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REHABILITATION INDICATORS: A METHOD
FOR ENHANCING ACCOUNTABILITY AND THE
PROVISION OF REHABILITATION SERVICES
PHASE III: DISSEMINATION, DEMONSTRATION, REFINEMENT
PART IV: PROJECT NARRATIVE
Table of Contents
Introduction to Part IV
1
A. Introductory Comments and Progress Report
1
B. Project Highlights
7
Project Framework
9
A. Introduction
9
B. Rehabilitation Indicators (RI's)
9
C. Basic RI Concepts
11
D. Defining Accountability
12
E. Accountability Problems and RI Response
13
F. A Comprehensive Model of Change in Rehabilitation
16
G. Rehabilitation Indicators and Units of Analysis
23
H. Defining Disability: Assumptions and Conceptualization
23
I. Defining "Needs": Assumptions and Conceptualization
25
J. The Structure and Functions of RI's
30
K. Models of Usage
34
1. Project Title
37
2. R & D Issues
38
A. Introduction
38
B. Program Planning, Management and Evaluation
38
C. Individualized Rehabilitation Planning
39
D. Defining "Functional Limitation," "Disability" and "Needs"
40
E. Improving the Information Base for Eligibility Determination
40
F. Other R & D Issues
42
3. Project Objectives
43
A. Introduction
43
B. Operational Objectives
44
4,5. Work Plan and Methodology
48
A. Introduction
48
B. Core and Modular Activities
48
C. Expected Progress; Project Staffing
49
D. Core and Modular Activity Areas
50
6. Utilization Plan
60
A. Expected R & D Product
60
B. Target Groups
61
C,D. Dissemination and Utilization
61
E,F. Implementation and Commitments
64
G. Indexed Abstract of Proposal
64
7. Cost-Benefit Measures
65
A. Target Groups and Size
65
B. Expected Benefits
66
8. Background
71
A. Project Staff / Committee Organization Chart
71
B. Staff Qualifications
72
C. Additional Affiliations
82
D. Table 5, Participants in Project Committees
83
E.1 Staff Commitments
90
E.2 Other and Priority Approaches
90
F. Potential Users
91
G. Implications for Legislation
91
9. Review of Appropriate Literature
92
A. Introduction
92
B. Review of Literature Useful for RI Content
92
Development
C. Relevance of Literature Review to Project Framework
94
D. Duplication of Other's Work
94
E. Review of the Literature on Prediction of Rehabilita-
95
tion Outcome
10. Progress Report
103
A. Changes in Plan
103
B. Progress Report
103
INTRODUCTION TO PART IV, PROJECT NARRATIVE
Several steps have been taken to improve this proposal's readability:
(1) Introductory Comments and Progress Report (see pp. 1-7 ) place
this proposal in the context of past, present and planned
activities.
(2) Project Highlights (see pp. 7-8 ) review some of the major ideas
incorporated into the project framework, outlining this project's
approach and selling points.
(3) Project Framework (see PP. 9-36) fully discusses the conceptual
underpinnings of rehabilitation indicators and their potential for
use.
A. Introductory Comments and Progress Report
These introductory comments will attempt to place this proposal in the
context of this project's past, present and planned activities. This proposal's
purpose is to obtain funding for Phase III, the third of this project's
activities.
Phase I (October 1974-May 1977) consisted of the development of the project's
framework (see pp. 9-36) and initial development of rehabilitation indicators
(RI's) to the point of the inception of initial field testing. Development of
RI's was based on the work of the Co-directors, Task Forces (constituted of providers,
clients and administrators of rehabilitation services), and staff.
Phase II (May 1977-October 1979), consisted of a two-and=one-half-year period
which involved developmental and field test activities. Phase II involved the
initial usage of rehabilitation indicators (RI's) with clients and service
providers within rehabilitation settings. The purposes of such field. development
included exploration of issues of reliability, validity, sensitivity, comprehen-
siveness, and acceptability to clients and providers. Other purposes included
intital attempts to explore dissemination and demonstration issues in preparation
for Phase III.
Phase III is an extension of previous work, but with a strong change in
emphases. The objectives of Phase III (October 1979-October 1982) are focussed
on one key factor: optimizing utilization of RI's in rehabilitation systems by
the end of Phase III, i.e., establishing sufficient credibility, utility and
momentum so that RI's will increasingly be adopted for use by rehabilitation
settings and researchers, such adoption becoming less and less dependent upon
RI Project efforts. Three areas of project activities are proposed during Phase
III: establishing demonstrations to evaluate RI usage in a variety of settings;
disseminating RI materials and concepts in a focussed, but expanded effort; and
using feedback from utilizers to refine the indicators and RI packages.
The strategy to be used in Phase III to address these objectives is one of
separating project activities and staff into "core" and "modular" areas. "Core"
defines the basic activities and essential staffing pattern needed to address
most project objectives. "Modules" address important, but separable, objectives
and would require additional resources; reviewers could choose to fund one or
more modules along with the core; but the modules could be submitted to varying
1
2
funding sources if not approved and funded along with the "core" in the intital
review.
Where is the RI Project now and where does it need to go? A summary of
progress is needed to place this proposal in context.
First, in terms of developing rehabilitation indicators, three sets have
been developed and have been tested in a variety of field settings. Status
Indicators and guidelines are presented in Appendix I; three versions of
Activity Pattern Indicators, their guidelines and initial training materials
are presented in Appendices II-IV; and Skill Indicators are found in Appendix V.
(Definitions of these types of RI's are presented in pp. 9-11.) The fourth
type of RI, Environmental Indicators, has not yet been developed, due to
insufficient resources during Phase II (see pp.6,11,14 of Appendix VI and p.12,
Appendix VII). However, in Appendix VIII a modular proposal is presented
requesting funds for this purpose (see also PP. 11,20 for a discussion of EI's).
Also, the final report for Phase II (due in October 1979) will contain an
expanded plan for EI development.
