem is that themoney to support ethics research and training has onl beenprovided by. and focused on public rehabilitation. Thus, thepre-service training that most rehabilitation professionalsreceived did not adequately prepare practitioners for thecomplex ethical decisions they would have to make. andin-service ethics training has been as ailable only on a lim-ited basis.

Private Non-Profit Rehabilitation

Community Rehabilitation Programs (ot- non-profit fa-cilities) are also undergoing significant change. In theirstud of' personnel shortages Cohen and Pelavin (1992)found significant need for trained workers in the areas ofsupported employinent, job development/joh placentent.vocational evaluatitm and administration.

Supported employment is the fastest growing area incommunity rehabilitation agencies (Ren/aglia & F.serson1990). Cohen and Pelavin (1992) found that a high school

2 7,Vallo11411 trnsell1011 P193 ., ti et Motte,t:taph

degree was the educational requirement for 58Ci of allsupported employment positions, and that a specific bache-lor's degree was only required for 9(i; of positions, with nopositions requiring a master's degree. Most supported em-ployment training is conducted on-the-job. in short termcertificate programs or at community colleges. The educa-tional requirements for the other three high need positions(job don elopers, vocational ealuators and administrators)were more varied.

A market-driven approach to curriculUM developmentwas utiliied to determine the specific eolucatiomal needs andrequirements for rehabilitation administration in a commu-nity rehabilitation program. Stensrud and Gilbride (1992)conducted a study using a marketing model of curriculumdevelopment (Kotler & Bloom 1984; Levitt 1986). Degreerequirements and course offerings front thirty-one existingundergraduate rehabilitation programs were collected andcollated. The professional literature was reviewed to deter-mine recommended competencies for rehabilitation facilityadministrators. (The literature ro, iew included: Bo wdieri.Riggar. Crimando & Matkin. 198g: Brabham & Emener.I 988: Men/ & Bordieri. I 986.1

These data were summarized and presented to a focusgroup comprised of five facility administrators, one stateagency administrator, and the director of the Iowa Asso-ciation of Rehabilitation and Residential Facilities. Thefocus group discussed the training needs of the employeesin their agencies and reviewed the summary of the compe-tencies and course offerings provided to them. The focusgroup made recommendations concerning curriculum anddegree type. and composed a draft list of competencies.

This draft list w as presented to a subcommittee of theDrake Rehabilitation Institute Advisory Board comprised ofrehabilitation consumers. The consumers revieW ed the draftlist and added additional competencies. degree require-ments. and course offerings.

The final step consisted of sending the second revisionto the focus group members for comments. After thisreview a final curriculum with specific competencies wasde eloped. (See Appendix for list of competencies.)

The results of this study suggested. and all the focusgroup members agreed, that competition with for-profitrehabilitation was a major personnel problem row facilities.Responders indicated that they- found it almost impossibleto retain employees with master's degrees due to the signifi-cantly higher salaries in the row-profit sector. The focusgroup cone; tided that bachelor's prepared employees weremuch more likely to stay at a non-profit agency. Thus theysuggested that training for facility administrators be con-ducted at an undergraduate le el. The focus gotup alsorecoinmended that the training program he more user-friendly to working adult students. This included et nphasison evening and weekend classes, off-campus course workand the use of technologies such as computer bulletin boardsto aid student/faculty communication.

Conclusions and IssuesFor Further Discussion

. The training needs of public, non-profit and for-profitrehabilitation seem clearly differentiated but rehabilita-tion counseling programs do not seem to be addressingthese differences.

2. The educational requirement of for-profit rehabilitationprofessionals seems to be at the master's degree level. withpostmaster' s specialty areas becoming more common.

3. There is a growing body of information, and specificskills that many private for-profit rehabilitation proi'es-sionals require such as expert testimony and disabilitymanagement w hich training programs are not currentlyproviding.

4. The training needs of non-profit rehabilitation profession-als seem to be dominated by short term specialty trainingand non-degree programs. with only a few positionsrequiring a Bachelor's or Master's degree.

5. Rehabilitation programs need to expand their recruit-ment to attract people into the field who would otherwisechoose a more traditional career path.

6. Graduate programs in vocational rehabilitation need todevelop strategies to broaden their financial base so theycan become more responsive to the emerging trends inprivate rehabilitation. To counterbakulce the influence ofRSA. the for-profit industry should assist prograins in this.

7. Training programs need to become more flexible. relevantand user friendly for students planning to pursue careersin private rehabilitation.

g. Rehabilitation programs need to become more marketsensitive and responsive in developing and modifyingcurriculum and program content. To do this private reha-bilitation (particularly for-profit) must work to influencethe content and criteria of both CORE and CRC.

In summary, graduate training in rehabilitation counsel-ing often inadequately meets the expanding educationalneeds of students preparing for careers in the for-profitsector. In order to effectively perform and compete inemerging pri vate sector applications (i.e. expert testimony ).students require a great deal of on-the-job, and post servicetraining. While increased education is the trend in for-profitrehabilitation, the non-profit sector increasingly cannotcompete for master's prepared students. Thus, two of theprimary organizations designed to improve the quality ofrehabilitation training and practice--CORE and CRC--arebecoming irrelevant for Lon-profit practitioners. Trainingthat is focused on the competencies required for specificjobs in the non-profit sector (i.e. job coaches) at the certifi-cate. AA or BA level seems to be an emerging trend. Whilepost-service (or in-service) training for non-profit practitio-ners has traditionally been sensitive and responsive to thoseagencies' needs. many pre-service training programs have

PM? A11,111,0,0 RehabrIshitom . 2 8 24

not. Utiliiation of a market driven approach to curriculumand degree development is one method by which pre-servicerehabilitation education could improve the quality and ap-plicability of training to both for-profit and non-profit pri-vate rehabilitation. Howe% er. incentives for educators andstudents w ill he necessary for this to occur.

References

Bellamy. G.. Rhodes. L.. Mank, D. & Albin. J. (1988).Supported employment. 13a1 timore: Brookes.

Blackwell. T. (1991). The vocational expert primer. Athens.GA: Elliou & Fitipatrick.

Bordieri, J.. Riggar. T. Crimando, W., & Mat kin, R. (1988).Education and training needs for rehabilitation adminis-trators. Rehabilitation Education, 2 (I). 9-1 5.

Brahham, R., & Emener, W. (I 988). Human resource devel-opment in rehabilitation administration futuristic per-spective. Journal of Rehabilitation Administration. 11..124- I 29.

Buckley, J. Albin, J., & Mank. D. (1988). Competencybased staff training for supported employment. In G. T.Bellamy, L. Rhodes, J. Mank & B. Albin. (Eds). Sup-ported employment: A community implementationguide (pp 229-245). Baltimore: Brookes.

Cohen. J. & Pelavin. I). (1992). 1992 survey of personnelshortages and training needs in vocational rehabilitation.Washington DC: Pelavin Associates.

Commission on Rehabilitation Counselor Certification(1992, Winter). CRC: The Counselor. Rolling Mead-ows, IL: Author.

Deutsch, P. (1985). Rehabilitation testimony: Maintaininga professional perspective. Albany. NY: MatthewBender.

Deutsch. P.. & Sawer (1986). A guide to rehabilitation.Albany, NY: Matthew Bender.

Fischer, J.. Rollins. C., Rubin. S., & McGinn, F. (1993). Theethical case management practices training program: Anevaluation. Rehabilitation Education. 7 (I). 7-15.

Gilbride. D.. Connolly. M. & Stensnid, R (1990). Rehabili-tation education for the private-for-profit sector. Reha-bilitation Education. 4. 155-162.

Holland. J. (1990). The occupations finder. Odessa. FL.Psychological Assessment Resources.

Kaiser. J. & Brown. J. (1988). Ethical dilemmas in privaterehabilitation. Journal of Rehabilitation, 54 (4). 27-31.

Kotler. P. & Bloom. P.(1984). Marketing professional serv-ices. Englewood Cliffs, N.J.: Prentice-Hall.

1,evitt.T.(1986). The marketing imagination. New York:Free Press.

1..)nch, R.. Lynch, R., & Beck. R. (1992). Rehabilitationcounseling in the private sector. In R. Parker & E. Siy-manski (Eds.). Rehabilitation counseling: basics and be-yond (2nd ed.) (pp. 73- 101). Austin TX: Pro Ed.

Lynch, R & T. Martin (1982). Rehabilitation counseling inthe private sector: A training needs survey. Journal ofRehabilitation. 48 (3), 51-73.

Matk in. R. E. (1985). Insurance Rehabilitation. Austin, TX:Pro Ed.

Malkin. R. E. (1987). Content areas and recommendedtraining sites of insurance rehabilitt:tion knowledge. Re-habilitation Education. 1. 233-246.

Malkin, R. (1983). The roles and functions of rehabilitationspecialists in the private sector. Journal of Applied Re-habilitation Counseling, 14 ( I), 14-27.

Matkin. R. & Riggar, T. (1986). The rise of private sectorrehabilitation and its effects on training programs.Jour-nal of Rehabilitation. 52 (2). 50-58.

Men/. F., & Bordieri. J. (1986). Rehabilitation facility ad-ministrator training needs: Priorities and patterns for the1980's. Journal of Rehabilitation Administration. 10.89-98.

National Association of Rehabilitation Professionals in thePrb, ate Sector (1992). 1992-93 NARPPS national direc-tor. Brookline. MA: Author

Nadolsky. J. (1986). Ethical issues in the transition frompublic to private rehabilitation. Journal of Rehabilitation,52 (1), 6-8.

Pacinelli. R. & Stude. E. (1991). Human resource develop-ment: Partnerships in rehabilitation education. Washing-ton DC: George Washington University Regional Reha-bilitation Continuing Education Program.

Parker, R. & Siymanski. E. (Eds.) (1992). Rehabilitationcounseling: basics and beyond (2nd ed.). Austin TX:ProEd.

Renzaglia, A. & Everson. J. (1990). Preparing personnel tomeet the challenges of contemporary empl,yment serv-ice alternative. In F. Rusch (Ed.) Supported employment:Models, methods and issues (pp.289-300). Sycamore IL:Sycamore.

Ritter. S.. & Leclair. S. (1990). The small employer disabil-ity management consortium as a case management andconsultation alternative. NARPPS Journal and News. 5(4). 15-24.

Rubin. S. E. (1993 ). Introduction to special feature on ethics.Rehabilitation Education. 7 (I). 2-3.

Rubin, S.E.. Matkin. R.E., Askhley. J.. Beardsley. M.M..May, V.R. Onstott, K,& Pucket. F.D.( 1984 ). Roles andfunctions of certified rehabilitation counselors. Rehabili-tation Counseling Bulletin, 27. 199-224.

Sales. A. (1979). Rehabilitation counseling in the privatesector: Implications for graduate education. Journal ofRehabilitation. 45. (3). 59-61.

Stensrud. R. & Gilbride, D. (1992 ). Long terni training grantin facilities administration. Funded by RSA 1993-1997.

Taylor, L., Goiter, M., Goiter. G., & Backer. T. (Eds.)(1985). Handbook of private sector rehabilitation. NewYork: Springer.

Vogenthaler. D., & Tierney, J. (1990). Assessing work-re-lated economic damages after head injury. Missouri.awyers Weekly, 4 ( I 5), 1-3.

Washburn. W. (1992). Worker conmensation disability andrehabilitation: An alert to claimants. Arlington. VA:CEDI.

29Nattonal Rehabthiatum Acsocuaum 1993 .Stilt,e, Monowaph

Weed, R. & Field, '1'. (1990). Rehabilitation consultant'shandbook. Athens. GA: Elliott & Fitzpatrick.

Weed. R. & Riddick, S. (1992). Life care plans as a casemanagement tool. The Case Manager. 3 ( ). 26-35.

Wehman, P. & Moon. M. (Ms.) (1988). Vocational reha-bilitation and supported emploment. Baltimore:Brookes.

Williams, J.. & Fidanza, N. (1990). Ensuring the success ofindustrial rehabilitation programs: The role of the reha-bilitation counselor in return to work. NARPPS Journaland News. 5 (5). 67-71 .

Appendix

Student Competencies for a Bachelor's Degree in Facilities Administration

I General Personnel Management:Human resource managenlentPerformance/productivity managementPersonnel assessment and appraisal techniquesStaff training and developmentRecruitment and retention of personnelRisk managementBusiness planning and marketingSupervisory communication skillsLabor relationsPsychology in business and industryGroup dynamics

2. Professional Development:Sensitivity to disability issuesOrientation to not-for-profit businessdministrative theoryRindamentals of management and organizational behaviorOrganizational roles, functions, and operationsOrganizational leadershipManaging organizational changePrinciples of service organizationsEthics in management and rehabilitationPractical experience in rehabilitation facility administration

3. Program Planning and Evaluation:Administration of rehabilitation programsRehabilitation service systemsDes elopment and supervision of rehabilitation employeesNot-for-profit employee performance managementCasew ork managementPr(Tram evaluationWorksite statistical applicationsResearch in rehabilitation

4. Fiscal Management:Financial managementPublic financing systems in rehabilitationFiscal/operations management in not-for-profit organizationsBudgeting procedures for middle managers

5. Technical Systems:Personal computers and business softwareManagement information systemsComputer applications for people with disabilitiesMaking work site accommodations

6. Public Relations:Individual and small group communication skillsPublic relationsCommunity educationProfessional and community relationsCommunity image definition and fund raisingLegislative and gove iimental relations in not-for-profits

7. Employment Services:Facility based employment modelsCommunity based employment modelsEmployer developmentConsulting to employersFinancing employment sers ices

S. Serving People with Disabilities:Medical and psychosocial aspects of disabilityHistory and nature of disability in AmericaPeople with disabilities in business and industryWorking with rehabilitation consumers and advocatesI.egislation and regulations affecting people with disabilities

Barrier identification and Disahilit advocacyWorksite accommodations and accessibilityJob analysis and redesign

3 0

0/9? S it ci Mmoi:taph A(1114111,11 Ri hohlualion 1 ii union

Excerpts of Reviews and Comments Chapter Two

Drk ate rehahilitation as a disci-pline is changing and e) ol ing

based on forces at W. ork on L.( nnpensa-t ion \\ steins. These kwces include:

1 . Changes in compens;.ition s) s-tems. such as repeal of mandator)rehabilitation within WorkersCompensation in sonic states.merger of short term disabilitand long term disabilit) insuranceproducts. etc.

2. Americans, \\ ith Disahilities Act.3. Health care ref orm.

What is emerging in pri% ate reha-bilitation is the concept of disabilit%management. a combination ofproactise medical and disabilit casemanagement. These sers ices may heprovided by a comhination of professional specialties. including nursing,rehabilitation counseling. ergonomicengineering, and a host of other re-lated professions.

The e \ tent to w Inch rehabilita-tion counseling maintains a place inthe new I) emerging disahilit) inan-agement concept depends upon thefollow ing:

Aailahilit ()I suppl) of qualifiedprof essionals.

.2. Professionals w ho !lase specificskills and competencies for dis-abi I it\ management.Role of disabi lit management af-ter health care reform.

Dr. Gilhride raises serious con-cerns ihotit the ability of the currentrehabilitation education s) stem tomeet the needs of pris ate rehabilita-tion I hs concerns include fundingand recruiting issues and constraintson curriculum in regard to accredi-tation.

Dr. CiiIhride suggests rehabilita-timi counseling education needs toe Pan( the I inancial base No that it

can become more responske toemerging trends in pris ate rehabilitation. In addition. des eloping flebilit) in curriculum design is desir-

1

able to develop necessar) skills !hal\\ ill he needed in the private sector.

I agree these are areas ss hich needto he addressed. Failure to do so ma)af feet the clualificat ions and supply ()I'rehabilitation counselors kw the pri-\ ate sector. As a result, services tradi-tionally pros ided h) the rehabilitationet mnselor (such zis job analysis, johmodification. and placement ) ma)shill to other related prof essilmal spe-cialties.

Catherine C. Bennett

Dr. Gilbride has presented an eAcel-lent critique of rehabilitation edu-

cation kw both the priS ate and publicsectors in rehahilitation. Dr. GilbrideciwrectI\ observes that there is, "sub-stantial disagreement e\isting. amongleaders and educators in the field ofrehabilitation concerning how broadka basic (2(mi-se should be defined" fortraining. in the pri \ ate secuw.

"the importance of heing certifiedas a rehabilitation consultant has cer-tainly added credibility to practitio-ners work in the private sector and thecertification mos (Anent cinitinues togaM strength and momentum. In ad-dition to the three programs refer-enced h) Dr. Gilbride (CRC. CIRS.CVN.), a say strong interest has beendispla)ed by prof essionals in becom-ing cert if ied as case luanagers (CCNIII is ex.pected that this strong interestin certification and eventual licensureh) state sl ill he part of the future.

With respect to Dr. (iiIhride's oh-sen ations regarding accreditation ofthe training program\ by CORN. it iscertain!) true that graduates of CORI'.programs hase a distinct ads antagesk hen applying for certification. Onthe other hand. I has c ids\ jos

CORI... along ss ith RSA trainingkinds, as part orthe state/federal qral-cp to large!) e elude des elopmenkin the prkate sector (s) ith no maliceinten(led ). This obsersation is hornout b \ the er) slow and pedanticmos ement Itissard an) resemblance of

3 1, pm, R. ,\%e 41,111011

speciali/ed training for candidatesmoving into -the pris ate sector and.more importantly . h) the contintnng"wad block" of requiring stipend re-cipients to work only in the publicsector following graduation. Thisclearl) is a punitive and exclusionaryloose h) RSA and the CORN creditedprograms.

Isinall). Dr. Gilbride has correct] \obsersed that there is a substantialinterest and mos ement tow ands kwensic rehabilitation h.) man\ s) uh in thepm ate sector mos enient. Requiredknow ledge and competencies canu uall) be obtained onl \ through non-unis ersity related seonnars and pro-fessional association conferences.\Inch more can he (kw by the Mil-s en.,it in formali/ing these :wens ofrequired information for all masterscandidates interested ni 1105 ing into

the pri). ate sector.

Tim Field

Dr. ( Iilbride presents a realistic siewof private sector rehahilitation in

tains of current practice and e pecta-tions. and relates this to educating prac-titioners for work in the for-prontarena. An iinpoilant delineation isIllade between private kw-profit andpriSate non-profit rehabilitation V. Inchresults in acknow ledging the di)er-gence in job tasks and required skillsand competencies of each group of re-habilitation professionals. This is aniniportant point since niany relnihilita-ti(m counselor education programs donot acknowledge these differences.

In contrast to other publications onthe kw-profit sector ss hich has e re-flected limited employment ens iron-mcnts. a full range of employmentsettings is identified in dn. manu-script. How es el% the primary focus ofrehabilitation educational trainingprograms tends to reflect public andnon-profit settings due to go) eminentunding Ion these areas. The need to

oilier training in for-pront rehabilita-tion is also necessar) hut does not

/(1, Sit //. F th,/losV //ph

have the funding suppon to provideincentive for des elopment of suchtraining. A market-dris en appntach,as descrihed in the manuscript, couldbenefit not onfs curriculum develop-ment but funding (.. I es e. I opment. asss ell. in pros iding a financial base interms of scholarships or assistantshipsfOr desen ing student. and consult-ation for facult.s . In addition. a lid !-fledged public aw areness campingncould be undertaken h.), \ arious phi-s ate sector pi(Ifessional rehabilitationorgani/at lOns and educational inst it u-tit ins to promote awareness of for-profit emplo mem Opportunities.Large emplo.s ers might also see therele \ ance of participating in such acatnpaign.

Another nuplication for the futureof for-proht rehabilitation is the elf cc-tis eness of socational rehabilitationsers ice delis en in regards to workerscompensation and other insurancecases. Professionals ss orking in thisarea must be pros ided training on is-sues specific to pro\ isions of insur-ance s stems "so that adequate docu-mentation of their effectiseness is pre-sented. In conjunction ss ith this. pro-gram es aluation sstems should beimplemented and maintained to as-sure ell'ectis eness and effic ienc.\ ofrehabilitation sers ices through appro-rriate outcome measures.

Juliet H. Fried

Dr. Gilbride points out ser clearlythat. in general. rehahilitation

education programs are not revolt-si \ C and sensiti \ c to the changes in therehabilitation industn as a ss hole.Roth the pri \ ate for-profit and pris atenon-profit sectors haw oohed Os etthe ears and their educational needshas e altered.

Rehabilitation educat ion programsmust therefore gross ss ith these newdemands. At the sante time. how es er.practitioners and their respect is c pro-fessional associations such as Na-tional Rehabilitation Association(NRA I. National Association of Sersice Pms iders in Put \ ate RehabilitationNASPPR ) and National Association

of Rehabilitation Professionals in the

Private Sector NA R PPS ). must assertthemsels es to effect the Council onRehabilitation (CORF.) and the Com-mission on Rehabilitation CounselorCertification tCRCC), the tss Iimar. organi/ations designed to im-pros e the qualit of rehabilitationtraining and practice". To accomplishthis. pris ate rehabilitation. particu-larl for-profit. must hegin to addressits ow n identit crisis.

As a profession. pri s ate rehabilita-tion is still relatis el \ new . Practitio-ners are constant 1. struggling ss ithethical dilemma. as indicated hs Dr.Gi Ihride. lie question of "ss ho is theclient?" is asked not just h.). the pro-fession itself, hut also being chal-lenged h other plaers in disabilitben.)fit systems and especialls in fo-rensic rehabilitation arena. The lack ofresearch data and the lack of documental ion Wilier compound this im-age cm "public relations" problem. Pri-s ate rehabilitation. as an industr.should and 11111s1 start to tackle theseissues. Again. this is ss here the lead-ership it) professional associations.CORE and CRCC ss ill pla a majorrole.

John W. Lui

Dr. (. iiIhride presents a thoutughploration of sarions training-re-

lated issues as the impact on the pri-s ate rehahihtation arena. Certification.accreditation and forensic issues arediscussed. ss ith numerous conclusionsand recommendations lOr further con-sideration summari/ing this article.

From the information presentedhere. it is clear that rehabilitationcounsel(w edtleation programs need toss ork towards evpanding their focusof training in order 10 include the ss iderange of settings where or r rehabilita-tion counseling students are em-plo!ed. With RNA limdIng has ingbeen I and still being) a niajoi I under

of rehabilitation counselor trainingprograms. it is understandable that thefocus of graduate programs has e beenon public sector work. 110550 er. ss iththe growth and the demand for quali-fied personnel c iii liii g from the pri-s ale sector, it is time for cducational

32P19 Smi it. mmt!,,m01;111141 \,111011111 l hablilhami,11 .1\irs mimiim

institutions to recogni/e the demand.and offer training to students that willresult in profitable, challenging ca-reers in the private sector.

As a Commissioner on the Com-mission fOr Rehabilitation CounselorCertification. 1 share the author's rec-ognition of the i mportance of the CRCcredential in the for- pB)fit ens iron-ment: it is m strong belief that ceitification is a ss a) of measuring thealue and the importance a profes-

sional places in their oss n "proles-sionafism". h submitting to the appli-cation proce,,,.. 1-). sitting for a na-tional e \amination. and b), maintain-ing their certification (and also theirknoss ledge-base) 1-) certificationinaintenance.

It is true that the phasing -out ()I' thebachelor's degree categon ss ill result intighter standards for obtaining ceniflea-tion. but I do not we it haying as signifi-cant an inipact on the labor pool as isindicated n the author. In fact. ss hileapproximatel 30'; of the applicants atthe close of the June 1992 (Ade hadhachelor degrees. the number of appli-cants in this categ(w) was unusuall highdue lo the plans to phase out that eale-go r. listoricall.s. the figures are lessthan 15'i of applicant p().01 p(issessing abachelor's degree.

kvpanding the Iiicus of graduatetraining prograins, and offering stu-dents a ss ider range of options at theconclusion of graduate training. canmil> help the educations institution.the future professional and the pris aterehabilitation field.

Patricia Nunez

The education of 5 ocational reha-bilitation counselors and s

ti(mal evalitators kw private sector re-habilitation nas been anything but for-s\ ard thinking. There appears to he aperception ss ith most universities thattraditional public rehabilitation mil-i/ed in a state rehabil itatim in agene orprogram is the only limn of rehabili-tation ss (wth teaching. This is unfOrtu-nate for the graduates of these programs because the likelihood of themss (irking for an length of time in thepublic sector is diminishing each day.

Working in private rehabilitation sec-tor at some point in their career. how-ever, is extremely high.

With the advent of the Americansith Disabilities Act, health care re-

l'orm. spiraling co s ts in workers com-pensation, and other changes whichaffect American business, it is reason-able to expect that business will relyon qualified rehabilitation prolessitals to address their nee(k. The diffi-culty is. that relatively few rehabilita-tion professionals have formal educa-tion in business related issues andneeds. Those that do, have little expo-sure until they complete an internshipss ith a private rehabilitation company.are employed by one. or are employeddirectly by a business or industry toprovide rehabilitation services and/ordeal ss ith disability management.

Working with employers in businessor industry is much different than work-ing with the traditional state vocationalrehahilitation concerns. Rehabilitationprofessionals. whether working in publicor private sectors. need to know the dillferences and must be able to utilite theirskills appropriately.

In addition, rehabilitation profes-sion ds in both sectors need moreinformation and training in forersics. Because of rising litigation,ss hether it is Social Security, work-ers' compensation, personal injury .or disability discrimination the pos-sibility of one being called to testifyin court is very high. Again. the cur-rent curriculum in most universitiesdo not offer any exposure in thisarea. As a result, the rehabilitation

professional learns these skillsthrough on-the-job training.

