The Implementation of Informed Choice in Vocational Rehabilitation: A Functional Definition and Self-Assessment Process prepared by Michael Collins Community Options Inc. "Rehabilitation Services Administration (RSA) still does not officially define choice. However, they do lead us in the direction of a definition." (Suzanne Tillman, RSA Vocational Rehabilitation Program Specialist and designated agency lead on "informed choice". personal communication, June 15,1999). Introduction Requirements for "informed choice" within the context of vocational rehabilitation services first appeared in the 1992 Amendments to the Rehabilitation Act. Yet, State Vocational Rehabilitation (VR) agencies still continue to struggle with implementation of the true intent of this requirement. Subsequent federal requirements and additional guidance related to choice have brought us closer to a common understanding of the term. This document contains a brief description of the evolution of federal legislation, regulation and attempts at additional guidance with regard to the intent of "informed choice" within the context of the vocational rehabilitation process. It concludes with the implementation experience of one State Agency's attempt to understand, honor the intent, and arrive at a reasonable response to this seemingly simple, but in reality, very complex requirement. Federal Requirements State agency requirements to "informed choice" as it relates to vocational rehabilitation services were first encountered in the Rehabilitation Act of 1973 as amended in 1992. Section2(c)(1) of the Act states that "it is the policy of the United states that all programs, projects, and activities receiving assistance under the Act shall be carried out in a manner consistent with the principles of: (1) respect for individual dignity, personal responsibility, self-determination, and pursuit of meaningful careers, based on informed choice, for individuals with disabilities." In addition, Title I, Part A, Sec. 1OO(a)(3)(C) provided one of the strongest provisions about informed choice. It stated that "individuals with disabilities must be active participants in their own rehabilitation programs, including making meaningful and informed choices about the selection of their vocational goals and objectives and the vocational rehabilitation services they receive." Although the Act contained numerous other references to informed choice, it offered neither a specific definition of what informed choice meant nor guidance for implementation of choice within the context of vocational rehabilitation services. Rather, State vocational rehabilitation agencies were granted the authority to define informed choice "within their own body of policy." (CITE) Additional Guidance Shortly after publication of the 1992 Amendments, a few additional efforts to help State agencies define "choice" within the context of the vocational rehabilitation process appeared in rehabilitation literature. One attempt at definition focused on consumer participation and decision-making in the consumer-counselor relationship as the key to defining choice and fostering empowerment. (Rehab Brief, 1994) Another article supported and further elaborated on this theme stating that "the key to effective decision-making by individuals with disabilities and the key to judging a provider's approach to offering such opportunities to choose is information-it's availability, it's comprehensibility, it's pertinence, it's timeliness and it's effect." (Morrissey, 1993) Most attempts were much more concrete and defined the key ingredient as simply the expansion of competition in the supply of rehabilitation services or more service options. (e.g. Weaver, 1994) A definition offered by Nebraska VR in its Vocational Rehabilitation State Plan of 1995 seemed to support this more narrow idea of choice and is typical among many State agencies with respect to their understanding of the intent of "informed choice." "Informed choice results from a rational and systematic decision-making process that occurs in a context that is free from duress and coercion and that is characterized by: 1) identification of available alternatives or options; 2) identification of the consequences (both favorable and unfavorable) of pursuing each alternative or option; 3) selecting an alternative option after weighing and deliberating each one and its consequences in terms of a personal scale of values; and 4) commitment and action to pursue the selected alternative or option." Most, if not all, definitions provided principles and guidelines for services that would arguably lead to a somewhat more consumer responsive vocational rehabilitation. But none addressed the implementation level concerns. Once we have an agreed upon definition, how can one discern that informed choice" is really operational and effective within a State VR Program? Choice Demonstration Projects In 1993, The Office of Special Education and Rehabilitation Services (OSERS) attempted to further contribute to an understanding of "choice" and the implementation of choice within a vocational rehabilitation context by funding seven Consumer Choice Demonstration projects within State VR programs and nonprofit organizations. They were charged with "increasing client choice in the rehabilitation process, particularly with regard to providers of rehabilitation services." (CITE-FR) The projects attempted to develop and implement choice strategies that could be adopted by State vocational rehabilitation programs. Though each of these projects developed its own choice definitions and