Second, and of key importance, this project has clarified for itself how
RI's relate conceptually to many areas of concern in rehabilitation: accountability,
defining disability functionally, defining client needs, measuring benefits, devel-
oping individualized plans, program management, etc. (see pp. 9-36 and Appendices
IX-XD. The conceptual clarification of these potential uses of RI's provide a
strong basis for the diversified application of RI's to multiple and key concerns;
the conceptualization influenced the design of RI's and proposed models of usage.
Third, the project has gained much practical experience in its field testing
activities, Table I summarizes the separate programs in which RI's have been or
are presently being tested. A full discussion of the results and implications
of initial field testing will be presented in the Phase II final progress report.
However, a summary of what has been learned thus far can be offered:
1. Numerous strategies for gaining entry to settings have been tried and
evaluated. The keystone of what we learned is simple: "start small and
work up." In other words, potential users of RI's in field settings were
more receptive when small efforts were initially suggested (for small
potential payoffs) rather than large efforts (with larger potential payoffs
and greater risk). With successful small efforts, larger efforts could
then be attempted.
2. The notion that settings can serve as "cells" in a research design
where each cell uses RI's in the same way, with only one or two exogenous
variables (e.g., disability group, type of agency) was quickly scrapped.
Our Phase II proposal had proposed such a design; but in searching for
settings to fit the cells, it was found that settings would vary greatly
in how they would use RI's. Thus, the concept of "usage models" (see PP. 34-36)
evolved from field testing experience.
3. In field testing it was found that the data collection paradigm would
need to vary from setting to setting; this fact had significant impact on
the development of RI materials. Thus, data gathering techniques needed to
address special problems associated with psychiatric and developmentally
disabled populations and with clients with less motiviation to cooperate
and with lower level verbal skills. The three types of API's evolved from
this set of experiences (see Appendices II-IV).
N
N
Setting/Project/Contact
Disability
Design
Completed/Planned
Status
Measures
1. Institute of
Post-
Longi-
300/300
Complete;
- Early form
Rehabilitation
operative
tudinal
data analysis
of API's
Medicine
cancer
near completion
/Cancer Research
Project/
I. Friedenbergs
/Psycho-social-
Spinal cord
Cross-
100/125
Continuing;
- Status RI's
vocational
injury; para-
sectional
data being
- API's
Research Project/
plegics,
analyzed
- Skills
W. Gordon
quadriplegics
- RI environmental
Longi-
35/40
Continuing;
questionnaire
tudinal
data being
analyzed
- Other non-RI
psycho-social
measures
/Vocational
Multiple
Longi-
10/10
Complete;
- API's
Department
tudinal
data analysis
Summer Work
complete, but
- Non-RI vocational
Program/
not warranting
interest measures
P. Hutton
report develop-
ment (see p.17,
App. VII)
/Muscular
M.D., mothers
Cross-
dystrophy
of M.D.
sectional
10/15
Continuing
- API's
children
- Extensive interview
Research Project/
F. Anderson
Electronic Device
Quadriplegics
Cross-
15/20
Continuing;
- API's
Research/
sectional
data analysis
- Status RI's
initiated
- Non-RI interview
J. Couniotakis
/Traumatic Brain
T.B.D.
Longi-
12/32
Continuing
- Status RI's
Damage Research/
tudinal
- API's
Y. Ben Yishay
/RI Project/
Non-disabled
Reliability
20/40
Continuing;
- API's
some data
M. Brown
analysis
3
TABLE I: Field Test Activities
N
N
Setting/Project/Contact
Disability
Design
Completed/Planned
Status
Measures
2. United Cerebral
MR
Longi-
35/40
Completed;
- Status RI's
Palsy of New York/
adults
tudinal
data analysis
- API's
Post-Institutional
presented in
- Goals (API & status)
Placement Project/
Appendix XIII
S. Diamond,
R. Schoenhorn
3. Altro Health and
Outpatient
Cross-
20/24
Completed;
- Status RI's
Rehabilitation/
psychiatric
sectional
data analyzed,
-
API's
Evaluation Research/
not yet written - Perceived
C. Benney
into report
well-being
form
longi-
tudinal
25/25
Continuing
- Status RI's
- API's
- Perceived
well-being
4. SCI National
Centers/Psycho-
social vocational
Research
/Phoenix/ W. Dexter
/Chicago/S. Harasymiw
Spinal cord
Longi-
40/150
Continuing
- Status RI's
/San Jose/ D. Mayclin
injury
tudinal
- API's
- Non-RI
/Virginia/ D. Thompson
psycho-social-
vocational measures
/Minneapolis/ G. Athelstan
5. University of Washington
/Chronic Pain Research/
Chronic pain,
longi-
475/575
Continuing;
- Early and later
W. Fordyce
spouses
tudinal
data analysis
versions of API's
in process
/Hemiplegia
Hemiplegics
Descriptive
73/73
Complete;
- Early API form
Research/
and spouses
see App. XVI
M. Clowers
/Other Research/
Hetero-
Descriptive
65/65
M. Clowers
geneous
Table 1, continued
N
N
Setting/Project/Contact
Disability
Design
Completed/Planned
Status
Measures
/Spinal Cord
SCI
Longi-
32/85
Continuing
- API's
Injury Research/
tudinal
W. Fordyce
6. Rehabilitation
Institute of Chicago/
Hemiplegics
Descriptive
12/20
Continuing
- API's
Hemiplegia Research/
S. Harasymiw
7. Woodrow Wilson
Multiple
Descriptive
9/20
Continuing
- API's
Rehabilitation
- Skills
Hospital, Virginia/
(planned)
Special Research
Project/ D. Thompson
Table 1, continued
5
6
4. In exploring during field testing the issues of reliability, validity,
relevance and comprehensiveness of the indicators, it was found that these
issues could only begin to be explored under project auspices. Although
RI's were tested in a variety of settings and with clients of many different
types of disability, questions of relevance of RI's to rehabilitation and
comprehensiveness were answered for only parts of the total target audience.
