J Occup Rehabil
DOI 10.1007/s10926-008-9154-z
Vocational Rehabilitation Services and Employment Outcomes
for People with Disabilities: A United States Study
Alo Dutta Æ Robert Gervey Æ Fong Chan Æ
Chih-Chin Chou Æ Nicole Ditchman
Ó Springer Science+Business Media, LLC 2008
Abstract Introduction This study examined the effect of
vocational rehabilitation services on employment outcomes
of people with sensory/communicative, physical, and
mental impairments in the United States. Methods The
sample frame includes 5,000 clients for each of the three
disability groups whose cases were closed as either rehabilitated or not rehabilitated by state vocational
rehabilitation agencies in the fiscal year 2005. The
dependent variable is employment outcome. The predictor
variables include a set of personal history variables and
vocational rehabilitation service variables. Results Sixtytwo percent of the clients in this study were gainfully
employed after receiving vocational rehabilitation services.
Individuals with sensory/communicative impairments had
the highest success rate (75%) compared to 56% for the
physical impairments group and 55% for those with mental
impairments. Logistic regression analyses identified job
placement, on-the-job support, maintenance, and other
services (e.g., medical care for acute conditions) as
significant predictors of employment success across all
impairment groups. In addition, diagnostic and treatment
(D&T) services (odds ratio [OR] = 1.57; 95% CI: 1.35–
1.82) and rehabilitation technology services (OR = 1.97,
95% CI: 1.67–2.33) were found to uniquely contribute to
employment outcomes for the sensory impairments group
as well as the physical impairments group (D&T services:
OR = 1.31, 95% CI: 1.15–1.48; RT services: OR = 1.41,
95% CI: 1.13–1.75), but not the mental impairments group.
Substantial counseling was associated with employment
outcomes for the physical (OR = 1.16, 95% CI: 1.02–1.32)
and mental impairments groups (OR = 1.18, 95% CI:
1.03–1.35). Miscellaneous training (OR = 1.31; 95% CI:
1.09–1.49) was specifically associated with employment
outcomes of the mental impairments group. Conclusion
This study provides some empirical support documenting
the association between vocational rehabilitation services
and employment outcomes of people with disabilities.
Keywords Vocational rehabilitation Employment Rehabilitation
A. Dutta (&)
Department of Rehabilitation and Disability Studies,
Southern University, 229 A. C. Blanks Hall,
Baton Rouge, LA 70813, USA
e-mail: [email protected]
R. Gervey F. Chan N. Ditchman
Department of Rehabilitation Psychology and Special Education,
University of Wisconsin, Madison, WI, USA
F. Chan
Stout Vocational Rehabilitation Institute, University
of Wisconsin, Stout, WI, USA
C.-C. Chou
Department of Special Education, Rehabilitation, and School
Psychology, University of Arizona, Tucson, AZ, USA
Introduction
Work is fundamental to the physical and psychological
well-being of people with and without disabilities [1].
Compared to persons who are employed, those who are
unemployed tend to experience a higher prevalence of
depression and anxiety disorders, use alcohol more frequently, and report lower scores on self esteem and quality
of life measures [2–10]. Recognizing the importance of
work, vocational rehabilitation professionals have consistently advocated for it as a fundamental human right of
people with disabilities [11]. Therefore, job placement of
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J Occup Rehabil
people with disabilities at the highest level possible has
been central to the mission of many vocational rehabilitation programs [12–14].
The United States state-federal rehabilitation service
program, which spends more than $2.5 billion annually,
plays a large and instrumental role in helping people with
disabilities obtain and retain employment [15]. The value
of state vocational rehabilitation services has been supported in the rehabilitation literature [16–22]. In general,
the employment rates of people with disabilities after
receiving vocational rehabilitation services are consistently
found to be around 60% [21, 22]. Employment outcomes
achieved by state vocational rehabilitation agencies remain
relatively constant among fiscal years, although considerable variance has been observed by disability type, with
persons with sensory/communicative impairments having
the best outcomes and people with mental impairments
having the poorest [22]. Job placement and on-the-job
support services appear to contribute most significantly to
employment outcomes [22], and manufacturing and service
jobs tend to be the most common job placement outcomes
[21].