implementation strategies, they did arrive at the following "composite" definition for the purpose of a group paper on consumer choice. (Strategies for Supporting Implementation of Informed Choice, 1998) "Informed choice is the process by which individuals participating in the VR program make decisions about their vocational goals, the services and service providers that are necessary to reach those goals, and how those services will be procured. The decision-making process takes into account the individuals values and characteristics, the availability of resources and alternatives, and general economic conditions. Implementing informed choice requires communicating clearly, gathering and understanding information, setting goals, making decisions, and following through with decisions. To the extent that the individual participates in the procurement of services, implementing choice may also involve basic consumer skills, such as money management and negotiating in the marketplace." This definition provides more specificity than previous offerings and points State agencies in the direction of implementation as well as future evaluation of effort. It addresses issues unique to vocational rehabilitation service programs. Using this definition, choice in a rehabilitation context includes the following components: 1 . choice of actual services needed to reach the consumer's vocational goal; 2. choice of who will provide those services; 3. choice of how the services will be purchased and delivered; 4. a description of the components of the decision-making process to be used when choosing goals, services and providers; (i.e. it must take into account the individuals values and characteristics, the availability of resources and alternatives, and general economic conditions.) 5. an implementation "process loop" for making informed decisions; (i.e. communicating clearly, gathering and understanding information, setting goals, making decisions and following through with decisions.) Note: This is the first definition in which significant attention has been given to the concept of personal responsibility. It acknowledges the need for active and full participation in the implementation of the vocational plan on the part of the consumer. 6. participation in the procurement of services including the negotiation and purchase of needed services and goods. (i.e. money management and negotiating in the marketplace.) This definition is particularly helpful in that it speaks to the actual method of delivery of services within the vocational rehabilitation context. It actually leads VR agencies in the direction of implementation of "informed choice." Final Regulations: March 13, 1997 The Rehabilitation Services Administration (RSA) reinforced the direction of the Choice projects definition by offering the following additional guidance in the State Vocational Rehabilitation Services Program Final Regulations which became effective on March 13, 1997. (see CFR Vol.62, No. 28, 2/1 1/97: Rules and Regulations, pp. 6329-6330) "Informed choice is a decision-making process in which the individual analyzes relevant information and selects, with the assistance of the rehabilitation counselor or coordinator, a vocational goal, intermediate rehabilitation objectives, VR services, and VR service providers." Although the above looks very much like an official definition, Section 361.52 then goes on to state: "the Secretary believes it would be inappropriate to impose through these regulations, an across-the-board definition of "informed choice,..." The Final Regulations contain two noteworthy additions that add to our understanding of the real intent of "informed choice." They are: a.) the requirement for the "availability of support services for individuals with cognitive or other disabilities who require assistance in exercising informed choice and b.) additional clarification that the "DSU" (Designated State Unit) shall provide the individual, assist the individual in acquiring, information regarding consumer satisfaction with relevant services to the extent that information is available." Agencies are now being told they should provide sufficient support or assistance for people to be able to make true informed decisions, a step which leads them naturally into the area of consume education. In addition, they are being directed to collect and provide consumer satisfaction data t further assist in informed decision-making. Rehabilitation Act Amendments of 1998 The Rehabilitation Act of 1973, as amended in 1998, while still stopping short of an official definition, clearly states each designated state agency's obligation with respect to consumer choice. The "informed choice" requirements in the 1992 Reauthorization of the Rehabilitation Act were strengthened and consolidated into a single stand-alone section. (section 102 [d]) It was strengthened by adding requirements that State VR agencies: 1 . develop and implement written policies and procedures about informed choice in consultation with their State Rehabilitation Council; 2. assist applicants and individuals in exercising informed choice during the assessment process; and 3. develop and implement flexible procurement policies that facilitate service provision and provide individuals with meaningful choices among procurement methods. Section 102[d] Each designated State agency shall "develop and implement written policies and procedures that enable each individual who is an applicant for or eligible to receive vocational rehabilitation services under this title to exercise informed choice throughout the vocational