Review of Employment Services for Individuals with Intellectual and Developmental Disabilities: A Comprehensive Review of the State-of-the-Field from 1996–2011
Suggested Citation: Gidugu, V. & Rogers, E. S. (2012). Review of Employment Services for Individuals with Intellectual and Developmental Disabilities: A Comprehensive Review of the State-of-the-Field from 1996–2011. Boston: Boston University, Sargent College, Center for Psychiatric Rehabilitation. http://www.bu.edu/drrk/research-syntheses/developmental-disabilities/employment-services/
Conducted by The Center for Psychiatric Rehabilitation with support from the National Institute on Disability and Rehabilitation Research (Grant # H133A05006)
Table of Contents
Summary of Findings
Review of Employment Services
Appendix A: Methodology & Definitions
E. Sally Rogers
940 Commonwealth Avenue West
Boston, MA 02215
Additional review and scientific consultation was received from Chas Moseley, Ed.D., and Rie Kennedy-Lizotte, BSSW MBA National Association of State Directors of Developmental Disability Services
For additional information, contact E. Sally Rogers at email@example.com.
Vocational services for individuals with intellectual and developmental disabilities (ID/DD) have been available for several decades. Legislative and policy initiatives stemming from the enactment of the Fair Labor Standards Act of 1937 which exempted sheltered workshops from minimum wage requirement helped to build the foundation for public support for the development and delivery of facility-based vocational services. Funding for vocational and employment services for individuals with ID/DD currently is furnished primarily through states’ Section 1915(c) Medicaid waiver programs. Job placement and other time limited supports are also offered through the state-federal vocational rehabilitation (VR) program. Waiver-funded employment services were at first only available to persons who had previously resided in an institution (ICF/MR). The Balanced Budget Act of 1997 permitted states to offer supported employment as an “extended habilitation service” to all persons funded under the state’s 1915(c) Medicaid waiver program including those without a prior history of institutionalization. The state-federal vocational rehabilitation program has funded vocational and employment services for persons with ID/DD since at least the early 1970s.
The purpose of this review of the literature was to examine the “state-of-the-science,” or “state-of-the-art,” in the delivery of vocational and employment services to individuals with intellectual and developmental disabilities with the goal of providing a comprehensive review of scientific and empirical literature regarding employment services.
This document is divided into two sections: the first section contains a bulleted list of key findings and conclusions and the second section contains summaries of the information we reviewed to draws the conclusions noted in the bulleted key findings. We began with a review of the history and legislation relevant to the delivery of employment services and then examined studies, documents, and reports as outlined in the summary below.
Summary and Key Highlights
I. Effectiveness of Employment Services
- No experimental or quasi-experimental studies of employment services or interventions for individuals with ID/DD were located in the literature. All studies were preliminary (by preliminary, we mean studied with research methods that cannot be considered robust or conclusive), and the data associated with the various models are described in the following Models of Vocational Services and Natural Supports section.
II. Trends in Delivery of Employment Services
- Early studies suggested that the percentage of 1915(c) Medicaid Home and Community-Based Services (HCBS) waiver participants receiving supported employment (SE) services was very low (West, Revell, Kregel, & Bricout, 1999).
- A very large unmet need for SE services in many states was documented by West and colleagues with many HCBS waiver participants are on waiting lists for SE (West et al., 1999; West et al., 2002).
- Participation in the waiver programs has had a profound effect on the development of residential services but far less of an impact on increasing employment services (West et al., 2002).
- West et al (1999) found that only 2.5% of HCBS Waiver participants across the nation were receiving waiver-reimbursed SE services. The single largest barrier to the utilization of waiver funding for SE was the requirement of prior institutionalization, which was reported by 90% of the states. Other major barriers included the requirement of having to be served first by VR (before waiver dollars could be accessed) or being found ineligible for VR services. In addition, West et al (999) reported that there not being enough providers to deliver SE services under the waiver.
- A survey conducted by West et al (2002) post the Balanced Budget Act of 1997 that removed the prior institutionalization requirement found an increase in waiver funded SE services from FY 1997 to FY 1999. Eighty percent of all states participated in this survey and the mean percentage of supported employment participants of HCBS waiver participants per state was 12.8 percent.
- Even after the removal of prior institutionalization requirement only 12% of known habilitation funding went toward SE services, with the remainder going to more segregated options (West et al., 2002).
- Analyses suggest large variations across states relative to the delivery of SE, with a high of 89 individuals per 100,000 receiving SE and a low of 1.1 in the lowest state receiving SE. The highest average hours worked was 36 hours, and 18 hours was the lowest (Rogan, Novak, Mank, & Martin, 2002).
- There are large variations across states in implementation of SE in rates of participation, populations served, costs, and supported employee outcomes (Butterworth, Smith, Hall, & Winsor, 2010; Rogan et al., 2002; Winsor & Smith, 2011).
- Based on longitudinal data that examined employment rates and positive coworker relationships, research suggests that SE providers may be improving their implementation of supported employment by ensuring that individuals with ID/DD are fitting in better in their workplace (Mank, Cioffi, & Yovanoff, 2003).
- There is wide variation in the delivery of state-federal VR program services in terms of length of time receiving VR services and expenditures per closure (Rogan et al., 2002).
- The growth in ID/DD funded agency day-work programs from 1988 to 2002 reflected a 58% increase in the number of segregated day program recipients from 236,614 individuals to 365,165 individuals (Braddock, Rizzolo, & Hemp, 2004).
- Between 1988 and 2000, supported employment exhibited rapid growth, increasing on average by 15% each year. However, that growth rate dropped to 3% between 2000 and 2002 (Braddock et al., 2004; Rusch & Braddock, 2004).
- Supported employment services received less than 20% of total day program funding in 2003 (Rusch & Braddock, 2004).
- Participation in facility-based employment and nonwork services has grown steadily over the years (Butterworth et al., 2010).
- The National Report on Employment Services and Outcomes (2010) demonstrated a decline in the estimated percentage of people served in integrated employment services from 23.7 percent in 1999 to 20.3 percent in 2009 (Butterworth, et. al.,, 2011).
- Evidence suggests that SE services are viewed as an add-on to employment services rather than a replacement for existing facility-based employment services (Butterworth et al., 2010; Butterworth et al., 2011).
- In 2003, federal support for segregated adult day programs (through Medicaid programs), including day habilitation and sheltered work, was four times the amount for SE programs (Butterworth et al., 2010, quoting data from Rusch & Braddock, 2004).
- There was a decline in the percentage of individuals served by integrated employment services from 25% in 2001 to 22% in 2008 (Butterworth et al., 2010).
- Of a total of 38,298 individuals with ID/DD served by Community Rehabilitation Providers (CRPs) nationally, 26% were counted as being in integrated employment (8% of whom were in enclaves and mobile work crews) (Butterworth et al., 2011; Metzel, Boeltzig, Butterworth, Sulewski, & Gilmore, 2007).
- Of a total of 38,298 individuals with ID/DD served by CRPs nationally, 74% were in sheltered employment, day habilitation, or nonwork community integration services (41% were in facility-based employment and 33% in nonwork services (Butterworth et al., 2011; Metzel et al., 2007).
- Nationally, only 20.3% of individuals receiving day supports from state ID/DD agencies participated in integrated employment services during fiscal year (FY) 2009 (Butterworth et al., 2011).
- Integrated employment has not changed substantially in 20 years (group employment declined and individual jobs increased slightly), although the role of nonwork services has grown (Metzel et al., 2007).
- The percentage of persons with ID/DD supported by state VR and ID/DD agencies through all state and federal funding was 21.9% in 2008 (Butterworth et al., 2010).
- More individuals continue to be supported in facility-based employment, typically earning subminimum wage, than in integrated employment (Butterworth et al., 2011).
- A total of 34% of the individuals were served in community-based nonwork in 2004, compared with 43% in 2009 (Winsor & Smith, 2011). After earlier declines, the percentage of individuals served in facility-based work and facility-based nonwork increased between FY 2008 and FY 2009 (Butterworth et al., 2011).
- The growth seen in SE between the mid-1980s and mid 1990s has not continued; the percentage of individuals receiving integrated employment services decreased from 21% in 2004 to 20% in FY 2009 (Butterworth et al., 2011; Winsor & Smith, 2011).
- Although the number of individuals with ID/DD increased by 22% from 1999 to 2009, the number of individuals receiving integrated employment services increased by 4.7%, and the percentage of individuals receiving integrated employment services declined from 23.7 % to 20.3% (Butterworth et al., 2011).
III. Trends in Employment Status and Outcomes
- Only 27% of the ID/DD population reported having a job in any given month compared with 75% of the general population (Yamaki & Fujiura, 2002).
- Supplemental Security Income (SSI) program participants worked significantly fewer hours and earned less than non-SSI recipients reporting a disability (Berry, 2000).
- Compared to those with other disabilities, individuals identifying themselves as having limitations due to mental retardation were younger, reported more disabilities, were less likely to be competitively employed, and were much more likely to work in segregated settings (Olney & Kennedy, 2001).
- Many more (50%) individuals with mental retardation were in noncompetitive employment (sheltered workshops and other segregated settings) than individuals with other disabilities who had received vocational services (4%) (Olney & Kennedy, 2001).
- State-level data in MD suggested that recipients of facility-based employment services work less and earn less than those served by community-based employment services (Conley, 2003).
- Of a total of 38,298 individuals with DD served by CRPs nationally, 26% were in integrated employment (which for this study includes enclaves and mobile work crews), 41% were in facility-based employment, and a total of 33% were in nonwork services (Butterworth et al., 2010; Metzel et al., 2007).