Recently, the evidence-based practice (EBP) movement
in medicine has permeated and affected a wide array of
health care and social service disciplines, and the field of
vocational rehabilitation is no exception. The construct
EBP is increasingly shaping vocational rehabilitation
research and practice. For example, the United States
National Institute on Disability and Rehabilitation
Research (NIDRR) has, in recent years, underscored the
need for NIDRR-sponsored research studies to meet standards for inclusion in evidence-based systematic reviews.
The Rehabilitation Services Administration (RSA) of the
United States Department of Education is beginning to
emphasize vocational rehabilitation services that integrate
the best research evidence with clinical expertise and client
perspectives. Clearly, there are both internal and external
pressures for rehabilitation agencies to continue to demonstrate that vocational rehabilitation is an effective service
and that rehabilitation counselors are using an array of
evidence-based interventions in their practice or risk losing
funding and support. Bolton and colleagues [17] contend
that rehabilitation outcome research needs to focus on
answering the question: ‘‘Which approach works best for
whom, how, and under what condition?’’ Answering this
question will provide counselors with information regarding what personal factors and service provision patterns
have a high probability of predicting successful outcomes
for a specified group of clients.
However, little is known about what personal factors
and service patterns might contribute differentially to
enhance employment outcomes of disability subgroups.
For example, the state-federal vocational rehabilitation
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program classifies people with disabilities into three major
disability groups (sensory/communicative, physical, and
mental impairments). The purpose of this study is to
identify key factors associated with successful employment
outcomes for each group. Specifically, this study poses the
following research questions:
1.
2.
How do demographic variables and the provision of
cash or medical benefits relate to the employment
outcomes of people with disabilities receiving vocational rehabilitation services?
What rehabilitation services are directly related to the
employment outcomes of people with disabilities who
qualified for state vocational rehabilitation services?
Method
Participants
Data for this study were extracted from the United States
Department of Education, Rehabilitation Service Administration Case Service Report (Form 911) which contains
personal history, types of services, and employment outcome information on all clients receiving state vocational
rehabilitation services in the United States. This large
archival dataset is furnished annually to Rehabilitation
Service Administration by state vocational rehabilitation
agencies across the United States. The RSA makes available this dataset for rehabilitation researchers upon request.
The fiscal year (FY) 2005 RSA-911 data were used for the
analyses in this study because it was the most current
dataset available at the time of this study. In FY 2005,
616,879 individuals exited the vocational rehabilitation
program. Specifically, 260,650 individuals exited the system without receiving vocational rehabilitation services for
reasons including: no disabling condition, unable to locate,
transferred, death, and disability too severe for services.
Additionally, 356,229 exited the system after receiving
vocational rehabilitation services, i.e., 206,695 (58%)
exited with employment and 149,534 (42%) exited without
employment.
The RSA-911 data grouped people with disabilities
broadly into three major disability groups: sensory/communicative (e.g., visual impairment/blindness and hearing
impairment/deafness), physical (e.g., arthritis, spinal cord
injury), and mental impairments (e.g., depression, schizophrenia, and learning disabilities). In FY2005, 52,795
individuals with sensory/communicative impairments
(15%), 104,093 individuals with physical impairments
(29%), and 199,341 individuals with mental impairments
(56%) were closed as either successfully or unsuccessfully
rehabilitated. For the purpose of this study, a stratified
J Occup Rehabil
Table 1 Demographic characteristics of vocational rehabilitation
clients
Independent Variables
Variable
Three sets of predictor variables were used for this study:
demographic variables; work disincentive variables; and
VR service variables. Demographic variables included
gender (male and female), race (African American, Native
American, Asian American, European American (nonHispanic origin), and Hispanic/Latino), age, education
(special education, less than high school, high school
graduate, associate degree, and college degree), pre-service
employment status (employed vs. unemployed), and cooccurring disability (alcohol or other drug abuse [AODA],
depression). Disincentive variables included the number of
government benefits (supplemental security income [SSI],
social security disability insurance [SSDI], temporary
assistance for needy families [TANF], general assistance,
veterans’ disability benefits, workers’ compensation, and
medical insurance not through employment). Vocational
rehabilitation services variables included assessment,
diagnosis and treatment of impairments, vocational rehabilitation counseling and guidance, college or university
training, occupational/vocational training, occupational/
vocational training, on-the-job training, basic academic
remedial or literacy training, miscellaneous training, jobreadiness training, disability-related, augmentative skills
training, miscellaneous training, job search assistance, job
placement assistance, on-the-job supports, transportation
services, maintenance, rehabilitation technology, reader
services, interpreter services, personal attendant services,
technical assistance services, information and referral services, and other services. A description of these services is
presented in Table 2.