rehabilitation process carried out under this title, including policies and procedures that require the designated state agency-- (1) to inform each such applicant and eligible individual (including students with disabilities who are making the transition from programs under the responsibility of an educational agency to programs under the responsibility of the designated State unit), through appropriate modes of communication, about the availability of and opportunities to exercise informed choice including the availability of support services for individuals with cognitive or other disabilities who require assistance in exercising informed choice, throughout the vocational rehabilitation process; (2) to assist applicants and eligible individuals in exercising informed choice in decisions related to the provision of assessment services under this title; (3) to develop and implement flexible procurement policies and methods that facilitate the provision of services, and that afford eligible individuals meaningful choices among the methods used to procure services under this title; (4) to provide or assist eligible individuals in acquiring information that enables those individuals to exercise informed choice under this title in the selection of the-- (A) employment outcome; (B) specific rehabilitation services needed to achieve the employment outcome; (C) entity that will provide the services; (D) employment setting and the settings in which services will be provided; and (E) methods available for procuring the services. (5) to ensure that the availability and scope of informed choice provided under this section is consistent with the obligations of the designated State agency under this title." These current choice provisions reinforce the language and apparent intent of the 1997 regulations which declare that the ultimate decisions and corresponding responsibility for the outcomes achieved rest with the individual seeking employment. The State agency and other stakeholders are clearly pointed towards an educational and support role in the rehabilitation process. Program Review Assistance The Rehabilitation Services Administration offers further assistance to State agencies with the following "review questions" from their Self-Assessment and Technical Assistance Guide for Fiscal Year 1999. This section of the Guide assists agencies to assess their efforts at meeting the 1998 choice requirements: 1 Have methods for providing individuals with information and support services for exercising informed choice throughout the VR process been implemented? 2. Have methods for involving the individual in decisions about the assessment process been implemented? 3. Have choice requirements related to the development of the IPE (Individual Plan for Employment) and IPE content, as addressed in those sections, been implemented? 4. Have more flexible policies that make the procurement process more efficient at an agency level and provide procurement options for individuals been identified, developed or implemented? 5. Have activities to support implementation of the choice requirements, such as revising written policies and procedures related to informed choice and providing training and guidance to counselors and consumers, been implemented? These questions from the guide suggest that the key ingredients for implementation efforts are: information and support (Q. 1), active involvement of the consumer (Q.2), implementation through the IPE (Q.3), flexibility in procurement options (Q.4), and training and guidance (Q.5). One State's Response: The Implementation of "Consumer Choice" in Vermont: Vermont's Division of Vocational Rehabilitation was one of the seven recipients of the earlier mentioned Choice Demonstration Project Grants. Using this Consumer Choice Project as its "learning laboratory", Vermont VR began the development and implementation of a long-term strategic plan designed to seek out a meaning for informed choice within the context of rehabilitation services and produce a "consumer directed rehabilitation program". The stated VR program goal is: "to provide an approach to vocational rehabilitation services that encourages personal responsibility while teaching and ensuring the necessary skills and supports for the consumer to assume that responsibility --and "own" their vocational goal. " Through this initiative, Vermont VR has implemented many new strategies and program options to facilitate its long-range planning and understanding of "increased consumer involvement and control" or "the real intent of choice." (Vision 2000: Vermont's Strategic Plan, 1998) This initiative has been framed around a set of values that form a functional working definition of "informed choice" within the context of vocational rehabilitation services delivered through a public rehabilitation program. 