For SCI patients in a medical rehabilitation facility, for example, it was
found that RI's were relevant and sufficiently comprehensive to address
most client problems; it is strongly believed that the RI tool will find
similar success with other groups, but the empirical evidence to bolster
such a belief will require a research program more extensive than any one
project could handle. Such a large data base cannot be fully obtained
under this project's auspices: pointing to a need for wider dissemination
of RI's to other researchers, with feedback of RI client data to the RI Project.
The Phase II objectives were phrased in terms of "determining" the reliab-
ility and validity of RI's. It is obvious to us now, after much and varied
field experience, that reliability and validity of assessment with RI's are
as much a function of the usage situation and usage model as they are of the
RI tool. Thus, our objective at this point is to explore these issues, to
discover how to set up situations to maximize reliability and validity--
through appropriately designed usage models, adequate training, etc.
Evidence is becoming available regarding test-retest reliability of RI's:
a sample of 20 non-disabled persons completed activity pattern indicators
twice, with a one-week interval separating the administrations; correlations
for both frequencies and durations of 10 of the 12. activity categories across
the two weeks were significant at the .05 level or better. This form of
analysis of the tool's reliablity under controlled conditions will continue,
as the tool is refined during Phase III. Nevertheless, whenever RI's are
used in field settings reliability issues must be explored, with careful
attention given to arranging the situation to bolster reliable information
gathering.
5. Evidence regarding the sensitivity of RI's for detecting the type of
changes expectable within rehabilitation programs is increasing. In all
studies that have been implemented in the field, using RI's, where data have
been analyzed-- even on a preliminary basis-- we have found strong evidence
that RI's provide valid measures of changed functioning. For three examples
of written discussion of RI use to describe functioning, see Appendices
XIII-XV. Also, see pp. 103+ for an expanded discussion of data analyses.
Fourth, a momentum of increasing involvement in field testing and disseminating
the project concept has been building in the past two years. For example, field
testing began in only three settings in early 1977 (using RI's with IRM cancer
patients, with pain patients and spouses at the University of Washington, and
with developmentally disabled persons at United Cerebral Palsy of New York); by
April 1979 testing has occurred in nearly twenty settings with an N = 1200+.
As a second example, contact with outside agencies in the early period of the
project was centered on the persons who participated in project task forces (see
pp. 83-89) by 1979 the project had developed its own newsletter to communicate
with interested field settings (see Appendix XII) the present mailing list is
approaching 1,000 and increasing (through letters of request) every day.
7
Where does the Project need to place its emphasis at this point? We believe
the project should build on its experience and momentum to increase its dissemination
(in focussed, selective ways) and should work to bolster the credibility of the RI
product, by improving the instrument per se (through increased data analysis) and
by exploring the utility of RI's to address multiple purposes that are of central
concern in rehabilitation systems. The RI tool is being developed and tested in
Phase II, but effort needs now to be placed on insuring that RI usage models are
evaluated and results disseminated, with the outcomes of such evaluation fed back
into tool refinement. This proposal incorporates a plan for developing, implement-
ing and evaluating diverse usage models and utilizing such activity as a base for
increasing the dissemination momentum and for obtaining additional evidence of RI
utility.
B. Project Highlights
Rehabilitation indicators provide a generic language that can be used to
describe the rehabilitation client's behavior and environment. These behavioral
and environmental indicators can be used to describe as broad or narrow a range
of goals and subgoals as needed by varying clients and varying rehabilitation
settings. Through comparison of descriptions of actual behavior and goals,
marked on the same indicator, the outcomes of rehabilitation can be described.
Rehabilitation indicators are sets of phrases that can be used to describe
what clients actually do or plan to do. The RI's as developed are neutral in
that what is relevant/irrelevant, good/bad, needed/not needed, desirable/undesirable
about the client's actual behavior, goals and outcomes is left to service providers
and resource providers (including clients) to decide. Criteria setting and value
judgements rest with the participants and do not reside in RI's, although RI's
can be used by participants to state goals and criteria.
Rehabilitation indicators focus on observable, modifiable aspects of
functioning: behaviors and multi-dimensional environmental barriers/supports.
However, the system of rehabilitation indicators is not "behaviorist." That is,
no prescription or suggestion is made relevant to usage of behavior modification
methods. The underlying notion within this project is that client behavior
change is the major rationale for rehabilitation efforts and can be objectively
described: therefore, behavior change is a good yardstick in determining
rehabilitation setting effectiveness, and avoids hinging accountability to
measures of non-observable constructs such as "improved motivation" or "enhanced
satisfaction."
Using rehabilitation indicators within rehabilitation settings will not
require adoption of any one approach or methodology, such as a goal attainment
model. The potential ways to use RI's are many: RI's are notably flexible. Thus,
goal attainment models as well as other approaches to rehabilitation service
provision can all benefit from use of rehabilitation indicators. RI's were not
developed with only the present State-Federal VR system in mind, so flexibility
of usage approaches has been built in.
Rehabilitation indicators form a non-jargon language that promises to
communicate well with many types and levels of participants in rehabilitation
efforts. Varying types of clients (those with MR, psychiatric, physical and
sensory impairments), varying types of service providers (counselors, nurses,
psychologists, physicians, aides, OT's, etc.) and types of service settings
8
(hospitals, State-Federal VR agencies, workshops, mental health centers, etc.)
can use the same language to discuss rehabilitation goals, needs, entry criteria,
problems addressed by differing rehabilitation services, etc. This language
should also help to enhance professionalization of rehabilitation counseling.
Rehabilitation indicators can serve several potential purposes that are
outlined above and are detailed elsewhere in this proposal:
a. Improving accountability for rehabilitation efforts by expanding the
behavioral dimensions defined in the information base (to include
vocational, social, independent living and others) and by increasing the
objectivity of the information base.
b. Improving the provision of rehabilitation services through improvement
of information that is used in forming individual rehabilitation plans and
program planning.
C. Providing a tool that can be used to operationally define "disability"
and "needs."
Rehabilitation indicators form a flexible tool, the use of which is defined
by the nature of the setting, clients, purposes served, methods of information
gathering and use, etc. A specific combination of such variables is referred to
as a usage model.