- In the state-federal VR program, time to closure and rates of closures in employment continue to be a problem, and there is significant variability across states (Butterworth et al., 2010; Butterworth et al., 2011).
- In the state-federal VR program weekly earnings and average hours worked in integrated employment at closure decreased slightly over the 2002–2009 period, whereas hourly earnings increased slightly (Butterworth et al., 2011).
- In the state-federal VR program, although weekly earnings in integrated employment increased, they continued to be substantially lower than those of the general population (Butterworth et al., 2010).
- In multiple studies, the average hours worked tended to hover around 20 hours per week, and wages earned approximated the minimum wage (Lemaire & Mallik, 2008; Mank et al., 2003) and include entry level jobs (Butterworth et al., 2011).
- Individuals placed in integrated employment earn more and work more hours than individuals in a mobile crew model (Keel, Mesibov, & Woods, 1997).
- In a large, national survey of individuals with developmental disabilities, approximately 27% reported being in community-based employment. Average hours worked per week was approximately 13–15 and wages earned per week was $78–$125, depending on whether it was individual or group supported employment or competitive employment (National Core Indicators, 2010).
- The percentage of individuals receiving integrated employment services decreased to 20.3% in FY 2009 (Butterworth et al., 2011).
- The percentage of individuals served in facility-based work and facility-based nonwork increased between FY 2008 and FY 2009 after declining prior to that (Butterworth et al., 2011).
- Low reimbursement rates in the HCBS Waiver program when compared with the VR reimbursement rates and caps on HCBS Waiver program reimbursements act as disincentives for community providers (West et al., 1999)
- SSA data show low numbers of individuals taking advantage of the work incentives available; individuals with ID/DD participate in these incentives less frequently than individuals with other disabilities (Butterworth et al., 2010; Butterworth et al., 2011).
- Workforce barriers to providing SE services include staff hiring and retention often due to low salaries for direct care workers. Barriers to employment for participants include: insufficient transportation, employment opportunities, insufficient resources to provide supports and work disincentives due to SSI/SSDI (Conley, 2001).
- Consumers, families and caregivers have a preference for employment outside workshops and that the degree of disability does not prevent individuals from performing in integrated employment based on comparing their findings with those of individuals in integrated employment (Migiliore, 2007).
- In a small sample of individuals with developmental disabilities and a secondary disability receiving the evidence-based supported employment and who lost their jobs, behavioral problems in the workplace, inattention or difficulty staying on task, and too much socialization were the most frequent reasons for job loss (Lemaire & Mallik, 2008).
- Administrative and programmatic barriers include staff turnover, funding issues, waiting lists, and low staff pay (Mank et al., 2003).
- Hours worked may be driven by systems issues because it takes more time and resources to find jobs that are more than part time. Personal disincentives such as loss of Social Security benefits are also an issue (Mank et al., 2003).
- Barriers to natural supports included negative attitudes from employers and coworkers, lack of expertise on the part of the employment specialist, and employers’ lack of time to engage in the supported employment process (Rogan, Banks, & Herbein, 2003).
- States vary widely in their commitment to integrated employment (Butterworth et al., 2011).
V. Predictors of Better Employment Outcomes
- Integrated employment may be related to adaptive skill acquisition; beneficial skills appear to be learned within integrative work settings and lost within segregated work settings (Stephens, Collins, & Dodder, 2005).
- Employment type does not appear to be related to challenging behaviors (Stephens et al., 2005).
- Consumers with severe/profound or moderate mental retardation were closed in competitive jobs at a significantly lower rate than those with mild mental retardation (Moore, Harley & Gamble, 2004).
- In a study of employment programs using natural supports, results indicated that the more typical the job, the more likely the job would pay well and positive social interaction would occur (Mank, Cioffi, & Yovanoff, 1997).
- Having less severe levels of disability corresponds to greater likelihood of being in community-based employment (National Core Indicators, 2010; Mank et al., 1997).
- Having less severe mental retardation is associated with higher social interaction and higher wages (Mank et al., 1997).
- Training of coworkers in working with individuals with DD was related to better outcomes for wages and integration in the workplace (Mank, Cioffi, & Yovanoff, 2000).
- The study results suggested that a job coach may negatively impact social interaction since interactions were minimal in their presence (Chadsey, Linneman, Rusch, and Cimera (1997).
VI. Findings Regarding Policy and Funding
- As long as rate and funding approaches are supported by clear policies, effective quality assurance mechanisms, and clear goals for employment outcomes, different approaches to funding can work. (Hall, Freeze, Butterworth, & Hoff, 2011).
- Consumers with DD served by the state federal VR program who received business and vocational training, counseling, and job-placement services were significantly more likely to achieve competitive jobs (Moore et al., 2004).
- The Best Buddies Jobs Program resulted in wages from 30% to as much as 50% higher in comparison to wages at the national level with pay levels of $7.00 an hour to $7.50 an hour across both sites. Hours worked per week exceeded the national average by approximately 15%. However, the authors did not have a comparable control group, so it is difficult to determine the extent to which these comparisons are valid (West et al., 2005).
- Students who participated in postsecondary education were more likely to work in competitive settings, to use no work-related supports, and to earn more, even though they worked fewer hours (Zafft, Hart, & Zimbrich, 2004).
- Individuals who graduated from an inclusionary vocational program fared better in terms of work outcomes (Luftig & Muthert, 2005).
- A consumer-directed family support program for individuals with DD appeared to result in individuals receiving higher wages over time (Heller, Miler, & Hsieh, 1999).
(Please note that all of the models presented here had only very preliminary data and the results should be considered very tentative.)
VIII. Cost Efficiency of Employment Services
- Studies from the 1990s showed that supported employment was a cost-efficient service (Cimera, 1998, 2000; Kregel, Wehman, Revell, Hill, & Cimera, 2000).
- By approximately the fourth year of operation of supported employment services, taxpayers experienced a positive net benefit (Cimera, 2000).
- Individuals with mild mental retardation are more cost-efficient than individuals with severe mental retardation (Cimera, 2000).
- Even after adjusting for the longer duration of services received by sheltered employees, supported employees were 64.5% more cost-effective (Cimera, 2007a, 2007b, 2008).
- The average supported employee used services with an accumulated cost of $8,212, compared with sheltered workers who used services costing $12,381 during the same period (Cimera, 2007a).
- Costs for supported employees were 33.7% less than the costs for individuals enrolled in sheltered workshops (Cimera, 2007a).
- Despite some initial concerns that the costs of delivering supported employment were increasing, data suggest they are not (Cimera, 2007c).
- Supported employees who received services from vocational rehabilitation agencies from 2002 to 2007 generated an average net monthly benefit to taxpayers of $133.10 and a benefit–cost ratio of 1.21 (Cimera, 2010).
- Benefit–cost ratios calculated for state federal VR services to individuals with DD were remarkably consistent from 2002 to 2007 (Cimera, 2010).
- The field should focus more on full-time work, greater variety in the types of jobs, investment in job development and job matching, and reduction of personal disincentives (Mank et al., 2003).
- The field should align federal, state, and local policies and practices that view employment as a viable and desirable outcome, e.g., “employment first” (Hall et al., 2011; Metzel et al., 2007; Wehman, 2006).
- The field should establish and measure employment as a key outcome, direct resources towards employment and away from other service models, value innovation, promote interagency collaboration, focus on employment benchmarks, invest in development of new leaders and a skilled workforce (Metzel et al., 2007).
- The field should identify and develop interventions for challenging behaviors in the workplace (Lemaire & Mallik, 2008).
- Assessment of job problems relative to deficient work skills, problems with motivation, etc., should be undertaken in order to develop appropriate interventions (Lemaire & Mallik, 2008).
- There should be a 5-year phase down of the Special Wage Certificate program to encourage the end of day program segregation and subminimum wages (Wehman, 2006).
- There should be a re-examination of the disincentives that accompany the SSI cash benefits (Wehman, 2006).
- Development of individualized service plans that focus on an employment or educational goal before graduation from high school should be undertaken (Wehman, 2006).
- States should develop policies and funding mechanisms that communicate the importance of work (Hall et al., 2011).
- There is a need for the field of supported employment to come to a consensus on the definition and operationalization of natural supports (Test & Wood, 1996).
- Research is needed to contribute to the development of more empirical evidence regarding the benefits of natural supports in supported employment (Storey & Certo, 1996; Test & Wood, 1996).
This review is focused on the employment experiences, services and outcomes of individuals with both intellectual and developmental disabilities. For this review, we examined research on both of these two groups since they are often combined in the services field. However, it should be noted that the definitions of intellectual and developmental disabilities are different. Developmental disability is defined as a severe, chronic disability that occurs because of a mental or physical impairment(s), before the age of 22 and that results in functional limitations in 3 or more major life areas (such as self-care, receptive and expressive language, learning, mobility, self-direction, capacity for independent living and economic self-sufficiency) while intellectual disability is defined as significantly sub-average intellectual functioning in addition to limitations in two or more life skill areas (NASDDDS, 2011).
Sheltered workshops were developed so that individuals with intellectual and development disabilities (ID/DD) could “work” in a structured environment where they typically performed simple, repetitive tasks and adjusted to a work-like setting. Over time, practitioners and researchers increasingly found that sheltered workshops did not build vocational skills for individuals with intellectual and developmental disabilities. In the early 1980s, integrated or supported models of employment that stressed integrated work, individual placements, and greater employer involvement began to gain traction (Mank et al., 2003). The rise of supported employment came about for several reasons: individuals with ID/DD were found to be able to work in such settings and to enjoy integrated employment more than sheltered work, and supported employment represented a clearer path to self-sufficiency and independence. Furthermore, studies found that supported employment is more monetarily beneficial for a range of stakeholders, including taxpayers and employers.