Sensory (%) Physical (%) Mental (%)
Gender
Men
49
53
56
Women
51
47
44
European American
72
(non-Hispanic) 72%
69
62
25
Race/Ethnicity
African American
16
19
Hispanic/Latino
9
10
9
Asian American
2
1
2
Native American
1
2
1
Education
Special education
2
2
13
22
21
35
Completed high school 39
43
32
Some post-secondary/
Associate’s degree
College degree or
higher
23
26
15
13
9
4
Less than high school
Co-occurring AODA
Yes
1
2
9
No
99
98
91
Yes
42
47
49
No
58
53
51
Work disincentives
random sample of 15,000 clients was selected (5,000 in
each impairment group) to study the association of vocational rehabilitation services on employment outcomes of
these three major disability groups. The demographic
characteristics of the sample are presented in Table 1.
Variables
Outcome Variable
The outcome variable used was competitive employment.
Competitive employment was defined in the RSA-911
manual as employment for at least 90 days in an integrated
setting, self-employment, or employment in a state-managed Business Enterprise Program (BEP) that is performed
on a full-time or part-time basis for which an individual is
compensated at or above the minimum wage (BEP refers to
vending facilities and small businesses operated by individuals with significant disabilities as well as home
industry that falls under the management of the state
vocational rehabilitation agency). Unsuccessful outcome
referred to clients who were not working after completing
their planned vocational rehabilitation program.
Data Analysis
Data extracted from the RSA-911 data were analyzed using
SPSS 13.0. Logistic regression analysis was used to
examine the association among demographic characteristics, provision of cash or medical benefits, VR service
patterns, and employment outcomes.
Results
Descriptive Statistics
There was significant age difference among the three major
disability groups, F (2, 14997) = 1048.60, P \ .001. Posthoc analysis using the Bonferroni procedure indicated that
clients
with
sensory/communicative
impairments
(M = 43.36 years, SD = 17.36) were significantly older
than clients with physical impairments (M = 39.28 years,
SD = 12.51) and clients with physical impairments were
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J Occup Rehabil
Table 2 Description of services provided by state VR agencies
Type of service
Description
Assessment
Services provided and activities performed to determine an individual’s eligibility for VR services, to
assign an individual to a priority category of a state VR agency that operates under an order of
selection, and/or to determine the nature and scope of VR services to be included in the individual plan
for employment (IPE); included in this category are trial work experiences and extended evaluation
Diagnosis and treatment
of impairments
Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy,
speech therapy, and drugs and supplies; this category includes diagnosis and treatment of mental and
emotional disorders
Vocational rehabilitation counseling Discrete therapeutic counseling and guidance services necessary for an individual to achieve an
and guidance
employment outcome, including personal adjustment counseling; counseling that addresses medical,
family, or social issues; vocational counseling; and any other form of counseling and guidance
necessary for an individual with a disability to achieve an employment outcome; this service is distinct
from the general counseling and guidance relationship that exists between the counselor and the
individual during the entire rehabilitation process
College or university training
Full-time or part-time academic training above the high school level that leads to a degree (associate,
baccalaureate, graduate, or professional), a certificate, or other recognized educational credential; such
training may be provided by a four-year college or university, community college, junior college, or
technical college
Occupational/vocational training
Occupational, vocational, or job skill training provided by a community college and/or a business,
vocational/trade, or technical school to prepare students for gainful employment in a recognized
occupation; this training does not lead to an academic degree or certification
On-the-job training
Training in specific job skills by a prospective employer; generally the individual is paid during this
training and will remain in the same or a similar job upon successful completion; this category
also includes apprenticeship training programs conducted or sponsored by an employer, a group
of employers, or a joint apprenticeship committee representing both employers and a union
Basic academic remedial or literacy Literacy training or training provided to remediate basic academic skills needed to function
training
on the job in the competitive labor market
Job readiness training
Training to prepare an individual for the world of work (e.g., appropriate work behaviors, methods for
getting to work on time, appropriate dress and grooming, methods for increasing productivity)
Disability-related, augmentative
skills training
Service includes, but is not limited to, orientation and mobility, rehabilitation teaching, training in the use