9
PROJECT FRAMEWORK
A. Introduction
Although the RI project's primary product will consist of rehabilitation
indicators, which are descriptors of aspects of client functioning, RI's have
been designed to address multiple purposes (e.g., enhancing accountability)
and, therefore, the product will also include guidelines or "models for usage"
describing data gathering and use of RI information to address these purposes.
As the Figure on the next page depicts, the RI product (both indicators per se
and usage models) has been strongly influenced by purposes RI's are expected to
address and expected constraints on usage within the operational level of
rehabilitation settings. Furthermore, the nature of RI's and usage models have
been strongly affected by, initial project assumptions and by conceptualizations
of purposes (e.g., defining "accountability") and other issues. The purpose of
this Project Framework is to discuss these conceptual and operational issues,
relating them to the RI product. In the remainder of this Section, RI's are
first outlined, then the product definition is expanded through clarification
of conceptual and operational issues.
B. Rehabilitation Indicators (RI's)
The lexicon 1 of RI's (see Appendices I-V) consists of four sets of descriptors
of observable, measurable and potentially modifiable client behaviors and environ-
mental elements. Two of the sets are referred to as 'primary RI's" and can be
used to describe 'quality of life' in terms of the client's elicited behavior;
"instrumental RI's," the other two sets of descriptors, are used to describe the
behavioral and environmental tools needed to attain the 'quality of life' the
client seeks.
Each of the two types of primary RI's focuses on different aspects of multi-
dimensional client functioning actually implemented within the client's environ-
ment. These are key indicators of quality of life functioning. The emphasis is
on how a client spends his/her time. Primary RI's describe what the client
chooses to do, not just what the client can do (which is covered by Skill Indicators,
see below).
1. Status Indicators (see Appendix I) describe categorical statuses of import-
ance to rehabilitation clients (e.g., competitive employment, living in a
long-term care facility) in several functioning areas: vocational, educational,
economic, transportation, and independent living. Specific, planned changes
in these client statuses can serve as the primary goals of rehabilitation
efforts. Status indicators account for major sources of variability in
the client's elicited behavior.
2. A second source of variability in the client's elicited behavior
resides in the activities the client selects: their nature (e.g., "going
to the theater, " "bathing"), where they are located, their frequency,
duration, etc. Activity Pattern Indicators describe these aspects of
functioning and other patterns of behavior cutting across activities:
client mobility, diversity of activities, isolation/non-isolation, etc.
(see Appendices II-IV for three versions of API's).
1. "A dictionary and/or special language."
as
Operationally defined problems and needs:
Usage Constraints:
- Accountability
Type of settings
OPERATIONAL
- Eligibility determination
Information availability
LEVEL
- Individualized planning
Information users
- Defining disability functionally
Resources
Etc.
Conceptual definitions of purposes:
Models of
Initial
Rehabilitation:
Assumptions:
CONCEPTUAL
- Accountability
LEVEL
- Defining disability
- Client change
- Observability
- Etc.
- Rehab processes
- Multi- dimensionality
- multi-setting
RI's:
Usage Models
1. Basic characteristics
- Data collection paradigms
PRODUCT
- Observable, meaningful
LEVEL
elements of client
- RI subsets
functioning
- Data reduction
2. Structured
- Multi-dimensional content
- Data usage
- Four aspects of functioning:
status, activity, skill,
environment
- Level of detail
- Disability modules
3. Functions
- Description
- Change
- Benefits
- Gains
10
- Outcomes
- Goals attained
- Etc.
FIGURE: 1
Conceptual and Operational Influences-on the RI Product
11
Instrumental RI's describe measurable and observable client-centered and environ-
ment centered elements that may hinder or support (be instrumental to) the client's
attainment of primary goals (status goals and activity pattern goals).
1. Skill Indicators (see Appendix V) are descriptors of the behavioral tools
of the client, which may be instrumental to the client's attainment of
primary goals (described with primary RI's). Skill indicators are behavioral
means to the end, describing what the person "can do."
2. Environmental Indicators (see Appendix VI) will describe potential
supports and/or hindrances to goal attainment that reside in the client's
environment. The "environment" is defined as physical, social, and
personal. Elements of the environment may be instrumental to goal attainment
and, thus, may need to be modified through provision of rehabilitation services.
Development of RI's began in 1974 in a rather simple context where one major
purpose--the enhancement of accountability for rehabilitation services--and a few
assumptions guided project activities. Since then, the assumptions and purposes
have grown into a complex project framework. In describing RI's, at the product
level, we have provided a brief outline of the lexicon (above); now we will
describe the initial assumptions and the later project framework that fully
define RI's and models of usage.
C. Basic RI Concepts
The original purpose for developing RI's was to improve accountability in
rehabilitation settings. The project principals assumed that by expanding the
range of outcome description in rehabilitation settings, using RI's, accountability
would be enhanced. The assumption was that the range should be expanded to include
social/leisure, ADL/self-care and vocational outcomes, including the environmental
component of each. The project principals also assumed that to insure greater
validity and objectivity of these multi-dimensional outcome descriptions, expansion
should be tied to client behavior. Thus, if judgementalness was to be avoided,
behavioral benchmarks would serve this purpose. These early assumptions were
expanded to include additional basic concepts: the system of descriptors (RI's)
should include only observable and inherently meaningful elements of functioning:
elements such as "reading a newspaper" and "walking up and down stairs," avoiding
non-observable elements such as ratings of "self-esteem or "job satisfaction." RI's
also exclude components of functioning such as "flexes arm," which although important
are labelled non-meaningful because components only acquire meaning when linked
to purposes, such as "brushes teeth." All included elements also must be potentially
modifiable within rehabilitation systems.
It was also assumed that an enhanced accounting system would need to be designed
so that it could be incorporated into service planning and service delivery processes;
such a system would become integral to service delivery and not be viewed as "added
on." From the outset of the project it was also decided that the accounting system
must be designed for use by multiple rehabilitation sub-systems, not just state
agencies- enhance information flow and accountability between agencies. Thus,
RI's would need to be useful, at the operational level to address multiple
purposes (e.g., accountability, individualized planning) and be flexible
enough to be usable within many types of settings.