The 1991 Survey of Income and Program Participation estimated approximately 2.1 million adults (1.5% of the adult population in the United States) had an ID/DD in that year (Yamiki & Fujiura, 2002).
The purpose of this review of the literature is to examine the “state-of-the-science,” or “state-of-the-art,” in the delivery of vocational and employment services to individuals with intellectual and developmental disabilities with the goal of providing a comprehensive review of the scientific and empirical literature. We began with a review of the history and legislation relevant to the delivery of employment services, and then examined trends in services delivered, employment status and outcomes, studies of the effectiveness of services delivered, models of services delivered, and best practices in employment services.
Appendix A describes the methodology used and definitions of the terms used to discuss vocational services and outcomes for individuals with intellectual disabilities.
A confluence of trends during the past few decades has intensified focus on the role of employment in the lives of individuals with ID/DD. As suggested by Olney and Kennedy (2001), individuals with developmental disabilities were historically isolated in their family’s homes or in various types of institutions, both public and private. Beginning in the late 1960s, there was a focus on deinstitutionalization, a corresponding increase in the funding of community-based services, and a focus on community-based living for individuals with intellectual and developmental disabilities. Special education services were dramatically expanded and mainstreamed, and facility-based workshops and day services expanded dramatically. Federal Medicaid spending (apart from the Federal-State vocational rehabilitation program) for “supported employment” services designed to promote integrated, competitive employment rose substantially from zero funding in 1997 to $108 million in 2002 (Migliore, Grossi, Mank, & Rogan, 2008). Although numerous monographs and documents have been compiled in the past decade to examine the community living and employment status of individuals with ID/DD (e.g., Braddock et al., 2011; Butterworth et al., 2011; National Core Indicators, 2010) we determined a need for a comprehensive examination of the empirical literature related to services delivered and outcomes achieved relative to the employment of individuals with ID/DD. The purpose of this review is to address that need.
The studies reviewed here cover the employment status of those with intellectual and developmental disabilities across differing degrees of disability and span varying periods. These individuals have primarily been served by special education systems, state mental retardation and developmental disability agencies, and state agencies of the Federal Vocational Rehabilitation Program. We focused on the period of 1996–2011 for our review of the scientific literature, expecting that a 15-year period would be sufficient to describe trends and the current state of the field. We conducted this review as a collaborative effort with the National Association of State Directors of Developmental Disabilities Services (NASDDDS).
Demographics of the ID/DD Population
A collaborative effort of NASDDDS and the Human Services Research Institute (HSRI), the National Core Indicators Program (NCI), has developed a set of approximately 100 performance indicators organized across five broad domains with the aim of standardizing and improving the quality of ID/DD services across states. Started in 1997, NCI had 25 states and four substate entities participating in 2008–2009. To collect quantitative data, NCI administers an Adult Consumer Survey from which demographic data are culled. In its last analysis, the NCI provides a glimpse of the overall demographics of the ID/DD populations based on nearly 12,000 individuals in 20 states. They found that among individuals served by state ID/DD agencies, 57% were female, and the average age was 43.5 years. Approximately 38% of individuals live on their own or in a relative’s home, and 26% reside in group homes (National Core Indicators, 2010). Most were unmarried. In terms of level of disability, 32% had mild intellectual impairment, 24% moderate impairment, and 14% severe impairment.
At the national level, an analysis of longitudinal data from the federally mandated Rehabilitation Services Administration (RSA) Case Service Report (also known as the RSA-911), an annual compilation of data submitted by state vocational rehabilitation agencies, revealed that 56% of individuals with ID/DD served by state VR agencies between 1995 and 2005 were male, and that the average age at application was 27 years (Migliore & Butterworth, 2008). This sample of individuals with ID/DD does appear to be demographically different from the NCI sample. Another national analysis of the RSA-911 data found that those receiving vocational services tend to be younger and have received more formal schooling than individuals who do not receive VR services (Olney & Kennedy, 2001). Compared to the national population, African Americans have been reported to be overrepresented in the ranks of those with ID/DD, and Caucasians are underrepresented (Yamiki & Fujiura, 2002).
National analysis of RSA-911 data (collected on individuals served by the state divisions of vocational rehabilitation) reported that 84% of those with ID/DD had mental retardation as their primary disability, 7% had epilepsy, 7% had cerebral palsy, and 3% had autism spectrum disorders (Migliore & Butterworth, 2008). In addition, secondary disabilities were common, although the reported extent of their prevalence depended on the data source. For example, a separate national study using RSA-911 data found that approximately 45% of individuals with ID/DD receiving VR services had a secondary disability (Cimera, 2009). The National Core Indicators Project data (collected on a broader sample of individuals with developmental disabilities nationwide; National Core Indicators, 2010) found that 30.6% of the nearly 12,000 individuals surveyed had a secondary diagnosis, and 12.6 % of those surveyed did not report a second. In the same study, the highest proportion of those with a secondary condition (36%) had a psychiatric condition (National Core Indicators, 2010).
National studies of employment data reveal that individuals with all disabilities and with intellectual and developmental disabilities tend to be unemployed in greater numbers than the general workforce. For example, according to a current population survey, 70% of people without disabilities are working and only 28% of those with a disability are employed (Butterworth et al., 2011).
Federal policies related to work and employment services for individuals with intellectual and developmental disabilities have evolved over the past several decades. Numerous legislative initiatives have been important drivers in the development and delivery of employment services to individuals with ID/DD. The Rehabilitation Act of 1973 and its successive amendments mandate equal opportunity for individuals with disabilities and nondiscrimination in the workplace (Rogan et al., 2002). In 1986 the Act was amended to include supported employment as an acceptable state-federal VR outcome, and SE was targeted for individuals with severe limitations who needed intensive and ongoing support in order to be employed. Amendments to the Act in 1986 resulted in grants for system change and establishment of model supported employment programs in virtually every state (Rausch & Braddock, 2004). Six years later, the 1992 Rehabilitation Act amendments focused on economic self-sufficiency, independence and inclusion, and increasing access to services, and they reemphasized the importance of integrated community-based employment. They also introduced the notion of “presumption of benefit”—referring to the fact that all individuals with disabilities are presumed to be able to benefit from VR in terms of employment. Consumer self-determination and involvement were also highlighted in the 1992 Rehabilitation Act amendments.
In 1998, further amendments to the Rehabilitation Act as part of the Workforce Investment Act of 1998 were designed to promote a unified state workforce investment system that connected VR with mainstream employment services. State vocational rehabilitation agencies are mandated by legislation to provide rehabilitation, placement, on-the-job support, and maintenance services to individuals with intellectual disabilities. Some authors have suggested that serving individuals with ID/DD requires a scope of services (e.g., on-the-job training and long-term supports) that differs from what is typically provided to individuals with other disabilities (Olney & Kennedy, 2001). Informed choice in selecting vocational goals was emphasized in this legislation, and individuals receiving SSI or Social Security Disability Insurance (SSDI) were presumed eligible for VR services. Further emphasis was placed on vocational services for those with the most significant disabilities. The Act also required that federal contracts be granted with preference given to those businesses employing workers with disabilities (Migliore, Mank, Grossi, & Rogan, 2007). All of these initiatives have served to push forward the agenda of community-based and integrated employment for individuals with disabilities.
Other significant legislation that has affected the employment status of individuals with ID/DD includes the Medicaid Home and Community-based Waiver Program [HCBS Section 1915 (c)] authorized by the 1981 amendments to the Social Security Act, which was important in light of the deinstitutionalization of individuals with ID/DD occurring at that time. This legislation enabled states to use Medicaid funds to provide community-based care, in-home care, and residential and vocational services to individuals with disabilities who would otherwise need care in a nursing facility care or an intermediate care facility for the mentally retarded (ICF/MR). The HCBS Waiver Program was a growing long-term care program (Lakin, Prouty, Smith, & Braddock, 1995) and had an important influence on the development and funding of day and habilitation services for individuals with ID/DD. Amendments to the Balanced Budget Act of 1997 allowed these funds to be used for individuals who had never been institutionalized. In terms of employment it should be noted that the state-federal VR program, as authorized under the Rehabilitation Act, funds only time-limited training and adjustment services, but the HCBS Waiver Program can fund both initial training and adjustment services, as well as ongoing support.
The 1984 Developmental Disabilities Act Amendments set employment services as a priority area (Rusch & Hughes, 1990) and, beginning in 2001, the RSA disallowed sheltered workshop (i.e., facility-based) employment as a viable employment status and instead began categorizing it as preparation for employment (Migliore et al., 2007).
The Americans with Disabilities Act of 1990 provided legal protections for adults with disabilities in the workforce or seeking to enter the workforce by protecting them from discrimination if they are able to perform the essential functions of a job with or without reasonable accommodations. In 1999, the Supreme Court decision in Olmstead v. L. C. confirmed that integrated employment was the preferred employment outcome for those with ID/DD. The Work Incentive Improvement Act of 1991 allowed SSI/SSDI recipients to retain health insurance benefits while working through the Medicaid Buy-in Program. At a policy level, President George W. Bush’s New Freedom Initiative emphasized the need for individuals with disabilities to participate fully in community life, including employment.