1. Informed Choice and Ownership Section 102[d]4 of the 1998 amendments clearly indicate that the "eligible individual" should be in charge of all important decisions leading to the achievement of the employment goal. This is interpreted in Vermont VR as encouraging State agencies and programs to strive towards consumer ownership" of all decisions and the results of those decisions. Vermont VR has determined that the implementation of the true intent of Choice is best viewed through an examination of this concept of ownership" of the rehabilitation process. The degree to which consumers are able to say, "Look what I have accomplished!" (i.e. I own it) as opposed to "thank you for helping me" (i.e. we did it for them) determines the degree to which VR reaches it's goal of assisting consumers to actually achieve ownership of their outcomes. Choosing goals, supports, resources and vendors or service providers are all identified as elements of ownership of these outcomes. Each individual goes through a planning process with their counselor to map out their personal goals as well as strategies to meet those goals. Service needs are determined and the program provides funds directly to the consumer so that they may, with the support and assistance of the program, negotiate and pay for those services. This puts ownership of the process and the results achieved squarely in the hands of the consumer. Under the old system, a person had to go to a specified vendor or provider with a state voucher. Under the new system, a person is able to control the money thus controlling the nature of their relationship with vendors or service providers. The consumer is able to negotiate for services and goods, assert their needs and shift the focus away from their previous role of client to their new role of customer. 2. Enhancing Informed Choice Through Education The Choice Demonstration Project's composite definition (p.7) led Vermont VR to consider education as a key to achieving ownership. That definition pointed out the need for informed decision-makers to be able to "communicate clearly, gather and understand information and set goals" as well as the need to ensure traditional consumer skills such as "money management and negotiating in the marketplace." The 1998 Amendments also contribute considerably to the belief that education is the key. Sections 102[d]1, 102[d]3, and 102[d]4 speak to the role of education in informed choice. The counselor role in this new system shifts from the traditional clinical to a more educational approach. If a consumer is to take ownership of their vocational goals, they need more than control of the money. They need to be equipped with information. For consumers who are not already skilled consumers, the counselor focus shifts to helping people learn to make better choices. Decision-making skills, problem solving and how to access resources within the community become a focus of the education relationship and constitute much of the current counselor in-service training. This education hopefully leads to better informed choice making which in turn could lead to increased ownership of the accomplishment (e.g. the job, the vocational plan). The consumer assumes more responsibility for making choices, choosing vendors, comparative shopping, and making important decisions as their skills increase. The counselor role then becomes one of assessing the consumer's ability to assume increasing amounts of responsibility for the accomplishment of their vocational goal. Counselors are taught that a continuum of consumer independence exists. The low end of the continuum is "Look what I (the counselor) have done for you. The mid-point is "look what we have done together. The ultimate goal is for the consumer to say, "look what I have accomplished!" This approach helps in setting and carrying out short term goals, making purchases, and making career choices. By ensuring that the customer is in charge, more personal responsibility for the process and real ownership in the outcome will likely occur. This approach is designed to assist in movement towards ownership. 3. Experiencing the Results of Informed Choice Once again, the Choice Project's composite definition led VR to consider another component of implementation of informed choice. That definition stated the need for consumers to "make decisions and follow through with decisions." It is the position of Vermont VR that unless consumers have the opportunity to practice ownership by implementing decisions they have made, they are really not able to learn and grow with their decisions. They have, therefore, attempted to remove all unnecessary barriers to people experiencing the results of their informed decisions. For example, consumers who need to purchase goods or services are able to experience the implications of their purchasing decisions by interviewing and choosing the vendor or provider based on their own criteria or their own individual needs and not just cost. They are then able to meet face-to-face with vendors or service providers to negotiate services, cost, terms etc., and thus take responsibility and experience the results of their decisions. This approach includes the consumer's ability to re-negotiate with service providers or vendors as necessary and even terminate the relationship if results are not satisfactory. In addition, VR has utilized a formal combined consumer, State Rehabilitation Advisory Council and staff analysis of all policies and procedures that govern its operation. The major question asked was "does this policy, procedure, or form enhance the ability of the consumer to experience the implications of their decisions or does it serve as a barrier to reaching goals? In addition to looking at the issue of consumer choice, the Division states a commitment "to streamline the process by which consumers are able to make informed decisions, experience the results of those decisions and take personal responsibility for achieving the desired employment outcomes." (CITE) 4. Accountability and Choice The State Vocational Rehabilitation Services Program Final Regulations effective March 13, 1997 contributed to the final piece of VR's implementation definition. It is stated here that VR programs shall "provide the individual or assist the individual in acquiring information regarding consumer satisfaction