To create a product that would be sufficiently flexible and credible to
serve adequately at the operational level, conceptual clarification was crucial.
Clarification was focussed on three inter-related areas: (1) the purposes RI's
12
could address (2) the aspects of client functioning to be incorporated into the
RI descriptors, and (3) conceptual models of rehabilitation processes that would
be useful as bases for establishing RI use in real world settings. These
conceptual issues are depicted in Figure 1 and discussed in the remainder of
this Project Framework.
D. Defining Accountability
The building blocks of accountability are defined as follows:
1. It is suggested that control of resources which allow rehabilitation
programs to operate is the key to accountability.
2. "Resources" includes money for services and also a host of non-
economic inputs that are necessary to rehabilitation programs, including
client time, energy and hope. The set of actors in this half of the
accountability relationship are referred to as "resource providers"
(RP). The major resource providers are clients and funding sources.
3. The other half of the accountability relationship are labeled
"service providers" (SP). These include rehabilitation counselors,
rehabilitation planners, and administrators among others. All act as
recipients of resources, deciding how they will be used in specific
programs with specific clients.
4. Before control of resources passes to service providers, the resource
providers tie expectations to the resources. For example, Congress defines
the purposes for which State-Federal VR funds should be used. The resource
provider's expectations may be categorized in terms of "who will receive
services," "through what means, " and "to reach what ends," or "input,"
"process," and" outcome, respectively.
5. Service providers are accountable to resource providers for use of
resources in line with these specific input, process and outcome expectations.
An accountable service provider must meet two criteria:
(a) Formulation of decisions that are compatible with the resource
provider's specific expectations and
(b) Generation of information or data that describes the results of
input, process and outcome decisions, i.e., who actually received
services, what means were used and what outcomes were attained?
6. Resource providers complete the accountability drama by using the
service provider's information flow as a basis for resource allocation
decisions, which are then tied to a new set of expectations.
The model of accountability that emerges from these elements is depicted as follows:
RP's EXPECTATIONS
RP's RESOURCE ALLOCATION
SP's DECISION MAKING
SP's INFORMATION FLOW
13
Thus, accountability is the joint responsibility of service and resource
providers. It resides in four basic processes which form a continuous cycle:
a. Formulation of expectations,
b. Decision making by service providers,
C. Generating and communicating information about services, and
d. Utilizing information to make resource decisions.
E. Accountability Problems and RI Response
The problems that resource and service providers encounter when they try
to be accountable can be organized around the four basic accountability processes
described above:
1. The Resource Provider's Expectations: Resource providers may couch
their expectations in too narrow a set of categories (for example, only
vocational outcomes). Or, expectations can be stated so vaguely that
they give little guidance to the service provider's decision making.
Inadequately formulated expectations can lead to narrow or vague concepts
of service.
One explanation for these problems in formulating expectations is that
resource providers may not have a suitable language for describing clearly
and unequivocally a broad range of expectations. The present language and
syntax of rehabilitation is useful in describing only some of the potential
expectations and outcomes of rehabilitation, for example, changes in
vocational status. Other types of outcomes, such as independent living,
may not be emphasized because they are not easily measured or specified
with present languages and methods.
2. The Service Provider's Decision Making: The problems that arise when
service providers are recipients of vague or narrow expectations were just
discussed. The service provider's decision making also is hampered when
multiple sets of conflicting expectations are being sent by multiple sets
of resource providers. For example, a funding source may expect a counselor
to work only toward vocational placement, whereas, the client expects
assistance for independent living goals.
3. The Service Provider's Information Flow: Many types of problems reside in
this aspect of accountability. First, accountability information must not
only meet the resource provider's needs, it also should be useful to the
service provider. For this to happen, information gathering and use must
be integrated into service delivery. Too often accountability data are
defined as something "added on" to service delivery; the service provider
is asked to "fill out the form and file it," but the information requested
is not useful to the service provider's day-to-day interaction with clients.
A second problem with information flow exists when a service provider
does not give an appropriate accounting to the client for decisions which
use the client's money, time, energy, and so forth. From the accountability
definition offered above, being accountable to the client is a responsibility
of the service provider; it is not a favor--it is the client's right.
A third problem resides in the language of rehabilitation decisions
not communicating clearly. Terms such as "work adjustment" and "under-
achiever" can be meaningless to many resource providers. For accountability
14
to occur, the language used must be precise and understandable by most
persons.
A fourth set of problems relevant to information flow stems from
accountability data being of such low quality that they are not useful to
to the resource provider's evaluation of a service program, nor do they
meet the service provider's need for good data to help in program planning.
Quality is reduced whenever the data are of questionable validity and
reliability. Also data quality is lowered whenever data so simplify the
description of outcomes that they underestimate the impact of rehabilitation
programs. Data collection formats may be insensitive to important client
changes that occur as a result of the provider's efforts. Also, simplistic
accountability data may not show clearly that lack of "success" can be
related to factors totally outside the client's and service provider's efforts
(e.g., high unemployment rates).
4. The Resource Provider's Allocation of Resources: Part of the accountability
"contract" is the stipulation that resource providers will use accountability
data to judge whether expectations have been met; this evaluation process
then becomes the basis for decisions concerning allocation of new resources.
When allocation is not based on this type of evaluation, but instead on
influence outside the accountability flow, the payoffs for a service provider's
being accountable are not operating fully. If resource providers ask for
accountability data and then do not use them, they are not living up to their
responsibility in the accountability relationship. Such decision making may
be less than optimal from two perspectives: (1) demoralization of service
providers and (2) decisions being formulated which are not responsive to
the service system's structure, functioning and outputs.
A related problem exists when resource allocation is based upon
simplistic data. Outcomes of rehabilitation programs are complex functions
of the client's disability level and of the client's efforts within a
specific environment and within the context of particular services brought
to bear to meet specific goals. Accountability is in trouble when little
effort is make to acknowledge this complexity in resource allocation. The
so-called 'numbers game' results from resource and service providers simplify-
ing a complex reality, focussing disproportionately on "number of successes."