As reported by Migiliore and colleagues (2008), states have signaled their intention to move toward integrated and community-based employment by instituting policies to that effect and then by discontinuing the flow of new funding toward workshops and facility-based employment services, however not all states have accomplished this goal. The Americans with Disabilities Act—and other related legislation—has attempted to increase the number of individuals with ID/DD engaged in integrated employment and, to some extent, the data and accountability systems have followed. For example the RSA-911, the dataset maintained by the Rehabilitation Services Administration (RSA), tracks employment outcomes for those assisted by state vocational rehabilitation agencies.
In 2002, the U.S. Department of Labor, Office of Disability Employment Policy, provided funds to support a national Training Technical Assistance project designed to help community rehabilitation providers facilitate integrated or “customized employment” outcomes for individuals with ID/DD. Customized employment was defined as a process for individualizing the employment relationship between an employee and an employer in ways that meet the needs of both. Customized employment can be thought of as a type of supported and integrated employment that is individualized and based upon the strengths and interests of the person with a disability and the needs of the employer or the self-employment business chosen by the job seeker (Butterworth, Gandolfo, Revell, & Inge, 2007).
However, despite legislative and policy changes in some states , a significant movement away from facility-based services and towards integrated employment has not continued at the pace predicted or observed in the late 1980s and 1990s (Inge et al., 2009; Rusch & Braddock, 2004). This is particularly true for those with more severe intellectual disabilities, for whom growth in supported employment placements over the years has progressed at approximately the same pace as the growth of segregated program placements. In general, the competitive employment rate of young adults with ID/DD has been stagnant since the early 1980s and, beginning around 2000, the integrated employment movement appeared to have lost much of its momentum (Rusch & Braddock, 2004).
One of the reasons for this stagnation is the emergence of a “dual system” of services for those with ID/DD: a supported employment system for those with mild intellectual disabilities and a segregated system (workshop employment and adult day care) for those whose disabilities are more severe (Rusch & Braddock, 2004, citing McGaughey et al., 1995, p. 270). Advocates of sheltered workshop employment believe that this segregated model serves a population unable to work in an integrated setting, and that the definition of successful employment should not disregard the value of sheltered workshops. Adult day programs (also known as community rehabilitation providers [CRPs] or activity centers) have, according to some data sources, received approximately four times more federal funding than supported employment programs (Butterwoth et al., 2010) and continue to grow in the face of opposing legislation and court cases.
Along with the persistence of sheltered workshop employment, several other factors have impeded a more robust growth of supported employment. Some are economic. For example, a high unemployment rate in the general population accounts for 48% of the variance in the competitive employment rate of individuals with intellectual disabilities (Migliore & Butterworth, 2008). Other systemic barriers also limit the growth of integrated employment, including the lower levels of postsecondary education for this population and misperceptions that sheltered workshop employment is more efficient for getting individuals with ID/DD to work (Zafft, Hart, and Zimbrich, 2004). Finally, individual-level barriers influence the likelihood and success of supported employment, including gender, transportation, the severity of an individual’s disability, and his or her age and education level (Moore, et al 2004; Mank, Cioffi, & Yovanoff, 1997; DHHS, 1999; Lemaire & Malik, 2008).
Furthermore, if those with intellectual disabilities achieve stable, integrated (or any type of) employment, they often face a new set of challenges. The ultimate hope of employment for those with intellectual disabilities, as established by the Rehabilitation Act of 1973 (and as amended in 1992), is financial self-sufficiency. However, such self-sufficiency is difficult to achieve given the earnings reality—one study placed earnings for this population at essentially half the income of the general population (Yamiki & Fujiura, 2002). The average weekly earnings of those with intellectual disabilities were approximately $200 in 2005, and this figure has been essentially stagnant since 1995. These earnings figures put individuals with ID/DD at or close to the poverty level for single adults under 65 years old, making financial self-sufficiency highly unlikely, if not completely impossible.
Outcomes from Vocational Services
No experimental or quasi-experimental studies of the efficacy or effectiveness of employment services, specific interventions or employment models for individuals with ID/DD were located in the literature. All studies were preliminary (by preliminary, we mean studied with research methods that cannot be considered robust or conclusive), and the data associated with the various models are described in the following Models of Vocational Services and Natural Supports section. The studies that were located suggest benefits from vocational services for people with ID/DD. Individuals who receive services are twice as likely to achieve competitive jobs as those who do not (Moore, Harley, & Gamble, 2004). Furthermore, those using supported employment services realized increases (albeit marginal) in their wages over time (from $102 per week in 1990 to $114 per week in 1995); those with ID/DD who did not use supported employment services realized a 40% decrease in real dollar wages in the same period (Yamiki & Fujiura, 2002, citing Wehman et al., 1998).
Even with assistance, obtaining a job is not guaranteed. Typically in the state-federal VR system an employment “closure” is achieved if an individual reaches his or her 90th day of employment. The closure level remained fairly constant between 1995 and 2005. Although it technically dropped from 64% to 52% in 2001, this was largely a result of disallowing supported employment as a viable employment outcome in that year. Interestingly, however, the number of employment closures in supported employment did not significantly rise after that disallowance (Migliore & Butterworth, 2008).
When an applicant does start work in an integrated setting, he or she may become more connected to social supports and government subsidies (Cimera, 2010). Many cost-benefit analyses assumed that when individuals are working they tend to rely less on income subsidies. However, examination showed that supported employees received $24.55 more a month in social support payments such as SSI or SSDI than they had prior to employment (Cimera, 2010). Furthermore, this was not a one-time observance; indeed, the average receipt of public benefits increased each year between 2002 and 2007.
Although the body of research on employment supports for people with intellectual disabilities has not included experimental studies, many researchers have tackled various dimensions of the issue. A summary of existing literature on employment programs and services for people with ID/DD follows.
Trends in Delivery of Employment Services
Participation in facility-based employment and nonwork services has grown steadily over the years (Butterworth et al., 2010). However, federal support of segregated adult day programs, including day habilitation and sheltered work, continues to be at four times the amount of support for SE programs (Butterworth et al., 2010; Rusch & Braddock, 2004). Most of the growth in ID/DD funded agency day-work programs from 1988 to 2002 was due to a 58% increase in the number of segregated day program recipients from 236,614 individuals to 365,165 individuals (Braddock et al., 2004).
As noted above, Home and Community-based Services Waivers have been an important source of funding for employment services and supports in states, although the overall percentage of HCBS Waiver participants who are receiving SE services has been low in the past (West et al., 1999). Although 50% of individuals participating in the HCBS Waiver are eligible for SE, approximately 10 years ago only about 3% of them were receiving SE services (West et al., 2002). This has led some authors to conclude that the waiver programs have had a profound effect on development of residential services but far less of an impact on increasing employment services (West et al., 2002).
Between 1988 and 2000, supported employment exhibited rapid growth, but that growth rate dropped between 2000 and 2002 (Braddock et al., 2004; Rusch & Braddock, 2004). Supported employment may be at a disadvantage with more funds going to day and habitation programs than SE ($488 million in 2000 versus $108 million in 2002, according to Rusch & Braddock, 2004). Examined another way, approximately 10 years ago only 12% of known habilitation funding went toward SE services, with the remainder going to more segregated options (West et al., 2002). The growth seen in SE between the mid-1980s and mid 1990s has not continued; 21% of individuals served were receiving integrated employment services nationally in 2004, compared with 20% in 2009, and a total of 34% of individuals were served in community-based, nonwork settings in 2004, compared with 43% in 2009 (Winsor & Smith, 2011).
In general, integrated employment has not changed substantially in 20 years (group employment declined and individual jobs increased slightly), although the role of nonwork services has grown (Metzel et al., 2007). One set of analyses reported a decline in the percentage of individuals served by integrated employment services from 25% in 2001 to 22% in 2008 (Butterworth et al., 2010).
The 2009 StateData report by the Institute for Community Inclusion documented wide variations in terms of commitment to integrated employment across states. Although progress has been made in some states, the StateData report notes that more individuals continue to work in segregated employment environments than in integrated employment settings. With 39 states and the District of Columbia reporting in FY 2008, the five states that had the highest percentages of people with intellectual and developmental disabilities in integrated employment settings were: Washington (87.5%), Connecticut and Oklahoma (both 55%), New Hampshire (46%), and New Mexico (43.5%). The five states with the lowest integrated employment rates were: Alabama (4.5%), Arkansas and Idaho (both 5%), Mississippi (6.5%) and Missouri (7.5%). Two states reported having more than 90% of individuals served in combined facility-based settings: Alabama and Arkansas (both 95%).
Older studies documented large unmet need for SE services in many states and, as noted earlier, that many HCBS Waiver participants are on waiting lists for SE (West et al., 1999; West et al., 2002). Other analyses suggest variations across states relative to the delivery of SE with a high of 89 individuals per 100,000 receiving SE in a state deemed “high functioning” versus a rate of 1.1 in the lowest functioning state. Average hours worked was 36 hours in the high functioning state and 18 hours in the low functioning state (Rogan et al., 2002). Overall, several researchers have concluded that there are large variations across states in implementation of SE, in rates of participation, populations served, costs, and SE outcomes (Butterworth et al., 2010; Rogan et al., 2002; Winsor & Smith, 2011). Examined from another perspective, of a total of 38,298 individuals with ID/DD served by CRPs nationally, 26% were counted as being in integrated employment (which for this study includes enclaves and mobile work crews), 41% were in facility-based employment, and a total of 33% were in nonwork services (Metzel et al., 2007).