of low vision aids, Braille, speech reading, sign language, and cognitive training/retraining
Miscellaneous training
Any training not recorded in one of the other categories listed, including GED or high school training
leading to a diploma
Job search assistance
Job search activities that support and assist a consumer in searching for an appropriate job; may include
help in preparing resumes, identifying appropriate job opportunities, and developing interview skills,
and may include making contacts with companies on behalf of the consumer
Job placement assistance
A referral to a specific job resulting in an interview, whether or not the individual obtained the job
On-the-job supports
Support services provided to an individual who has been placed in employment in order to stabilize the
placement and enhance job retention; such services include job coaching, follow-up and follow-along,
and job retention services
Transportation services
Travel and related expenses necessary to enable an applicant or eligible individual to participate in a VR
service; includes adequate training in the use of public transportation vehicles and systems
Maintenance
Monetary support provided for expenses such as food, shelter, and clothing that are in excess of the
normal expenses of the individual and that are necessitated by the individual’s participation in an
assessment for determining eligibility and VR needs or that are incurred while an individual receives
services under an IPE
Rehabilitation technology
The systematic application of technologies, engineering methodologies, or scientific principles to meet the
needs of, and address the barriers confronted by, individuals with disabilities in areas that include
education, rehabilitation, employment, transportation, independent living, and recreation; includes
rehabilitation engineering services, assistive technology devices, and assistive technology services
Reader services
Services for individuals who cannot read print because of blindness or other disability; includes reading
aloud and transcribing printed information into Braille or sound recordings if requested by the
individual; generally are offered to individuals who are blind or deaf-blind but may also be offered
to individuals unable to read because of serious neurological disorders, specific learning disabilities,
or other physical or mental impairments
Interpreter services
Sign language or oral interpretation services performed by specially trained persons for individuals who
are deaf or hard of hearing, and tactile interpretation services for individuals who are deaf-blind;
includes real-time captioning services; does not include language interpretation
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J Occup Rehabil
Table 2 continued
Type of service
Description
Personal attendant services
Those personal services that an attendant performs for an individual with a disability such as bathing,
feeding, dressing, providing mobility and transportation, and so on
Technical assistance services
Technical assistance and other consultation services provided to conduct market analyses, to develop
business plans, and to provide resources to individuals in the pursuit of self-employment,
telecommuting, and small business operation outcomes
Information and referral services
Services provided to individuals who need assistance from other agencies (through cooperative
agreements) not available through the VR program
Other services
All other VR services that cannot be recorded elsewhere; included here are occupational licenses, tools
and equipment, initial stocks and supplies, and medical care for acute conditions arising during
rehabilitation and constituting a barrier to the achievement of an employment outcome
significantly older than clients with mental impairments
(M = 30.57 years, SD = 12.35). The mental impairments
group had a higher proportion of men and African Americans than the sensory and physical impairments groups.
The mental impairments group also had a higher percentage of people receiving cash or medical benefits and
individuals with lower educational levels at the time of
application.
The average time for persons with disabilities to become
eligible for state VR services was 1.32 months. On average, people with sensory/communicative impairments
spent 25 months in VR compared to 28 months for people
with physical impairments and 24 months for people with
mental impairments. Case expenditures were significantly
higher on average for persons with sensory/communicative
impairments (M = US$5,462) compared to physical
(M = US$4,816) and mental impairments (M = US
$3,006), F(2, 14,997) = 87.91, P \ .001. For the overall
sample, the employment success rate was 62%, with individuals with sensory/communicative disabilities having the
highest success rate (75%) compared to 56% for people
with physical disabilities and 55% for people with mental
impairments. Nineteen percent of individuals with sensory/
communicative impairments reported finding employment
at the professional/technical level as compared to 16% for
people with physical impairments and 7% for individuals
with mental impairments.