Dr. Gilbride addressed these issuesin his action paper. The recommenda-tions ss hich he and the review groupproposed were well thought out andw ill hopefully be implemented. Ifthey are not. rehabilitation profession-als who graduate from our universitieswill continue to he inadequately pre-pared for their profession.

Jeffrey J. Peterson

Dr. Gilbride articulately outlinesthe current issues in educating

practitioners for work in the privatesector. Apparently correlated withfunding and the needs of the popula-tion served. non-profit rehabilitationhas emphasiied consulting and dis-ability management services. Dr. Gil-bride explains how this divergencehas resulted in the des elopment of jobtasks with vastly different skill re-

quirements. Individuals employed innon-profit rehabilitation settings withfew exceptions require only shortterm specialty training or non-degreeprograms. Dr. Gilbride makes a co-gent argument for the development oftraining programs for paraprofession-als to be employed in private not-for-profit rehabilitation settings.

Rehabilitation professionals in for-profit settings have increasingly di-verse employment options. This di-

ersity presents challenges to the tra-ditional graduate level training avail-

33

able through Rehabilitation ServicesAdministration (RSA) funded mas-ter's degree programs in rehabilita-tion counseling. Required to matchthe missions of the State/Federal vo-cational rehabilitation program. theRSA funded graduate programs has efocused upon competencies requiredin the public and non-profit sector.Similarly. Dr. Gilbride's paper re-flects that CRC and CORE. the sameorgani/ations which has e success-fully promoted rehabilitation coun-seling as a profession and prole.s-sional training. to different degrees.need to address relevance fOr pris ate-for-profit professionals.

Minimally., the addition of gradu-ate course work in pros iding experttestimony, life care planning and ethi-cal problem sok ing through rehabili-tation departments would assist reha-bilitation professionals address thesetopics with a uniform perspective. Intry experience, possessing a basic un-derstanding of these topics before en-tering proprietary rehabilitationwould facilitate the mentoring proc-ess required to acquire these skills andreduce staff turnoser.

Regardless of the ty pe of training.the importance of addressing theneeds of working adults cannot beoveremphasifed. Flexible. relevantand timely curriculums can only en-hance the quality of sers ices providedby private sector practitione.

Stephen A. Zanskas

%,111(.1)(11 Ihibtliratual 1%w. ninon 1993 1It il:t ortm:r aph

Seminar Recommendations Chapter One & Two

The lot kiss ing is a sunimarv of thereconunendations and implica-

tions for action as they relate to thediscussions of chapters One & I'wo.

These recommendations were de-veloped by an individual ss ark groupand the style of presentation reflectstheir own format along with implica-tions for action.

The following recommendations willserve to address the changing needs forrehahilitation education and training fOrthe next decade and beyond. "rhe recom-mendations call fora total reexaminationof the manner in which rehabilitationeducation is currently and traditionallyachies ed. Changes will he required pri-marily due to the significant changes inour society with respect to developmentsin hoth the private and public sectoN ofrehahilitation. emerging national healthcare policy, spiraling costs for both work-ers' compensati(in and health care. andspecial needs for managed health care.

Service Delivery

I. Public rehabilitation pwgramsshould serve private clients througha merging of public and private pro-grams brought ahout by anticipatedchanges in health care reform.

2. There should be a national registryof qualified rehabilitation pros id-eN and independent contractors,including graduates of the rehabili-tation training programs.

Programs for rehabilitation servicedelis cry should he by "choice" ofthe client.

3.

-I-. Funding strategies for the unker-sity programs should be bniadenedto include training needs for inde-pendent contracting and clientchoice sers ice delivery programs.

Training

. 'Me Council of Rehabil Um ioncation (CORE) should expand cur-

riculum to include private sectorissues related to all service delis -cry sy stems.

2. Professionals assoc iat kills shouldbe inore active in articulatin;.: thetraining needs of their inembers.

3. Graduate stipend recipients shouldbe required to "pay hack" to any'service delivery system.

4. Curriculum changes are needed inareas of. for example. business andindustry. joh analysis and labormarket information. coinpensationprograms. legal and forensic is-sues. insurance and disability inan-agement.

5. A future natitmal conference of theNational Council on Rehabilita-tion Education (NCRE) should fo-cus on the merging of public andprivate sector programs.

6. Current faculty are encouraged toexpand their awareness of insur-ance rehabilitation and case man-agement issues as part of their con-tinuing education. w ith opportuni-ties for innovative research andwriting.

7. 'Ihe Rehabilitation EducationJournal should have a special issuedirected toward public and privatesector rehabilitation c(mcerns

8. mtinuing education programsare needed ftw more "lifelong edu-cation" for all professionals in thebroad field of rehabilitation -- to hesponsored by universities. busi-ness and industry, poifessicina I or-gan i/at ions. and others.

Research

. fhe National Institute on Disability and Rehabilitation Research(NIDRR I should establkh a Re-search and Training Center for

"Rehabilitation in the 2Ist Centurythe coming together of public

and pris ate sector rehabilitation."

2. Major organi/ations (CS AVR.NRA, NARPPS. NCRE. CORE, andothers) should collectivel andequally sponsor an independent studygroup to address the issues related tothe merging the public and pris atesector rehabilitation.

Legislation

All recommendations listed abosess ould be addressed hy a s ariety offunding and legislative sources in re-inforcing needed changes.

I I ii ii. Mi.mwiaph \altomil Rclwhiblainm I%\o, han3 4 .?

Chapter Three

Insurance Issues and Trends:A Focus on Disability Managementincluding RehabilitationPatricia M. Owens

Introduction

This paper presents broad-ranged insurance issuesand trends in the context of work place disabilitymanagement (DM ). DM in the work place ap-plies to both insured and employer self-insured

disability benefit programs. Rehabilitation is an importantpart of disability management. and practitioners must viewtheir role (and he trained to carry out this role) in the largercontext of comprehensive DM.

As in any developing field. the prediction for the futum of DM

is extensive and intensive change. Trained rehabilitation profes-sionals can "catch the wave" and help shape this change.

Organization of The Paper

Disability and work place DM are defined. Next. keaspects of three workplace disabi lit) programs (ie) Work-ers Compensation (WC) programs for illness and injuriesarising out of and in the course of employment, non-WCdisabilit programs and the Social Security (SS) disabilityprogram are reviewed and related to DM.

Rehabilitation services are then discussed from the view-points of specific DM participant, and payors ( insurers,employers and employees I.

The paper ends with a brief discussion of four changeagents - The Americans with Disabilities Act (ADA ), Health('are Reform, Twenty-four hour medical and disability cov-erage. Social Security 1) lability Program Reform, and

their likely bearing on DM and the private rehabilitationprofessional.

Patricia NI Wen.. Vice Pie.ident ol Prop anN tNtmice Conipon ()I Arno 'can, INbI It,inti. Mame

Disability Management

The Disability Risk:A working definition of disability and a basic under-

standing of the disability risk is essential to explore tliebroader issue of work place disability management.

Disability occurs when a medical (physical or mental ) condi-

tion impairs a person's capacity to function at a prescribed level(with or without accommodation). Work-based definitions ofdisability can require that a person be unable to perform some or

all of the functions of his or her own usual occupation or. theycan be more stringent and require that a person cannot perform

the functions of any occupation. For WC. a person may hcdisabled and qualified for benefits when a work-caused accidentor injury reduces their earnings capacity because of a loss in the

ability to function. Often this reduction in earnings capacity isquantified by a payment schedule. For example. a linger garners

so many dollars and an arm more dollars. The degree of the loss

is often the source of litigation. The point hem is that definitionsof disability for compensation in lieu of wages vary.

The follow ing statistics help us understand the likelihoodof someone being disabled:

In 1989, I in 7 Americans reported physical andmental conditions that interfere with life activities.(1)

In 1990. 14.2 million working age persons reportedthat they were limited in that they were limited bysome disability that interfered with work. (1)

In 1991 there were 8.4 work-related injuries per 10(1full-time private sector workers, 3.9 lost work-daycases and 86.5 lost work days. (2)

35Vatwmil Rchabashinon I wu 14111( )11 P)(14 We, tfonovilph

Disability claims rose in 1992. Both SS and UNUMLife Insurance Company report increases in incidenceand duration. In 1992, SS Incidence was 5.4 perthousand (11 ). UNUM Life Insurance data covering5 million lives indicates that there was a 237c increasein disability claims in 1992 over 1989.

Leading causes of claim for SS are I. Mental, psy-choneurotic and personality disorders, 2. Cancer. 3.Circulatory System.(20)

General Accidents are the highest cause for UNUMfollowed by cancer, heart conditions and back disor-ders. Six % of claims are for psychiatric conditionsand on the rise.

Work disability may be partial (some work can still bedone) or total (essential functions of work cannot be per-formed at all). Disability may last for only a few days ormay he permanent. In the western world, public and privatedisability compensation systems have evolved to provideincome fOr persons whose disabilities keep them from work-ing. Deborah Stone, in her definitive book, The DisabledState, discusses payments for a disabled condition in theframework of redistributive justice. In the U.S. both publicand private funds arc set aside when a person's medicallydeterminable physical or mental impairment of functioninhibits their ability to earn a wage. Employers pick up alarge p(wtkm of the tab.

Disability in \ ol \ es more than the severity of an impair-ment that reduces function and precludes work. II involvesmany personal, socio-political and economic factors. Al-though the length of this paper does not permit an in depthdiscussion or the spectrum of contributing factors, it is

important to acknowledge that disability designation. fre-quency and duration are driven by a complex system ofinteractive phenomena.

Defining Disability Management(DM)DM is a term that describes actions and programs to

control the human and dollar costs of disability in the workplace. These actions center on the costs of the disability bothat the individual and organizational level.

DM programs reflect the employ er's overall humanresource philosoph \ and strategy. Employers IA ho needskilled workers for complex jobs and place a high valueon the people who w ork for them w ill pro \ ide more inbenefits to attract and retain employees. In such an envi-ronment. DM is aimed at pro enting disability but, whenit ine \ itably occurs, providing accommodation and ade-quate compensation to replace lost w ages resulting fromreduced function. These employers emphasize rehabilita-tion and return to work.

Con\ ersely . DM may be minimal if employ ers have ahuman res(mrce philosophy that accepts high employ eeturnmer especially A.\ hen jobs do not require high skillle\ els. In this setting, \ acancies can easily be Idled by

full-or part-time replacements. When an employee can'twork because of sickness or accidents, they usually rely onpublic programs for protection. If WC is not involved,employees with disability are terminated when they areunable to perform their essential job functions and use uptheir allotted (if any) sick days.

The size of the employer is an important factor in the magni-

tude of DM. DM initiatives of smaller (under 5(X) employees)employeN may only include short-term and/or long-term bene-fits provided through an insurer who includes limited DM serv-ice. The smaller the employer, the n tore informal and low-budget

the DM programs may be. ( A fairly recent occurrence is the local

business consortium. These "business groups on health", arespringing up in communities throughout the US. while originally

geared to rising medical care costs and medical care issues, arealso considering pooled resources for dealing with disabilityissues including return to work and ADA responsibilities.)

A Disability Management Model

The Organization's Philosophyand High-Level Commitment

DM flows from a precisely stated organizational philoso-phy and high level organizational commitment to a portfolioof programs and services. Benefits handbooks are mostoften used to communicate employee health, medical anddisability benefit and management programs and how theyinteract to all employees.

The most comprehensive DM philosophy takes a posi-tion on work safety. healthy life styles and includes disabil-ity prevention and Employee Assistance Programs ( EAPs ).Effective DM provides for adequate benefit levels. fairclaims decisions including appeals. early interventionservices, job modification and reasonable accommodation.Medical and rehabilitation services support maintenance orrestoration of function and return to work.

Linked Absence PolicyGood DM requires a clear-cut absence policy including

absence for sickness and disability. Employees must knowwhen an0 how they will be paid for absences. Definitionsof disabil ity, disabi Ii ty compensation system provisions andprocesses. the roles of management. employ ees and third-party providers must all he clearly explained.

Employee rights and obligations regarding disability,along with employer responsibilities under the ADA shouldhe included. Special industry job requirements and restric-tions and drug -testing policy are often pertinent and shouldbe stated.

Information SystemsEffective DM is huilt on an information system that

captures data. provides information and reports on disabil-ity related issues such as benefits costs, types of illnessand accidents across programs so that targeted action canbe taken. The most ad \ anced system will pro\ ide for costbenefit analy ses. Indirect costs ot disability such as loss

36/QV? Stt ii /6 h1blh1ilf,,P1 1N,,, 'atom

of productivity and worker replacement costs need to hefactored in. For larger firms, data and information areproduced at the division level as well as in the aggregatefor the company so that distinct problem areas can beidentified and rectified.

Benefit Plans:Incentives and DisincentivesAll disability benefit plans need incentives to encourage

return to work. These can be financial in nature. with benefitrates being at some level below take-home wages. How-ever. other work place factors can provide incentives ordisincentives for work vs. disability. It is important thatemployees consider work a more attractive alternative thandisability. It is not always financial incentive that tips thescale for keeping an employee at work or returning them towork. Personal relationships at work and at home may beinvolved. Early return to even partial duties can help pre-vent an employee from developing a disability mind-set.

automobile accident and other casualty insurance paymentsin addition to the Social Security and WC offsets morefrequently encountered.

SettlementsSettlements. i.e.- payouts of disability benefits are

viewed by some as a DM strategy. Settlements provide adifferent payment option for disability claimants. The pay-outs which may be in a lump sum or a series of payments,are awarded in exchange for the claimant waiving futurerights to benefits.

This practice lowers the os erall costs for employers andinsurers because the settlement is generally lower than thetotal of the payments that would be paid. Settlementsrelease money that employers and insurers hold in reserveto cover the projected claim duration and this benefits thepayor.

Settlements are advantageous to the employee/claimant

The Progression of Disability

-

,

zfr

Minimumabilitylevel rebuked forjob/occupation

There should be a serious atteinpt to identif and under-stand both individual and organizational incentis es anddisincentives to return to 1t ork. Funding levels, plan de-signs and administrative oversight are all important.

Integration of Programs and Cost-EffectivenessInsurers ss ho underwrite emploce disability benefits

programs (Noll Workers Compensation and non-occupa-tional illness and injury benefits) and third-party adminis-trators or employers who self-fund and self-administer dis-abilit related programs look for ways to manage disabilitand control costs. They has e singly and jointly becomemore sophisticated in understanding program integration.This means making pn)granis work bigether in evervtme's

,t interest to minimize the full cost of disability, includingmedical care costs, and to achiese masimum cost benefitsfrom DM initiatis es.

One of the main objectis es of integration. to manageos erall benefit les els to pros ide financial incentis es forreturn to ,1 ork ss as discussed earlier. hut it bears repeatingin this contest. Some disability benefits now integrate with

" REST COPY AVAII

because they get a sizable sum at one time ss hich can provide

tOr greater ff. in retiring debt or investing. Settle-ments appear to be on the rise especially in disputed or "gray

area" claims.WC settlements are referred to as Compromise and Re-

lease (C&R f agreements. John F. Burton indicates there areno national data on these agreements. (10) A study bBurton with the Workers Compensation Research Institutecould not establish whether ('&R agreements increasedecrease the costs of WC.(9) Burton says "I am not suress het her ....C&R agreements...are increasing...(although mysuspicion is that...ff hey are". I le also belies es.that theyincrease the us eral I costs.) Ill )

Managing Disability For IndividualsIn a model DM program ss ith a clear philosoph. organiza-

tional pp)gninis and high level coi tumitment. there is still a need

to foclis on the individual. When an individual becomes dis-abled. individuals and their families need to be able to lel> on

clear. fair and consistent guidelines and practices. l',quitable

claims ismuire on crediNe es idence of the medical condnion

3 7\111011.1/ R141,1b1/110/1011 11,1111,1011 / ii. ct Slotiol't aril

showing what a person can or cannot do as a result of a funct ionalimpairment. Systematic, interested decision-making and follow-up by the claims payc: and the employer will be present. Iden-tifying when maximum medical recovery occurs and takingactions to return persons to work in their own or other jobs arefundamental. Return to work is the optimal goal: rehabilitationpotential must be considered and realistic rehabilitation begun asearly as possible based on the individual's needs.

Viewing individual disability as a continuum. DM ac-tions for an individual may occur at a variety of points.(See Chart below, reprinted with the permission of UNUMCorporation.)

The Workers' Compensation System

Program DesignThe Workers' Compensation system began in the early

I 9(X)s and now has separate programs t'or each or the fiftystates and the District of Columbia. Under these programs.employers pay the costs of all work connected injuriesregardless of fault. Each state is responsible for its ownprogram. hut each program provides the same basic type ofbenefits. A worker must show a connection between theinjury and work before any benefits can be collected.

Benefits include a weekly amount (usually two-thi';.dsof w ages subject to a maximum) paid while the worker isout of work or until maximum medical improvement( MMI ) has been reached. If after MMI the person still haspermanent impairment hut is not totally disabled, compen-sation will he due in the form or permanent partial pay-ments based on a schedule for specific impairments. theloss of earning capacity. or actual wage loss. If after MM Ithe person is totally disabled. payments are determinedaccordingly. Therefore indemnity payments may he madefor temporary disability, permanent partial disability andpermanent total disability. Each state has a different wayof computing the indemnity payments, which may he paidin a lump sum or in increments.

'According to the theory of workers compensation, theworker was not supposed to benefit from the accident. hutwas entitled to a cash amount designed to preserve livingstandards." say Berkowit/ and Berkowit/. I 991. (7) (Note:stirs ivor benefits are also as ail able.)Medical Benefits

In addition to the indemnity pay ments. WC pays for fullmedical care without any limits for work related injuries.Again quoting Berkow it/ and 13erkowiti, the worker isentitled to "the medical care necessary to reach the point ofma \ imum medical improvement." (7) Medical benefits arethe fastest grow ing segmen) of WC costs and this has led toa \ ariety of reform i(leas, especially an emphasis on man-aged medical care.

RehabilitationBerkowit/(90) and Berkow it/ and Berkow it/ (91 ) main-

tain that rehabilitation has alv:ays been an intent of the W('program. The goal of rehabilitation is to restore workers to

Iv.d ice r 11,mm:with

their pre-injury abilities, not to improve their pre-injurywork capacity. Formal mandated programs grew in theI 970s, with California in the forefront. They began toweaken in the 1980s and 1990s, mainly because of their costand lack of documented cost effectiveness (as measured byreduced WC costs overall and/or earlier return to work.)Another reason cited for the failure of WC rehabilitation wasincreasing litigation, which could encourage an employeeto stay out of work while pursuing a settlement.

Interaction (Offsets)WC is the first payor but integrates with Social Security.

In most states Social Security is offset by WC benefits, hutsome states have a reverse offset so that SS is the first payor.Other STD and LTD benefits integrate or pay only contractamounts that exceed WC payments. As an example, for onelarge company, 75% of the STD payments also involve WC.This happens when STD payments are at a higher replace-ment rate, to cover a WC waiting period and when the natureof the work causes frequent WC claims.

Funding MechanismsThe purchase of insurance to cover WC cost is the most

common funding method. Some states permit employers toself-insure, but these employers must meet strict eligibilitystandards, mainly financial criteria. (Self-insuring employ-ers substantially increased their share of benefits from12.4% to 20'7( from 1960-1990. The relative share peakedat 20.5 `, in 1983.) (10)

Most States provide for price control. Premiums arebased on hook rates developed by a rate-setting organi/a-t ion. All carriers must use these rates in selling WC policies.While adjustments are permitted, all carriers are subject tothe same type of rate adjustments based on like formulas.Carriers compete on the basis of dis idends and sei vice.among other factors.

There are two distinct (but not equal) WC insurancemarkets. Voluntary and Residual. In the voluntary insur-ance market. carriers believe the premium they are allowedto charge allows them to meet profit objectives. Employersare willing to pay these rates. Therefore. insurance carrier."\oluntarily" market to employers.

When state insurance commissioners will not approverate increases to acceptably profitable levels. carriers mayno longer offer voluntary insurance to some industry seg-ments. When employers cannot get voluntary cos erage theyare forced into the residual insurance market established bymost states to provide risk relief.

Residual markets are on the rise. These state-run marketsoperate like assigned risk pools for automobile insurance.Insurers ()Fier ol not any insurance only to selected indus-tries. Employers in other industries may be assigned to astate-operated pool or to a specific carrier. All losses os erand alNis e premiums collected from these pooled employ ensmust be shared by insurers doing business in the state.Self-insured emplos ers tistizilly do not have to contnhute tothe residual pool.

38Ntittont/I Inth/trotton Is sot 1,111051 /.1

There is now some movement away from price controls andother state mandates. Deregulation began in the early 1980s. So

called "open competition" allows insurance companies to deter-mine rates. Arkansas. Colorado. Connecticut. Georgia, HawaiiIllinois, Indiana, Kentucky, Louisiana, Maryland, Michigan,Minnesota, New Mexico. Oklahoma. Oregon, Rhode Island,South Carolina. Texas, and Venriont have some form of opencompetition. Maine law includes reference to open competitionbut most of the premium is in the residiral market. It is interesting

to note that Moves to more open competition have been made inthe hopes of lowering WC costs fOr the employer and thusencourages insurers and employers to kx)k for ways to bettermanage risks. (eg) DM.

Program CostsAccording to John Burton, data for 1991 and 1992 sug-

gest that WC costs have increased on the a% erage of W ay ear since the beginning of the decade. To put this inperspective. costs increased to 18.6 (4 between 1971 and1979. slowed to 4.3(,? between 1979 and 1984, and grew13.3 a year between 1984 and 1990. For 1992, Burtonestimates that the WC expenses would be 2.57(.; of payrolland that WC costs will accelerate in 1993. (10) When

iewed historically, the rise in WC rates can he linked witha variety of factors including increased personnel, workplace accidents and higher benefit levels. Increase in medi-cal costs have been a major contributor to the overall upwardspiral. Other factors include increased litigation and greateruse of compromise and release agreements. (10 I

DM and Workers' CompensationIt is clear that the Workers' Compensation system pro

ides a fertile field for DM. In fact. many argue that losscontrol, safety and prevention activities trace their begin-nings to efforts to control WC costs.

Insurers and employ ers understand the need to encouragesafety at w twk and to prevent injuries before they occur.Safety equipment, work site intxlification and self managedss ork safety teams were among the first DM activities, allgenerated by W(' cost control strategies.

In a three-year eollaborative research project, 1111111 andHabeck (12). using a random sample of 22(1 Michiganemploy ers from seven industries. correlated differences inemployerl)M with disability outcome measures. The studytook into account differences among industry h pes. Em-ploy er programs were studied from an organ itational per-spective seeking out wide-ranging interactive programs in-cluding safety inter\ ention to prevent the occurrence ofaccidents and disability, early intervention to seek out dis-ability risk factors and coordinated 1)51 scr ices hif costeffective restoration of function and return to work.

Hie Ineastlres Or he effectiveness or consequences of the

employer used by I hint and I labeck, were theincidence of w ork -related disability, the duration of disabiih and the total number of lost 1\ orkda,-,. Successful em-ploy els, Identified ia the statistical analy ses.Tlicse Ci wipani es l (Iv generally f( quid to he ad anted ii)

safety efforts and very active in injury management. Theyhad implemented at least some form of return-to- workprograms. The study demonstrated that companies whichemploy progressive wide-ranging DM have been rewardedby disability prevention and lower WC' costs.

Employee Disability Benefits, (Non-WC)These benefits generally include medical benefits, salary

continuation for absences due to sickness or accident, shortterm disability benefits and long term disability benefits andare described categorically.

Medical BenefitsThere are no definitive data sources that relate the availability

of non-WC medical benefits to salary continuation, short-tenndisability (STD) or long-tenn disability (I.TI)) benefits offeredby employers. Data indicates that smaller employers are leastlikely toofThr medical benefits and many do not. Most employers

who offer formal salaty continuance. STD or LTD programswhen queried, indicate that they. provide at least mininial medical

benefits. Few employers, large or small effectively link medicaland disability benefits for prevention or early recover. Howe \ er.

them is growing awareness of the effect on each program has on

the other in terms of prevention and return to function.

Salary Continuation and STD

Program DesignMany employers provide some type of sick leave or

salary continuation at I 00(4 of earnings for short-term ab-sences or incidental time off because of minor illnessesand/or to see a doctor. These may be informal arrangementsand vary based on industry. seniority. type of job or industryas well as other benefit programs that may begin paying aftera contractual elimination period.

STD plans are more formal and typically begin pay ingbenefits after salary continuation or sick pay has run out oron the first day of hospiutli/ation. Sonic STD plans areprovided in lieu of sick pay after a short waiting period.

STD plans generally replace 40(4 to 70'4 of earnings butcan replace as much as I 00ei . Benefit periods range from30 days to six months. Roughly 9(N ot employees eligiblefor STD benefits return to w ork within eight weeks or less.

Integration (Offsets)There may be integration with other benefits. especially

with WC. For many firms, non-WC disability is the t.oini-nant or sole occurrence. partly because pregnancy can be the

largest cause of STD claims. Because of the short-termnature of their disability, those eligible for SID benefits areusually not entitled to Social Security . Sonic employ ersofket lOr personal injury settlements.

Re habil itationSince most short mcmi dmsabif iir remits with link inter\ enhon,

sr stematic rehabilitation is not licquent. I low ever w hen early

intenention is a 1)51 goal. empliiyers arid insum seek OW

39Vilf,ftai ha/01/0/11M 1%%,, pp/ 511 It, fe./1

potential LTD claims during th SID period and begin eady casemanagement including rehabilitation.

With a six month (or longer) STD (or salary continu-ation) eligibility period, rehabilitation may be consideredand is usually made available based on an assessment ofpotential for success measured in overall cost savings. Re-habilitation may also be considered as part of reasonableaccommodation under the ADA.