There is wide variation in the delivery of state-federal VR program services in terms of length of time receiving VR services and expenditures per closure (Rogan et al., 2002). These data have led experts to conclude that SE services may be viewed as an add-on to employment services rather than a replacement for existing facility-based employment services (Butterworth et al., 2010).
To summarize issues in delivery of employment services for individuals with ID/DD, the following trends seem evident:
- The initial growth seen in development of supported and integrated employment options has not continued.
- There is a wide variation in the delivery of state-federal VR services to individuals with ID/DD in terms of availability of integrated employment and other matters of quality.
- Segregated, facility-based, and nonwork options continue to grow. (See Appendix B for an in-depth description of trends in employment services.)
Trends in Employment Status and Outcomes
Studies of employment status and outcomes over the past two decades have revealed that people with intellectual or developmental disabilities are less likely to be working than people without disabilities and, when employed, are likely to earn less than individuals without a disability or having a different type of disability. A 2002 study found that approximately 27% of the ID/DD population reported having a job in any given month, compared with 75% of the general population (Yamaki & Fujiura, 2002). Compared to those with other types of disabilities, individuals identifying themselves as having limitations due to mental retardation were less likely to be competitively employed and were much more likely to work in segregated settings (Olney & Kennedy, 2001). In multiple studies, the average hours worked tended to hover around 20 hours per week, and wages earned approximated the minimum wage (Lemaire & Mallik, 2008; Mank et al., 2003). Additionally, one study found that SSI participants worked significantly fewer hours and earned less than non-SSI recipients reporting a disability (Berry, 2000).
As noted in the previous section, a survey of more than 38,000 individuals with ID/DD being served in community rehabilitation programs suggested that 67% were engaged in work-related activities. However, of those only 26% were in integrated community-based employment (which includes enclaves and mobile work crews) although 41% were in facility-based employment and 33% were receiving nonwork services (Butterworth et al., 2010; Metzel et al., 2007). In the most recent NCI survey (reflecting 2008–2009 data), 7,718 respondents answered the question of whether they had jobs in the community (i.e., integrated employment), and 26.8% of those respondents stated “yes’”
For those with ID/DD who had an express vocational goal of supported employment, 42% did not obtain this employment by the time their cases were closed in the state-federal VR system (Cimera, 2008). This does not necessarily mean that unsuccessful applicants were unattractive to employers or otherwise unemployable: the percentage of individuals leaving the program without supported employment, who later found an integrated position, is significant and in studies has ranged between 28% (Dean et al., 2002) and 37% (Hayward & Schmidt-Davis, 2003).
It should be noted that many integrated employment closures may not be new outcomes: in 2005, 16% of individuals placed in integrated employment already held that type of position at the time of application to the state-federal program (Cimera, 2008). In other words, a significant proportion of individuals that counselors helped to place in supported employment jobs were not unemployed or in sheltered workshop employment. Rather, they simply moved from one integrated employment position to another or were provided rehabilitation services to maintain a job.
Even with policy changes that have become increasingly more supportive of integrated employment, those with intellectual disabilities remain more likely to be placed in sheltered workshops than people with other types of disabilities. A national study found that, in 1995, almost 60% of adults with intellectual disabilities received sheltered workshop placements, compared with only 5% of those with other disabilities who received vocational services (Olney & Kennedy, 2001). In 2005, 51% of all individuals with intellectual disabilities who sought supported employment were successfully “closed” in such a position by state VR (Migliore & Butterworth, 2008). Those with more severe intellectual disabilities were less likely to be placed in an integrated employment position. When examining the outcomes for those individuals served by state developmental disability agencies, which tend to serve those with more severe intellectual disabilities than the state-federal VR system, only 25% to 30% were placed in integrated employment (Rusch & Braddock, 2004). The remainder of these individuals (74% in 2005), one study estimates, is placed in sheltered workshops (Metzel et al., 2007).
This is not to say that the number of those with more severe intellectual disabilities in supported employment has not increased. Indeed, that figure grew from 23,000 in 1988 to 118,000 in 2002. Specifically, supported employment jumped from being a 9% share of all employment to a 19% share. Then, between 1994 and 2002, that number increased another 5%, to 24% of that population. Still, in 2002, the number of individuals with severe disabilities placed in day programs was the same as in sheltered workshops and supported employment combined. However, more positively, also in 2002, for the first time the number of individuals with severe intellectual disabilities placed in supported employment reached the same level as those placed in sheltered workshop placements (Rusch & Braddock, 2004).
Unfortunately, just 10% of individuals with ID/DD transitioned from sheltered workshops to supported employment in 1995, and that rate dropped to 2% by 2005 (Migliore & Butterworth, 2008). Although it is unclear what is driving this trend, it is not because these individuals are necessarily unable to work in integrated community-based employment. Indeed, studies have shown that this is a population that can make the transition successfully (Butterworth, Fesko, & Ma, 2000; Murphy, Rogan, Handley, Kincaid, & Royce-Davis, 2002). Studies suggest that the typical earnings of sheltered workshop employees are approximately $100 per week, or about half of the average earnings of an individual in supported employment. Using older data, this average did not appear to rise between the observed years of 1997 and 2002 (Rusch & Braddock, 2004).
Several studies have found that individuals in integrated or community employment work and earn more than those in facility-based employment. For example, one study reported that individuals placed in integrated employment earned more and worked more hours than individuals in a mobile crew model (Keel et al., 1997).
As noted earlier, a large, national survey of individuals with intellectual and developmental disabilities found that approximately 27% of those polled reported being in community-based employment. Average hours worked per week was approximately 13–15 hours and wages earned were $78–125 weekly, depending on whether it was individual or group supported employment, or competitive employment (NCI, 2010).
Although those in integrated employment earn more than individuals in community-based employment, earnings are still quite low. In 2008–2009, only 42.5% made at or above their state’s minimum hourly wage, and the average hourly wage was $6.25 (NCI, 2010). In 2005, using state VR data, Cimera (2008) found earnings for those in integrated employment averaging $200 per week. Another national study put the average earnings of workers with ID/DD in supported employment in the state VR system between the years of 2002 and 2006 at $176.87 per week, or slightly lower (Cimera, 2009). Again, the persistently low hours and part-time employment may be the reason for this stagnation in wages, although when interpreting these data the larger economic environment should also be taken into consideration.
When earnings for individuals with ID/DD are put into the context of the general population, the difference between the earnings of those with intellectual disabilities and the general population is large and appears to be growing. Specifically, in 1995, the average weekly earnings of the general population were $483; in 2005, that figure was $596 (Migliore & Butterworth, 2008). Looking at those with ID/DD in supported employment, their average weekly earnings in 1995 were $189. Over the years, this figure rose slightly, hitting a high of $207 in 2003, before decreasing to $200 in 2005. These earnings figures put the average individual working in a supported employment job at, or close to, the poverty level for a single adult less than 65 years old (Milgore & Butterworth, 2008).
Hours worked in supported employment using state VR data have remained relatively steady, with a slight decrease in recent years. In 2005, those in integrated employment worked 26.5 hours per week; this is a decrease from 1995 when that figure was 28.5 and the highest observed in a 10-year period (Cimera, 2008).
Although policy reforms that encourage increased support for individuals with disabilities who want to work have resulted in some progress, significant variability and problems still remain throughout the country. In the state-federal vocational rehabilitation programs, for example, time to closure and rates of closures in employment (as noted in the previous section) continue to be a problem, and there is significant variability across states (Butterworth et al., 2010). The weekly earnings in integrated employment for VR programs has increased, but it continues to be substantially lower than the weekly earnings of the general population (Butterworth et al., 2010). In summary, the following trends in employment status and outcomes have been noted-
- Individuals with ID/DD are less likely to be working than individuals with other disabilities and, when employed, earn less and work in more segregated settings.
- Data from various sources suggests that individuals with ID/DD tend to work part-time (about 20–25 hours per week) and to earn roughly the minimum wage.
- Job placements in integrated community-based employment are not the impediment to implementation of integrated employment.
See Appendix C for more detailed information on the studies that were reviewed for this section.
Types and Quality of Integrated Employment
The career prospects for those in supported employment have been, for the most part, limited. The most frequent jobs into which individuals are placed are custodial or food service occupations, followed by positions in retail and assembly/manufacturing (Mank et al., 2003; NCI, 2010). The least frequently held positions tend to be in human services and recycling. There has been no change in the general proportions of people with intellectual disabilities employed in various jobs over time, with the exception of the percentage for custodial jobs, which increased from 11% to 22% (Mank et al., 2003).
When asked about the type of employment they prefer, individuals with intellectual disabilities employed in a sheltered workshop report a preference for supported employment (Migliore et al, 2007). Of those in integrated positions, the overwhelming majority (92.6%) report liking their jobs (NCI, 2010). On the other hand, after individuals achieve the goal of integrated employment, there can be issues with job quality, which might reflect the entry-level, low-skill jobs into which they tend to be placed.
In addition to issues related to job quality or level, people with intellectual disabilities are disproportionately placed in short-term and temporary placements. In fact, of those who left their integrated employment situations, 43.8% reported doing so because it was a temporary position or they were laid off; 13.5% were terminated due to poor attendance, attitude, or work quality; and 12.5% left voluntarily because of stress, hours, location, or transportation problems (Lemaire & Malik, 2008). According to one study, the number of hours worked might be low among this population because of the personnel time and resources it takes to find jobs that are more than part time (Mank et al., 2003).