Logistic Regression Analyses
A logistic regression analysis was computed separately for
each impairment group to examine the association between
vocational services and employment outcomes. The first set
of variables to be entered into the logistic regression
analysis were demographic variables, which included age
(with age 16–34 as the reference category), gender (with
men as the reference category), race/ethnicity (with European American (non-Hispanic origin) as the reference
category), education (with college graduate as the reference category), provision of cash or medical benefits, and
employment status at application. Co-occurring psychiatric
disabilities and AODA were not included in this analysis
because of low occurrence (\5%). In step 2, all VR services were entered as predictors. Table 3 presents the
logistic regression analysis results.
The omnibus tests for each of the three logistic regression models were found to be statistically significant. The
Negelkerke R2 for the three models ranged from .16 for the
mental impairments group, to .18 for the physical impairments group, to .28 for the sensory impairments group,
indicating medium effect sizes for the associations between
vocational services and employment outcomes. The nonsignificant Hosmer and Lemeshow goodness of fit tests
indicated all three models fit the data reasonably well.
Several demographic covariates were found to be significant including the race/ethnicity factor. African Americans
with sensory impairments were found to have a 20% lower
chance of finding successful employment after receiving
vocational rehabilitation (OR = 0.80; 95% CI: 0.67–0.96),
Native Americans with physical impairments were found to
have a 51% lower chance of finding successful employment
after receiving vocational rehabilitation (OR = 0.49; 95%
CI: 0.31–0.78), and Native Americans with mental impairments were found to have a 50% lower chance of finding
successful employment after receiving vocational rehabilitation (OR = 0.50; 95% CI: 0.31–0.82) than European
Americans.
Age was also found to be a significant predictor for the
sensory impairments group, but not for the physical and
mental impairments groups. Compared to clients between
the ages of 16 and 34, those between the ages of 35–54 were
1.39 times more likely to be employed (OR = 1.39; 95%
CI: 1.19–1.63), those between 55 and 64 were 1.88 times
more likely to be employed (OR = 1.88; 95% CI: 1.47–
2.39), and those 65 years or older were three times more
likely to be employed (OR = 3.30; 95% CI: 2.40–4.54).
Education is a significant predictor for the sensory
impairments and physical impairments groups. People who
were more educated (at the time of application) had a higher
chance of employment success. Clients with sensory
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J Occup Rehabil
Table 3 Odds ratio for vocational services by disability group
Service
Sensory disability
OR (95% CI)
Physical disability
OR (95% CI)
Mental disability
OR (95% CI)
1.03 (.90–1.17)
Assessment
1.10 (.94–1.30)
1.00 (.88–1.15)
Diagnosis and treatment
1.57 (1.35–1.82)*
1.31 (1.15–1.48)*
Counseling and guidance
.99 (.87–1.14)
1.15 (.98–1.34)
1.16 (1.02–1.32)***
University training
.82 (.66–1.04)
1.22 (1.04–1.43)***
1.20 (.99–1.46)
Vocational training
1.30 (1.00–1.69)
1.08 (.91–1.28)
1.71 (1.43–2.04)*
On-the-job training
–
–
Remedial training
–
–
Job readiness training
.96 (.73–1.26)
Augmentative skills training
1.11 (.87–1.40)
Miscellaneous training
Job search assistance
1.13 (.90–1.41)
1.06 (.85–1.33)
1.14 (.90–1.45)
–
.94 (.76–1.17)
1.29 (1.010–1.52)**
1.18 (1.03–1.35)***
–
–
1.12 (.94-1.34)
–
1.31(1.09–1.58)**
1.28 (1.09–1.49)**
Job placement assistance
1.66 (1.34–2.06)*
2.23 (1.91–2.61)
2.12 (1.83–2.44)*
On-the-job supports
2.23 (1.68–2.96)*
1.97 (1.59–2.44)
2.40 (2.05–2.81)*
Transportation services
.69 (.57–.83)*
.93 (.80–1.08)**
Rehabilitation technology