How can RI's address the accountability problems outlined? Clearly, some
problems are beyond the reach of RI's, but they have potential to address the
following:
1. The Resource Provider's Expectations: RI's provide a multi-dimensional
language of observable behavior and environmental elements which will be
useful in formulating multi-dimensional expectations about who is to
receive services and the range of valid outcomes, Expectations can be
formulated precisely, drawing upon any or all of the RI content areas.
2. The Service Provider's Decision Making: Through use of RI's, decision
making can be enhanced to the extent that it is based upon the RP's
expectations and upon client functioning and outcome information. Both of
these sets of information can become more precise, focused and reliable if
based on RI's. Decision making may be enhanced, particularly, in formulating
a strategy for challenging environmental barriers to client goal attainment,
in that RI's will constitute a fully developed language for describing
environmental events. More credit can be given for changing the environment
15
if a language is available for documenting changes and their relationship
to client outcomes. More credit needs to be paid to the service provider
who links a client to needed transportation or gets an employer to modify
the task structure of a job.
3. The Service Provider's Information Flow: First, because RI's constitute
a comprehensible language, RI's should communicate well across types of
rehabilitation settings, across and within professional groups, and among
differing levels of participant sophistication.
Second, RI's are based on observability, which is expected to create
more reliable and valid data, that are intrinsically more meaningful and
less likely to be manipulated. It is recognized that no system of data
collection can avoid totally the 'fudging' of data, but there is less
reason to manipulate the data when the accountability system gives proper
credit for a broad range of efforts and a broad range of outcomes.
A crucial third point about RI's is that although they can be used as
an external evaluation system, RI's can be used in ways where they are not
an add-on, but are integrated into service delivery and follow up. Within
this latter usage model, the RI lexicon provides multi-dimensional content
which indicates possible goals, problems, and strengths; this can be used
by the client and counselor in developing an individualized plan. The
lexicon reminds the client and provider of the range of behavioral and
environmental variables that need to be taken into account prior to and
after goal selection.
Information flow can be improved, also, through insuring the flow of
information to the client. Moves to insure this aspect of accountability
have been increasing from two major sources: clients themselves are
demanding greater accountability, and funding sources are writing into law
and regulations, measures to insure that information does indeed flow to
the client. When information about services is shared with the client in
a form that increases the client's understanding, accountability is increased.
The client needs sufficient information to make informed decisions about
options he/she can take within the rehabilitation planning process.
Information can also be improved by increasing the congruence
between accounting information and the resource provider's expectations,
i.e., specifically and objectively describing client access, rationalizing
services provided, as well as describing rehabilitation outcomes.
In describing client access, defining the "severity of disability"
and "type of disability" of client's served needs to be part of the
information flów. By using behaviorally based information such as RI's
val idity of information relevant to access increases and criteria for
and priority of access can be set in behavioral terms.
In rationalizing services provided, accountability will be improved
through research to relate input and process variables to outcome. RI's
will improve the description of clients at entry and client outcomes, to
enhance this aspect of accountability.
Accountability will be enhanced by RI's expanding the dimensionality
of outcomes described, to include social, educational, vocational and
other aspects of functioning and by expanding the range of functioning
16
levels that are defined as "successful outcomes." For example, reliance
on "26 closures" to define "success" within the State-Federal VR system
does injustice to rehabilitation efforts which improve client vocational
functioning to a point of less than 60 days employment, to efforts which
far surpass this minimum level of success and, also to changes in non-
vocational areas. By adding dimensions to outcome descriptions and by
allowing a range of functioning to be described on each relevant dimension,
a substitute is being offered for a single point of "success." This will
allow more appropriate credit for rehabilitation efforts and will tend to
create less distortion of rehabilitation efforts, resulting from attempts
to hit very narrow targets of "success."
4. The Resource Provider's Allocation of Resources: RI's are not meant to
provide the sole input to influence resource allocation. However, RI's
will allow information of greater reliability and specificity to flow into
this process. Client benefits (or outcome) will be more comprehensively
defined and inter-related to input and process variables.
Finally, a basis is being laid with RI's to define "disability"
in environmental/behavior (functional) terms; RI's also can be used to
define unmet needs of disabled persons. These RI capabilities also will
assist the resource provider's decisions regarding resource allocation.
This accountability conceptualization has two impor tant consequences.
First, the ideas have been incorporated into RI usage models at the product
level. Second, the discussion of accountability highlights the need for a
focussed information system--an information system that reflects better descriptors
of client functioning and changes in functioning. In the next sub-section, a
model of client change within a rehabilitation context is offered. The model has
been a major influence in selecting aspects of functioning to develop as RI's.
F. A Comprehensive Model of Change in Rehabilitation
Typical models of process and outcome analysis that are implicit in studies
of rehabilitation outcome (see PP. 95-97) relate various client factors to
the gross agency status outcomes through correlational, regression or factor
analytic techniques," (Walls and Tseng, 1976, P. 213). The problem with these
approaches to examining outcomes is that the outcomes and inputs are grossly
specified, other important variables are ignored, the relationship is analyzed
out of its context, and/or the relationships between and among the predictor,
criterion and other variables are simplified in the extreme. Below, Figures 2
and 3 schematicize these implicit designs. Figure 4 schematicizes the type
of change model that is incorporated into this project framework; it depicts
a network of predictor and criterion variables. Figures 2 and 3 oversimplify
the complex nature of both sets of variables. Relationships within each set of
data are not examined. These two approaches assume simple, direct relationships
where complex multivariate interactions exist.
In contrast, Figure 4 depicts the network of interactions available for
analysis when examining outcomes of rehabilitation. "Rehabilitation" is
3
defined within this project as an active process that is designed to reduce
the client's disability level and improve functioning.
2. Walls, R. and Tseng, M. Measurement of client outcomes in rehab. In Bolton
(ed.) Handbook of measurement and evaluation in rehab., 1976
3. Reduction of disability is the purpose of most rehabilitation; however, for
clients with chronic deteriorating conditons, the purpose may be viewed as
stabilizing rather than reducing the disability level.