Funding Mechanisms/CoverageSTD is often funded by an employer hy purchasing

insurance. Self funding (with third party administration) ispopulai- with larger employers because the incidence ofdisability is predictable and costs can be accurately budg-eted. When the employer is paying for the benefit. self-in-surance, especially if self administered, can seem less ex-pen,,ive because there are no third-party premiums or fees.

With the defined contributions as opposed to definedbenefits on the rise. employees may hax e to make their ownchoice about STD cox erage. They have a limited employerpros ided benefit and they must decide how to use it. Or.employees may he offered an opportunity to enroll in a planat their own expense.

The larger the company . (he more likely it is to base aformal STD plan. Department of Labor publications indi-cate that x9,-; of companies over I(X) employees have aformal plans xx bile only 59'i of companies with less than100 empl,'yees do so. (15) (16) In unioniied companies.there may be sex eral plans depending on bargainine. units.

Long-Term Disability Plans

Program DesignI:ID plans ixiy benefits for an extended period. often to

age 65. depending on the delini t ion of disability. General Ithese benefits pick up xx here STD benefits end. Earningsreplacement is about NV ; of pre-disahility earnings. up to ama xiinum dollar anuitint. While large companies may selfinsure. most has e a third party administrator. Most small toini(l-si/c businesses and many large businesses rely on aninsurance compaox to assume all or part of the risk.

There are a variety of plans available with definitions ofdisability that change afier the initial period of disability .For the first two y ears of employ ee eligibility. I :11) plansusual lx define disability as the inability of the employee toperform the functions of his or her own occupation becauseof injurx or illness. After two years. the definition becomesinore stringent. and the employee must he unable to perfornithe functions of any occupation.Partial and Residual Payments

In LTD patlial or residual benefits xx hich encouragereturn to work es en w hen a person cannot do the fullfunctions fully at. increasingly common. (Note: partialdisahilik may also be a provision of ',Me STD plans).These pros isions allow persons to get wages for the w orkthey do and collect benefit \ up to a specified cap. usuallxhased on prior earnings. ( ienerally there must be at least a

20% reduction in pre-disability earnings for benefits tocontinue.

RehabilitationMost LTD benefits programs, insured or self insured, con-

sider rehabilitation. Large employers and insurers may have theirown in-house rehabilitation specialists. Others rely on third-party provider\ on a fee-for-service basis. There is usually ascreening matrix for rehabilitation referrals will be made.Screening criteria include employee mutivation. in-house jobavailability vs. rehabilitation for out placement is feasible. Thefinal decision often turns on the cost of rehabilitation vs. the costof continued hendits. in addition to job availability. At this time.ADA also plays a part in the process. Both employers andins trers are looking for measures of cost effectiveness measureswhich, unfortunately, many rehabilitation professionals are un-able to provide.

Integration (Offsets)LTD plans generally integrate with Social Security and

Workers Compensation. In fact, insurers and employerscount on this integration or offset to help defray costs. Asindicated earlier. sonic employer plan\ off'set for personalinjury payments.

Funding Mechanisms/CoverageEmployers often provide LTD as a fully funded benefit

either through insurance or by self funding. The larger theemployer, the greater the likelihood of self-funding. MostsniaIler employers (500 or less employees) insure the bene-fit. Emp!oyers with as many as !WM() employers maychoose to insure part or all of the risk because the incidenceis more Unpredictable and the duration can he very long andthus expensive.

Again, as xx ith STD. the move tow ard defined emplox enbenefit contrihutions means that employers may offer I:IDbenefits but the employee has to choose them os en someother benefit. or pay for the coverage.

Department of Labor statistics indicate that 19'; of com-panies w ith 100 or few er employ des has e long term disabil-ity prognuns. Of companies xx it h more than 100 employ45'; hax e a long-term plan.( 15) (16) The observationsearlier about STD xx it h regard to emplox ers and unions alsoapply here.

Individual Disability CoverageSome employees and self-employed persons have indi-

idual disability income insurance. Earnings replacementas erages 60'; to 70'.; of pre-disability income but canapproach X0';.. Ilic individual nature of this cox crape.coupled with high-income replac:Inent 10d,, and a posilion of no offsets for other programs. makes it especiallyattractive to highly compensated professionals as s ela supplement for corporate executives. Disability isinarily defined in terms of inability to perform the dutiesof one's ow n occupation for the entire benefit period.usually until age 65.

4 0

IP, I 5 wr tr. r 11,,rirrooplr \ritiorril Relialrthirittror In

Program Costs (LTD-STD)The 1989 annual costs for short and long term disability

exceeded $87 billion, while medical expenses for disability-re-lated conditions added another $80 billion (Berkowitz and Green1989) (17) The growth rate is unclear but an fif-; to 18(4 rate is

commonly used. Various factors effect this growth rate includ-ing the numbei: of newly covered employees.

DM and Non WC Employee BenefitsAs with WC, organizational and individual costs of

disability mandate better and more humane managementof disability in the work place. The goal of DM costsavings is prevention NA, here possible through EAPs andother wellness programs. When disability does occur, theaim is to lower the employer's total cost by early interven-tion in the disability continuum to keep employees at workor return them to work. DM efforts aim specifically ataccurate, consistent docum,mtation of disability, restora-tion of working capacity and return to work through avariety or interventions.

There is Itms litigation in the non-WC arena, so there mayhe more opportunity for effective return to work and ulti-mate cost savings. When employees huy their ow n disabil-ity coverages. there may he different motivations to respondto disability management programs or for employers to pushthem. This is an area that needs further study to determineits effect on disability management.

The Total Cost of Disability StudyIn 1991 and 1992. I coordinated a research project for

UNLIM Life Insurance Company of America. (Researchersincluded Monroe Berkowitz. James Chelius. David Dean.Donakl Gals in and Sara Watson.)

In this 12-employer case study we found that disabilit \costs, excluding medical costs for non-WC but includingWC medical costs, averaged just over 8(4 of payroll; 4? indirect costs (benefit payouts and administration ); almost 44in hidden costs (lost producti \ ity. replacement rates, poorerquality, calculated in relation to lost V, orkdays and averagesalary of absent employees): and slightly less than I C.( inDM costs for programs to prevent and reduce disability.From other data we know that pri \ ate disability costs aregrow ing at a rate of at least 7c; a y ear. The average dollarcost per employ ee in the study was 52.285. (('helius. Galvinand Owens, 92) (I 8)

The study documents the increased cost of medical carefor persons filing for disability claims. In one company .medical care costs for persons on disahility were 7.4 timeshigher than mm-disabled employees. In another company .

costs were 16.5 times higher. Think of the potential formedical cost Nil \ ings when disability can he prevented.

The Social Security Disability Program

The Social Security disability, program has its ow n spe-cial blend of political, social, legal and judicial underpin-nings. This discussion centers on the insured Social Seen-

rity Disability Insurance ISSDII program as opposed to theneeds-based program Supplemental Security Income ISSIprogram). While SSDI is less than 50 years old, it has, likethe Social Security System, undergone incremental change(read expansion ). The r cmgress, courts, Presidents, disabil-ity advocates and progi am administrators have all workedtheir will on SSDI.

Many SSDI observers have noted what is termed "thependulum syndrome" of the SSID1 program. If we look at100 Social Security claims. 30 may be clear-cut denialsand 30 elear-cut allowances, and 40 are equivocal andrequire judgment. The decision on the 40 may go eitherway especially over time, as the underlying payment phi-losophy changes.

The 1992 incidence rate is expected to be about 5.4awards per 1,000 insured workers. (20) This is the highestrate since 1978. In the absence of corrective legislation, theassets of the DI Trust Fund will be exhausted late in 1995.due to higher-than-predicted incidence rate coupled withlonger durations of disability.

The House Ways and Means SubCommittee has char-tered a study by the National Academy of Social Insuranceto review disability policy and the Social Security disabilitysystem from a broad public policy perspective, including itsrelationship to other public and private programs. Thisstudy arose from concern about current structure and cost.

There are three main areas of interest in comparing theSocial Security program with WC and employee benefits: -the definition of disability. SSDI' s position as first payor inthe pecking order of integrated disability benefits, and theprovisions relating to rehabilitation and return to work.including the oft-debated incentives and disincentives.

The Social Security DefinitionThe definition of disability for Social Security pay went

is rigorous. Paraphrased. a person must he so in [paired byreason of a medical condition that, given age. education, andwork experience he or she cannot perform the functions ofany job that exists in the national economy. The disabilitymust he expected to last a year or result in death. There is afive-month waiting period horn the onset of disability topayment. Other disability benefit prorr:tin.earlier. man with a less severe condition.

Social Security As First PayorSocial Security payments are reduced by civil service

retirement and disability benefits as well as WC in moststates. Since for employ ee benefit programs. SSDI is thefirst payor. both employers and insurers often require theirclaimants to exhaust all levels of appeal to gain SSDI andemployers and insurers fivquently pay for legal repre-sentat oti

After tw o years SSDI beneficiaries get Medicare whichcan become first medical insurance payor for disabled em-Plo)ees s). ho are no longer considered actisely employed.(Transfer to Medicare accounts lor big medical costs sav-ings for insurers and employ ers.)

41Aational Rehabilitalson -11,1(1/10n Ilonovaph

Social Security and return to work incentivesWhile SSDI does have return to work incentives for benefi-

ciaries -- a) trial work pedods when a person can work and still

get SS benefits and, b) re-entitlement for SS beneficiaries who

fail in their return to work attempts. -- few SS beneficiades doreturn to work and leave the rolls. Actually less than 1(4 ofpeople leave SS because of return to work. (Note, this tendency

of SS beneficiaries to stay on benefits may also contribute tolonger incidence for persons collecting under private disability

plans if they are also entitled to SS.)Rehabilitation opportunities through state vocational re-

habilitation agencies have been a part of Social Securitysince its inception. Reimbursement to state xocational re-habilitation agencies occurs only when the SS beneficiarystays at work for at least nine months. With the strictdefinition of disability and the reimbursement method it iseasy to understand reluctance on the part of state agencies

to routinely work with this population.Social Security conducted many demonstration projects

over the years to try to improve the return to work successes

of its beneficiaries. Tests of pri \ ate and non-profit rehabili-tation providers have also been without real success. SS iscurrently conducting c Tly case management experimentsdubbed "Operation Netwc.rk". Some of the cases are man-aged hy SS employees in the district office, some by staterehahilitation personnel and some by private providers.Results have are yet to be published.

Congress continues to search for additional incentives for

return to w ork hy SS beneficiaries, and this is one of themandates for the study mentioned earlier. Many argue thatwith the current definition of disability, the first-pay statusand no "job hanks" for rehabilitated individuals, most SocialSecurity beneficiaries will never return to work.

There are just too many reasons for beneficiaries to stickv. ith the SS payment rather than risk loosing both the benefit

and medical insurance. In addition, many employers arereluctant to hire these persons and maintain that reasonableaccommodation would generally bring about undue hard-ship because of the severity of the impairments or becausethe majority of Social Security beneficiaries are not quali-fied for jobs.

Participants and Payors in DM(Insurers, Employers, Employees):

Rehabilitation Viewpoints

"For rehabilitation professionals to remain partners inthe human resource initiatk e (DM ) requires that we care-full y. examine the paradigm (mf our service model in lightof public criticisms, and that we understand and incorpo-rate successes innovative employers are realizing in theprevention and management of w ork injury and disabii-ity." illaheck. rel .13 )

"The problem of exactly how rehabilitation set.% icepro\ iders shotikl he selected is not so much w hether the

puhlic prt)gram or private providers should fulfill this rolethe public prcigrani has largely abandoned the field to the

prk ate sector it is how the private provider should heselected....Back of the controversy about selection is theissue of whom the counselor represents." Berkowitz andBerkowitz, 1991 (7)-

"LTD benefits are generally provided on the basis of totaldisability from one regular occupation or from other occu-pations commensurate with background. experience andresidual abilities.... In order to effectively adjudicate theseissues....rehahilitation practitioners providing services toLTD claimants must have a working model on which servicedelivery will also be based." Keppel. 1990 (2 ). Ms. Keppel

suggests a "Real Job Market-Mode: for LTD Rehabilitationand Claims Adjudication." (Real jobs need to be available)

Carolyn Weaver in her discussion of the need to changethe public vocational rehabilitation system by providingouchers for public-program beneficiaries who could then

shop for the right service, makes many important pointswhich have general application. (Ref. no.21) Her majorpremise is that. "Public agencies and private firms, ifcompeting to attract new customers, would have the incen-tive to experiment with new diagnostic and evaivationtechniques. new methods of case management or place-ment. as well as new forms of administration and financing

as they attempted to supply w hat customers wanted at a

price they were willing to pay." Custo ers in this case arethe actual usffs of services.

The private rehabilitation provider does have a uniquerole. The rising costs of rehabilitation services in Work-ers' Compensation without documentation of significantcost benefit have led to a reversal of mandatory rehabili-tation requirements. Employee benefit insurers and em-ployers who self-insure generally espouse the virtues ofrehabilitation hut also want to see results that spell success

in their terms.Employees may not have the incentive to participate in

rehabilitation if their disability status looks better than re-turning to work in a hostile en \ ironment. This is especiallyif they are long-time workers with the physical problems ofaging and frequently unhealthy life styles. When the eco-nomic environment results in layoffs and dow nsizing. aw orker with an impairment may feel more secure on disabil-

ity and may resist any rehabilitation effort.Employers who are insured may not see any value in

bringing a person hack to work when the insurer is payingthe benefits, unless there is an issue of experience rating andtheir insurance premiums can be lowered hy return to work.Once a replacement employee is hired and working at full

pace, rehabilitation may cc)st more.Insurers who believe rehabilitation is possible for a

gi \ en entployee may be reluctant to push an employer for

fear oh loosing a customer. or if the insurance company hassold a policy through a broker and the employer goes tothe broker and complains. the insurer inay choose not topush the issue in the face of loosing both the employer and

the hroker as customers.However. rehabilitation professionals may be able to

deflect these negative attitudes and create positive rehabili-

4 2NV? Su lf.ci Alimogmph Voluquil nehabibtalum Atith relfum

tation results with cost-effective approaches and realisticassessment of the motivations of all parties. However reha-bilitation professions must define practice guidelines and bebetter trained in the dynamics of DM and the interaction ofthe programs at play in the work place, balanced with theirresponsibility individual clients.

Responsibilities and rights under the ADA are also im-portant. If an employee with a disahility is motivated towork and the employer can make reasonable accommoda-tim, including flexible hours, switches to vacant positionsand changes in the physical plant. it is the employee's rightand the employer's responsibility to work toward job place-ment. Rehabilitation can he the linchpin.

Watch for These Change Agents!

The ADAThe ADA is not just another piece of legislation that will

quietly be set aside. The National Council on Disability. an

independent federal agency charged by Congress to analyieand provide recommendations on issues of public policy forpeople with disabilities, was instrumental in initiating theADA. This agency has also established the ADA Watch.an ongoing activity that will report to Congress and thepublic. Key findings include the following:

Complaints fi led under the ADA thus.fitr indicate thatcerwhi key areas need greater attention. includMg,lor exam ple. accommmlating current emphfryee. with

Major elements of employee benejit plans are beingcalled into question by the ADA, such a.s whether anemployer's health mre plan may discontinue mver-age of certain benefits specifically needed by peo2lewith divthilities. (231

A(cording or EEO( record% through May, 2: "zri Ofthe cluirges related to (ft.commodation.s: back has thehighes; impairment (ategory.

The Al );\ w ill suppon most DNl objectives and w ill alsomos c more recalcitrant employers into the fold. "Rehabili-tation professionals base more muscle to achieve return towork goals for employ ees with disabilities who w an( toret to-w ark and that means more success." says Kay eMcDc itt. RN.MS.CRC. Regional Director of DisabilityManagement Services.

Health Care ReformHealth care reform can only. have positive effects for

persons who have not had access to health care. I hiwethere could be some negative ramifications for DM andrehabilitat ion professionals.

There inay he less money Frain emploNers to pros ide forother employ ee benefits. While employers most w ho pro-

ide non-mandatory disability coverages generally also pro-s ide health insurance, others do ii(4. With increased costs

of health care, other employee benefits may he dropped orthe employer's contribution reduced.

Inclusion of WC in the health-care reform package couldrevise payments for WC medical care. First dollar coveragemay be gone, and that can in turn affect medical-carechoices. Moreover, the indemnity WC benefit, which mostoften encourages or provides rehabilitation services, maydrastically change both in terms of who insures the benefitand how it is managed.

There is also concern that more conservative treatmentin managed competition could reduce agg,essive return tofunction, return to work efforts of employers and disabilityinsurers. The basic plan may not include this type of treat-ment. If global budgeting prohibits extra-contractual pay-ment or slows access to treatment. disability incidence andduration can he increased.

Rehabilitation professionals may have a whole new castof characters with whom to work in case management. Theaccess to records and the very existence of records maychange. Funding for rehabilitation if not in the plan must hesecured from other sources.

Twenty-Four Hour CoverageTwenty-fot.r hour coverage has been used mostly, ill

conjunction with discussions of medical benefits. In gen-eral it means that no matter how an injury or illness arose.the same "insurance" plan would pay for treatment. To putit another way. medical care (or disability benefits) areprovided regardless of whether the illness or injury hap-pened in the course of employment. The employer has a

specific financial responsibility for some or il I of the costs.As much as we hear about this concept. it is not in effectanywhere at this point. There are still distinct benefits andrules for each medical and disahility program.

State law provides for twenty-four hour coverage inFlorida hut it has not been implemented because of somereal sticking points around reduction in coverage now pro-vided under the WC statutes. Other states have taken someaction and Texas allows employers to opt out of the W('system but they remain liable for WC injuries. Californiahas introduced legislation for twenty-four hour disabilitycoverage but much debate remains ahead before final pas-sage accmding to most commentakIrs.

In effect. the health care reform, if it maintains its posi-tion on inclusion of WC Medical benefits, puts twenty-fourmedical cos erage in place. Employers must provide medi-cal care benefits for all illness and injury. It is not clear ifthe first dollar pa ment status of WC would be maintained.If so, this would increase costs. Also. if WC remains in thehealth care refiwin package. there it too w on Id be subject tomanaged care approaches.

Separating out medical care lonn the WC indemnitybenefit may give more impetus to twenty -four hour disabil-ity cos erage. Legislation introduced in California includestwenty-four hour disability coverage. (24) Ni 1w. non-WCcos erage does not generally provide benefits for permanentpartial disability where there is some loss in work fiinction

4 3\alumal lichabthwfwn .1% %,r1 Icing M it;er Monotvaph

but the person can return to work. This ke type of benefitthat is the most subject to litigatir . o/e can expect adifferent type of disability management with twenty-fourhour coverage. Current WC rehabilitation provisions wouldno doubt change.

Twenty-four hour coverage can mean that insurers whospecialiie in the now separate coverages may need to formjoint ventcres.

Social Security ReformDisability advocates, disabled persons and tax pay ors,

while united in their drive for Social Security reform, havedifferent perspectives on the issue.

The thrust for Social Security reform seems anchored inproviding more support for persons with disabilities to allowthem to enter or remain in the work force. The trend is awayfrom strictly cash benefits for total disability toward acombined compensation-and- support-services strategy thatenables a person to he productive.

Another reform element is the move away from a strictlymedical model in determining disability. Many people whomeet the current Social Security medical listings do in factwork. Critics maintain that disability benefit, should hebased on functional abilities compared to essential functionsof jobs. Social Security should then provide financial sup-port in the way of wage supplementation for lower payingjobs or ser\ ices to increase functional ability, which can inturn ha\ e earning capacity.

Rehabilitation professionals would have important rolesto play under either reform scenario.

Summary

Public and private insurance trends are built on the needfor cost sas ings related to human resources. There aresavings \\ hen disability is prevented but also k hen personswith disabilities can be producti \ e in spite of disability.

DM. founded on sa \ ing human and dollar costs relatedto disability is becoming more sophisticated. Rehabilita-tion is an essential element of an integrated DM program inthe work place.

Rehabilitation professionals can succeed w hen they un-derstand DM and the perspectives of the key play ers: em-ploy ers. eniplc)yees and third-party payors. primarily insur-ers. Rehabilitation professionals must link their acti \ ities to

cost- saving objectis es and learn how to measure and report

cost savings.Profound change is in the wings. The ADA. health care

reform. the potential for twenty -four hour disability . .

erage and re \ ision ol the Social Security Sy stem are in

\ arious stages of de \ elopment. The ADA is being inter-preted by government agencies and courts in relation toactions both taken and not taken. I lealth care reform ispredicted to he an ongoing process o er the next few y ears.Social Security disability policy is being studied and rec-ommendations for change formulated.

(I have not discussed Long Term Care Insurance as it isnot currently a major employee benefit nor is the definitiontied to inability to work. I do believe however that rehabili-tation professionals should watch this area. Long Term('are is tied to activities of daily living. Rehabilitationservices to enhance, restore person's abilities to engage inactivities of daily living will surely be in greater demand.)

Rehabilitation professionals can help shape changes thatoccur and certainly the field will be reshaped by' the changes.

Epilogue

DmopolyI find it intriguing to view DM as Dmopoly, a hypotheti-

cal board game where the player's objective is to havemoney proportionately assigned to each token they aregiven: there is an ideal balance among tokens, given themoney available. The first player to reach tile prescribedbalance wins. If no one reaches the ideal state, the playerwho is the closest wins.

The tokens represent an Insurance Company. Employer.Employee. Rehabilitation Providers. Doctors and otherhealth care providers. Ergonomic Design/product firms, etc.Each participant begins with a ceilain amount of seed moneyassigned to each token. Players may receive money from asmings pool or contribute to a cost pool determined bymovement around a board with spaces representing variousdisability events or DM activities. Movement is based onthe roll of dice. Players may land on squares that permitthem to insure all or pail of the risk or to reinsure for theirinsurance token. EAPs can he purchased and Rehabilita-tion professionals can get money if they are hired and showcost savings, but the employer or insurer has to give upmoney io hire them. However, cost savings may he takenfrom the savings pool and allotted to each token, includingthe employee. There are penalty spaces when for example.supervisors are uninformed on DM policy.

This flight or fancy graphically illustrates the potential com-plexity of DM. Players must have an overall strategy fOrall tokens

and record their plays. They must continuall y. check that alltokens are moving toward the optimal balance.

REFERENCES

Disability Statistic Abstract. Number 2. December 1991.Number 4. May 1992, The Institute for Health and Aging.School of Nursing. Uni ersity of Cal ifornia.

2. Monthly Labor Review. Vol .115. No. 12. Table 50. p.1(16.

(December. 1992)3. Stone, Deborah A.. (1979) The MAabled State. Temple

l'n \ ersity Press. 1984.4. Akabas, Sheila II.. Gates. Lauren 13., Galvin. Donald E.

I 992 Disability Management. AM ACON-1. 1992

5. Schwan/. G.E S.D.Watson. D.E. Galvin and F.Li pofft 1989 The Msability Mmtagement Source/wok.1. Washington. D.C.: Washington Business Group onHealth.

4 4/fa? -.sit tk-f A/awl:fork \affawl /what/awn iatum

6. Berkowitz, Monroe, (1990) Journal of Disability PolicyStwhes, Should Rehabilitation Be Mandatory in Work-ers Compensation Programs?, Volume 1, Number 1,Spring 1990

7. Berkowitz, Monroe and Berkowitz, Edward, (1991) Re-habilitation Counsel* Bulletin, ournal of the Ameri-can Relwbilitation Counseling Association. Rehabilita-tion in the Work Injury Program, Volume 34. Number3, March 1991.

8. Berkowitz. Edward, (1987) Disabled Policy. America'sPrograms .for the llwidicapped, A Twentieth CenturyFund Report, Cambridge University Press, 1987

9. Burton, John, with Workers Compensation ResearchInstitute (WCRI), (1993 ) John Burton's Workers' Com-pensation Monitor, Cost Drivers. in Six States, Volume6, Number 1. January/ February. 1993

10. Burton. John, ( 1993). John Burton's Workers' Compen-sation Monitor. Workers' Cong. .sation Costs, 1960-/992: 'The Increases. The Causes. and The Con.se-quence s. V olume 6. Number 2. Marchl April, 1993

11.Ilabeck, Rochelle V.(1991 ) National Associathm of Re-habilitation Prolessimals in the Prii.Itte Sector. Manag-ing Disability in Industry, Volume 6, Number 4. August.1991.

12. Hunt, H. Allan. Habeck, Rochelle V., (1993) W.E.t Ipjohn Institute for Employment Research. The Michi-gan Disability Prevention Snuly, Research Highlights

I3.1labeck. Rochelle V. (93 ) Achieving Quality and 'aluein Servh.e to the Workplace Work Injury Management,Oral presentation. Printing in progress.

14. UNUM Life Insurance Company of' America. (1992)Disability Management: Costs and Solutions. A speciall'N141 report on the co.sts, management and preventionof disability. Mailable from t)NI. M. Portland. Ma.

15. Id izabeth Dole and Janet I.. Norwood, (1989 1 EmployeeBenefits in Medium and Large Firms, Bulletin 2363.I. .S.1)ept of Labor.13ureau ofl.abor Statistics ( Washing-ton. D.C.. GPO, June, 19900

16. I.ynn Martin and Janet L. NorwoodA 1990 ) EmployeeBenefits in Small Private Establislunews, Bulletin 2388,U.S. Dept. of Labor. Bureau of Labor Statistics (Wash-ington, D.C.. GPO, September 1991)

17. Monroe Berkowitz. and Carolyn Greene (1989) Disabil-ity Expenditures. American Rehabilitation, Volume 15,#1, Spring 1989.