Job losses occur more often in frequently placed occupations, such as custodian, dishwasher or bus person, hostess or cashier, food preparation, and lawn maintenance (Mank et al., 2003; Olson et al., 2001; Yamiki & Fujiura, 2002). Given that a significant proportion of applicants are placed in these jobs, this means that many individuals with intellectual disabilities are frequently in transition between jobs, making it difficult to advance in the labor market. As an example of this, in 2008–2009 fewer than 28% of those in integrated employment positions had benefits associated with their position (NASDDDS, 2009).
Even with these challenges, those with intellectual disabilities have reported similar levels of satisfaction with their employment when compared with individuals with other disabilities, even when the types of jobs worked are often different (Olney & Kennedy, 2001).
Models of Vocational Services and Natural Supports
West, Wehman, and Wehman (2005) examined competitive employment outcomes for 49 individuals involved in the Best Buddies Jobs Program. Best Buddies Jobs uses a supported employment approach, which combines job placement assistance, training, and support at the work site, and job maintenance services delivered to the consumer, employer, coworkers, families, and others, as needed. Outcomes measured were earnings and fringe benefits, workforce participation, job retention, supports utilized, and employer and consumer satisfaction. The study reports that consumers enrolled in the Best Buddies Jobs programs consistently earned higher wages, received a greater share of benefits, and had higher rates of job retention in comparison to those in other supported employment programs serving this population. Hours worked per week exceeded the national average by approximately 15%; however, the authors did not have a comparable control group, so it is difficult to determine the extent to which these comparisons are valid. In addition, the authors provided statistics from the study on job retention levels: 93% of the Miami workers were still employed after 24 months, and 88% of the Los Angeles employees were still employed after 12 months, both exceptionally high figures when compared with national averages for this population.
Heller, Miler, and Hsieh (1999) examined the impact of a consumer-directed family support program for adults with developmental disabilities over a 4-year period. The sample included 78 caregiver respondents whose relative with a developmental disability was enrolled in the Home-Based Support Services Program (HBSSP) in Illinois, which was implemented in 1990. The control group included 146 caregiver respondents who cared for an adult with a developmental disability but who were not enrolled in the HBSSP program. Program participants had an increase in monthly wages from $14 to $212 over the 4 years and had higher wages than the control group ($212 vs. $110). Nearly half of the participants (45%) used the HBSSP funds for educational and vocational training, and they were significantly more likely to use educational and vocational services than the control group (62% vs. 33%). Despite these gains, nearly one third of the participants were not employed. Community integration increased significantly over time for the participants, but did not differ significantly between the participants and the control group at the follow-up.
Zafft, Hart, and Zimbrich (2004) describe the College Career Connection (CCC) study of youth with ID/DD, a model designed to assist students with significant intellectual disabilities to choose, gain admission to and successfully complete an inclusive post-secondary educational experience at a local community college. The target population was high school students. In this study they present findings of a matched cohort study of 40 students; 20 who participated in post-secondary education and 20 who did not. The authors concluded that participation in post-secondary education correlated positively with competitive and independent employment.
Similarly, Luftig and Muthert (2005) describe an inclusionary vocational/technical high school program for individuals with developmental disabilities. They followed 36 students, including 19 with mental retardation, for 3 years, on average, after they left the high school program. Among those students with mental retardation, 68% were working, and the average wage for the whole sample was $8.90 per hour, above minimum wage. The authors concluded that individuals who graduated from an inclusionary vocational program fared better in terms of work outcomes, although caution should be exercised because of the small sample size.
Mank, Cioffi, and Yovanoff (1997) conducted a study to examine the relationship between employment outcomes for individuals with developmental disabilities and natural support. They collected data for comparison with data on individuals without developmental disabilities in order to gain an understanding of unique employment conditions and features of individuals with developmental disabilities. Recruitment occurred across 14 employment programs and included participant surveys. Measures included a demographics sheet and a new measure that assessed how “typical” the job was for an individual with developmental disability in terms of job acquisition, hiring, compensation, work roles, orientation and training, and social aspects of the job. Results indicated that the more typical the job, the more likely the job would pay well and positive social interaction would occur. In addition, wages had a positive relationship with levels of interaction; less severe levels of mental retardation were more likely to correspond to higher social interaction and higher wages; higher levels of social interaction were related to typicalness of the job experience. In addition, higher levels of social interaction and wages were positively related to more typical employment status after accounting for developmental disability.
Mank, Cioffi, and Yovanoff (2000) extended their 1997 study, already described, to examine the possibility that higher levels of direct support (4 or more hours per week) are associated with lower rates of job “typicalness,” integration in the workplace, and lower wages. Participants were recruited from 13 vocational programs that used natural supports on the workplace. Results indicated that outcomes for wages and integration in the workplace increased with increased training of coworkers about how to work with individuals with developmental disabilities.
Test and Wood (1996) conducted a review of 15 studies of natural supports in the supported employment process for individuals with developmental disabilities. The authors suggest that natural supports in supported employment can be described as “supportive relationships on the worksites that assist individuals in completing work-related tasks and responsibilities.” A review of these studies highlighted the need for further research within this topic because of limited outcome measures and inconsistent definitions of natural supports. The studies reviewed were primarily descriptive, highlighting a need for more experimental study. In general, the studies reviewed suggested that natural supports were beneficial to facilitating the supported employment process, and that much research is needed to contribute to the development of more empirical evidence regarding the benefits of natural supports in supported employment.
Storey and Certo (1996) conducted a literature review of eight articles to examine the use of natural supports in the workplace to increase integration in the workplace for individuals with developmental disabilities. This review of literature of natural supports also found a range of definitions of natural supports. Based on the literature, the authors suggested the following definition of natural supports: “people who are not disability service providers but who provide assistance, feedback, contact, or companionship to enable people with disabilities to participate independently, or partially independently, in integrated employment settings or other community settings” (Storey & Certo, 1996, p. 2). The authors suggested that natural support research focus more closely on performance measures and quality improvement of this role. The authors concluded that more empirical validation of the value of natural supports in the workplace is needed.
Rogan, Banks, and Herbein (2003) carried out a qualitative study to examine how employment specialist roles and responsibilities have changed and how they operationalize natural support, as well as both effective strategies and barriers to implementing them. The authors used a participant observation methodology that included 39 work sites and 170 employees, employers, and supervisors. Findings indicated that employment specialists had different ideas about the nature and outcomes of natural support in the workplace, congruent with divergent definitions of natural support in the research literature. Results also indicated that job coach roles have changed in recent years from a human service approach to a business approach. Barriers to natural supports included negative attitudes from employers and coworkers, lack of expertise on the part of the employment specialist, and employers’ lack of time to engage in the supported employment process.
To summarize information on models and supports:
- We were unable to locate any study of vocational models of service delivery with strong research designs or adequate methodological controls.
- The Best Buddies model of SE, provision of family and caregiver supports, inclusionary secondary school experiences, and exposure to post-secondary education may hold promise for improving vocational outcomes for individuals with ID/DD.
- There is anecdotal evidence that natural supports in the workplace may improve employment outcomes; however this area of employment services is plagued by a lack of consensus about definitions of natural support, lack of research evidence, and a lack of training approaches to foster natural supports.
See Appendix D for detailed information about the studies reviewed for this section.
Barriers to Employment for People with Intellectual and Developmental Disabilities
Structural barriers to increased supported employment and self-sufficiency.
There are a number of systemic barriers to increased placements of those with intellectual disabilities into supported employment. Perhaps foremost is the way that the federal government and states fund supported employment services and programs. Although the funding picture in support of integrated employment has improved over time, growing from virtually zero in 1988 to $108 million in 2004, day programs enjoyed funding at four times the level of that for supported employment programs and, overall, supported employment received only 20% of the total day program funding, as noted earlier (Butterworth et al., 2010). Increases in adult day care enrollment since 1993 can be attributed to the fact that two Medicaid programs, HCBS and Clinic and Rehabilitative Services, underwrite these programs (Rusch & Braddock, 2004). An early study found that the HCBS Waiver Program’s low reimbursement rates when compared to the VR reimbursement rates and caps on HCBS Waiver program reimbursements might act as disincentives for community providers to provide supported integrated employment (West et al., 1999).
In 2001, Conley noted workforce barriers to providing SE services because of challenges in hiring and retaining staff due to low salaries for direct-care workers. A subsequent study found that other administrative and programmatic barriers include high staff turnover, funding issues, waiting lists, and, again, low staff pay (Mank et al., 2003).
The economy might have affected the growth rate of supported employment as well. The unemployment rates experienced in the overall labor market have been found to negatively affect the likelihood of supported employment success for individuals with intellectual disabilities. Changes in the overall unemployment rate account for 48% of the variance in the competitive employment rate of individuals with intellectual disabilities (Migliore & Butterworth, 2008). A Government Accounting Office (GAO) study also found that one third of the variations in competitive employment outcomes across states were the result of differences in the states’ employment rates and per capita incomes (Migliore & Butterworth, 2008, citing GAO, 2007). However, economic conditions cannot fully explain stagnation in the growth of supported employment. The most recent studies of employment outcomes observed the years between the late 1990s and the mid-2000s, which was largely a time of economic growth for the United States. However, the employment rate of those with intellectual disabilities did not enjoy a similar rise.