17
PREDICTOR1
PREDICTOR1
CRITERION
1
CRITERION
PREDICTOR
2
PREDICTOR2
CRITERION2
PREDICTORN
PREDICTORN
CRITERION
N
Figure 2
Figure 3
PREDICTOR
1
CRITERION
CRITERION
A1
B1
PREDICTOR
CRITERION
CRITERION
2
A2
B2
PREDICTOR
CRITERIONA
CRITERION
N
N
BN
Figure 4
18
The model adopted in this project framework consists of two sets of variables:
those associated with rehabilitation systems and those associated with rehabil-
itation clients (see Figure 5, p. 19 ).
1. System Variables:
The first element of the rehabilitation system is constituted of the
general goals, expectations and eligibility requirements that rehabilitation
systems adopt as the guiding premises of their efforts. Goals and access
criteria may be adopted from funding sources, from consumer advocates, from
laws or statutory regulations and from longstanding traditions and conventions
of professionals and other groups. Whoever are the providers of resources
(funds, time, energy) can formulate goals and criteria which guide overall
resource allocation, access and individualized client planning. The client
is a resource provider and, in this capacity, also contributes to the over-
all goals the rehabilitation system must address.
Second, "resources" include money to train and hire personnel and to
purchase services and equipment, and also includes the time and energy of
the client. The amount of resources available are limited and, thus, will
help to determine the system's goals, eligibility requirements and the
services that are brought to bear for any client.
Third, "planning" is the system's process of determining a client's
addressable needs and the determination and implementation of an appropriate
course of action to meet those needs. Planning can vary in terms of the
amount, type and source of information that is obtained in formulating
the plan; in the degree to which services and goals are planned specifically;
in the degree to which needs, goals and services are integrated logically;
in the degree to which the plan is developed by the client and counselor;
and in the degree to which it is specified in writing. Planning is based
upon information relevant to client variables, the rehabilitation system's
goals, and available resources and services. Formulation of the plan will
help determine the services provided to the client and may in itself modify
client variables (e.g., the client's goals may be modified by the planning
process).
Fourth, "services" include all actions on the part of rehabilitation
system personnel and on the part of the client to change client variables.
Examples of services include medical treatments, psychotherapy, physical
therapy, educational programs, vocational counseling, etc. The type,
level and timing of services is a function of resources available and the
individual client plan; these service variables should impact upon all
elements within client variables.
2. Client Variables:
Historically it has been the case that for purposes of studying and
modifying behavior within rehabilitation settings, the continuous flow of
the client's elicited behavior is subdivided into units of useful sizes
and types. These units are isolated from the natural flow of the client's
behavior and from the external context in which the behavior naturally
occurs. Thus, if we are interested in behavior change, "behavior" can
be looked upon both as a continuous process occuring within the client's
natural context and as discrete units isolated for the purpose of
modification, study or measurement of change.
4. Except those variables that only vary across clients, not within clients,
e.g., I.Q., demographics.
19
Rehabilitation Goals and Expectations
Resources
Services
Planning
Intra-Client
Client's
Environment:
Social,
Health
Physical
OLIENT
Intra-Psychic:
Psych. Constructs
Knowledge
Skills
Behavior:
Goals
Statuses and
Activities
FIGURE 5
Model of Rehabilitation Processes
and Client Variables
20
The treatment and modification of behavior (in isolated units) is
associated with a set of questions: What can the person do? What are
the skills of the person? These questions focus on behavior defined as
"means to ends," "tools" or "capabilities." These questions, if asked
over time, are important sources of information about behavioral change
and, under certain conditions, about the impact of rehabilitation on
client behavior.
Another set of questions is relevant to the continuous behavior
within a natural context: What does the person do? What behavioral
pattern is chosen and elicited by the client? These questions focus
on behavior, not as a tool, but as an end in itself. These questions
also need to be asked (over time) to look at change in life functioning
as rehabilitation progresses. The set of client variables included in
the change model has incorporated a point of view that addresses these
two forms of behavior.
Three major sets of client variables are defined within this model.
The relationships between these sets of variables are based upon
Kurt Lewin's (1936) 5 formulation that behavior is a function of the person
and the environment: B = f (P,E). Within the change model, it is suggested
that statuses and activities are behaviors selected by the client (B,
behavior) and are a function of the client's physical and social environment
(E) interacting with client demographics and intra-client variables,
including skills, health, knowledge, goals and psychological constructs
(P, person).
a. Client's Environment: The client's environment is constituted of
thousands of elements that, to varying degrees, support and hinder the
client's progress in reaching multidimensional goals of rehabilitation.
The person's environment can be thought of in terms of a matrix of
social and physical factors crossed by vocational/social interaction/
recreational/economic/self-care/political areas of functioning. The
client's environment may be directly modified by rehabilitation
service interventions or by the client's actions. Changes in the
environment can affect changes in all other areas of client variables
(e.g., statuses, health, skills, etc.).
b. Intra-Client Variables: The first element, "client demographics,"
includes aspects of the client, such as gender, race, psychosocial
history, age, etc. This set of variables is not subject to change with-
in a rehabilitation context.
Second, "health" includes level and type of impairment, where
impairment is defined as a structural modification in a person that
leads to functional modification (Nagi, 1975). "Health" also includes
physical well-being and illness in general.
Third, intra-psychic variables include cognitive and psychological
variables that can be changed by and mediate rehabilitation progress:
5. Lewin, K. Principles of topological psychology. New York: McGraw-Hill, 1936
6. Nagi, S. In EB. Whitten (ed.), Definitions of pathology, impairment, functional
limitations, and disability. National Rehabilitation Association, Mary E. Switzer
Memorial Series No. 1, 1975, pp. 1-8.
21
1) "Psychological constructs" are constituted of measures of
psychological and emotional functioning, such as level of
self-esteem. The person's perceived well-being (Andrews and
Withey, 1976) 7 or subjective 'quality of life' is an import-
ant construct which may mediate or be impacted by rehabilitation.
2) "Knowledge" refers to the client's pool of information that
he/she can draw upon and use in implementing activities in his/
her life.