18. James Chelius, Donald Galvin, Patricia Owens (1992)Disability: It's more expensive than you think. Businessand Health. March 1992. Copyright 1992 and publishedby Medical Economics Publishing. Montvale, N.J.07645-1742

19. The Social Security Disability Insurance Program. AnAnalysis (December, 1992) Report of the Department ofHealth and Human Services pursuant to a request fromthe Board of Trustees of the Federal Old-Age and Survi-vors Insurance and Disability Insurance Trust Funds.

20. Committee on Ways and Means. U.S. House of Repre-sentatives. (1992). The 1992 Green Book, BackgroundMaterial and Data on Programs Within the Jurisdh.tionof the Committee on Ways and Means. May 15. 1992(Washington D.('.. GPO, 1992)

21. Allison Keppel, (19901 Issues in Long Term Disabilitywul Risk Analysis, Journal 4Th-irate Sector Rehabilita-tion, Vol. 5, No.l. 1990.

22. Weaver, Carolyn L. (1991) Choice in Rehabilitation: AProposal for Empowering People with Disabilities, TheAmerican Enterprise. July/August. 1991. Vol.2. No. 4.

23. ADA lVatch Year One: A Report to the President andthe Congress on Progress in Implementing the Ameri-cans with Disabilities Act. April 5, 1993. National Coun-cil on Disability.

24. Equal Employinent Opp(munity Coni mission. NathmalData Base Report. 5131/93.

25. California Workers' Compensation Institute, (1993).Framing the I.5.111( A: Twenty-Four lour Coverage, Re-search I Ipdate

4 5

I I Aalitut.11 ReliabtIlhawn timoi Atirt.et 31°,1ot:tapir

Excerpts of Reviews and Comments Chapter Three

Dr. Owens emphasizes the insur-ance industry in her analysis of

the trends and issues in rehabilitation.and not inappropriately so. The needsof the insurance industry have likelybeen the foundation for and the majordriving force behind the formation ofthe private sector in rehabilitation. Al-though it is interesting to have thisinsight, the more useful question is,what else is out there that may eitherbe equally useful to us in private prac-tice as a referral base, or what mayheomie one in the future?

A broad referral base is essential forany private practitioner as it helps avoidthe catastrophe of having it all "go away"

on short notice. A broad referral base islikely equally useful for the 'health' <inkfield in general. Can we. for example.think of ways to generalize our applica-nuns in insurance mhabilitation to othersettings'? What else are private practitio-

ners doing that (he fiekl doesn't generally

know about? Do we even know who is,in private practice in terms of theirdemo-graphics and professional identities'?There are so many unanswered questions

that we must have for correctly identify-ing the broader nends in our field, aknowledge of which is likely essential toour ultimate survival as a unique field in

the century to come.This suggests taat in our field we

should set the 'trend' of determininghow to monitor our own field as wellas that of our cohorts. all the better forour own business knowledge andlong-range planning. I do not believethis effort is presently in place. and weneed it for our ow n guidance in a% old-ing becoming too dependent on a solereferral source, even if on the surfaceit looks as substantial as does the in-surance industr . After all, we oncethought the same of the savings andloan industry, didn't we?

Phillip Bussey

ms.Owens pros ides excellentOs er iew ol the trends and issues

inolved in pris ate secuw rehabilita-

tion today. In particular, this paper isa very good overview of the variousactivities involved in private sectorrehabilitation including a summary ofthe various programs of the practicingrehabilitation consultant.

A major arca of reform would he inthe health care area. One of the mostinteresting phenomena that has oc-curred in the last five years in privatesector rehabilitation has been thenearly startling growth of the casemanagement association based in Lit-tle Rock, Arkansas. To illustrate, theirfifth armual conference drew nearly2.000 practitioners this last year. Inaddition, the Commission in Chicagohas received over five thousand appli-cations for the grandfathering of thecertified case management exam. Itwould seem that the tremendous inter-est gis en to this area is directly relatedto the upcoming reforms in the healthcare area. In fact. many professionalsin the private sector field look to casemanagement as the new big growtharea for private sector rehabilitation.In my opinion. t his growth has alreadyestablished itself.

Related to the health care move-ment. the ADA law and its implica-tions for the future still remain to heenormous. While the response toADA has been rather sluggish andsomewhat immobile. recent courtcases as well as those that are pend-ing will serve as a strong stimulus foremployers to begin taking seriouslythe intent of the law wider ADA.When employers begin to realize thatthe ADA means serious business, thepotential for private sector consu1t-ing will manifest itself rather quicklyfor rehabilitation consultants andprivate companies.

In both of these areas. the ADA andcase management. there are tremen-dous needs for training and technicalknowledge if the rehabilitation con-sultant is going to he a reliable re-source for both funding sources andemployers in the future. II ssould seemthat a tremendous amount of ss orkneeds to he accomplished in order to

4 6St% it., A/o/kn.:tap/I .\ anima/ Rehabilitation 1 \101 ninon

adequately provide competentlytrained professionals to meet theseemerging needs.

Tim Field

T he potential for employment ofrehabilitation professionals in

workplace disability management hasyet to be fully real ii.ed by the profes-sional rehabilitation community. "rhedisability management model de-scribed by Ms. Owens expands thetraditional private sector rehabilita-tion professional s role to includeprevention programs which focus onemployee wellbeing, health andsafety. All too often, the focus is onrehabilitation following disability. Inaddition, workplace disability man-agement has tended to center onworkers compensation rehabilita-tion. Ms. Owens reminds us that reha-hilitation provisions are common inshort-term. long-term and individualdisability plans. and the social secu-rity disability program.

One particular point made in re-gard to workers' compensation pro-grams has been expressed in thismanuscript as well as in other 1993Switzer papers. It also relates to otherinsurance rehabilitation systems. Thispoint focuses on the weakening offormal mandated rehabilitation pro-grams as part of workers' compensa-tion legislation. Without documenta-tion of rehabilitation effectivenessand efficiency in terms of human anddollar costs. 55 orkplace disabilitymanagement will never he realized toits lull potential. The public rehabili-tation system has been able to docu-ment this data for years through pro-or= evaluation metluxls.

The author's discussion of a hypo-thetical board game, DMopoly. al-lows the reader to view the complexi-ties surrounding disability inanage-ment. (This hypothetical board gameis similar to the actual board gamet it led 'The Disability Trap" by ValparInternational.) Disability manage-

4 2

ment should not he a haphazard sys-tem but one which has a positive, for-ward-moving strategy where all of themany parties involved maintain clear,open communication and work inconcert with each other for a success-ful outcome. The complexities of thesystem need to he minimized so thates eryone involved in the process. par-ticularly the worker with a disability.receives appropriate, timely and costeffective services.

A variety of "change agents."hich are expected to significantly

impact disability management, ispresented. These include: theAmericans With Disabilities Act.health care reform Twenty-four cov-erage and social security reform.Since the national state and localens iron ments will see much changein the near future regarding theabos e issues , rehabilitation profes-sionals must be keenly aware of ex-isting. proposed and new pieces oflegislation and policies so that theycan accurately predict the trends indisability management and respondaccordingly. Rehabilitation profes-sionals have much expertise to offerin these changing times , and mustbe proactis e in dealing N.% ith currentissues. We cannot afford to sit hackand wait for things to happen: ss emust participate in legislative ef-lofts and policy changes to ensurethat rehabilitation is s iessed as a

orthss bile option in disability 'flan-agement.

Juliet H. Fried

Oss e n paper effectis ely inns-

%Nitrates the complexity and di ver-sits of insurance issues in disabilitymanagement. A er. iinportant issueis the need for a comprehensive andintegrated disability managementmodel. I3oth in education and practiceour Mk7iety has increasingly mos edtoss ard specialization and narrow isfocused expertise. Over-special ization, and thick ss alls bets% een prot.es-

sionals will not work in disabilitymanagement. Art eflectise disabilitymanagement model requires profes-sionals from many diserse disciplines

and perspectives to work together ef-fectively to meet common goals.

Owens suggests that there is animportant role for rehabilitation pro-fessionals in disability management.Clearly there is overlap between themission of vocational rehabilitationand the purpose of disability manage-ment. The field of rehabilitation needsto look closely at the type of skills andexpertise it can provide t.o employersand insurers to facilitate reductions ininjuries. prompt and effect ive medicaland vocational rehabilitation, andswift return to work.

A second point raised by Owensconcerns disincentives to return towork. The importance of secondarygains and systemic disincentives areareas that still require public policyattention. and serious considerationby. practitioners.

Dennis Gilbride

Tolle workplace disability manage-ment (DM) model is discussed in

length bv Ms. Owens. Rehabilitationis emphasized as an integral role inthis inodei ss ith return to work as theultimate goal. In order for this to hesuccessful, rehabilitation potentialand rehabilitation planning must bedetermined as early as possible.

To control rising cost of. regardless or what disability

benefit programs. it is obvious thatreturn to work is the absolute goaiand early intervention the only ac-ceptable rehabilitation philosophy.Thus is the concept of managed careand 24-hour coverage. Employersss ill be fully ins olsed with the reha-bilitation process of their empkiyeesutilizing the resources and skills olateam of health-care providers, reha-bilitation practitioners and claimsadjusters. As the payor of disabilitybenefits, employ ers should and w illhas e the act ii al control of the "cases".This true interdisciplinary approachw ill he the model of the future. inter-estingly. this will also assist employers to comply ss ith the regulation andspirit of the Americans with Dis-abilities Act ( ADA). The actualbeneficiaries s ill he the employ ees,

4 7

the individuals with disabilities andsociety as a whole.

John W. Lui

T he author provides a comprehen-sive review of the various types of

insurance coverage, coverage trends.settlement issues, and a sampling ofthe disincentives within the currentsystem for successful rehabilitationoutcomes. All of these issues are ana-lyzed within a disability managementperspective.

In discussing the Social Security'system, the author points out that lessthan It of the social security popula-tion is temtinated yearly because ofreturn to work. While I cam aware ofdie existing disincentives to work. Iwas truly startled by that very dismalstatistic. Clearly, there needs to hemach more research into identifica-tion of the work disincentives for so-cial security recipients. along with re-alistic strategies which can assist withmos Mg a greater number of personswith disabilities into the workforce.Hopefully. the studies currently beingconducted will provide us ss ith somecritical data on how to begin to ad-dress the issue of helping peoplemos e from dependence to productis -ity and independence.

Along the lines of social securitybenefits. the author continents thatmany employers may be reluctant tohire social security recipients becauseof either undue hardship or the lack ofqualifications on die part (lithe recipi-ent of benefits. While I do not feel thata blanket statement such as "All per-sons with disabilities are lacking johqualifications." ss ould be accurate orfair. I think that ss e in the rehabilita-tion field need to do a better job inpreparing students and young personswith disabilities to he ready and pos-sess skills for the w orld of work. Re-habilitation counselors ss (irking ontransition tear mis. within sclumol dis-tricts, and in conjunction ss.th stateVR offices can contintle to pros ideservices that are essential for the com-prehensis e education of young per-sons ss ith disabilities. Offering to em-ployers skilled. motis ated ss oi kers

.%allo) talkehablhhaNWA%%,41aNan pi9 Itt 11, rt A/o/sot:writ

who can help the employer to meettheir business needs will be the mosteffective way to reduce or eliminatereluctance to hire based on a stereo-typical impression of a specific groupof people.

Patricia Nunez

Nis. Ow en's essay is a comprehen-

sive primer on disability man-agement. benefit systems and per-spectives w hich impact private sectorrehabilitation. The range of rehabilita-tion programs described within thescope of disability imwagement arebased upon the economic val tle of anindividual emplo cc. Situ ilarly. the

existence of disability managementprograms is based upon their ability todocument cost savings to the organi-zation.

Rehabilitation is portrayed as anintegral component of disability man-agement programs valued for its abil-ity to reduce benefit expenditures byrestoring workers to their pre-injwyabilities or other types of work. Statis-tically supported, Ms. Owens de-scribes an increasing incidence of dis-ability claims, escalating costs anddramatic legislative changes.

Citing the ADA. Health Care Re-form. Twenty-lour hour coverage andSocial Security Reform as fourchange agents influencing disabilitymanagement, Ms. Owens identifies

4811,1 Opt, \tit le.11111 RI I 101 le 1,s,), in

an unstable, concentrated and turbu-lent organizational environment. Shecorrectly states that rehabilitation pro-fessional can shape the field and thefield of rehabilitation will be shapedby these agents of change.

Perceptive rehabilitation profes-sionals that efficiently observe, ana-lyze and process the changes in theirenvironment will prosper. In a fieldalready recognized for demands of ac-countability. the documentation ofboth "hard" and "soft" case manage-ment savings appears crucial.

Stephen A. Zanskas

1-1

Seminar Recommendations Chapter Three

The following is a summary of therecommendations and implica-

tions for action as they relate to thediscussion of chapter three. These rec-ommendations were developed by anindividual work group and the style ofpresentation reflects their own formatalong with implications for action.

Service Delivery

The following are implications forservice delivery within the private re-habilitation sector. These affect theneed for research, training./ education,policy and program development aswell as legislation.

. Recognition of the changing anddiserse needs for private rehabili-tation sers ices with regard to dif-ferent insurance product lines.

The field is going through a signifi-cant period of change that w ill af-fect the way insurance companiesand employers structure and pro-s ide disabilit) income productsand sers ices. Some of the Lesforces at work are the Americanswith Disabilities Act, healthcarereform. 24-hour coverage. etc.

As we mos C through this period ofchange. the private rehahilitationprofession needs to be know ledge-

able about the implication thesechanges will have on the services

e deliver. We must be preparedas a profession to es ols e to meetthe future needs of our customers.

In addition, we serve a broad rangeof insurance prodUct lines whichhave diverse needs. These pi oduct1 ines i nc hide Workers' Compensa-

tion. short-term disahility. long-term disabilit indis idual disabil-ity income, personal injur , and I i-abi i c(Is el ages.

Across these product lines. therema be similarities in the nature ofthe sers ices required. How ever,Mete are often basic diffeiences

such as the expected outcome,funding sources, etc.

The similarities and differences arenot always well understood by theprivate rehabilitation profession. Italso appears there is no clear un-derstanding on the part of insur-ance companies and employersabout how best to utilize privaterehabilitation to influence the out-come of cases.

More needs to he done to stimulatecommunication and an exchangeof information between the insur-ance industry and private rehabili-tation professionals. We need todevelop a better understanding ofthe respective issues which affectboth groups. This has implicationsfor joint research and educa-tion/training.

2. Timely referral/early intervention.

Research has repeatedl) shownthat timely referral and earl.s inter-s ention are keys to successful out-come on cases. However, moreneeds to he done to educate ens-ionlers on this fundamental con-cept and how it can impact the out-come of cases.

3. Prolessi(mal definition of privaterehabilitation services.

The sers ices pros ided by pris ate re-

habilitation professi(mals ollen blurwith sers ices provided by other pro-

fessional specialties. Private reha-bilitation needs to develop a clearstatement of the range of servieesthat are within the scope of our pro-fessional expertis:2.

.4. Resolution of the customer/clientdebate.

Private rehabilitation needs to de-fine. understand and resolve theissues surrounding obligations tothe customer versus the ohliga-t ions to the client (consumer) Pri-

ate rehabilitation needs to de-N. clop clearer guidelines regardingthe private rehabilitation p-oviders

4

\emeeneel Re belbelteellion leeelew

responsibility to each party in-volved.

Policy or ProgramDevelopment

We recommend certification bod-ies require a specified amount ofcontinuing education units regard-ing insurance industry educationsuch as outcome measures, per-formance expectations, and thedisability management spectrum.

2. Develop a workshop or focus groupat the National Disability Manage-ment Conference which will heheld in Washington. DC in the Fallof 1993. Topics to include in theworkshop are as follows:

disability management model

expected outcomes

performance delis ers expecta-tions

The structure of the workshopwould he interactis e in CI tiding pri-vate rehabilitation providers whocan share information ahout thesers ices we provide, outcomes andservice specifications such as earlintervention and time required oncases to pros ide specific wt.\ ices.

3. Des elop an Adjustors Guide to pri-s ate rehabilitation services for ad-justors within the Workers Com-pensation industry.

4. We need to generate more ongoingcontact and interactkm ss ith insur-ance coinpanies. We recommendthat the Switzer Scholars initiateaction on this and encourageNASPPR to zissume ongoing re-sponsibility.

5. We request that the Nat ionzil Reha-

bilitation Association (NRA ap-proach the Social Securit Ad-ministration regarding the releaseof the results of the DemonstiationProjects utilizing pris ate rehahili-

I

tation sector for rehabilitation ofSocial Security claimants.

Training ofStaff/General Public

. Develop additional training andeducation for customers (the insur-ance industry and employers) re-garding private rehabilitation serv-ices. his would include:

more information rei,Nirding theservices we provide

when and how to utilize privaterehahilitation services to effectoutcome of cases

benefits of early interven-ti(m/timely referral

referral informati(m we needfrom the customer in order toprovide ser% ices

2. Devek)p nuire education and train-ing for priN ate rehabilitationpro\ iders regarding the insuranceindustry . This would include:

eX pect ed outcomes

perf(wmance requirements

legal issues affecting and regu-lating 1 he insurance Mdustry

We recommend CORI'. incorpo-rate more principles of private re-habilitation in graduate le \ els ofrehabilitation counselor educa-tion.

4 1Ve need to disseminate more infor-mation On private rehahilitationand rehabilitation in general to thegeneral public.

Research

I There is a need for joint researdibetw een the pro. ate rehabilitationprofession and ti. insurance in-dustry ..lhe research needs to focuson ideal outcomes. performancestandards ttitl measurements, andthe es ol\ ing disahility manage-ment model. 'Hie design of the re-search to sonic estent w ill depend

upon the disability income productline being addressed.

Organizations to include in consid-eration of joint research are as fol-lows:

California Workers Compen-sation Research Institute

International Association of In-dustrial Accident Boards andCommissions

National Counsel on Compen-sation Insurance

Workers' Compensation Re-search Institute

American Association of StateCompensation Insurance Funds

Insurance RehabilitationStudy Group

2. We need additional research onhow to effectively educate thefront line adjustor w ithin theWorkers' Compensation industry(and other product lines).

3. We recommend an interchange ofinformation between insurancecompanies in the private rehabili-tation profession regarding re-search that has already heen com-pleted. We feel the National Re-habilitation Associati(m needs tohe proactive in requesting re-search information and dissemi-nating it to pr()Iessional members.

4. We need additional research toidentify the outcomcs of privaterehabilitation. This would ilk-elude:

methods of ()income measure-ments

cost benefit analy sis

sers ice delis ery methodolol. y

NIDRR (in the U.S. Dept. ofI.ducation ) sh(mld he appr()ached

regarding availability for fundingof this type of research.

5. Develop a inodel for cost-henel'ilanal y sis for the different productlines including ss orkers' CoMpen-ation. long-term disability etc.

(). rpdate the study of the compara-tive analy sis of outcomes of pub-

lie and private sector rehabilita-tion done by Berkley PlanningAssociates.

Legislation

As we address the healthcare re-form issue, assure that rehabilita-tion professionals are included asreimbursed service providers as apart of the healthcare reform plan.

1. Individual rehabilitation profes-sionals need to lobby on the statelevel for legislation effecting dis-ability/health policy.

3. We need additional legislation inregard to the Social Security Dis-ability Insurance program for addi-tional incentive to return to work,including time limited benefits withrehabilitation per the recommenda-tion of the Pain Commission.

4. Have input into the National Acad-emy of Social Insurance study ofdisability policy.

Other

l'rk ate rehabilitation professionalsneed to take personal responsibilityto develop and disseminate profes-sional information and education.

2. We need to test methods to increasepublic ass areness of rehabilitationand should seek partners withinother professional organizations toassist in this process.

3. As Sw itzer Scholars. we need to hesure the Switzer Monograph is dis-tributed to our customer set to in-crease knowledge and awareness of

pris ate rehabilitation issues.4. Private rehabilitation professionals

need to he proactive with change toevolve our profession accordingly .

5. Des elop a long range plan for pri-vate rehabilitation and developleadership to iinpicni, t`.1at plan

within the National RehabilitationAssociation and NASPPR.

s,,,i (I 110,11,CI \pitional Rp 11$11,111111110lky(3 tea NM ..1(1

Chapter Four

Trends & Innovations In Private SectorRehabilitation For The 21st CenturyJohn W. Lui

For over two decades, private sector rehabilitationhas experienced tremendous growth. Increasednumbers of experienced public sector rehabilita-tion counselors have switched to the private sec-

tor. Many graduates from both the undergraduate and gradu-ate level programs in rehabilitation counseling or relatedfields have gone directly into the private sector. This wasdue to s arious reasons: the unmet service needs of industri-ally injured workers by most state rehabilitation svstems:the mandatory rehabilitation statues in state worker compen-sation laws: the perceived intrinsic factors in the job itselfsuch as basic salary incentives, caseload, training Opportu-nities and professional esteem (Howell. 198.1). During thistime. private sector rehabilitation evolved and 'natured.

While most counselors are still engaged in providingservices in the disahilits benefit systems such as workers'compensation. long-term disability, social security, etc..others are expanding into the medical institution/systems.the legal system. business and industries, and lime (nenbegun to service public/governmental agent ies. In the19)0s. due to ,..ome major legislation and social movements,crisis in the health-care and state w orkers compensationsy stems. crisis within financial institutions including boththe banking and insurance industries, and the poor natiimaleconoinic conditions, private rehabilitation is again at an-other crossroad. The effect of these many factors will he telhs the entire field of rehabilitation and especially prk atesectiir rehahil it at ion deep into the 2Ist century .

The Americans ss ith Disabilities Act (ADA ). the landmark ck il rights bill ol 1990 w as hailed by people w ithdisabilities as well as the rehabilitation coinmunity . Reha-bilitation counselors. the supposed everts in \son, mg withpcopk. w ith disabilities. are suddenly gurus in addressingdifferent Tilles in the .\ DA. Their skills in job zinaly sis. job

lohn 55 I iii I \ ( S. CRC. (In, 1,,11,1,1

development, and job placement. and experiences in thedisability field give them great access to one particulargroup that is severely affected by this law and is eagerlyseeking assistance the employers of the business andindustry. The need of a well-w ritten job description identi-fying essential and marginal functions will greatly enhancethe employers' compliance to the employment section of thelaw. Their knowledge base in joh modification will alsoassist the employers. the employees and job applicants inthe area of reasonable accommodation. With special train-ing in accessibility, they are also the consultants in dealingwith architectural harriers. They will also he involved asexpert witnesses on either the plaintiff or defense side in thecase of lawsuits derived from non-compliance with this law.Since ADA is a cis il rights hill that will continue to be testedand updated. private rehabilitation will remain active withits existence.

Also eff,ctive in 1990 was the Individuals With Dis-abilities Education Act ( IDEA t otherwise known as PublicLaw 10i The whole issue of "transition from schoolto work" emphasiied career oriented. vocational enrichedand community integrated experience for students. Thistranslates to ample opportunities for practitioners in pri-s ate sector rehabilitation in the areas of vocational evalu-ation. vocational counseling, job placement services, sup-ported employment services, and independent and com-munity living sers ices. Already springing up in the marketplace are private employment agencies operated bs reha-hilitation counselors spcciali/ing in the placement of indi-

iduals ss ith disabilities including students. With the na-tion's focus on education, school sy stems may also pros eto be the new employment Netting that attracts rehabiliia-0011 professionals front the pris ate sector. Nonetheless.IDEA ss ill continue to create attract is c referral and fund-ing sources for pris ate rehabilitation.

5 1 0,, ,

The Rehabilitation Act was re-authoriied and amendedin 1992. e common philosophy it shared with ADA andIDEA was choice and empowerment for individuals withdisabilities. One of the tools that will enable such a conceptis assistive technology. While ADA does not specificallymention assistive technology, "reasonable accommodation"and "accessibility" will require the use of such. The Reha-bilitation Act Amendments and IDEA certainly have spe-cific wordings on this issue. Both of these two public lawshad actually mandated the use of technology many yearsago. But it was not until the passage of Public Law 100-407.The Technology-Related Assistance for Individuals withDisabilities Act of 1988. that the federal government echoedits recognition that all people with disabilities can benefitfrom technology (Langton. 1991). The inception of ADAsuddenly makes "assistive technology" household wordsamongst practitioners w ho are involved with the employ-ment process of individuals w ith disabilities. Their skillsand interest in this area will continue to grow as they beginto learn and accept that besides the placement phase wheretechnologies are commonly considered, that there are otherplaces in the rehabilitation process where consideration ofthe use of technology or technology related services shouldtake place (I _ngton, 19911. This whole area of assistivetechnology will has e an impact on the private rehabilitationpractitioners in their day to day work, will bring otherprofessionals into the arena of private rehabilitation such asoccupational therapists, physical therapists and rehabilita-tion engineers, will create new career opportunities for somepractitioners with special skill sets and interests, and willcreate demand in new market areas.