1.97 (1.67–2.33)*
1.41 (1.13–1.75)**
Maintenance
1.49 (1.17–1.89)*
1.27 (1.06–1.52)**
Interpreter service
1.11 (.86–1.43)
Attendant service
Reader service
Technical assistance
Information and referral
Other services
.96 (.83–1.10)
–
1.37 (1.15–1.63)*
–
–
–
–
–
–
–
–
1.05 (.72–1.52)
.97 (.78–1.20)
1.51 (1.27–1.80)*
–
–
1.08 (.89–1.30)
1.07 (.88–1.29)
1.25 (1.08–1.44)**
1.41 (1.22–1.62)*
Note: OR odds ratio, 95% CI = 95% confidence intervals. Some services were not included as predictors because the number of clients receiving
these services was minuscule
* P \ .001; ** P \ .01; *** P \ .05
impairments who were graduates of a special education
program had a 58% lower chance of obtaining employment
(OR = 0.42; 95% CI: 0.27–0.67) compared to clients with
sensory impairments with a college degree [the highest
degree]; high school dropouts had a 38% lower chance
(OR = 0.62; 95% CI: 0.48–0.82); and high school graduates had a 26% lower chance (OR = 0.74; 95% CI: 0.58–
0.96) of obtaining employment. Similarly, high school
dropouts had a 50% lower chance (odds ratio [OR] = 0.50;
95% CI: 0.39–0.65), high school graduates had a 36% lower
chance (OR = 0.64; 95% CI: 0.51–0.81), and individuals
with some postsecondary education or AA degrees had a
32% lower chance (OR = 0.68; 95% CI: 0.53–0.87) of
obtaining employment when compared to those with at least
a college degree. Education had no bearing on employment
outcomes for people with mental impairments.
Employment status at the time of application was significantly related to rehabilitation outcomes for all three
major impairment groups. People with sensory impairments who were employed at the time of application were
four times more likely to be employed at the time of closure (OR = 4.05; 95% CI: 3.43–4.77). The OR is 2.79
123
(95% CI: 2.37–3.28) for clients with physical impairments
and 1.53 (95% CI: 1.29–1.82) for clients with mental
impairments.
Provision of cash or medical benefits reduced the chance
of finding employment. Clients with sensory impairments
had a 40% lower chance of obtaining employment
(OR = 0.60; 95% CI: 0.52–0.70). The reduction in chance
for those with physical impairments was 37% (OR = 0.63;
95% CI: 0.56–0.71) and 39% (OR = 0.61; 95% CI: 0.54–
0.69) for people with mental impairments. Co-occurring
psychiatric disabilities was a risk factor for people with
physical impairments, resulting in a 42% lower chance of
obtaining employment (OR = 0.58; 95% CI: 0.48–0.71).
Job placement, on-the-job support, maintenance, and
other services were significant predictors of employment
success across all impairment groups. For job placement,
people with sensory impairments receiving this service
were 1.66 times (OR = 1.66; 95% CI: 1.34–2.06) more
likely to be employed than those who did not; for physical
impairments, it was 2.23 times (OR = 2.23; 95% CI: 1.91–
2.61); and it was 2.12 times (OR = 2.12; 95% CI: 1.83–
2.44) for people with mental impairments. For workplace
J Occup Rehabil
support, people with sensory impairments receiving this
service were 2.23 times (OR = 2.23; 95% CI: 1.68–2.96)
more likely to be employed than those who did not; for
physical impairments, it was 1.97 times (OR = 1.97; 95%
CI: 1.59–2.44); and it was 2.40 times (OR = 2.40; 95% CI:
2.05–2.81) for people with mental impairments. Maintenance services increased the odds of employment by 1.49
times (OR = 1.49; 95% CI: 1.17–1.89) for people with
sensory impairments; 1.27 times (OR = 1.27; 95% CI:
1.06–1.52) for people with physical impairments; and 1.37
times (OR = 1.37; 95% CI: 1.15–1.63) for people with
mental impairments. Other services also increased the odds
of employment by 1.51 times (OR = 1.51; 95% CI: 1.27–
1.80) for people with sensory impairments; 1.25 times
(OR = 1.25; 95% CI: 1.08–1.44) for people with physical
impairments; and 1.41 times (OR = 1.41; 95% CI: 1.22–
1.62) for people with mental impairments.