Another barrier to improved employment outcomes is the difficulty this population has accessing post-secondary education. One of the primary reasons that those with intellectual disabilities tend to work low-skill, low-wage jobs with little growth potential is that they enter post-secondary education at much lower rates than the general population. Only 37% of those with intellectual disabilities continue with some type of education after high school, compared with 78% for other high school graduates (Zafft, Hart, & Zimbrich, 2004). Those with intellectual disabilities that do have higher levels of education tend to fare better in the vocational rehabilitation system—they are placed in integrated employment at higher rates than those with less education and, once placed, typically stay in those positions longer and earn higher wages (Cimera, 2008; Gilmore, Schuster, Zafft, & Hart 2001). Legislation such as the Individuals with Disabilities Education Act of 2004 (IDEA), as well as a multitude of other evolutions, have paved the way for those with intellectual disabilities to more easily access schooling after high school, and more young people are taking advantage of that opportunity (Zafft et al., 2004). Nevertheless, the percentage of those with intellectual disabilities that go on to post-secondary education stands at less than half the rate of high school graduates in the general population (Zafft et al., 2004).
The persistence of sheltered workshop employment—and the stagnation of integrated employment—can be blamed in part on the perception that workshop employment is more cost-effective. Although cost-efficiency studies have debunked that claim, it continues, perhaps because sheltered workshops allow those with intellectual disabilities to “get to work” (and for more hours) right away. This increases the perception of short-term efficiency. Supported employment, on the other hand, requires more up-front preparation and coordination with employers (Cimera, 2010). The amount of time that individuals waited from the time of application to the date of closure (if they even had a closure) in the VR state-federal system averaged 714 days (just about two years) in 2005. This number was 993 days if the applicant was a student. These gaps in employment pose a challenge to both the applicant and the system trying to help them become employed. Also, sheltered workshops may be more cost effective per hours worked because individuals do tend to work more hours in that arrangement than in integrated employment. Nevertheless, the constant supervision needed for all of those hours typically makes sheltered employment more expensive overall than supported employment (Cimera, 2007a, 2007b, 2008). In addition, over the years, sheltered workshop and day programs have simply become institutionalized in our society. Long-standing legacies of local support predate the supported employment movement by several decades and ensure the continuation of sheltered workshops and activity centers (Rusch & Braddock, 2004).
Another barrier to increasing the prevalence of supported employment may be the process for obtaining supported employment services through vocational rehabilitation. The “on-the-ground” personnel, in the form of employment counselors, can present a based on their interpretation of the Rehabilitation Act and clarity of goals for their clients. Positive outcomes are associated with personnel who interpret the Rehabilitation Act in a vigorous way—they have clear goals for their clients of self-sufficiency and for helping them obtain integrated employment (Migliore & Butterworth, 2008).
From an extensive and in-depth case study, Hall, Freeze, Butterworth, and Hoff (2011) concluded that: (a) states need to tie priorities to funding; (b) states need to use explicit values about outcomes and quality of services in the rate setting process; (c) interagency collaboration may help states to ease financial burdens for employment services, and (d) rate decisions and service definitions grounded in an employment goal and good leadership enable decision making and priority setting. Few of the states reviewed could point to incentives for integrated employment beyond a higher rate for employment services than for facility-based or nonwork services. Hall and colleagues concluded that funding must be goal focused—there is no one size fits all approach—and should include both increasing incentives and eliminating disincentives; funding must be connected to and consistent with larger systems strategies (e.g., training and evaluation initiatives) and should focus on the quality of direct support staff. Funding must be seamless in the transition from job development and stabilization services to longer term supports. That implies that any partnership between ID/DD and VR agencies must recognize the differences between the two systems in regard to funding, goals, and services rendered. The authors also concluded that states need to develop policies and funding mechanisms that communicate the importance of work. As long as rate and funding approaches are supported by clear policies, effective quality assurance mechanisms, and clear goals for employment outcomes, different approaches to funding can work. Examples of states mentioned in this study with such positive practices are Colorado, New Hampshire, and Washington (Hall, Butterworth, Winsor, Gilmore, & Metzel, 2007).
Many studies have documented the challenges of implementing supported employment and have cited national barriers and questions about the efficacy of existing strategies, some of the key ones have already been noted. However, as Rogan, Novak, Mank, and Martin (2002) point out, state level interpretations also greatly affect and determine the effectiveness of integrated employment implementation. Rogan and colleagues (2002) cite several factors that influence states’ ability to comply with federal mandates, including leadership, congruence of agency mission and priorities with the mandates, the nature of inter- and intra-agency communication, resource allocations and limitations, and competition among conflicting mandates.
An additional and important challenge to the integrated employment model is the workplace environment. Workplace barriers included negative attitudes from employers and coworkers, lack of expertise of the part of employment specialists, and employers’ lack of time to engage in the supported employment process (Rogan et al., 2003).
Individual-level barriers to receipt of employment services and increased self-sufficiency.
A number of individual-level barriers, both personal and environmental, diminish the likelihood that individuals with intellectual disabilities will be employed in an integrated, community-based setting.
First, although the RSA discontinued the practice of categorizing disabilities into levels ranging from mild to profound in 2001, those with more serious degrees of mental retardation are significantly less likely to receive vocational services than those with mild retardation (Moore et al., 2004). This raises the issue of “skimming”: counselors (and the larger systems within which they work) have historically, and continue to, define success as job placement (Cimera, 2007) and evidence suggests that those with less severe disabilities are easier to place. Although individuals may be classified as having the same primary condition, ID/DD, and degree of disability (most significant), there exists a range within that degree. It may be assumed for some individuals that only sheltered workshop services are suitable but others are regarded as capable of supported employment. Skimming has also been called “order of selection” and presents such a significant issue because of limited resources—federal and state budgetary constraints limit the number of people able to be served by vocational rehabilitation programs (Moore et al., 2004). Cursory judgments may be made when deciding which applicants to put forth for supported employment (Moore et al., 2004). Although dated, one study found that 93% of those in supported employment had mild or moderate developmental disabilities; only 7% had severe developmental disabilities (Mank, 1998). This lopsided proportion in favor of those with mild disabilities has been called a “promise deferred” for those with intellectual disabilities, as well as their families (Moore et al., 2004).
Diagnoses influence the likelihood of supported employment and a significant proportion (estimated at between 30% and 45%) of individuals with intellectual disabilities have a secondary diagnosis (NCI, 2010). Those with the label of “behavioral challenges” tend to have poorer employment outcomes (Mank et al., 2003). Also, studies are conflicted regarding whether secondary disabilities—the most prevalent of which are psychiatric disorders—factor into placement. Secondary disabilities were not found to be a factor in Lemaire and Malik’s study (2008) or in another study by Moore and colleagues (Moore, Feist-Price, & Alston, 2002). They were found to be a slight factor in the NCI analysis and were considered a factor by Rimmerman, Botuck, and Levy (1995). Although secondary disabilities may or may not factor into the likelihood of placement, they should not, from a cost standpoint, since those with secondary conditions have been found to have the same the cost efficiency as those with only one diagnosis (Cimera, 2010).
The latest NCI analysis (2010) found that where individuals lived (in terms of the setting) was associated with whether they held integrated employment. For instance, those living independently were the most likely to hold an integrated employment position (35.8%) and those living in an institutional setting were the least likely (13.2%). This association carried through to earnings. Those living independently earned the most ($6.68 per hour), on average, and those living in institutions made the least ($4.14 per hour). The study did not report on whether there was a correlation between the degree of disability and residential setting (and thus wages earned), although this is a very plausible explanation for this finding.
Individuals with intellectual disabilities, like those with any type of disability, are also cautious of increasing their hours and wages past the point where they may jeopardize their benefits (Mank et al., 2003). Analysis of the national Survey of Income and Program Participation data from 1991 found that more than 50% of all adults with intellectual disabilities were the recipients of income support, compared with 7% of the general population (Yamiki & Fujiura, 2002). Often, the funds received, particularly for young adults (ages 18–29) were less an income supplement than a primary source of income (Berry, 2000). Hours and wages may be kept low not only because of the challenges this population has with full-time employment, but also because of fear of risking the benefits upon which they rely. SSA data show low numbers of individuals taking advantage of the work incentives available, including those that may assist in retaining benefits; individuals with ID/DD participate in these incentives less frequently than individuals with other disabilities (Butterworth et al., 2010).
A study by Lemaire & Malik (2008) that focused solely on those with intellectual disabilities found that the odds for placement in integrated employment were about equal for men and women. Although individuals of white ethnicity constituted 64% of all integrated employment closures, neither ethnicity nor gender was found to be a barrier for placement, although gender may factor into placement and success in that placement over time. However, once placed, women worked significantly fewer hours and the duration of their employment was often shorter than men’s (Lemaire & Malik, 2008). Another study, focused on those with general disabilities found that, for those individuals who receive SSI, men have a 50% better chance of working than women (Berry, 2000).
Additional barriers to employment for participants were identified by Conley (2001) and included insufficient transportation, too few employment opportunities, and inadequate resources to provide supports. Conley also mentions work disincentives due to SSI/SSDI (Conley, 2001). In some instances, behavioral problems in the workplace, inattention or difficulty staying on task, and so forth prevented individuals with developmental disabilities from keeping their jobs in integrated settings (Lemaire & Mallik, 2008).
Predictors of Better Employment Outcomes
Our review of the literature found several factors that predict employment outcomes. Some of these factors are malleable and, unfortunately, some are fixed. For example, several studies found that less severe levels of disability correspond to a greater likelihood of being in community-based employment (NCI, 2010; Mank et al., 1997) and are associated with higher social interaction and higher wages (Mank et al., 1997). Consumers with severe/profound or moderate mental retardation were closed into competitive jobs at a significantly lower rate than those with mild mental retardation (Moore et al., 2004).