As ss e approach the new centurY. we must face uP toone of the most ob \ ious hut often overlooked domesticissues in the United States: "the abilities of communitiesto work and live together more productively with all typesand groups of People" ( Wehman. 1993). In 1990. almostone in four Americans had African, Asian, Hispanic. orAmerican Indian ancestry, in contrast to one in live in198(1 (Leung, 1993 ). A society of multi-ethnicity is hereand is here to stay. Private rehabilitation practitioners willencounter greater diversity in the clients they serve and inthe workplace that they are employ ed. Since these provid-ers practice in a wide array of employment settings andsystems. their likelihood in meeting clients of other cul-tures is no doubt s ery high. This lack of knowledge aboutcultures other than their own will create unintentionalroadblocks to pro\ ide specific services or to successfullycomplete the rehabilitation process (Watson and Filen-berg. 1993. ) While there exists little information in reha-bilitation literature in minority ethnic population utili/a-lion of human service delivery- programs, these studiesss ere confined specifically in the state/federal s ocationalrehabilitation systems. There is de)initely a scarcity ofresearch on the same topic in pri \ ate rehabilitation. Thishuge sacuum of information w ill ses erely compound thedifficulties pris ate rehabilitation practitioners must face toaddress the issue of disersth

5%, Vonot:trlph /MI/ Holt iI

It ss as obvious that one of President Bill Clinton's goalafter he takes office is to overhaul the health-care system.The intent is to expand the system to include the 37 millionAmericans who have no health insurance and the roughly35 million with substandard insurance, and to ultimatelycontrol the cost of health came for all Americans (Newsweek,1993 ). In addition, it is estimated that 15'7( of Americanswill reach 65 or older by year 2000 (National Geographic.1993), sl hich will mean increased need for medical andrelated services. Together with our national focus on AIDSand HIV+ and a resurgence of polio and tuberculosis, themomentum is towards some kind of reform. The shape.form, and funding of this program of universal health co\erage has vet to bc unseiled by the administration. But somelocal governments such as Massachusetts, Oregon, Minne-sota. Maryland. and Hawaii are already experimenting withtheir own health-care reform policy. Private rehabilitationpractitioners working in the health-care or related programssuch as those of medical rehabilitation, mental health, psy-chological rehabilitation, geriatric and viral infectious dis-eases will see a major impact and great opportunities.

In connection with health reform, workers' compensa-tion is also experiencing many changes all over this country.Workers compensation insurance is regarded as one of themost critical problems faced by business and industry. Be-tween 1980 and 1991, employers' prenliums for workers'compensation insurance have increased hy close to 3(X)percent, from $22.3 billion to 'an estimate of S62 billion. In1990, about 25 percent of all employers were unable toobtain mandatory workers' compensation insurance cover-age in the voluntary' market, as compared to 5.5 percent in1984. This forced the employers to seek coverage from theirstate's assigned-risk pool resulting in considerably higherpremiums with little claims serY ice. In some states such asMaine and Rhode Island, the percentages of employers inthe assigned-risk pool were as high as 80'4 and 87e; respec-tively (Thompson, 1992). While there are many contribut-ing factors creating this crisis, there are as many disabilitymanagement strategies employed by business and industryto tackle the problem. The two broad but interrelated topicalareas are managed care and legislative reform (Hale. 1992 ).

The managed care concept. such as Health MaintenanceOrganiiation (HMO) and Preferred Provider Organiration(PPO). has been used in the health-care system for many\ ears with a very good success record. It is not until recentyears that managed care techniques are being recogni/ed asa viable alternative to the \Yorkers' compensation system(Brain. 1992. ) This true team approach has one main objec-tive: "coordination of medical care to maximi/e a rapidreturn to work and prevent the de \ elopment of long-termdisability." (Brain, 19921. This disability management strat-egy ss ill immensely alter the traditional role of each medicaland rehabilitation professional and totally change the deli \ -cry of medical and \ ocational rehabilitation sery ices typi-cally provided to industrially injured workers.

We shall witness an increase in the entry of other profes-sionals especially nurses. s ocational es aluators, occupa-

5 n

tional therapists and pity sical therapists in pris ate rehabili-tation. The tenns "case management" and "case manager"ss ill be redefined. While Certi Hed Rehabilitation Counselor(CRC) and Certified Insurance Rehabilitation Specialist(CIRS 1 arc still the necessary credentiak. Certified CaseNlanager (CCNl ss ill attract the most attention and becomethe preferred qualification to w ork in a \orkers' compensa-tion managed care program. From a business standpoint. thi s

ss ill modify pris ate rehabilitation practitioners; usual cus-tomer base and may be es en their financial picture. Ibeentrepreneurial ty pes w ill e plore or establish joint entures

ss ith others to des clop their ow n PPO, and may be their ow nmanaged care pmgrams. There ss ill he new computeriiedprograms that will perftwm all functions necessary in a

orkers' coinpensation managed care program to includeno les, than: utili/ation re\ iess . hill audit:ng, loss timeanaly sis, lost ss ork das analy sis. PP() database, emploserdata base, light duty /job modification, joh analy sis. etc.Laptop computers ss ill be an essential ss orktool for allpractitioners so that they can input, retries e and updateinformation on their cases instantly .

The other strategy in tackhng the workers' compensationcrisis lies in the hands of lass makers. I3ombarded 11\ com-plaints from employers on the astronomical cost of workers'colopensation on one side and insurance industry 's concernOs er rate inadequaes . legislators has e but one of tss 0choices: major rate hikes or major ref onus (Thompson,1 992 t. It is ohs ious ss hich direction they w ill take. espe-cially in consideration of the current economic climate. Asainple of some states that introduced workers compensa-tion reform packages in tile last three years includes: Colo-rado, Maine, Nlars land, Massachusetts. Minnesota, NewHampshire. Oregon. Pennsy Is aMa. Rhode Island. andTe \as. Reforms ranged from total oserhaul. rejection andreductitin of proposed rate increase. premium reduction.medical-cost management. legal cost containment. deduct-ibles and mandatory managed cafe program. These sw eep-inn changes. especially ss hen dictated by lass ss ill af feet the

entire industry of pris ate rehabilitation in those particularstates almost instantls

For mans sears, and still true for some states' ss orkers'coinpensation lass . there are no specinc qualification re-quirements for practitioners to pros ide socational rehahili-tation sers ices to the industrially injured ss orkers. WhileNational Rehabilitation Counsehng Association t N RCA useveriencing the "licensing" mos einem through out thecountrs (Professional Report. 1 992 i, pris ate rehabilitationis also facing credentialing and licensing legislation in thess orkers' compensation sy stem. This is certainly inevitableas pris ate rehabilitation as a profession matures and thus theneed to protect and upgrade this socation. At the same time.it is just as important that the injured workers should receisquality care and be protected from impostors and unethicalpi actuc s. This trend ss ill most positively continue and maycoincide with some ol the states' pmposed reforms.

.As mentioned in the beginning of this article. public lawsin recent \ ears ss ill no douht lease their footprints hey ond

the 2 I st century . ADA ss ill continue to pros ide manv op-portunities for the practitioners who possess the appropriateskills. To safeguard the citi/ens and businesses. it is fore-seeable that there ss ill he state regulations certify ing"nidivitluats to become "ADA Es pens". The Commonwealthol Nlassachusetts already has such a statue. As there aremore test cases challenging this law . so ss ill the pris atepractitioners' ethics and skills.

Due to IDEA and die Rehabilitation .Act Amendments,pris ate rehabilitation may everience attrition of its profes-sionals to school systems, the state units of Dis ision ofVocational Rehabilitation or other community rehabilita-tion programs. At the same time. there ., a mos ement inrecent years toss ards "public-pris ate partnership." 'INs ises ident in both federal and state programs such as :eterans.Administration. Dis ision of Vocational

Rehabilitation. Social Security Administration. and JobTraining Partnership Act. etc. As the rehabilitation dollarshrinks in the N orkers- compensation sy stem due to pooreconomy and legislative reforms, more and more pris aterehabilitation firms and practitioner, mas shift to thesesources to climpensate for res enue loss.

The affix al of these three public lass s ss ill assure thatzissistise technology ss ill continue to he the growing fieldboth in the public and private sector rehabilitation. Know l-edge in the appli.cat.on of assistise technology in the reha-

itat ion process will help to address the issues of "choiceand empowerment" and success" and successful outcomefor the individuals with disabilities. Private rehabilitationpractitioners must acquire a basic Understanding of svhatassistive technology is and ss hat can realistically be e \-peeled from its use (Langton. 1993), Thev must leant toss ork with speciali/ed technology sers ice pros iders andother professionals to form a "technology team" to identifypossible solutions to functionalneeds. An organitat R in suchas RESNA that is "an interdisciplinats tissociation tor theadvancement of rehabilitation and assistis e technol(Igymay he an e \cellent ource.

As the population of the United States continues to change.pi-kale rehabilitation practitioners lutist be ready to facc thesechallenges if they are e \pected to he effectise. there is a

strong need of research in the entire lield of pris ate r2habilitation.

there is an urgencs of doing research On the arca o: "ul ti-ethnicil

and the rehabilitation process in disability ben.: sy stems and

medical rehabilitation sy steins. Training and ed.. .. ',Hi in dealing

ss ith clients, and co-svorkers ss ith different back Ands ss ill het p

practitioners become mote assure of their o -)ersiinal and

professional biases anti inure sensitise to othe:- \say in

dealing with issues of disability adjusunent. 1.. age barrier.

e pressing. and verbaliiing emotions and help ,ck.1.!ng helms ior

(Chan. I .am, Wong. Leung and 1 'mg. 1988: I cute. 993There is no doubt that health-care reform is on the hori-

ton. There is also prediction that President Clinton ss ittinclude ss orkers' compensation medical henefits in the na-tional health-care ref orm package (Thompson. I 993 m. If themanaged care concept pre s ails, it ss ill mean major changes

;Ind opportunities for pm ate rehabihtation practitioneis.

low nal i h',11,11,11rhithw 1991 Stitt tIonoo,11,11

24-h(mr medical coverage and team appr(mch in managinghealth-care patients or indu.triall, injured w orkers w ill bethe norm. Besides the emplo.ver. and the emploee. prac-titioner. niti.t de clop a fa orable orkMg relation.hip iththe other pnifessional, in the nem ork to become effective.National A.sociation of Service Providers in Private Reha-bilitation (NASPPR ). the recentl formed div i.i(m of Na-tional Rehabilitation A.sociat ion (NRA), ith its charter toinclude "all other. interested in the rehabilitation process"\\ ill pros ide a gi cat forum .hare ideas, to foster sv nergand to effect legislation collectiv elv .

e approach the 21st Centur, one thing is sure:priv ate rehabilitation as a field has inatured. It has gone froma uitall mwegulated indu.tr two decades ago to becomeone of full regulation. Its practitioners have diversified toinclude profes.ionals in many (L.ciplines to address theentire proce.. ()I' rehabilitation and client care. Licensingvs ill be in place to in.-41re the necessary qUalification. and\kills to practice thus e.tablishing a les el of professionalcompetence and esteem. The organiiation of a professionalassociation nationwide l'urther indicates the stabilitv and.tav ing pow er of thi. field. Priv ate rehabilitation cannot hein a better po.ition to meet the challenge. in 2001 andbe\ ond.

References

Brain. Gail 1:. (1992). Managed care programs. Occupa-tional Di.soriler of Cpper Extremity, s9-9q. Nes\York, NY:. Churchill Livingston.

Chan. Fong.. Lam. Chow S.. Wong. Daniel.. Leung Paul (K.Fang. Xue-Shen. (1988. Winter). Counseling Chine.eAmericans vs ith disabilities. Journal of Applied Relia-bilitation Counseling. / 9(4 ). 21-25.

I late. Jeffrev E. (1992). "Disability inanagement in work-er' compenvation: sunvy oj current practice mid

(-I I /ono t;ltii

demenul among New Hampshire employers". Prepai ed tomeet requirement for a Master, Degree in Bu.ines. Ad-ministration at Pl mouth State College. Pl mouth, NH.

lowell. Joanne C. (1983) Dillerences between public andpris ate rehabilitation sers ices and the profe..ional, vs hostaff them. liturnal of Applied Rehabilathinint:, I 4(2 ), 17-22.

1.angton. Anthon J. (1991. J ul ). Ltili/ing Technolog inthe s ocational rehabilitation proce.s. ty.yucy Appla-

1..ailligoti(1:n.ii:\clitshs(iisnii)vt.1-..1r1e:;(1)"3".)Shi)::.:::i..ig I. Niaking more effectiveuse of as.istiv e technolotz y. in the vocational ev aluationproces.. Vocational Evaluation and Wor( ..lilacamentBulletin. 26(1 ). 13-19.I .eung. Paul. (1993) A changing demograph and it.

challenge. Journal of Vocational Rehabilitation, 3(1). 3- I .

Nlorganthau. Toin.. Hager. Mars.. Thomas. Rich.. & Chit.Eleanor. (1993. Nlav 17 ). Dow n to bras. tack..New.% wet

Rile. Scott l..ynn. (1993. June). Okinawa: A terrific placeto grow old. National Geographic. Geographica.

Tars das. (1992. Nlay/June). Rehabilitation c( mn.el-ors actise in licensure. Profi.ssional Report 01 the Na-tioiud Rehtibilitation Commeting ,A.ssociation. V -

Thompson. Roger. (1992. July). Workers' comp co.ts: Outof control. Nation' Busine vs, 22-30.

Thompson. Roger. (1993. Nlay ). Health reform ai in. atworkers' comp. Narion s Busine.s.v. 34-36.

Watson. Albert L. & Eilenberg. Laurie. (1993. Spring) Themulticultural counselor. CRC: The Coun.sehir, 2-4.

Wehman. Paul. (1993) From the Editor. J011171(11 of Voca-

tional Rehabilitation, 3(1). 1.

ou nal eq lit habilitation

5 4

Excerpts of Reviews and Comments Chapter Four

Mr. Lui's paper focuses on keychanges in legislation. the 55ork

place. and the structure of compensa-tion systems which will create a newplay ing field for a private sector reha-bilitation for the future. We are at athreshold of change that will affectservice delis ery for the sear 2000 andbey ond.

Some of the implications forchange are as follow s:

1. Rehabilitation eduction appearsto he geared to produce profes-sionals for the public sector. Weneed to ensure that w e have a sup-ply of qualified professionals forthe pris ate sector and need to ad-dress the funding of rehabilitationeducation and curriculum toachiese this.

2. Rehabilitzdion counselors V. illneed to he better prepared to dealmodification and field accommo-dation in the work place. Therew ill need to he additional empha-sis inrehabilitation counselor edu-cation.

3. The trend to global business expan-sion may create issues of rehabili-tation ser ice delis cry on an inter-national basis for those companiesss ho has eexpanded bey ond I. 'n itedStates' borders.

4. We will see increasing dis ersity inthe ss ork force.One issue for reha-bilitation w ill be the increasingneed for bilingual or multilingualcounselors. The aging sx ork forcewill also create additional chal-lenges in terms of the range to na-ttwe of disabilities.

5. A significant barrier to employ memfor indis iduals 55 ith disabilitiesmay he remos ed as a result ofhcalth care reform. The increasedaccess to health care needs to becoupled w ith legislatise changesfor incent i es within the Social Se-curity compensation N\ qem to

SI

stimulate and facilitate return toork.

Catherine C. Bennett

belies e D :hr. Lui has to) ed on to1 some of the major issues of relevanceto our field in the years to come, suchas the Americans with Disabilities Act.a federal law that inay be revised butlikely will never go away. fie alsodraws our attention to the more in-stantly important issue of many otherprofessions calling themselves reha-bilitation practitioners. miuty of whomhil,e no training or experience of con-sequence in our field.

He therefore brings us to the mostimportant question of all, will wcsurvive as a profession at all in the2Ist century? The federal govern-ment is in a phase of cutting backspending by passing along federallymandated programs to be providedsolely or mostly by state funding. InMary land w e can already see its im-pact in the provision of community-based mental health sers ices, whichare being phased out as the state inturn passes the oNigation along toindi idual counties which can not af-ford to pros ide them. Public sectorrehabilitation can not help but he af-fected by a trend of this type. Pri atesector rehabilitation is no less sul-nerable in its own w ay.

Our first task in planning for the21st centurx should he to find out ifwe are at risk fOr even survis ing. andif so. to w hat degree. ()ur planning.education. ers ice delivery and all theother elements that comprise what wepresently think of as rehabilitationcounseling as a pnIfession w ill haveto take these finding \ into considera-tion, but hopefull) ill a proactive andcoordinated fashion in xx a> s that V. illbe new to W. all.

We are the beneficiaries of thess ork of the giants of our field, likeMary Swit/er. persons 55 ho did mitwait lot es cuts to oxertake them.Rather, they ss orked to shape the

5 ci.1 to »al of n, bah/Eta/ion

events for the benefit of rehabilitation.That is our challenge, and one whichI beliec we must meet to assure oursurvival ill the years to come.

Phillip Bussey

Rehabilitation in the pris ate sectorhas indeed experienced enor-

mous growth and expansion since itsinception in the late 1960's. The foun-dation for such a mos ement hasclearly found its roots in the state fed-eral pmgrams that had been in placefor nearly seventy years. New fundingsources, primarily the insurance com-panies for compensation programs.has e required rehabilitation pr(Ifes-sionals to deliver services in new andinnovative ways for returning the in-jured w orker to jobs.

In his paper, Mr. Lui has identifiedsome new programs that will furtherredirect the private sector movementia the next decade. Namely, the ADA.Public 1ils\ 101- 476. and public law100-407 w ill clearly identify newtrends and required innovaticms forservice deliver). In particular. theADA will redefine the role of the pri-

ate sect ir rehabilitation practitioneras litigation identifies the critical is-sues in the hiring and employmentprocess as well as fueling a greaterinterest for resolutions in behalf ofpersons with disabilities. There in-deed will be a greater diversity ofclients and prograins responding toclient needs ss hich in turn will requirea varied responses on part of the prac-titioner.

One of the major shifts that w ill berequired. in ni opinion. is the sourceof training for rehabilitation profes-sionals in both the public and privatesectors. Them( e staid university pro-grams that have been funded by theRSA for the last forty years will needa thorough ree s aluat ion and reassess-ment with respect to the ernergingneeds of the professional in areas ofsers ice delivery. As new laws are en-acted, at both the federal and state

vg 1 5,1 Abuwt,,larIt

levels, one can not assume that ourcurrent training pnigrains will alwas sbe adequate for the practice of profes-sionals in these new areas. Relianceupon the professional associations tomeet these needs w ill not suffice. Theuniversity prtigrams inust be implic-itly insolved from the inception andhe able to resptind to all professionalsin the rehahilitation movement.

Tim Field

The strength of Mr. Lui's manu-script lies in its comprehensi 5 enessand enth.asiastic discussion of trendsand innosations in pris ate sector reha-hilitation for the next ceroury As ises idenced throughout the text. numer-ous opportunities exist for the futureof private for-profit rehabilitation pro-fessionals. The only thing presentingcontinued gross th in the field is thelack of an entrepreneurial spirit to ad-dress these trends and forecast others."lhe future of rehabilitation dependsupon not only our ahility to forecasttrends hut also to actis ely des clopsers ices which are consistent ss iththese tendencies. Mr. I.ui presents ass ide range of excellent ideas and op-portunities sk Inch utiliies the exper-tise of pris ate sector rehabilitationprofessionals. Indis iduals and com-panies must take ads a ntage of current

and future oppOrt Unit ies.

One area highlighted in this manu-script was that of assistise technol-ogy . With the Technology -RelatedAssistance for Individuals ss ith Dis-abilities Act, the Americans with Dis-ahilities Act. the Rehabilitation ActAmendments and other legislation.know ledge of assistive technologsss ill he necessars for practitioners inboth the public and pris ate sectors.However, opportunities exist formany private forprolit rehabilitationprofessionals to des clop special skillsand expertise in this growing area andfind themsels es in great demand ss hen

it comes to issues of reasonable ac-cononodation and accessibility. Al-though many rehabilitation counsel-ors see assisti se technology as a serv-ice to be purchased from other relatedprofessionals. this area has great

pm? %intl., I llorunooph

pnunise for all of those rehabilitationprolessi(mals s il ling to expand theirtypical roles and skills.

Another area highlighted in thismanuscript was that of multi-cultliral-ism. Private rehabilitation profession-als will not only need to be sensitiveto and possess some knowledge ahoutvarious cultures, they may also find anopportunity to specialtie in specificcultures by developing a significantamount of know ledge and expertise inworking with individUals from thesepopulations.

Mr. Lui should be ciunmended forhis recognition of rehabilitation pro-fessionals. other than counselors.who are and ss ill be ins olyed in ad-dressing the entire process of reha-bilitation and client care within theprivate secoir. It is important to rec-ogni/e that a ss ide affay of rehabili-tation related professionals areamong those working inde-pendently, as well as with teams. inthe coordination and provision of cl t-ent sers ices. This is evidenced in thearious Is pes of national rehabilita-

tion certifications including : Certi-fied Vocational Es aluator. CertifiedRehabilitation Counselor. CertifiedInsurance Rehabilitation Specialist,Certified Rehahilitatim RegisteredN ur,,e and the recently created Certi-fied Case Manager, to name a few. Inrecogniting this disersits of reha-bilitation professionals and the s ari-ous certifications they possess, it is

also important to indicate that thismay he the basis of inany problemsencountered in the private sector re-garding turf and ethical issues. Thereare was s. how es Cr. of dealing ss ithsuch issues by bringing people to-gether from various disciplines todiscuss commonalities and differ-ences. and communicate this infor-mation to the sarious professionalgroups they represent.

Juliet H. Fried

ui identities a number ol iniponantI.ifactors that will impact on the fn-tore provision or rehahilitation. Healthcare reform will ohviousls hike tre-mendous impact. How es Cr. at this

56h,, i.1

early date it is IRA clear how health care

sk ill change as a result of reform, nor is

it clear that vocational rehahilitationhas presented a thoughtful policy on itsrole in a comprehensive phi.

Lui points out the obvious oppor-tunities that rehabilitation providerswould seem to has e in assisting em-ployers in implementing title one ofthe ADA. However. the limited dataas ailable suggests that at present re-habilitation is not playing as central arole as many assumed it would.

The impact of the technolo* res 0-lot ion and the changes it will bring tothe world of work can't be empha-si/ed enough. Advances in assistivetechnology and new types of informa-tion processing jobs will provide op-portunities for people with even themost ses ere disabilities undreanted ofa decade ago.

1.11i discussed the entry of otherprofessionals into private rehahilita-don. Ile noted llokk central case man-agement has become to the entireprocess and he mentioned the newcertification as a case manager(CCM I. This ss hole topic raises ques-tions concerning ss hat pris ate reha-bilitation is. svhat training hest pre-pares people ft w work in this field. and

the relationship 1)etss MI rehabilita-tion counselors. rehabilitation nurses.told other allied health profes.sionals.

Dennis Gilbride

iThe author has allowed us a briefglimpse into the next (Tilton , and

it is clear that private sector rehabili-tation as we know it will be undergo-ing some major shifts and changes inthe years to come. -NO specific areas

winild like to continent on are diver-sity and regulating ADA services.

The author recogni/es that therehas been some research in the area ofminority ethnic populations and theirinterfacing with the state/federal reha-bilitation systems. Hosves er, ss hen

One considers the age of the state/led-eral sy stem, the hrief amount of litera-ture devoted to multicultural issues isindeed shocking. Therefore. it is notsurprising that in the (relatively newfield of pHs ate rehabilitation. issues

of cultural diversity ha\ e not begun tohe adequately addressed. It is undeni-able that the more information a reha-hil itat ion counselor know s about a cli-ent's background. values and fam-ily /community support 55 stems, thegreater the likelihood of that coun-selor \\ orking effectively with the cli-ent. Clearly this is an area that is wideopen for future research, and we needto begin to incorporate multiculturaltraining into inservice and profes-sional sentinars targeting. pris ate reha-bilitation practitioners. Obtaining in-formation about a clients' cultureshinild become as automatic as re-searching an unfamiliar drug. or anunusual diagnosis.

The Americans \\ ith DisabilitiesAct has indeed opened many thiors forpersons \\ ith disabilities. It also, in myopinion. has the potential to become atremendous "money -maker" for justabout anyone who \\ ants to marketthemselves as "expert" in the area ofADA. The potential for misinforma-tion to he given to employers or othersrelative to the law will only serve toembitter and alienate entployers whoare already somewhat anxious ahtmtthis whole business, to say the least!Regulation of these "experts". as men-

tioned by the author, can not onlyser\ e to protect the consumer of theexpert's services, hut also will ulti-mately result in a fav(wahle outcoinefor persons with disabilities.

Patricia Nunez

Mr. Lui's article characterizes pri-s.ate sector rehabilitation as ex-

periencing tremendous grow th andmaturation over the past tw o decades.He suggests this growth is evidencedin the ever expanding employmentopportunities available to indk idualsin private sector rehabilitation. How -e \ cr, as the field has matured. Mr. Lui

Perceptively identifies sweeping so-cial and legislative movements. crisesin worker's compensation and healthcare as well as a stagnant economywhich he predicts will influence reha-bilitation well into the 21st century.

The Americans with Disability Act(ADA). the Individuals with DisabilitiesEducation Act (IDEA). reauthorizationof the Rehabilitation Act and Technol-mk-Related Assistance for Individuals\\ ith Disabilities Act were passed he-tween 1988 and 1992. These laws have

laved the foundation for choice and cm-

5 7

pow ennent for individuals with disahili-ties. The implementation of civil rightslaw, transition from school to work andassistive technology represent new mar-kets for piivate sector rehabilitation pro-fessionals.

A number of other factors are pre-cursors to change. Demographicallyour population is aging and increas-ingly ethnically diverse. Rapidly es-calating worker's compensation andhealth care costs along \\ ith an esti-mated 72 million uninsured or under-insured Americans predict health carereform. An influx of other alliedhealth professionals into private reha-bilitation markets will continue todrke the demand for cenifications.

Mr. Lui's paper reflects a dynamic.turbulent work environment. Opti-mistic in his appraisal of rehabilita-tion's position to address the futurechallenges. his article suggests a num-ber of opportunities for future re-search and entrepreneurial. market re-sponsis c. private sector rehahilitationprofessionals.