In addition, diagnostic and treatment (D&T) services
(OR = 1.57; 95% CI: 1.35–1.82) and rehabilitation technology (RT) services (OR = 1.97, 95% CI: 1.67–2.33)
were found to uniquely contribute to employment outcomes for the sensory impairments group as well as the
physical impairments group (D&T services: OR = 1.31,
95% CI: 1.15–1.48; RT services: OR = 1.41, 95% CI:
1.13–1.75) but not the mental impairments group. Substantial counseling (SC) was associated with employment
outcomes for the physical (OR = 1.16, 95% CI: 1.02–1.32)
and mental impairments groups (OR = 1.18, 95% CI:
1.03–1.35). Job search assistance increased the odds of
employment by 1.29 times (OR = 1.29; 95% CI: 1.10–
1.52) for people with physical impairments and 1.28 times
(OR = 1.28; 95% CI: 1.09–1.49) for people with mental
impairments.
University training was significantly associated with
employment outcomes for the physical impairments group.
People with physical impairments who received university
training were 1.22 times (OR = 1.22; 95% CI: 1.04–1.43)
more likely to be employed than those who did not receive
university training as a service. Miscellaneous training
(OR = 1.31; 95% CI: 1.09–1.49) and vocational training
(OR = 1.71; 95% CI: 1.43–2.04) were specifically associated with employment outcomes of the mental
impairments group. Transportation services was negatively
associated with employment outcomes for people with
sensory impairments, with a reduction of 31% in odds of
obtaining employment for those who needed transportation
as part of their vocational rehabilitation services.
Discussion
In this study, individuals with sensory/communicative
disabilities were found to have a significantly higher
successful employment rate (75%) than people with
physical disabilities (56%) and people with mental
impairments (55%). Whereas, time spent in vocational
rehabilitation by individuals with mental impairments (i.e.,
2 years) was the least followed by those with sensory/
communicative disabilities and consumers with physical
disabilities. This disconnect between time spent in the
vocational rehabilitation system and relatively low
employment outcomes of populations with mental impairments and physical disabilities could have been due to a
renewed legislative focus on provision of services to people with most significant disabilities demonstrating the
greatest need. Individuals with sensory/communicative
impairments (19%) and people with physical impairments
(16%) had significantly higher percentages of professional/
technical placement than individuals with mental impairments (7%). Job placement assistance, on-the-job support,
maintenance, and other services were found to be related to
employment success for all three disability groups. Medical
rehabilitation treatment services and RT services were not
as important as predictors for clients with mental impairments as for clients with sensory/communicative or
physical impairments. Conversely, vocational training and
miscellaneous training (e.g., general educational development [GED] training) were found to be significant
predictors of employment success for people with mental
impairments but not for the other two impairment groups.
For people with physical impairments, SC, and job search
assistance services were found to contribute additionally to
successful employment outcomes. Importantly, provision
of cash or medical benefits, was found to be a significant
risk factor across all three impairment groups. For people
with sensory/communicative impairments, the need for
transportation assistance during rehabilitation was a risk
factor that significantly reduced the odds of employment
outcome. For people with physical impairments, cooccurring psychiatric disabilities (e.g., clinical depression)
reduced the odds of successful rehabilitation outcomes.
This study reported the highest cost of services and
employment success rate was for those with sensory/
communicative impairments, followed by those with
physical impairments and then mental impairments. In this
study, the R2 for the sensory/communication impairments
group was the highest, indicating that this group may be the
most homogeneous and that vocational rehabilitation services that could benefit people with these disabilities may
be more well-defined and established.
An important finding of this study is the adverse effect
of receiving provision of cash or medical benefits on
employment outcome. One of the major barriers to gainful
employment for persons with severe disabilities is weighing the financial benefits of paid work against the real
possibility of losing disability-related benefits. Hennessey
123
J Occup Rehabil
[23] reported that \3% of SSDI recipients left the rolls
because of working at what the Social Security Administration (SSA) calls the ‘‘substantial gainful activity’’ level.