with relevant services to the extent that information is available." Vermont VR has further determined that the choice of vendors or service providers is only a small part of the philosophy of "informed choice." Consumer input is critical in informing VR how to better promote and ensure true ownership of both the rehabilitation process and the employment outcome. As a result of this strategic planning process, VR committed to the utilization of consumer evaluation as a basis for establishing overall program as well as staff performance standards and vendor and service provider report cards." (CITE) Further, VR has determined that consumer feedback will determine both consumer and staff training needs. The Vermont VR long-range strategic plan states that consumer feedback and evaluation will be used to: a.) identify systems barriers to ownership and b ) portray the only true picture of DVR effectiveness." (Vision 2000) DVR made a decision early on in the systems change process that the driving force behind any change had to be consumer satisfaction. Philosophically, a counselor no longer works to satisfy a supervisor first and a supervisor no longer works to serve the system first. All staff are trained, supported and rewarded for serving the consumer first. The stated philosophy is that "if staff can provide the necessary supports and resources, then individuals will experience success." Counting the number of people placed in employment only tells a small part of the story. Customer based evaluation is used to determine the degree of satisfaction with services and supports provided by the program. This information is then used to drive program change, staff training, and personnel performance evaluations. By having a system of consumer input, Vermont VR believes they can truly lay claim to being a consumer-directed organization and honoring the intent of "informed choice." Program Review Assistance Just as the Rehabilitation Services Administration attempted to provide states with guidance to evaluate their compliance, Vermont VR is in the process of developing its own internal guide based on the components of this functional definition of "informed choice". (see attached Self Assessment Guide) Summary Vermont's Division of Vocational Rehabilitation, utilizing the experience of its "learning laboratory" as well as the guidance provided by the increased clarity on "informed choice" contained in the regulations of March, 1997 and Section 102[d] of the 1998 Amendments have developed a functional working definition of Choice. They believe that informed choice can best be realized through an examination of ownership, education, experience and accountability in the context of public rehabilitation. It is their contention that the degree to which a program can be designed and implemented to ensure consumer ownership of accomplishments defines the degree to which that program can truly claim to be honoring the intent of the "informed choice" requirements of the Rehabilitation Act. Their strategic plan concludes with: "The Division of Vocational Rehabilitation is dedicated to serving its customers in a manner that enhances their choices and their success, creates an atmosphere of counselor-consumer teamwork, encourages active participation in the process and provides the basis for customer satisfaction in the results." Informed Choice: Self Assessment Guide: Assessing Implementation Efforts in State Vocational Rehabilitation Programs 12/99 Ownership: Who decides? 1 . How are individual employment goals determined? 2. What is the process for determining the need for supports and resources? 3. How are service needs addressed? a. How are vendors and service providers selected? b. How are actual services to be delivered and payment mechanisms determined? What is the negotiation process? c. How are services and goods paid for? (cash, voucher, agency authorization, contractual arrangement with agency) 4. Are there any agency policies or established procedures that affect the ability of an individual to make the necessary decisions to own the achievement of their employment goal? Education: How do people become informed? 1 . What staff training is provided on "informed choice"? Does it address traditional consumer skills such as negotiating in the marketplace and money management as well as problem-solving and decision-making procedures? 2. How are the training needs of staff determined and delivered? 3. What consumer training is available and provided to assist people to be better 4. What process is utilized to determine individual consumer need for additional information or education? 5. What supports are available to assist consumers to make better informed choices? 6. Are there any agency policies or established practices that affect the individual's ability to become better educated and better informed about necessary decisions that will affect their vocational rehabilitation? Experience: What does the consumer actually do? 1 . How are perspective vendors and service providers selected? What criteria is used? 2. Who negotiates cost with the providers/vendors? How and by whom is method of payment determined? e.g. hourly rate, fee-for-service, grant, etc.) 3. How is the vendor/ provider relationship terminated or re-negotiated if it becomes unsatisfactory? 4. Are there any agency policies or established practices that inhibit the individual's ability to experience the results of the informed decisions they have made? Accountability: What drives change? 1 . What is the process by which consumers provide input to the state agency? 1