Stephen A. Zanskas

lout nal ,1 Rehabihrotivil / Q"? St% IL( Monovarh

Seminar Recommendations Chapter Four

The fa," ing is a summars or therecommendations and implica-

tions for action as they ivlate to thediscussion of chapter Four. These rec-ommendations were des eloped by anindis idual work group and the style ofpresentation reflect ,. their own fonnatalong ss ith implications for action.

Program or PolicyDevelopment

. A National body to ads ocate forlegislatise change in worker'scompensatitm

A hotly to monitor changes in the en-s ironment that w ill have long-termimpact on rehabilitation. i.e. thenew health care plan. ADA.Pur-pose is for ads °eating the incliisionand recognition of rehabilitationcounselors and prolessionats inlegislation.

3. Clearinghousehmalysis of actions. de-

cisit ins. es al uations related to legi sla-

t is c changes fOr the iRimose of relating

it to rehabilitation practice.

4 Des elop position papers such as"The Role of Workers Compensa-tion in the L:nisersal Access De-hate". and "The Role of the Reha-bilitation Counselor in the l'niser-sal Access Debate".

Training

. Insist on comprehensise know l-edge Of important pieces of legis-lation such as ADA s hich Inashe amended. but will not likel y. goassay in our lifetime.

2. Include new skills in continuingeducation training. such as medi-cation. process consultation whichss ill help rehabilitation counseltwstrain those outside our profession.

3. I:Ilc(wrage pris ite et)Inpanics to dolow pay and no pay internships.maybe use "In mentory of- grantst'or funding.

4. Offer a clearinghouse of trainers toprovide programs in rehabilitationtopics to min-rehabilitation profes-sionals, i.e. employers, physicians.claims people. the general public.

5. Educate practitioners on the valueof public relations.

O. Encourage consumer ins oh ementin training.

Research

I. Suwon research in rehabilitation by:

a. Granting sabbaticals for timeto do needed research. and

h. Pas for it through shared con-t ri butions form companies.school. Grants

58

PIO S. II I I th.,1,11.11,11 1011111,11 t hilbillItMeM

c.CO-ordinate Nhabilitatitm re-search ss ith other reles ant re-search.

d. Of ler technical help in skillssuch as writing.

c. l'se rehabilitation educationstudents for support help.

I. l',ncourage professional asso-ciations to help in training forss riting. research. fund raisingactivities. etc.

2. Solicit industry support for re-search. e.g. shared data from com-panies for projects. es aluating es-isting data.

3. Cooperative State Agency /Pris atesector research projects such asservice delis ery.

4. Help students identify non-gos ail-ment sources of money for supportkir research.

Other

Puldicit sl hat is a RehabilitationCounselor. ss hat do they do?

2. Get the category of RehabilitationCounselor hack on the Strong('ampbell Scale. Interest Scale)

3. Opt for more articles on Rehabilita-tion Counselors in career literature.

S./

Chapter Five

Ethical Issues In The Private SectorEdward P. Steil an

Steljan has addressed probably the mostjicult area and collection of issues in all of rehabili-tation. Every itssociation or group that (writes alongtends to develop. and usually does, an ethics standardstatement JOr their organization and group of mem-bers. At this day tve have approxiinately twenty dif-Jerent ethics standard stawnwnts by tlw variou.s rehabilitation counseling asso(iations and alliedgrolip.s that would hare some direct or indirect bear-ing on the practice of rehabilitation (onsultants.

As Air. Stellan has correctly observed, the centrali.s.Vle /Or private sector rehabilitation i.s anti alwayshas been "Vt. ho is the di Oa

Tim Field

I I' aril I ' an. I I ' ch.rhi alum. I !It . I r I k. 11111101.

is defined by The Oxford American Dic-tionary as "moral philosophy." Moral is definedas: i ) of or concerned with .. ' goodness andbadness of human character. or \N ith the princi-

pals of what is right and wrong in conduct, 2) virtuous. 3)capable of understanding and living by the rules of morality.

These definitions will give shape to our discussion onthis complex issue. Ethics, or the lack of ethics. have aprofound effect upon the service delivery system whichcurrently provides overriding direction to which individualsand what type of rehabilitation services are provided. Givenmy experience is in the workers' compensation case man-agement system, the example.s I will sight related to ethicalquandaries will he from personal cases, or have been relatedto me by other rehabilitation counselors.

It is difficult to discuss ethics without using negativeexamples to produce insight. That being the case. I must becareful to qualify that it is my helief that a major percentageof people providing medical, counseling. therapy, insuranceclaims, rehabilitation and related services, try to work ethi-cally within the system in which they practice. I did notdescribe the negative information in case examples. to inferthat other professionals, or we as rehabilitation counselors.indis idually or as a group, are unethical.

I cannot state strongly enough that I am not sighting examplesfor an) purpose other than to inili/e information which I belies e

to be true to promote growth and insight in ethics.A continued ethical complaint levied against rehabilita-

tion counselors ss orking in medical management and voca-tional sers ices involving insurance claims is that the clientis the insurance company or defense attorneys as opposedto the individual. This ethical concern w ill permeate theexamples utili/ed fir our discussion.

I thical dilemnlas 55 ould appear to he a direct consequence ofthe current practices in nmst jurisdictions w hich create an ads er-sarial system. This directly effects ethics because of the percep-tion that a practitioner must choose "a side" for which to special-iie. Once having arisen. the rehabilitation counselrir must then

Q\ ell toned RI /Wirthnitioil ()Y.,. lit 11,i I lir MuChipil

manipulate information to pronlote the cause or orientation forwhich one has engaged. This often eliminates the rehabilitationcounselor's ability to objectisely assess information and develop

an objective rehabilitation plan.Rehabilitation counselors ss ho fight to maintain neutral-

ity may be perceis ed in the industry as limiting their poten-tial for business growth. Although it appears these rehabili-tation companies has e a percentage of the available work, itis not the lion's share. It is difficult to assess whether arehabilitation counselor's w illingness to "package" the re-habilitation variables to satisfy a pre-determined outcomeor goal. is a cause or effect of the current orientation andethical dilemmas permeating our industry. By this. I amquestioning whether rehabilitation counselors have tochoose a side and fortify that position, or because rehabili-ation counselors are available to do so since their servicesare purchased.

Labor Market Surves s has c the potential to be misusedand misrepresented depending on the difference between thestated purpose. the real purpose, and the motivation of theindividual producing the Labor Market Survey. As in allprivate sector rehabilitation issues. depending on the lassgoseming practice. service provi rs expertise. and themarket-driven motivation of services, the individuals per-fOrining Labor Market Surveys can be effected. This effectwill be on the quality. content and orientation of LaborMarket Surveys, and may pre-determine the outcome.

The following example outlines how. a Labor MarketSurvey can be utili/ed for a specific purpose in a misdi-rected attempt to support a pre-determined position. flowthe information is utili/ed. anti the process in which it wasproduced, raises ethical concerns related to ss ho is the client.

and ss hat are ethical rehabilitation processes and services?A Itirty -four y ear old foreign horn registered nurse. ss ith

below as erage English speaking ability . recovers from a losshack injury . with a thirty pound lifting capacity . Experienceincludes emergency room, orthopedic. and psychiatric nurs-ing. Silbsequent to reaching maximum medical recovery .the hospital. as employer. states no positions are availablego. en current rehabilitation variables. ftc insurance carrier.ss ho oss is a captive rehabilitation company . tenon nated

temporary total disability benefits indicating gists!' medicalstahility . and the as ailability of nursing positions. rehabili-tation sers ices are not necessary . In the jurisdiction in ss hichfins inatter transpired. there are no legislatise guidelinesregarding ZI ss orkers right to placement services it' tlie are

medical k stable and are perceis et', as has ing transferrableskills for a job ss hich is believed to exist in a reasonablequantity Nor is the definition of the purpose. process. orstandards foi a Labor Nlarket Stirs ey defined.

Employment ss as not secured hy the nui se through anon-sophisticated personal job search of approximately siill) months. Plaintiff's attorney then engaged a CertifiedRehabilitation Counselor to perliirm an es ;dilation of em-ploy ahi I ity and placability . The rehabil itat ion counselor in-dicated the nurse w as both employ able and placeable. Theiehabilitation satiahies of a tinny pound lilting capacity .

5i ii lfors,oupir

and below average English speaking ability were cited ascause to initiate a self-directed job search program super-s ised by a rehabilitation counselor to identify appropriatess ork settings and facilitate securing employment.

Rather than funding the self-directed job search, a non-certi-fied rehabilitation counselor enlployed through the captive reha-

bilitation company was asked to contact employers and deter-mine "what opportunities might exist for a registered nurse with

the medical restrictions as stated on the report (sedentary or 30

pounds or less of' weight restrictions)."What followed was an individual contacting hospitals.

blood banks, nursing homes, health companies, and doctor'sclinics that \sere advertising positions available asking. Doyou have positions available for a registered nurse with athirty pound lifting capacity?

Fifteen ( 15) companies were contacted. and as would beexpected. given the Americans With Disabilities Act, andother pertinent legislation, most gave affirmative answers.

The ethics related to the abose matter may appear obvi-Ms, but they point to how external influences along with themotivation and ethics of people in control of purchasingrehabilitation services call effect the outcome of rehabilita-tion activities.

It is unfortunate. but it appears the request fOr service inthis matter most likely was, produce a Labor Market Sur\ eywhich will show there are jobs for a registered nurse with athirty pound lifting capacity.

It inay also be reasonable to believe the person producingthe Labor Market Suns ey was not pros ided the evaluationand recommendations poiduced by the Certified Rehabili-tation Counselor.

Ethical Questions/Concerns

Was the Certified Rehabilitation Counselor ethical w henrecommending placement sers ices for an apparently em-pkiy able and placeable individual?

Should rehabilitation counselors demand all informationrelated to the matter they arc addressing, no matter howspecific the request for sers ice?

Was the captively employ ed rehabilitation counselorethically hound to point out that placeinent sers ices mayassist and expedite empk)y ment?

Should insurance conipanies be able to direct the sers icesof their capt is e rehab i li tat ion compan es,?

Absent legislation defiMng standards of practice w hatethical guidelines should rehabilitation professionalsfollow?

What are the ethics and objectis e standards invoked mprislut ing a product that ssould he called a I ahor MarketSursey?

lite general purpose ol a I.ahor Market Sui sey is toluu ily information about the as a.ilability of a type ofjoh. for

example, registered nurse.

G

hahhhapm sawn

If possible. the Labor Market Sur\ ex shoukl determineas much of the fol kik\ ing outlined information as possible.

. noes the job exist in a quantity large enough to make ita \ iable job goal?

2. What pre-requisite skills are necessary for employ ment?

3. Who hires registered nurses'?

-I. What are the w ages and benefits associated w ith regis-tered nursing positions in different job settings'?

5. Are there posititins ax in table mum for registered nurses.and does it appear thee w ill he in the future'?

6. What are the essemial physical demands necessary toperf(irm the job functions.

A more specific or singular purpose may he requested.such as to determine the wage range of registered nurses.This in and of itself may not seem unreasonable to do. Theethical dilemma is related to the purpose of the Labor MarketSurvey, as defined and utili/ed in the example above, andhow it may pre-determine the process. content. and orienta-tion of the Labor Nlarket Survey.

Ethics Questions/Concerns

Are the rudimentary thoughts outlining w hat a LaborMarket Survey is here. ethical or objective enough?

Who should determine w hat a I .abor Market Survey is'?

Who should determine how a i.ahor Market Survey isconducted'?

I low ethical are any of the actix ities stated'?

Another example of ethical concerns related to w ho is theclient and w hat is ethical acti ity fix a numher of profession-als is addressed in the follow ing outline of rehabilitationxariahles: a thin\ -fix e (35) ear old forklift truckdrix er/warehouse laborer ith a diabetic condition and ex-tensi%e computer skills. sex erely strained the right ankle.Reflex S mpathetic Dy sift iphy ensued.

Subsequent to referral to a rehahilitat ion counselor, and lim-ited progress being inade. deterioration occurred. I:\ aluatum bya prominent Anesthesiologist and Pain Nlanagement Specialist.determined an electric w heelchair would be needed I'm an ex-tended period of tinie, and the cause was either DiaheticNeat ipath or Reflex Sy mpathet ic l)ystrophy.

'pon learning this information the orker compensationcan ier denied pay mem for the w heelchair. The indix idualrequested the health benefits carrier purchase the w heelchair. and w as told insurance cox erage had lapsed.

W, lien the doctor learned from the indix idual that bothsotnces denied funding to purchase the w. heelchair. a new[mon Vl is %%Own. h stated the electm ic v heelchmair w as

necessitated hy Reflex S\ mpathetic Dystrophy, w. ith the

assumed purpose being that k orker compensation henefitswoukl then apply.

The rehabilitation counselor recommended evaluationby an independent endocrinologist to address the issue ofcause and pursued alternate funding sources for the w heel-chair in case insurance benefits would not be available. Theworker compensation insurance carrier terminated the serxices of the rehabilitation counselor, and maintained theposition of not purchasing the wheelchair.

In the jurisdiction where this applies, there is disputedcase law regarding whether the individual or the insurancecarrier has the right to choose the rehabilitation counselorpros iding service. That being the case, the indk idual andplaintiff s attorney requested the rehabilitation counselorproceed with rehabilitation services.

Ethical Questions/Concerns

Lthically, what should the rehabilitation counselor do?

What are the ethical concerns for the rehabili.tat.on coun-selor related to the rights of the individual, anesthesiolo-gist, insurance company. and plaint iff- s attorney?

These tw o examples also lead to the following:

Ethical Questions/Concerns

Can w e define w hat rehabilitation ethic's are?

Can w c legislate morals or ethics?Can we stop short-sighted people from controlling

claims cost through purchasing inappropriate. inadequate.misdirected or unethical services? What actions arc w eethically hound to take under these circumstances?

Can we hope "had rehabilitation" will suffocate itself orethically are we hound to some kwni of action'?

These questions. and tlu)se raised throughout this w ork.ptlint to the lack of clear understanding in die current mar-ket-place of w hat constitutes ethical rehabilitation counsel-ing practices.

Promoting w hat may hopefullx become a self-fulfillingprophecy . and returning to the definitions that began di'schapter, it becomes important to reali/e the terms "nioral"and "ethical" need to define for us a; rehabilitation counsel-ors, an orientation. a spirit, and an attitude that directs theacti ities pros ide as practitioners. to the inch% iduals inneed of our ser\ ices.

This orientation should mon \ ate us to answer thesedifficult ethical questions as best our know ledge and ahilityallow s. and also promote the educating of consumers andassociated professionals in the purposes of rehahilitationbeing the pro% ision of objectk e. positix el 11101I\ aled. and

goal oriented rehabilitation ser\ ices.For Your Information

Vdt,,thil IhibIlmitht Nos.01 si

Swit/er Scholar Tim Field has noted the following in a special which serve as a guide for professional practice. Some ofreport that he is prepating kw publication in late 1993.

Ethics in Rehabilitation

.1-he pnifession of rehabilitation has evolved so rapidly in the

last two decades that it is %irtually impossible to the mmement

ithin a single dimension. For instance. ocational rehabilita-

tion" which was defined primarily by the stateifedeml prognunhas ()ken been considered the "mainstream" for rehabilitation.While the state/Weral program has remained fairly stable internis of regulations and policy and pmcedures regarding casepractice. other segments of the pmfession have been expanding

in a satiety of directions.The most notable areas of acti% itv ha e been in the

prk ate sector of rehabi htat ion which ss ould include sers icesoffered by any \ endor through insurance funding. l'rk aterehabilitat ion companies ha e formed to provide sers ices tostate workers' compensation programs. including such pro-grams as federal employees. longsht we workers, coal minersand others. Sers ices providers has e included professionsIliun the fields of education and rehabilitation, nursing.occupational therapy . phy ',leaf therapy. and most recently .case loanageinent. As each new g rou p enters the rehabilita-

tion mo\ ement there im ariabi %%ill also emerge a neworgani/ational group and a new code of ethics tusuallyassociated s\ ith a new set of standards for performance t.a result, the rehabilitation profession is now blessed torcncumbered twit!) se eral ethics standards statements all of

"5,51 5 1/,555,55,5pil

the organitat ions that have drafted ethics statements are:

National Association of Rehabilitation Professionalin the Private Sector

National Rehabilitation Counseling Association

American Board of Vocational Experts

American Nurses Association

National Board for Certified Counselors

American Counseling Association

Certified Insurance Rehabilitation Specialists

National Association of Social Workers

National Forensic Center

American Pschological Association

The reader is encouraged to consult w ith the appropriateorgani/ation for further information regarding a statementof ethics for specific areas of practice. Ohs iously . the repro-duction of each of these statements would be prohibited 1.)\space in this publication.

Fds. note: Special thanks to Tim Field for sharing thisinformation prior to publication of his forthcoming text.)

6 27/.1 III, Ills .11 tam.,

Excerpts of Reviews and Comments Chapter Five

Ethic,' in the pri\ ate rehahilitationsector is a difficult and impfwtant

issue. "lhe examples ci ted by Mr. Stef-fan are \ alid and of genuine concern.

Ihree factors influence the ethical he-

ha \ ior of rehahililation pmfessionals:

. Fundanientl character of the eha-hit nation counselor.

2. Professional training and founda-tion in ethics imparted by rehabili-tation education.

3. Demands placed on the rehabilita-tion counsekw from customers w ithin

the private rehahilitation industr.

There is little that Lan b, kine to alter

the fundamental charactc: a rehabilita-tit in counselor brings to his/her pnifes-skin. However. rehabilitation educationmust ccintinue to emphasize prolessior al

ethics in the curriculum. As well as pro-\ iding professional guidelines. actualproblem mil .ing practices with ethicaldilemmas would he saluahle for studentsRi gain a greater loci of insight intohandling real life situations.

In terms of the issue of unethical de-

mands of customer.. I think it is iinp(w-tant to note that many insurance compa-nies and other consumers of pn ate reha-

hilitation set, ices expect and fully sup-Nil the ethical requirements of the reha-bilitation counseling profession. To en-courage unethical practices can backfire

in the claim administration or judicialpnicess, calling inki question the fairness

of the claim es aluation processor im ali-

dating the basis on w Inch claim decisions

were made.

There is no doubt unethical de-mands are made on rehabilitation pro-fessionals from time-to-time. P ap-pears more needs to he done in edit-cating customers through industrymeetings. seminars. etc. on the ethicalissues in rehabi itat ion counseling andthe pitfalls to the customer in operat-ing outside of these parameters.

Catherine C. Bennett

11,

Dr. Steffan's paper on ethical is-sues in the pu sate sector of reha-

hilitat ion accurately points to some ofthe prohlem areas that arise in a ty pi-ca] insurance-oriented case, and heciwrectly draw s up a list of concernsthat appears to he a combination ofethical issues related to prolessitmalpractice, and 'non-ethical' issues suchas those related to business practice. Ipersonally w ould has e liked to haveseen more of an overview article onthe topic rather than getting into thefiner details of. l'or example. the con-tent of a labor inarket survey. ss hich isan inaccurate 55 av of deriving dataahout the nature and extent of the ex-isting labor market for a person w tilla disability. Might it not he more use-ful to ask the question of why are wedoing labor market surreys in thefirst place?

This question alone leads us to they et hroader topic for the field of howdid we get forced into doing thingswe know professionally are of mar-ginal usefulness in the perspectis e ofour work, and how is the data beingused or misused by others? In turn.

e are then obliged to ask, if it is

useful to others and is w ithin thescope of the ordinary practice of theirfield. such as sorker's compensationlaw . us h \ shouldn't 55 e pros ide a re-quested sers ice?

In slum. 55 e are again remindedthat in rehabilitation counseling usedo not w ork in isolation but rather incontact w nil many other professions.Our considerations on ethics mustthus take into account so many fac-tors that can not be described in ashort paper that we must simply takethe topic as y et another area that willrequire continuing discussion overthe years to conic, oriented tow arddefining the important areas to herefined user tinle. Our discussionmight better be oriented tow ard de-termining the lorum for the discus-sion and helping it take place. andperhaps giving a little time to thMk-ing of how ss e can make sure that thepersons entering off held are w ell

RI III I ,e,i

63

grounded in an ethical foundation fortheir his es hefore they reach us.

Phillip Bussey

Mr. Steffan has addressed proh-ably the most difficult area and

collection of issues in all of rehabili-tation. Es ery association or group thatcomes alting teikls to des clop. andusually does. an ethics standard state-ment for their organization and groupof memhers. At this day ss e has e ap-proximatelx twenty different ethicsstandard statements by the various re-hahilitation counseling associationsand allied groups that us ould has e

some direct or indirect hearing on thepractice of rehabilitation consultants.

As s In. Steffan has correct! \sers ed. the central isstle for pris atesector rehabilitation is an I a.ways has

been "Who is the client?" A secondcritical issues has also been identifiedby Dr. Gilhride in his chapter w ithreference to "cost containinent".

Who is the Client?

The client is not always the per-son 55 ith a disahility or a handicap-ping condition. In a review of almostany of the ethics standard state-ments, you w ill find that the client isindeed identihed as the person ss iththe disabling condition. hut in prac-tice w ithin the area of pris ate sectorrehabilitation that is not alw ays thecase. A case in point. is the ty picalrehabilitation consultant who ishired by insurance to most expeditiously and cost effectisely return aperson w ith a disability to sork.Other interested parties include, ofcourse. the us orker us ho is injured.the employer. the attorney s t if any t.and the rehahilitation consultant hintor hersell. All parties have a 5 estedinterest in the alleged rehabilitationprocess and further inore, all partieshas e a legitimate role to play . In my

iew the -client- should be perhapsidentified as the process that in-oh es all of the parties for the most

flY I SI% II I

equitable resolution of issues ;11Solsing injuries in the w ork place.

Cost Containment

The eontainment of rehabilitationciists is a major problem and is con-tributing heas ily to the redefinition ofthe pris ate sector as we knoss it today .For instance. California is seriouslyconsidering putting further caps andfinancial constraiiits On pris ate sectorrehahilitation consultants (and com-panies) as a means of reducing andcontrolling the exorbitant cost of thexx orkers compensation program.While I stronglx feel that the rehabili-tation community ha, tai.en unfair hits

ith respect to the spiraling cost, it isalmi true that the prix ate sector com-munity has done a cry poor job sub-stantiating the cost benefits of pros id-ing rehabilitation sers ices for the in-jured worker. At the same time. therehas e been abuses ss ithin the pris atesector group w it h respect to doliblebilling. unfair hilling. and other re-lated questionable practices by the re-habilitation consultant. Related to thisdes elopinent, many states has e andxx ill continue to most' aw ax from theconcept of mandators rehab which isviewed as a major component in con-t ri huting to the high costs of rehabili-tation and workers compensation. Inthis instance. the "client" becomes theworkeN coinpensat ion fund that is he-nig assaulted by exorhitant costs.t il remedies are found in the cost con-taimnent area. some workers 55 ho areinjured NA ill suffer fmm the lack ofadequate sers ices.

Tim Field

The issue of ethics is a to ,c whichsurfaces often in the pris ate tor-

profit rehabilitation sector. Es ery -one seems to has e their ow ii ideasregarding what is and is not ethicalbeliis or. It w as Interesting to seethat Mr. Steflan began his mann-seript ss jilt 6 dictionary definition ofthe terms "ethics" and "moral" in aneffort to pros ide a common frame ofreference for the reader. Despite thewell-established dictionary defini-tions. there still exists different per-

ceptions of w hat is considered ethi-cal behaxior in the field of rehahih-tation. It is easy to understand thisconfusion given the number of pro-fessional codes of ethics which existwithin the rehabilitation commu-nity. In addition to rehabilitationcounselors, s ocational ex aluators.ss o different groups of private sec-tor professionals. occupationaltherapists. phy sical therapists andcase managers, among others. has etheir ow n set of ethics.

While the adversarial nature of in-surance rehabilitation tends to pro-mote what might he pereeked as un-ethical behas i or. rehabilitation pro-fessionals need not succumb to suchunprolessnmalisin. Their opinions re-lated to choosing ''a side" do not andshould mit he bought for a fee. Ohjec-tis ity is still a s alued commoditx inprix ate for-profit rehabilitation. Com-nlimicating this objecti ity in a clear.c(mcise inanner thmugh educating re-lated prkifesionals and consumersabout the purpose. process and out-comets of good rehabilitation prac-tice is one of the keys to promotingethical hehik

Although sonic individuals read-ing the examples of ethical dilemmasin this manuscript may . iew thesesituations as unethical, others w illdisagree and say it is a honest. objec-tix e difference of opiMon. We needtO be able to clearly recogni/e w hendifferences of opinion are consideredunethical behas ior and when they are

iewed as honest, objectis e opin-ions. Perhaps a monograph or casestudies hook on ethical dilemmasand ethical behavior in rehabilitationnnght he des eloped to include all ofthe rehabilitation professiimals inolx ed in the prk ate sector. This

publication could include such ex-amples as the ones in this manuscriptss ith responses to specific questionsand eoncerns follow ing each case.Before any effort is made on such aproject. it w (mid he beneficial andnecessary . as the author points out, todefine ethical and moral behas ior inrehabilitation in terms or...an orien-tation. a spit-it. and an attitude thatdirects the actis ides we pros ide aspractitioners. to the intik iduals in

199h SII ti o 11. mo,L,./p/i \oitso qua /6 habitilom,,,i tontom 6 el

need of our Nen. ices." This may he amajor. but necessary . undertaking.