However, he also reported that if SSDI beneficiaries had
knowledge of the trial work period and the extended period
of benefits eligibility under new laws, as well as confirmation that they would receive Medicare benefits, the
effects of receiving cash or medical benefits would dissipate. Therefore, rehabilitation health professionals need to
be familiar with disability-related benefits (e.g., social
security, Medicaid, Medicare, food stamps, state health
care programs, TANF benefits, housing, veteran’s benefit,
vocational rehabilitation, fuel assistance, etc.) received by
their clients and the benefits counseling training provided
by the SSA. Diagnostic and treatment services were associated with employment outcomes for people with sensory
and physical impairments. Providing needed surgery,
prosthetics and orthotics, nursing services, dentistry,
occupational therapy, physical therapy, speech therapy, and
drugs and supplies appear to help improve functioning and
health status of people with disabilities and improve
functioning leads to employment. Low-income people with
disabilities also need basic services (i.e., maintenance
services and other services). For example, monetary support could be provided for expenses such as food, shelter,
and clothing that are in excess of the normal expenses of
the individual and that are necessitated by the individual’s
participation in vocational rehabilitation.
African Americans and Native Americans were found to
have lower odds of obtaining competitive employment
compared to European Americans. Disparities in vocational rehabilitation services have been studied extensively.
In general, research has revealed that people from racial
and ethnic minority backgrounds do experience more
problems than their European American counterparts at
every step in the vocational rehabilitation process [24]. For
example, numerous researchers have found that African
American vocational rehabilitation applicants were less
likely to be accepted for vocational rehabilitation services,
compared with European Americans [24–30]. If found
eligible for services, African Americans were also less
likely than European American clients of vocational
rehabilitation services to be rehabilitated [24, 30, 31].
Individuals with visual impairments aged 65 years or
older were found to be three times more likely to obtain
employment than individuals with visual impairments
between the age of 16 and 34. A close examination of this
older adult group indicated that 75% of these clients were
employed at the time of application. Apparently, they utilized vocational rehabilitation services to help them
maintain their jobs, receiving mainly comprehensive
assessment (78%), D&T (57%), counseling (65%), and RT
services (45%).
123
Finally, successful employment outcome is defined by
the U.S. Department of Education Rehabilitation Services
Administration as employment for at least 90 days in an
integrated employment setting. Ninety days is a relatively
short time. It may be more accurate to examine employment outcomes based on job tenure that is at least six
months or one year. Alternatively, state vocational rehabilitation agencies provide follow-along services for some
of their clients and it may be useful to examine the associations between vocational services and employment
outcomes with clients who received follow-along support
services.
Implications for Occupational Rehabilitation Practice
The findings of this study suggest that state vocational
rehabilitation services are associated with employment
outcomes. State vocational services can be of value to other
rehabilitation health professionals in this era of managed
care. Fawber and Wachter [6] contended that vocational
intervention is also appropriate in medical rehabilitation.
They recommended a treatment-oriented job placement
process that seeks to distribute responsibility for employment outcomes among all interdisciplinary team members
throughout the entire medical-vocational rehabilitation
continuum. The important benefit of aggressive vocational
programming within the overall operation of any medical
rehabilitation treatment program is its capacity to provide
direction, focus, and meaning to other therapies or services
[6]. In this sense, VR is best regarded as a ‘‘pull factor’’
therapy (i.e., the therapy that provides direction) and, as
such, is distinguished from other ‘‘push factor’’ therapies
(i.e., those that focus on improving functioning) [32].
Hence, the probability of a successful vocational outcome
is enhanced when all therapies can be related to work, and
vice-versa.
The value of addressing vocational issues within an
acute or post-acute rehabilitation program at an early stage
after injury/illness is therefore immense [33]. In addition,
Horn et al. [34] indicated that acute care patients who lack
socio-economic resources (e.g., private insurance) can
benefit from vocational rehabilitation services. Since a
large segment of people with disabilities is from lower
socioeconomic background, they can benefit from vocational rehabilitation services, both pre- and post-discharge.
Therefore, the findings of this study can be of interest and
use to practitioners in occupational therapy, physical
therapy, speech and language therapy, and recreation
therapy.
Acknowledgments This study was supported in part by funding
from the Rehabilitation Research Institute for Underrepresented
Populations (National Institute on Disability and Rehabilitation
J Occup Rehabil
Research Grant #H133A031705) at Southern University, Baton
Rouge, Louisiana.
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