More encouraging, several studies noted that integrated employment might be related to adaptive skill acquisition; beneficial skills appear to be learned within integrative work settings and lost within segregated work settings (Stephens et al., 2005). In a study of employment programs using natural supports, results indicated that the more “typical” the job, the more likely the job would pay well and positive social interaction would occur (Mank et al., 1997). Training coworkers of individuals with ID/DD was related to better outcomes for wages and integration in the workplace (Mank et al., 2000). One study found that a job coach can negatively impact social interaction in the workplace because interactions with coworkers were minimal in their presence (Chadsey, Linneman, Rusch, & Cimera, 1997), although this relationship may be complex and warrant further study.
The Costs of Vocational and Employment Services
Discussions of the costs of vocational services frequently revolve around a comparison of supported employment costs versus workshop placement costs. The findings from these comparisons show that cumulative costs of supported employment are lower, making these services more cost-effective in the long term. Even after adjusting for the longer duration of services received by sheltered employees, supported employees were 64.5% more cost-effective (Cimera, 2007c). The average supported employee used services with an accumulated cost of $8,212, compared with sheltered workers who used services costing $12,381 for the same period (Cimera, 2007a). A Wisconsin study confirmed that the cumulative costs of supported employment were 33.7% less than costs of sheltered workshop workers (Cimera, 2007a).
The cost-effectiveness of supported employment of those with more severe intellectual disabilities in the state VR system may be even greater: over an employment cycle (the period between starting to receive services and exiting or stopping receipt of services) it was $6,619 for supported employees versus $19,388 for those in sheltered workshop placements (Cimera, 2007c). That Cimera study, although small, took into consideration cumulative costs incurred to support employees during an entire employment cycle and not just the upfront costs that tend to be higher with supported employment. It also only included employees defined as having “most significant” disabilities. Finally, this study made an adjustment that accounted for the fact that individuals tend to work more hours in sheltered employment placements; nevertheless, the cost efficiency numbers are better (64.5% more cost effective) for supported employment.
When compared to other recipients of state vocational rehabilitation services, those with intellectual disabilities incurred $233.36 in costs for each hour worked, and $37.31 for each dollar earned (Cimera, 2009). Those with secondary disabilities did not incur higher service costs (Cimera, 2008; Cimera, 2010). Examining education levels, those who attended—but did not complete high school—were among the mostly costly to serve when examining the cost for each eventual dollar earned. Conversely, those with post-secondary education required the most time from VR counselors “on the front end” but, once employed, worked more and had higher wages than those with less education, thereby decreasing their cost for each hour worked and dollar earned (Cimera 2008).
Although only a few studies of cost efficiency have been conducted, the findings are encouraging. Cost-efficiency studies have been defined as those that answer the question: Do the monetary benefits of a decision outweigh the resulting monetary costs? (Johnston, 1987). Studies from the 1990s suggested that supported employment was a cost-efficient service for states (Cimera, 1998, 2000; Kregel et al., 2000). By approximately the fourth year of operation of supported employment services, taxpayers experienced a positive net benefit (Cimera, 2000). Benefit–cost ratios calculated for state federal VR services to individuals with ID/DD were remarkably consistent from 2002 to 2007. In total, supported employees who received services from vocational rehabilitation agencies in 2002 to 2007 generated an average net monthly benefit to taxpayers of $133.10 and a benefit–cost ratio of 1.21. (Cimera, 2010).
Despite some initial concerns that the costs of delivering supported employment were increasing, Cimera (2009) in a study looking at supported employment costs across the United States between 2002 and 2006 found costs were not increasing. The average national cost of supported employment in 2006 was only 15.6% higher than it had been in 2002 ($4,688 vs. $4,054, respectively). Furthermore, when examined by cost per hour worked, costs only increased by 10.8% ($177 per hour in 2002, compared with $ 196 per hour in 2006). Finally, cost per wages earned remained relatively constant ($26.04 for each $1 earned in 2002, compared with $25.92 per $1 earned in 2006). However, the cost of providing supported employment services did vary significantly between—and even within—states (Cimera, 2010). Some states (nine of the 55 states and regions investigated) were not cost efficient in providing services to supported employees (Cimera, 2010).
Employers frequently regard their experience of hiring those with intellectual disabilities as a positive one and that hiring and training costs are minimal (Lemaire & Malik, 2008). Hiring individuals with intellectual disabilities was found to contribute to the goals, image, and diversity of organizations; the employees tend to have good attendance and longevity; and employers indicate that—if given the opportunity—they would hire them again (Lemaire & Malik, 2008). From a monetary standpoint, when hiring an individual with an intellectual disability, employers are likely to be eligible for a tax credit equivalent to 40% of the first $6,000 earned by that employee. However, employers rarely exercise their right to this credit (Cimera, 2010). It is unclear why that is the case, but it can be hypothesized that the process of applying for and receiving the credit may be, or may be perceived to be, too cumbersome.
Other Noteworthy Issues Related to Improving Employment Services
- The StateData report (Braddock et al., 2011) enumerated factors which can contribute to better integrated employment opportunities and outcomes for people with intellectual disabilities, including high performing ID/DD agencies, collaboration between those agencies and VR, improving the delivery of SE services within CRPs, and addressing individual and family factors.
- In addition, several states, including Vermont and Washington, have promoted person-centered approaches to employment and services.
- Several states have identified the period of transition between high school and adulthood as an opportunity for helping young people with intellectual disabilities transition directly into integrated employment environments (Rogan et al., 2002).
- As has been well observed in the general population, the education that those with intellectual disabilities receive prior to receipt of vocational services affects the success of those services. Specifically, an individual’s achievement of post-secondary education is positively correlated with rates of integrated employment (Zafft et al., 2004; Cimera, 2008). Also, targeted vocational programs that teach skills for a particular occupation have been shown to help participants achieve more skilled employment and earn more in the process (Luftig & Muthert, 2005).
- Several studies accumulated evidence suggesting the value of natural supports.
- High-performing states in integrated employment “generally have a clear and visible data collection systems that includes individual outcome data” (Hall et al., 2007). Unfortunately, most of the 37 states participating in the FY 2007 National Survey of Day and Employment Programs reported they use service funding records (i.e., the number receiving funding, by service). Only seven states reported that they collected data related to employment outcomes at the individual level.
- As noted earlier, the National Core Indicators Project began in 1997 to encourage members to develop a standard set of performance measures to manage quality and enable comparisons across states. Twenty-five states and four regions or counties currently participate in this indicators project.
- The data come from a combination of sources including survey and administrative data and can be used to promote quality improvement.
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Description of the Literature Search Process
We performed a search across several research databases using numerous employment related keywords. This process yielded a total of 37 reports and studies. We contacted experts in the field of employment services (e.g., Butterworth, Wehman, Mank, and Revell) to obtain suggestions about relevant reports and articles. We also searched the websites of key states to examine reports on the delivery of employment services. We notified state directors of ID/DD services to forward relevant reports to us for inclusion in this review. Lastly, the National Association of State Directors of Developmental Disabilities contacted 18 of their states that have made a special effort to develop supported employment services in an effort to solicit reports on employment services.
The terminology used to discuss vocational services and outcomes for individuals with intellectual disabilities may be new to some readers as it is rarely used in other contexts. Therefore, we have included a brief definitions section that details the terms used throughout the paper.
Sheltered or facility-based employment. This type of employment is also known as noncompetitive employment. Sheltered workshops are also referred to as workshops, industries, affirmative industries, and training or rehabilitation workshops. Sheltered workshops are facility-based day programs attended by adults with disabilities as an alternative to working in the open labor market (Migliore, 2011). The type of work performed is relatively simple, with tasks such as assembling, packing, woodworking, servicing, or sewing. Adults with disabilities are always subordinate to staff, are typically paid below minimum wage and placements are often long term. Goals may vary ranging from assessment and rehabilitation and transition to the general labor market. Individuals participate in workshops because it is assumed that the open competitive labor market is too challenging (Migliore et al., 2007).
Supported employment. This type of employment was defined in the Developmental Disabilities Act of 1984 (P.L. 98-527) as: (i) paid employment for persons with developmental disabilities for whom competitive employment at or above minimum wage is unlikely and who need ongoing support to perform in a work setting, (ii) is conducted in a variety of settings in which persons without disabilities are employed, and (iii) is supported by any activity needed to sustain paid work including supervision, training, and transportation (p. 2665). Supported employment services are those services that will lead to integrated, competitive employment.
Integrated employment. This type of employment can be defined as work in the general labor market where the proportion of workers with disabilities does not exceed the natural proportions in the community and where wages are at or above minimum wage. Depending on level of disability, individuals may need support finding jobs, training for the job, and retaining employment (Migliore et al., 2007).
Community rehabilitation providers (CRPs). These agencies are a major source of employment and day services for persons with ID/DD (Metzel et al., 2007). In 2005, there were more than 8,100 CRPs nationwide, and they are primarily supported with federal and state dollars. The services provided by CRPs can be categorized along two dimensions: purpose (work or nonwork) and setting (facility-based or community). CRPs facilitate both sheltered workshop and integrated employment placements.
Natural supports. This term describes workplace characteristics that help individuals with disabilities to have engaging and satisfying employment experiences, such as accepting and supportive coworkers (Storey, 2003).
Employment closure. When an individual with intellectual or developmental disabilities is served by the state-federal VR program, the ultimate goal of those services is placement in an integrated employment position. Should that individual achieve 90 days of continuous employment, this is considered an employment closure—a success for both the vocational system and the individual served. However, closure is considered extended past that date if recipients continue to receive services after the 90th day. Placement in a facility-based, nonintegrated employment situation is no longer considered a successful closure by the state-federal VR program.