Juliet H. Fried

There is little doubt that ethics basereceived a great deal of attentnin in

private rehahilitation. Steffan suggeststhat a central cause of ethical dileinmasin workers' compensation rehabilita-tion is the ads ersarial system. Oftenrehabilitation pnis iders are hired not toprovide services or gis e an inde-pendent opinion. hut rather to help oneNide develop its case against the otherside- Wlnle an attorney is expected imdrequired to be an ads i)cate and presentinformation in the most fits orable lightin an attempt to win. this behavior isgeneraII s iessed as unethical hy reha-hilitation providers.

The adversarial sy stem. xx hile notAway s aesthetically pleasing. isgenerally regarded as the bestmethod to reach a just conclusion.Perhaps many of the ethical dilem-mas that rehabilitation professionalsencounter ha N. e more to do sx ith dis-closure than with moral,.

For example. rehabilitation pro-fessionals hike trainmg and exper-tise in understanding the impact ofdisability On employment. If an at-torney vs :nits to buy that expertise todevelop data to support his/her caseperhaps that is ()K. The problemmax come because rehabilitationpkilessiOnals portray themselves a,neutral when in fact someone in par-ticular is pay ing their bill. May be weshould explicitly des clop two typesof forensk rehabilitation. Type (meis based on actise ads ocacy and ispaid for by one pal't T pe two isactual expert testimony. it rims) bepaid for bx both parties, and it Is

expected to he object is e and neutral.

Dennis Gilbride

Thought pros oking- \s ould be thebest V, a to describe Mr Steffan's

paper. "Ethics". this abstract and in-tangible word st ill no doubt be thecentral focus lOr prk ate sector teha-hilitation for many ear,. to come. l'et

this hot topic must be addressed hthis profession and industr. Formany states. ethical concerns ha\ eproduced licensing bills or credential-ing procedures .f(ir rehabilitation prac-tices. Debates w ill go an fore\ er\\ het her licensing or credentialing\\ ill pniduce better rehabilitation. orbetter practitioners.

Few things are clear: I I Rehabili-tation is mit an exact science: 2) Ethi-cal does not necessaril equal maxi-inal potential. particularl rehahilita-tion in disability benefit prognuns andforensic rehabilitation: 3) Vnlikeother professions. there is no strong"peer re\ iew process in our profes-sion:4 ) 'Mere are few if an inaiprac-tice law suits against rehabilitationpralitioners.

Recommendations: Rehabilita-tion education programs must ad-dress ethics in their curriculum toraise students' ethical conscious-ness. Rehabilitation professional as-sociations must make ethics anagenda including the establishmentof an Nthics Committee and the in-eorporation of regular training w orkshops. Coninns \ion on Rehabil ta-I on Counselor Certification

iCRCC) should include ethics as oneof the cernfication maintenanc; re-quirements. I .astl .. practitioners in

k ate rehabilitation need to recog-nue that the\ are itd ocates for therehabilitation process.

John W. Lui

I am m full agteement ith theauthor's initial assertion that a ina-

torit of persons emploed within theprk ate sector make .an effort to workethicall \ ithin the sstem in \\ hichthe practice.

I ha\ e heard the question "Who isthe client'!". and ha e iics er had aprohlein cring that question: thechent is the our er1s:e I cithei \ ocational in medicalase management i. and the customer

is the PI 'MAL\ SI .R of our sen ices(Other \ ocational or medical Casemanagement i All of our rehabilitanon el Ions should be du cited tow aids ohlaming twain \ cosi el lei.

tk e ser\ ices to help the client returnto their pre-injur or illness lifest le.Our customer (the insurance COM-pan . for example) is expecting us tobring a case to resolution as quicklas possible the least costl,v thebetter. It is the responsibilit of therehabilitation professional to edu-cate our customers that cheaper is notalw s the least costl v a to go\\ hen dealing w ith work-related in-jury. It is also the responsibilit ofthe rehabilitation professional toeducate the client as to the impor-tance of their assumption of an act iverole in the rehabilitation process.

The ser \ ice that me offer to ourcustomers needs to he professional.aecurate and the same no matter s hoiss purchasing the service. I lime\ er.I know that in the "real world". thedesire to keep a customer happ...and coming hack, can sometimes0\ erride a professionals best judge-ment. Hos ever. the issue of ethicaldilemmas ohs iousk is not sirnpl a

"pri S ate rehahilitation" issue. butone that permeates the entire reha-bilitation field. For example. howman times is the judgement of afacilit -based rehabilitation coun-selor o \ erruled (or ruled) b an ad-ministrator \\ ho is tr\ mg to maintaina fee-for-sers ice income les el, andadmits into the rehahilitation pro-graill an indis i dual w. ho s ouldclearl :ienefit from a more appropri-ate setting or set.% ice?

While a Code of Lthics for reha-bilitation counselors exists. thereneeds to he a significant increase inthe time and attention paid to thisissue both in rehabilitation coun-selor training programs and in-

ser \ ice training. As a condition ofCAR l- accreditation. facilitiesshould ha\ e to document regularstall. mid management training ses-sions int he area of ethics. Certifica-tion bodies should require that a Cellain percentage of certificationmaintenance credits be de\ oted toethics. I'm ate rehabilitation compatiles should be up-flont kk ith poten-tial customers h marketing theirsers Ices as pl'ort."0,1011al aild ethical.Hie professional associations\RCA. ARC \ ) need to tegulai K

offer to its' members professional.practical training on ethics.

Patricia Nunez

ard Steffan's paper challengesrehabi Ii tat ion c( iunsel ors in the pri-

vate sector to clearly define ethicalpractices in order to impro \ e the qu al-

it of sers ice del is er . Ile promotes theunderl ing basis for this definition as apositi ef uw. t is ated orientation in the

pro\ ision of objecti5 e goal (wientedsers ices. Implicit in his essa is thefundamental understanding that edu-cating consUrners and professionalsabout the purpose of rehabilitation fir\ trequires that rehabilitation profession-als understand their ow n purpose.

Through the use of case examples.\ Ir. Steffan raises m(we questions ahout

ss hat constitutes ethical rehabilitationpractice than can he addressed in eitherhis es.a or this res less . There are how -

es cr. two questions w hich zu-e essential

to Mr. Steffan's paper. These are %5 hether

rehabilitation ethics c;in be defined and

whether imirals or ethics can be legis-lated.

Rehabilitat ion ethics ha \ e been de-fined, kssent tal \ . the issue is \\ hether

rehabilitation ci uunselors. regardlessof their sector of empki\ ment, elect toact in an ethical manner. Morals orethics cannot effectk el \ be legis-lated. I bow es er, standards of conduct

or hehavior can he regulated and en-forced. Regulation and enforcementrequire\ a Lunt. orm standard of con-duct ss Inch is independent of fundingand a central authorit \ to addresscomplaints.

Addressing the complexit of etln-cal issues ss ill require a comprehen-sk e approach including training. pro-essitivai support, public

relations and legislation.

Stephen A. Zanskas

65 5,11

Seminar Recommendations Chapter Five

The 1011ow ing is a summars of therecommendations and implica-

tions for ziction as the relate to thedi.cu.sion ol chapter fise. The.e rec-ommendation. were des eloped b anindis idual work group and the st le ofpresentation reflects their own Icirmatalong ith implications for action.

'Me follow ing reconimendationsand implication. for action addressethical issues confronting the field ofrehabilitation and rehabilitationpros ider.. The recommendationscall for the focus of rehabilitation tobe the ind o. idual with a disabiht\ .emphasin ng an indis dignitthrough choice. Ethical i..ues anddilemmas are inherently difficult toaddre., as a topic .ince the arisethroughout indis idual and orgainia-tional decisions, policies and actionsregardless of the source of funding.Proactise leadership is required kthe rehabilitation communit to pro-mote and enforce ethical behas ior.Des elopment of a uniform code ofethics for all rehabilitation pros idersIs e..ential to this process.

Service DeliveryThe focus of the rehabilitation proe-

e.. MIN be on the indis idual ss itha di.abilit..

2. Rehabilitation pros ider.. their pro-les\ tonal as.ociations and certivi.cation bodies need to des clop auniform ethic. code.

3. Rehabilitation pros ider..hould onlspros ide sers ices within the .olpe oftheir training and expertise.Te.tumm . ss hen required..hall bepros ided objectis el

5. Rehabilitation pros iders need to un-derstand and tctisel .eek to influ-ence the lass in their turi.diction.Rehabilitation pros Riers need tou.e de.criptions of helms ior ratherthan ludgmental languagjor label.55 hen comniunicatmg about the m-ills idual participating in .ers icesRehabilitation pios iders should beguided 111 their pi Alice k the concept "pi iminn non litliele". I e.

Obit\ e all, do no harno

8. Broaden the outcome measure.\ed to assess the efficienc and

succe\,, of rehabilitation .ervice..9. Inch s iduals should he allow ed to

choose their own \ers ice pros ider.

TrainingI The Rehabilitation Sers ice. Ad-

ministration (RS.A) and the Couticil of Rehabilitation Education.hould require curriculum expan-5ion to include a .pecitic course inapplied ethical deci.ion-making.The proce.5 of ethical deci.ion-making should he incorporatedthrtnighout the curriculum.

2. Applied ethical decision-makingshould comprise I Ori of the totalnumber of continuing educationhours required kw credential main-tenance k each of the respectis ccmilication organi/ation..

3. kmplos cr5 need to pros ide insers -ice training on ethical deci.ion-making as a proce...Emplo crs of rehabilitation practi-tioner\ need to pros ide appropriateles els of training and supervisionto emploees prior to their engag-ing in practice and throughout theirpractice. Thi. .hould include amentoring proces. h an experi-enced puiles\ional.

5. Prole.sional organi/ation.. certifi-cation bodie., and indis idual .ersice pros iders need to seEeducate the public (i.e. the referral.ource. the indis idual ss ith the di.-abi eniploers. the pm or, andother profe..ionaki about the pur-po.e of rehabilitation, .tandards ofethical conduct and the gries ank.eor complaint proce...

6. Curriculum chans,les are required toinclude the techMques of prof e

con.ultation III order to ini-pros e pi ofe',11.mal interaction..

7. Piole..ional organi/ation. .uch asthe National Rehabilitation A.so-elation I NRA i, and its dis isionsneed to espand their namingtunities mailable to their member..

8 Ihe National Rehabilitation A..0clown should conduct a tiss it/el

\.1:1../Nil Is% .

6 6

Memorial Seminar on ethical i.-. nes confnmting the field of reha-bilitation.

Policy or ProgramDevelopment

I Di \eilY.ion of rehabilitation sers icesshould locu, on the rehabilitationprocess rather than setting. fundingsource or other external \amiable..2. A "Bill of Right." should he des el-oped and pros ided to the per.on ss itha disability at the time sell ices areinitiated and implememed. Nlini-mally. this document should include:the pros ider' . ethical code. addre.. thei..ue of ptivac . and explain the com-plaint or grievance process.

3. A central regi.tr or credential forrehabilitation pros ider./practitio-ner. should he developed. Boardspeciali/ation would fall ss ithin

this main credential.

ResearchThe effectis enc.s of the ethic.training package des eloped h thegrant frtim the National Instituteon Di.abilit and RehabilitationRe.earch tINIDRR) .hould bees aluated in proprictar and non-proht rehabilitation .etting..

2. Research appears indicated on theinteraction of the ADA and pri-s ac laws and the implication\ ofdns interaction on the pros ision ofrehahilitat ion .ers ices

3. Additional re.eareh is required toidentils both "hard" and -soft" out-come mea.ures of rehabilitation.ers ices efficiencs and .ucces..

LegislationI. Rehabilitation pm\ idet . and thew re-

.pectisneed It pioactis 0 ads ,ince app.( ipn

ate legi.latise initiatise. or relOnn. ona It val. \tate and ledeial les el.

2. Rehabilitation pis is 'ders and their re .spectis e prole.sionalneed to beconie proacnseb. inst ths ed

mu the credentialing 111O\ elltent.

Special Invited Paper

The History ofPrivate Sector RehabilitationIloyd NI. Holt

The emergence of any new field is generally the result ofconcomitant changes occurrirc in related fiekls. To un-

derstand the orignis of prk ate-sector rehabilitation, we needto understand the dy mimic changes which occurred in theinsurance industry and resulted in the, need for privaterehabilitation case manageinent services.

The insurance industry faces its own business cycleswhich are not dissimilar to economic cycles. There are times%1 hen premium income is insufficient to co \ er the dollaramount of claims and administrati \ e expenses. When thishappens. insurers ha\ e to draw upon investments for sol-vency . Another cominon practice during such tinies is toreduce operational e\penses. The I 960's and 1970's foundmany insurers making significant operational changes toreduce costs, .116 as. disposing of company cars for claimadjusters and resorting to telephonically recorded state-ments from insurance claimants. This resulted in apprecia-ble sa\ ings in operational 'expenses but the loss of permmalcontact created a vacuum fOr indk iduals h0 % ere injured

or encountered a significant disabilit \ .During this same time. claim losses were accelerated by :

Ii competition betw een health and disability insurers. 2)iberal i/ation of Worker's Compensation laws. 3 ) the devel-

opment of auto no-fault legislation. 4 ) the start of the "liahil-it\ crisis". A discussion of these e \ ents follow s,

Competition: !health insuiers expanded or de \ elopedproducts issued to eniployees (group insurance). membersof prol essional associations (group franchise insurance ) andthmugh indk [dually underw ritten contracts; examples in-clude medical. major medical and hospital indemnity co\erage. Disabilik co \ eriwes defined "total disability as the

insured person's inability to perlorin each and Cs cry duty of

I IOW \i 11011. ( US. Is coodwahn. Paninn 1111,1111,1110n lot

nIc onnkei Itchdhlindnon hm McitiodnA come! inI d I IC I, III,' 10" '4 PI CsIdC111 01 Ow nailimat sso, Luton

0I Idels III kt'Ildb1111,111(,11 iN \ 'IPPR I. 1)1\1,101 Of

\ Rch.11,111i,iti(n \ sso.

"his other occupat ion"( regular job) for a period of two years:thereafter, tom! disability was defined as the inability of theinsured (person) to perform "any occupation"for \\ hichhe/she was reasonably qualified by education, training orexperience. During the 1960's and 1970's the "his occupa-tion" definition of total disability was e:.panded from twoyears to five and even seven years. The "any occupation"definition which had previously been limited by short termcontracts found liberali/ation wh:n contract lengths \\ ereincreased to "lifetime" accit'ent benefits and sickness bene-fits pay able to "age 65".

With these increased contract lengths. insurers startedadding "rehabilitation clauses" w hich basically integratedwages paid with disability payments to those individualsattempting return to w ork. These clauses \\ ere seldomused since few claimants sought jobs on their own andfew er still found their w ay into the state \ ocational reha-bilitation system. Without prk ate sector case inanage-ment, these claims continued uninterrupted. In group con-tracts w hich reduced benefits for indk iduals recek ingsocial security disability payments. no one w as availableto help the indk idual either qualify for social securitybenefits or demonstrate that return to work was possible.The sy stem needed case management ser\ ices.

liberalization of Worker's Compensation Laws: By theearly I 970's, workers compensation henefits in many states were

insufficient loco\ er lost wages. In addition. mime states eN. en had

inaximum "healing peritxls" afier benefits were paid to theCx piratic in or the healing period (often an mnd one year) the claim

w as settled or the medical benefits w ere held open m) that lin Lire

medical bills for treatment of the compensable injury could lxpaid. With the labor moveinent. worker's conip laws fbundhealthy incivases in benefits and the elimination of "healingperiods". States started looking more at the welfare of claimantsal time of wifientent..." as thew ajoh logo hack to"*" Some states

thought this question w as so important that "mandatory \ tva-

\11111,lioll Rehab,/ falwit ti. ii,;.67

PP/

tional rehabilitation" under worker's compensation emerged instates such as California which pa.ssed AB760 in 1976. Similar

laws appeared in Georgia, Pennsylvania, Washington State,Minnesota, Colorado and elsewhere.

In the mid 1970's, many states which had given theemployer (insurance company) the right to choose the at-tending physician for the injured employee suddenly relin-quished that authority and gave the right of choice to theinjured employee and/or attorney. This accentuated the needfor medical case management services.

Auto no-fault legislation: Several states developedcomprehensive no-fault automobile insurance laws. Michi-gan was one of the early leaders; this law initially provided:

) unlimited lifetime medical benefits for treatment of inju-ries, 2) wage loss replacement of up to $1.000/month for upto three years, 3 ) the ability to sue the party at fault only ifthe injured party had a permanent disfigurement, a perma-nent loss of a body part/function, or death of the injuredparty. Similar comprehensive auto no-fault laws appearedin Pennsylvania and a few other states, but most tates

utilized a more conservative system designed to expeditehandling of small losses while allowing large losses to revertto typical tort liability handling. In those states with com-prehensive no-fault coverage, medical case managementflourished and vocational rehabilitation work increased.

The liability crisis: This had its roots in the 1960's and1970's when medical malpractice awards skyrocketed.Where liability seemed restricted by monetary policy limits,there suddenls began a trend toward increased productliability suits and related contingent liability actions. Sinceliability settlements looked at both medical expenses paidand wage losses incurred. private rehabilitation case man-agers were called upon for expert opinions on issues such asa person's employahility. and li fecare planning issues re-lated to a person's future medical expenses. The entire"forensic rehabilitatitm" area ads anced as healthcare costssoared, and a new form of case management was needed.

In a pre s ious Sss itzer Seminar paper. John J. Benshoffgas e George T. Welch the credit for founding private-sectorrehabilitation in 1970 ss ithin a unit of INA (the InsuranceCompany of North America which was later to merge ss ithConnecticut General and he know n as ('IGNA).INA/CIGNA had been using rehabilitation nurses for \exeral y ears prior to 1970 in many of their larger offices. Theirjoh included medical care coordination. medical cost-con-tainment and vitcational rehabilitation long before the ternisbecame fashionable! Those of us who w orked for (and ss ith )

(ieorge Welch in the early days of private-sector rehabilita-tion understand that his talent ss as in making rehabilitationconsulting sers ices a fee- for-sers ice business ( in Welch'sterms. "blending a business ss ith a pmfession" ) .

Welch launched Internatiimal Rehabilif,atain Associates( later to be cal k.d ntracorp) in May . 1970. Most of the initialcase managers ss ere nurses s's ho pros ided medical casemanagement sers ices, ensuring that each pe- ,on teem edthe best medical care it\ a ilable to mitigate the claimantsinjury . These nurses ss ere also called upon to pros ide direct

job placement services and were quite successful. Most ofall. these nurses provided excellent case control at a timewhen it was desperately needed and not being furnished byinsurers or anyone else. Rising benefit levels and liberaliza-tion of laws previously outlined complimented this need andenhanced the success of this beginning.

In 1975 vocational rehabilitation by master credentialedcounselors started gaining popularity. Many nurses did notfeel totally comfortable with vocational cases and felt theyneeded better vocational supers ision. With the passage ofAB760 in California mandating master credentialed soca-tional involvement and with the emphasis being placed onvocational outcome in non-mandatory jurisdictions. voca-tional rehabilitation emerged as another critical facet of thecase management process.

Although some may think that rehabilitation started inWorker's Compensation. the pioneering efforts actually hadtheir origins in the liability, arena. (Mv introduction to reha-bilitation was in 1969 at the Health Insurance Associationof America annual meeting in Boston. One of the sessionswas on rehabilitation and showed a mos ie The Rehabilita-tion of Bob Burgeon" a movie made by INA \\ Neil showedhow extensise medical and socational rehabilitation wasused to greatly enhance the life of a liability claimant w bileactually saving the insurance company money---a trueWIN-WIN scenario). If utilizing rehabilitation were toprove its effectiseness as a humanitarian, cost-effectiseprocess. its higher costs had to demonstrate its worthinessin mitigating losses and reducing claim settlements. Thiswas hest documented in the liability area. Worker's Com-pensation became the primary source of private-sector reha-bilitation because there ss as nes er a doubt us er who wasliable and to what extent.

Even George Welch would be the first to admit (as he didt(l me many times ) that he was not the founder of the conceptof merging rehabilitation with insurance claim handling.Welch frequently spoke of one of his ow n heros the late

Ante Fougner ho wrote and spoke prolifically to his kilos\prolessiooals in the insurance industry front 1948 until hisuntimely death in 1965. His message ss as loud and clear inpushing for a change in boss his industry perceived autoaccident "victims" and its reluctance to accept rehabilitationss ith its emphasis on the positise - "what remains" ratherthan "what's lost" (what functions are impaired, how muchearning power is reduced, etc.). Fougner. the pioneer in

iess ing the integration of rehabilitation in liability cos er-ages said "acceptance and application of rehabilitation pre-cedes settlement. Rehabilitation is designed. not to settle anargument but to solse a problem. 13y, sok ing the medicalproblem or. at least. arresting. "fixing" and reducing it the

legal argument should be more clearly defined, beingsharply. reduced". Fougner said this in early 1962 ss ell

before rehahilitatiint case managentent (either ntedical or\ ocat tonal ) came 10 the l'Orernolt in the pris ate sector.

Today . ss e are confronted ss ith challengin12 issues health

care reform. Worker's Compensation reform or the adapta-tion of "24 hour cos erage". and. the potential IN phiciw2 a

R, ,,. (..3 8 ,, I

cap on medical malpractice awards. May we as a societynever forget the struggle undertaken b these pioneers topro\ e that rehabilitation is beneficial for clainlants andsociet while szo, ing insurers moner. Perhaps the da) w illsoon come w hen we e olve into a new line of thinking suchas that uttered h Arne FotTner on Januar 25. 1962 beforethe New York State Bar Association Insurance Section e

Intl \I free oursel es from the habit of thinking e'.clusielin terms of inone as the sole means to settle arguments and

to solve problems. In the entire (claims) process, lawyersand insurance representatives hme been satisfied to act therole of mercenaries. and this in a field of disaster where thecries are loud and clear for Sainaritans"! We remain opti-mistic to see the development of a new unified s stem ofinsurance \\ hich will delete the notion of e cessi c mone-tar gian ano inciwp(wate the critical elements of medicaland \ ocational rehabilitation case management. It is best forthe claimant, hest for the pa or. and hest for societ.

6 9

\ 11 it.. 1,11tL'141/01

Special Invited Paper

Choice, Autonomy andIndividual Provider SelectionStephen A. Zanskas

empow erment of indis iduals with disabilities through1.choice and control of set's ices has developed as a focus ofrehabilitation. "l'he development of these thenies zis trends inour society is reflected by the civil rights nature of rehahilita-tion lecislat ion. This trend began with the civil rights aspectsof Sections 503 and 504 of the Rehabilitation Act of 1973 andtheir prohibition on employ mein discrimination against indi-

iduals ss ith disabilities hy federal contractors.Constnner control of sers ices has conceptually been ad-

s zinced by the independent lis ing Mos ement. A mos ementcreated bs the Reauthori/ation of the Rehabilitation Act in1978. Passage of the Fair Hou \ing Amendment Act. Air'arriers Access Act and the Americans with Disabilities Act

ieflect our society 's desire to turther empow er indis idualsss ithi disahil it ie. I NC11 199 1 ).

Choice. snupb., del ined. is the act or power of choosing.The pow er to independently ntake a choice among alterna-tis es and exercise ones ehoice requires autonomy . Choiceand innononly reflect the quintessential aspects of humandignits . Qualities long denied indis iduals with a disahilitw hen selecting a rehahilnation counselor or other sers icepros ider. The denial of these aspects of human dignityrepresent a 1 undamental structural paternalism in the pros i-

sion or \ motional rehabilitation sers ices and the ultimateact of discrimination.

ks idence of this structural paternalism is found in the101st Congress Ccinference Report on the Americans ss ith)isabilities Act of 1990. Among the congressional findings

is this pow erful statement:"indis iduals ss ith disabilities ire a discrete and insular

mi non ss ho has e been faced ss ith restrictions and limita .tions. sublected to a histor of purposeful unequal treatment.and relegated to a position () I. political powerlessness in OModel . based on characteristics that are be ir.d the control

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of such indis iduals and resulting from stereotypic assump-tions not truly indicatis e of the individual ability of suchindis 'duals to participate in. and contribute to society."

Individuals with disabilities alone or with their repre-sentative possess the ability to inake independent informedchoices regarding ss hether a pros ider's education, experi-ence. expertise qualifications ineet their unique needs. flosses er. indis iduals ss ith disabilities. ss ith fess exceptions. havebeen precluded front making an independent, int.( winedchoice regarding ss hich counselor's or pros ider's education.experience, qualifications or expertise stould most likelymeet their unique needs. Rather. indis iduals ss ith

has e been assigned to "professionals" by geographiclocation. agency contractual relationships. "disability" orreferied bs third party pay ors ss ithout being ads ised of theexistence of tlternatis es. It is not that indis iduals ss ithdisahility their family members. or representatis es are un-able to arrise at informed decisions, rather. lack of choice inthe \election of a pros ider appears to he structural and afunction of economics. Services for indis iduals ss itO dis-ahi li ties iire often puni hased by the tax pay or (tr an insurancecarrier. Reliance upon third party pay ors and their concernsfor economy or other measures of success is not zilss a sconsistent with individual des elopment. Individuals ss ithdisabilities need to control the method of pa ment. ss hetherhy soucher or some other system to obtain equal status inour society.

Structuralls . rehabilitation counselors ;Ind other rehahili-

tation pros iders require independence from the potential forconflict between the s alues of the purchaser 01 sers ices and

the indisidual who presents for sers ices. Managed compe-tition of rehahilitation prolessionals would establish a mar-ket place of indis idual pros iders for considetation and selection by an indis idual ss lilt a disabilit). No longer resuicted to an igenc.s.. contractual relationslup oi thud part

7 0It I I', \,10,111/ R, 11.1,111111;1, haw,:

preference. the individual w ith a disability could freelychoose their service pros ider.

To ensure quality and equal opportunity for selection, theinanaged marketplace of rehabilitation professions wrequire a central registry of professionals, subscribing to auniform code of ethics. providing enfoicement for ethicalbreaches and!? w legal iolations and a method of paymentpresented by the participant in sers ices.

Debates regarding w hether an indis idital ith a disabilityprefers to he considered a client or consumer are moot w henthe person lacks autonomy and choice. 1.ack of choicerelegates individuals w ith disabilities to the second classstatus of a recipient.

Our culture has proithited self- determination. The mereexistence or a disabilik does not eliminate that expectation.Managed competition regardless of w bether an indis idualreceives sers ices as a benefit or entitlement w ould empowerindividuals with disabilities to choose a rehabilitation pro-

lessional. C'hoice and autonomy are fundamental aspects of'human dignity and empowerment. Extending the right ofchoice in the selection of a rehabilitation professional toindiY iduals with disabilities would convey as a society therecognition that individuals w ith disabilities do not requirepaternalistic protection based upon stereotypic assump-tions.

Paradoxically, the systems which des eloped to enableindis iduals to attain independence. ci il rights and thechoices w hich currently exist can now be perceis ed asrepresenting the baiTiers for anal ning these same goals.

References

Conferewe Remny.1merimas teith Di.sabilnio Art of 1990(Report 101-5%, 101st Congress. 2nd Session. 1990) p. 3.

Pmition Paper on Reauthorbnion Ad (The NationalCouncil on Independent Living. NC1L. 1991) p. 1-4.

71

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Special Invited Paper

Rehabilitation in Workers' Compensation:A Growth Potentiall3ruce Grow ick

It is a generally icknowledged fact that rehabilitation andworkers compensation are made for each other. In work-

ers' compensation, the problem is an injury which preventsan employ ee from returning to work, and the solution isrehabihtat ion \\ hich assists disabled workers in returning to

ork. Workers' compensation is more than just a paycheckfor someone ()If of \\ ork. medical doctors for acute care, andlaw \ crs for necessary litigation, it is also about returninginjured w orkers to product i e. meaningful act ity--a job toreturn to. Rehabilitation facilities nationw ide can pla \ two\ cry important and complementary mles in tehabilitatinginjured w orkers: case manageinent and w (wk hardening. Thepurpose of this article is to describe the different kinds of

orkers conipensat ion insurance. and how industrial reha-

bilitation can hell' to e both moneY andWorkers' Compensation is a s \ stem of insurance de-

signed to protect employ ees and einploy ers from the costsof industrial injury . This insurance sy stein is federally man-dated but administered by legislative and regulatory groupsat the state le\ el. Each of the fifty states has created apatchy, (wk of laW s and regulations governing their w orkers'compensation. Although this can be confusing to risk man-agers v ho must adinillister w orkers' compensation benefitsin se \ eral stales at the sante time. it has allow ed states thefreedom to tailor their w orkers' compensation systems to fitthe needs of their ow n workers and employers.

For this reason, it is important for rehabilitation special-ists to understand and appreciate the diffei cut benefits andser\ ices w Inch are "allowed" in their state, and also how

( iim% ik l'h 1) . 1 ht: I /hi" ',hoe t '111..1,11

wkers' compensation insurance is administered fromstate-to-state. From knowing what rehabilitation ser\ icesare authoriied. and how employers have obtained their

orkers' compensation co\ erage, rehabilitation facilitiescan develop the necessary ser\ ices hich are needed andinarket them appix)priately .

There are three basic types of coverage for workers'compensation. a state operated w orkers' compensationfund. prix ate insurance companies, and employ er self-insur-ance. Each of the fifty states has at least one of these conduitsin place to pro\ ide workers' compensation co\ erage, andmost states alkm employ ers a choice ainong these threeco \ erage formats. The follow ing is a brief description of thethree ty pes of insurance co \ erage.

State Fund InsuranceAbout half of the lift states ha c a state-managed ( i.e..

public, not-for-profit workers' ) compensation fund. Thesefunds operate in the same way as pri \ ate insurance compa-mk.-. employing claims examiners and adjustors. actuariesaid accountants. The state hinds offer only workers' com-pensation insurance, and therefore are considered single lineinsurance entities. Premiums are paid hy employers into thefund, the amount of which is determined by the type of w ork(e.g.. coal miners are probably more likely to be injured onthe job than registered nurses). the number of accidents thec()mpany has had in the recent past (called their "expertencerating". and other factors such as the number of safet \\ i(datitnis hich ha \ e been reported al the company (i.e..)SI IA \ iolations).

I 01 .111 Ilf) 11, M \ 1C1 ul the .talule 01 the RI) st.th... the 1 )imi I.( (.ohtinht,t. 11,1111. to 16. 1 dist itt ot Oh.

pi 0% Ink 0. 01 I tho 1')92 edition 01 miii i 01 It otkel . Comm ri,atwn ,1,s. poh11.1ted thc I S I 11,11111v! 1,1

72pp, 11, /11/11/1111111111 s ,.. 6.X

These premiums are used to pay for all of the expensesrelated to resolving a claim including rehabilitation serx -ices. If a state has a separate rehabilitation agency for

orkers compensation. it is usually expected that aninjured worker w ill he ser\ ed through that program w lien-

er possible. If no state industrial rehabilitation agencyexists. then injured w orkers are ty pically referred to pri-% ate rehabilitation companies w. hich arrange for services( i.e.. case management ) necessary to return an employeeto competitk e employ went. Until that injured employeeis returned to competitk e employment. an outstandingliability exists for the state fund.

Private InsuranceMany states prefer to has e pri ate insurance companies

w rite wtwkers' compensation insurance :or employers. Thebelief here is that competition among the insurance compa-nies w ill low er the premiums employ ers ss ill ha% e to pay .

Once again. premiums are based upon the safety history ofthe company, and the inherent risk factors in \ ols edin the ccimpany's particular kind of work.

Rehabilitation services, in states w here prk ateorkers' compensation insurance can be "w ritten,"

is usually perf(wmed by private rehabilitation com-panies. Rehabilitation coinpanies compete for newreferrals of industrially injured w orkers from pri-\ ate insurance companies. Once again. the out-standing is not remmed until the injuredemployee has returned to w ork or the case has beensettled. The ten largest prk ate workers' compensa-tion w riters are indicated in Table I.

Self InsuranceAn additional alternati e. soinew hat unusual and

quite different fon n fl_lose pro ionsl discussed, isemploy er self insurance. In this mode of cox erage.the eniploy er sets aside a certain percentage of thecompany 's prollt into an escrow account ss Inch canbe used only to pay kir V. orker.' compensation costsaccrued by the company . An ads antage of this planis reduced insurance costs to the emphiy er. sincethere is no actual "premium" to be paid. If no injuriesar accidents occur on the job, then the employ erdoes not f orfeit any inone.,.. as 55 ould be the case ifa repllar premium had to be paid to an insurancecompany or state lUnd. On the other hand, the employ ermust be able to spare a modest amount of profit to place in(Ins account to cos er all possiNe claims. For this reason.self-insurance is chosen mostly by wrs large corporationsin states w here it is a legal cos erage alternatis e.

Rehabilitation costs are likewise the responsibility of theciunpany II tlss es er. the self insured company has u)tal freedimiin securing rehabilitation ser ices for its injured employers. II astate has an industrial rehabilitation agency. the sellinsuredeinployer may use those so:\ ices. but is responsible for all costs

inctuTed. lite self-insured company Ina> also opt to choose apas ate m chabilitation company to pros ide rehabilitation sen ices

to its injured workeN. Again. the costs are paid out of theself-insured company fund. Whether the mode of cox erage bestate fund. private insurance, or self-insurance. employers ingrowing numbers are 1(x)king to rehabilitation services as ameans through which workers compensation costs can be mi ni-

mited. This reali/ation has caused an explosion of opponunityfor rehabilitation agencies and professionals. And there are two

important roles that rehabilitation companies can Play: casenianagentent and/(w work hardening.

Industrial Rehabilitation ServicesSimilar to other ty pes of rehabilitation. case management

in rehabilitating injured workers is a process b ss hich an

indis idualized plan or program of rehabilitation is des el-oped by a rehabilitation professional. and monitored tocompletion. By working closely w ith the disabled employ ecin an actis e program of rehabilitation. insurers and employers can facilitate an indis idual's return to work. hi the caseof successful rehabilitation. the employee once again be-

The 10 Largest Workers' Compensation Writers

The 1990 Rankings as compiled by A.M. Best,

an Insurance Rating Organization

1992 Direct Premiums

(Billions of Dollars)

Company

Liberiy Mutual Group

CIGNA Group

American International Group

CNA Insurance Companies

Travelers Insurance Group

Aetna Life and Casualty

Hartford Insurance Group

Kemper International

Insurance Companies

Nationwide Group

Continental Insurance Group

1990 Market Share

(Percent)

$3,772 10.8

$2,001 5.7

$1,939 5.5

$1,870 5.3

$1,759 5.0

$1,679 4.8

$1,666 4.8

$1,538 4.4

$1,260 3.6

$1,213 3.5

Table 1

comes a pfiiduct is c. contri but ing incinht I of the w ark forceinstead of depending on disabi lit pay ments.

In soine slates, case managers must possess ininimumqualifications before they can des clop a rehabilitation planon behalf of the employ er or the insurance company . Nlost()hen the rehahd itat ion professional must be either a certihed rehabi If tat ion counsekir or nurse. Because ever\ orkerss ith a disability has unique needs. successful industrialrehabilitation rehes on an indk iduv.lifed program managedby a well trained ehabil itat ion professional. Industrial reha-bilitation. like most types of rehabilitation. must he s mew edas a dy namic process requiring direct ins ids einem andpersonal ittentian b he caw manager.

7 30.1 %till I, t11,11,,:,,II.11

When des eloping a rehabilitation plan for an injuredorker. the case manager must take into consideration a

client's financial needs and legal rights under workers'compensation in that state. The rehabilitation plan may

inedical nianagemenl. functional capacit,, assess-ment, job anal) sis. transferable skills analy sis. job modin-cation, job placement assistance, and es en retraining ifnecessary . Of course. any of these sers ices can be purchasedat a local rehabilitation facility if they are as ailable. It is notuncommon. for case managers in ss orkers' ciimpensatitm.to refer clients for sers ices to the facilits in ss hich casemanagers are employed.

The newest and most used facility -based Nen ice in in-dustrial rehabilitation now aday s is work hardening. Workhardening is an individualiied. ssork-iwiented act is its thatinvols es a client performing simulated or actual ss ork tasks.These task\ are structured and graded progres-as ely to in-crease psychological and physical uilerance. and to impros eendurance and productis ity . Work hardening pros ides atransition between hospital-based care and return to ss orkss hile addressing the issues of productivity. safety . physicaltolerances and worker behaviors. Many ss ork hardeningprograms are located in outpatient medical facilities. orfreestanding rehabilitation centers.

Work hardening can be integrated into other rehabilita-tion sers ices. such as pain/stress management. s ocationales aluation. and career counseling. Work hardening ses icescan be provided independently if other components of therehahil itat ion plan are completed. or it-a client, by virtue ofhis or her condition. needs only the ocationally reinforcingaspects of ss ork hardening. In either case. ss ork hardening is

quickly becoming a vital component of many industrialrehabilitation programs. In fact. ss (irk hardening is a newaccreditation categors used by Cominission of Accredita-tion of Rehabilitation Facilities and is now required in somestates kir reimbursement by insurance companies.

The hasic goal of industrial rehabilitation is to assistinjured ss orkei s in returning to gainful employ ment. Froma financial standpoint. the employer sas es money in threess ays ss hen rehabilitation is successful: the overall costs ina claim are reduced: the injured worker returns to workfaster: and the anniunt of workers' compensation the e spe-rience-rated employer must pay in future premiums is re-duced. In Oh io. an independent actuarial firm conducted astudy in 1987 and discos ered that more than S25.000 ss assased when an injured worker returns to ss ork throughrehahilitat ion. It is obvious that the employer and the em-ploy ee have a lot to gain by using rehabilitation sers ices.

Conclusion

Workers' compensation and rehabilitation are indeedmade for each other. Since the ultimate goal of ssorkers'compensation is returning the injured ssorker to employment. and vocational rehabilitation is composed of sers icesaimed at employment for people with disabilities. it is onlynatural that industrial rehabilitation in America has flour-ished the last 15 years. What rehabilitation has to offer isss hat employers and insurance companies svant for theirinjured employees-good. cost-effective rehabilitation sothat both money and !is es are sas ed.

PO): I '1,11,1:S.11.1!

7 4

\.111.,11,11 I.. 1h111111111111111 10110,1

End Notes

Rehabilitation in the 90'S and BeyondBarbara Greenstein

The field of rehabilitation has undergone manychanges, driven by the perceised needs in the market-

place. The earliest roots arc the attempts of communitiesto support individuals with disabilities: we have growliinto numerous professional disciplines. In 1993. we arefragmenting ourselves and losing the foci N of our V, ork.In order to plan for the future, we need t.) take stock ofour strengths and w eaknesses:

Strengths

I. We know that the individual with a disability is the focusof the rehabilitation process.

2. We have core knowledge encompassing medical. \ oca-tional. cultural. legal. and technological issues.We hike broad experience with both kval and natnmallabor market trends.

4. We ha\ e skills that are \ aluable in many settings besidestraditional vocational rehabilitat ion: medical institutions,the legal sy stem, and business and industry .

5. v\...c are flexible and creative in looking fOr solutions to theemplovinent problems of the disabled individuals we sent:.

3.

Weaknesses

I. We ha \ e become fragmented into many tiny disciplines.some of' \\ hich may ha\ e less than ID° practitioners inthe entire country.

2. We spend alit of el foil "guarding our turf" and defendingthese tiny disciplines.

3. We do not understand how being accountable lor our prolessional actions is a sign of our maturity as a piulession.

As we stand on the edge of the Twenty -birst Century. itis important to contemplate how we can build on ourstringths and minimi/e our \\ eaknes. I:11'q we titles( look

at the similarities we shale as rehabilita:ion prof:ssionals.Our common core of know ledge crosses a.l the disciplinesw here we work. and it is this core that del i nes our proles-

\,111,01,1I

sional identity. We are rehabilitation profssionals. not re-habilitation counselors or job placement specialists or voca-tional evaluators.

Unifying ourselves as rehahilitation professionals meanshaving a single certification by which the outside world canrecogni/e us. As %e. expand our services into the legalsy stem and business and industry, it is important for thesenew consumers to have an easy way to know who has thequalifications to perfornl the desired services.

The issue of accountability has emerged both becauseof disabled individuals becoming more in \ olved in direct-ing their own rehabilitation programs, and by the expim-si(m into industry.. There can be no debate about the rightsof disabled individuals to recei \ e high-qualit \ ser\ ice andto hold the providers accountable for delivering it. In

industry, accountability is the norm, from the line workerho must meet production quotas, to the executive who

must deliver a certain level of profitability to the share-holders. Accountability does not mean that our profes-sional judgement is being questioned: it means that ourprofession has matured.

In the futun:. rehabilitation professionals with expertise in\ arious areas will provide services in many settings: puNic andprk ate agencies. medical facilities. homes, legal settings, andbusiness. Individuals w ithdisabilities w ill have expanded oppor-

tunities for fulfillment in their lives. Remembering our roots w illlead us to the future of rehabilitation.

Dedication

This paper is dedicated in lo ing mentory of Mck inGreenstein (2/28/20 211/93 m \ father and mentor. In adistinguished 25- car career in rehabilitation. he ser\ ed asa staff member of the Chicago Jew ish Vocational Sen ice.and as the ksecutke Director of the Kennet.ly Job TrainingCenter in Palo. Park. II.. and the Orchard Mental I lealthCenter in Skokie. II.. At all times. he sought to bringdi)2nity to the lk es of physically and mentally disabledindk iduals. Rest in Peace.

75 pp, ,t It.,

National Rehabilitation Association

OfficersSpencer NlosleyPresidentGreen Bay. Wisconsin

Tommy AllenPresident-ElectClemmons. North Carolina

Larry JohnsonPast PresidentMontgomei,.. Alabama

Jerry BensmanTreasurer,Atlanta, Georgia

Board Members at-Large

Susan G. ShermanAtlanta. Georgia

Janes B. Adamspaducah. Kentucky

Yvonne JohnsonAtlanta. Georgia

David PriceLansing, Michigan

Willie HorneJackson. Mississippi

Barbara .1. JaegerAustin. Texas

Regional Representatives

Great Lakes

James S. BuscettaSouthfield. Michigan

Pacific

Flo CurnuttSan Jose. California

Great PlainsKenneth L. BoschBoulder. Colorado

Mid-AtlanticFrances SalbeckJoppa. Maryland

tloromvaph

Northeast

Nancy DumartAshland, Massachusetts

SoutheastSusan WeeseLouisville, Kentuck)

SouthwestViola LopezHouston, Texas

Division Representatives

Nantional Association onMulticultural RehabilitationConcerns

Thomas C. BridgesDetroit, Michigan

National Association ofRehabilitation Instructors

Mary ChandlerMantee. Mississippi

National Association ofRehabilitation Secretaries

Patricia BriggsFt. Washington, Maryland

National RehabilitationCounseling Association

Faith S. KirkRockville, Maryland

Vocational Evaluation andWork Adjustment Association

Doug SeilerHolland, 1Vlichigan

National Association of JobPlacement Development

Frank StrongSioux Falls, South Dakota

National Associationof Service Providers inPrivate Rehabilitation

Carolyn B. ThompsonFrankfort. Illinois

v,,,,/ RchIhrhhilwri iiii, 6

National Associationfor Independent Living

Chuck GrahamColumbia, Missouri

National Rehabilitation Ad-ministration Association

Kathy WilliamsFrankfort, Kentucky

Council Representatives

Council ofDivision Presidents

Robert NeumanFond Du Lie. Wisconsin

Council ofChapter Presidents

Brian FitzgibbonsTeneck, New Jersey

National Staff

Ann Ward Tourigny, Ph.D., CAEExecuti,e Director

Michelle High leyDirector of Admin. & Meinhership

Ronald J. AcquavitaDirector of Communications

Phillip A. BongiornoDirector of Governmental Affairs

Committed to Enhancingthe Lives of Persons

with Disabilities

Switzer Memorial Seminar

'9,40

At the reception. friends and colleagues of the late Mary Switzer: Joseph Fenton (NI DRR),Deno Reed (RSA & NIDRR retired), Martin McCouitt (RSA & NIDRR retired. S. Norman Feingold

(formerly B'nai Brith Vocational Service)

ar,

Carl Hansen, Chairperson, Switzer Memorial Committee,introduces Justin Dart, Jr. (Justin Dart, Jr. is the Chairmanof the Presidenrs Committee on Employment of People

with Disabilities, and a chief architect of the ADA.)

la

J

Listening attentively at the seminar are scholars, Phil Bussey.Ralph Crystal. Estell Davis. and Tom Davis.

7 7\111011,1I n( habill 11111, .11

i:SICOPV MIAMI

, IL, I 11.,11,0.41th

1993

At the reception. Bill Mc Cahill (recipient of Switzer Award), withMiriam Stubbs (left) (formerly with RSA) and Ann Tourigny, NRA

Executive Director

Committed to Enhancingthe Lives of Persons

with Disabilities

<Ay&

P -.)41

Mark Shoob, Acting Deputy Commissioner of RSA.

At the reception Charles Harles, Director of INEABIR, and James Galetka,Executive Director of RESNA

PPR Stt II (1 Mr,IletiVrlith Ntalf.1101 R01411,11111111011

-,1,p#wr..nr;g60,

Mary E. Switzer

e people realiIe that Mary L.Swit/er had a satisk ing and full\

successful career in federal go\ em-inent e IU k oy me n I that spanned se\

eral decades prior to her fonnal entryinto the field of rehabilitation. She

SS as Idly years old \\ hen she becamedirector of the Office ofVocational Rehabilitationin I 950. and she brought tothe position a superior in-tellect and abilit \ . Hermany talents and experi-ences in economics, theleg islatis e process. go -ernment administration,health. welfare and publiceducation ss ere only a fewof the composite assetsbrought \\ ith her. She en-tered the ino \ ement at acrucial point in its es 010-lion. II ss a. a 011ie in\\ hich difficult decisionshad to be made betweenmaintaining the status quoor i1105 ing to a larger andunknow n future, but ss ithincreased opportunity to',or\ e tens of thousands ofpeople w it h disabilities y et

in need.Follow ing a life pattern

hi support of increasedsers ices to people w ith ainure responsise and hu-manitarian go\ ernment tochanging human needs.she readil \ committed her-self to the less certain hut more hope-fully expanded future for rehabilita-tion. The rest is histiwy . Ihe breadthand humanit \ of Mary Swit/er arestamped fore \ er On the passage Of

1.mt 565 with its research anddemonstration features, its concernfor rehabilitation education, its man-date to construct necessary rehabilita-tion facilities. its totally new charac-teristic of international efforts and co-operation regarding rehabilitation.

1900-1971

and perhaps. above all. in its expandedfunding base for more personnel andprograms fOr those in need of rehabili-tation ser\ ices. In the years that fol-lowed. she went on to es en greaterlegislative and governmental leader-ship heights on behalf of both disabled

awtirds. Also recorded are her presi-dencies of many organi Lotions includ-ing the National Rehabilitation Assti-ciat ion. wlaise Members and their ef-forts she held in high esteem. But shedid not reach the heights of her abilitywhen she \\ as made the first Admin-

istrator of the Social Reba-

and disadvantaged people.Despite the demands on the na-

tional and federal scene, her presencews almost ubiquitous on behalf ofprogram development and extendedsem\ ices to needy people. On a re-gional, state or local les el, be it publicor oluntar\ ser \ ices, if it were in theinterest of rehabilitating those in need.somehow sht.' would "arrange to hethere.-

The Who's IlluP has chronicled hetmany national and international

\rail 'mil R, habilitation }tie., lal le

hiliation Services, nor whenshe retired from the position,nor when she became inter-nationally involved in theWorld Rehabilitation Fund.Instead. she found her great-ness when she touched each(if us. bringing our full hu-manitarian efforts and quali-ties to the fore on behalf ofdisabled and disad \ antagedpeople. While readily rec-ogniied as a mil \ great ad-ministrator in the classicalsense. her true capacity andability can only be appreci-ated when sse reali/e thatthese accomplishmentssprang l'ann tin inner expres-sion of sensim ity. emo-tional refinetnent and dedi-cation to sei've all less fortu-nate people. Her egalitarianquidities were not ctintrisedbut spontanetws, steminingfrom hi. is e and respect for alllising things.

All of us in the NationalRehabilitation Associationand in rehabilitation. and allpeople with disabilities.

ha\ e had better. more meaningful andproductise lives becatise her

presence and her being \sere sul fi-ciently large to embrace and accept usas we are and help us better under-stand w here we should be.

What nnIn can be said than that wehad the joy and pri \ ilege of know ingher?

hitten. hrimiti/ /hi/Our/lir rti\ '1)e, cniki. 10-1

7 9 rt r th.rsosvarir

Previous Monographs Issues Also Available

Sin,:e the first annual Mary E. Switzer Memorial Seminar in 1976. the Switzer Motiffizraph has illuminated the research andrecommendations of prominent scholars within the field of rehabilitation. Switzer Monotzraphs have proven themselves to he

useful tools for administrators, practitioners. policy makers, legislators. researchers. education specialists and consumers. To order aparticular issue or issues. simply duplicate this form to the National Rehabilitation Association, 633 South Washington Street,Alexandria, VA 22314, along with your check or credit card information.

Please send me the following Monographs:

#1 Out qf print.#2 Rehabilitation qt. the Older Blind Person: A Shared Responsibility#3 The Role qf Vocational Rehabilitation in the I 980s: Serving Those

with Invisible Handicaps#4 Rehabilitation of the Mentally III in the 1980s#5 International Aspects of Rehabilitation: Policy Guidelines Or the 1980s#6 lVomen and Rehabilitation of Disabled Persons#7 Rehabilitation in the Public Mind: Strategies of Marketing#8 New Technologies and Rehabilitation in the Infonnation Age#9 Social Influences in Rehabilitation Planning: Blueprint for the 21st Century#10 The Transition to Work and Independence.for Youth with Disabilities#II The Aging Workforce: Implications jOr Rehabilitation# I 2 The Rehabilitation of Persons with Long-Term Mental Illness in the 1990s#13 Technology and Employment of Persons with Disabilities#14 Employment (Ind Disability: Trends and Issues for the 1990s#I5 ,Aging, Disability and the Nation's Productivity#I6 Rehabilitation Facilities: Preparing For The 21 st CennuT

.-111 available illonographs arc SI0.00

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City. State & Zip

Daytime Phone #

Send & Make checks payable to :

National Rehabilitation Association.633 South Washington StreetAlexandria, Virginia 22314

For information on hulk orders. call (703) 715-9090

FAX (703) 836-0848. TDD (7031 836-0849.

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80

Switzer Memorial SeminarsAs a living tribute to the memory of Mary E. Switzer. each year a special

topic of vital interest to the rehabilitation of persons with disabilities isexplored in depth. One of the outcomes of each seminar is a SwitzerMonograph which clarifies the thinking in a given area of rehabilitation andsets v,oals and objectives for positive action. Those individuals invited toparticipate in the Seminar are designated as Switzer Scholars

81

Mary E. Switzer MemorialSeminar and Monograph

To perpetuate the memory of a great woman and great leader inthe field of rehabilitation by establishing a memorial that will evand

and enrich services to persons with disabilities.

Committed to Enhancingthe Lives of Persons

with Disabilities

BEST CO