3) "Skills" refer to the client's pool of learned behaviors that
the client can draw upon and use (within a supportive environment)
in order to reach the goals of rehabilitation. Skills can be
categorized in terms of self-care, mobility, cognition, communication,
social ADL/interpersonal, homemaking, child care, vocation, recreation,
education, etc. Examples of skills include "irons clothing,"
"shampoos hair," 'turns on TV/radio."
"Skills" are defined as the smallest units of behavior that
have specific, immediate uses. A "skill" is a meaningful unit
of behavior in and of itself and is likened to a tool. The
tool has at least one specific, immediate use (e.g., hammering
nails) and usually has several secondary uses (retracting nails,
crushing ice cubes, etc.). A tool is a human-defined construct,
as is a skill. Thus, the handle of a hammer, the head and sub-
parts of the head may each be "useful" but when put together
they form a tool which has more uses than the sum of the parts.
Similarly, "walking" is a skill composed of many sub-parts, but only
when the microbehaviors are combined in a set pattern does the
person become "mobile."
Skills may be highly complex or simple, varying in number of
sub-parts. They vary also in degree of contribution of the three
components of behavior: cognitive, motoric and social. Also,
a skill can be central to a person's functioning, having wide
impact or can be peripheral, having lesser impact on elicited
behavior (e.g., "walking" and "skiing," respectively).
The environment affects skills in two ways: the environment
defines and teaches skills and is necessary to support skills once
attained. For skills to be attained the environment needs to
become focussed and experienced by the person in a fashion syntonic
to skill acquisition and retention. The person's experience of
the environment, then, mediates skill attainment. Secondly, as
was mentioned above, once a skill is attained, it must have
specific environmental" support for it to be incorporated into
elicited behavior.
4) "Client goals" are formal or informal statements that define
the types of statuses and activities for which the client will
extend efforts to achieve change. These goals may be realistic
or not, are intrapsychic concepts, and may or may not become
incorporated into the formal rehabilitation plan.
These expectations or goals are based on the person's values
and are modified by awareness of skill levels, environmental
7. Andrews, F.M. and Withey, S.B. Social indicators of well-being. N.Y. Plenum,
1976.
22
supportiveness, and the person's actual functioning level. Thus,
personal expectations act as a "plan" for behaviors elicited; the
"plan" needs support from the person's pool of skills and from
the person's environment.
C. Statuses and Activities: Statuses and activities are interactions
of person variables and the client's environment.
Statuses are categorical channels of behavior that to a large
extent account for much of the variability in elicited behavior that
follows entry into the chanelling status. In our culture, "statuses"
include employment, transportation, living arrangements, education,
etc.
Activities are purposive sets of behavior attached to a single
setting within a social context, e.g., going to church, riding a
bicycle, reading a book at home, dining out, etc.
Statuses and activities are often the focus of treatment and
goals in many rehabilitation settings, and are the locus of important
changes in behavior that are associated with rehabilitation, i.e.
where measurement of outcome should be enhanced.
Once statuses and activity patterns have been described, the
variance in elicited behavior that remains will consist largely of
idiosyncratic sub-activities (e.g., "telling a joke at a business
meeting," "waving to a friend"), and 'personality' traits (e.g.,
"laughing nervously," "talking forcefully") that can be important
to the person, but also may be less relevant to rehabilitation and
difficult to describe as they occur in elicited behavior.
Statuses and activities constitute the elicited behavioral
elements of client variables, and are a function of environmental
and intra-client input. Services impact upon the intra-client
variables and/or the client's environment which interact to produce
changed statuses and activities in line with client and/or system
goals. Changes within the elicited behavioral elements will serve
as feedback to the modification of the rehabilitation system's
goals and expectations. To influence outcomes, the client can
affect the rehabilitation system through the planning process and
also can act directly upon the environment to produce change that
will support the acquisition of new statuses and changed activity
patterns.
As a final comment regarding this model, the status and activity
elements can define important aspects of the client's objective 'quality
of life,' especially in the context of the client's specific rehabilitation
goals. The other client variables (environment and intra-client) can be
looked upon as means to obtaining an enhanced quality of life. Thus, the
behavior elements (status and activities) constitute the major goals and
primary outcomes in rehabilitation; changes in intra-client (skills,
psychological constructs, etc.) and environmental (social and physical)
elements constitute instrumental and mediating outcomes of rehabilitation.
23
G. Rehabilitation Indicators and Units of Analysis
The units of observable behavior and environment that become foci of
treatment and are used for measurement of change are important to discuss.
In subdividing the environment and behavioral stream, there is no one best unit;
units selected are "good" only in relation to the purposes for which selection
is made.
Our approach for selection of units has been to note that some behavior is
"means," some is "ends;" units will differ for the two types of behavior. Also,
means and end behavior are both analyzed and dissected for the purpose of treatment,
modification, and measurement of change. Thus, the units into which means end
behavior are subdivided must be useful for treatment and modification purposes
and for purposes of measurement.
Within this project the unit selected for "means behavior" is that of the
"skill." As was discussed above, skills vary in complexity and size, but a
"skill" by definition is useful in and of itself. Also, "skills" are immediately
understandable (e.g., we all know what "walking up stairs" means, but
not necessarily what "30 degree range of arm motion" means, which is not a
"skill"). Skill indicators were developed to describe this aspect of behavior.
When the stream of the person's elicited behavior is subdivided into units,
many possible choices can be made as to units that are useful and appropriate.
The Project's approach has been to try to select units that are understandable
and will account for major sources of variance within societal contexts.
Statuses are categorical channels of behavior that to a large extent
account for much of the variability in elicited behavior that follows entry into
the channelling status. Activities are purposive sets of behavior attached to
a single setting within a social context, e.g., going to church, riding a
bicycle, reading a book at home, dining out, etc., that also account for large
amounts of behavioral variance.
The units of "ends" behavior (statuses and activities). are easily understand-
able, are often the focus of treatment and goals in many rehabilitation settings,
and are the locus of important changes in behavior that, are associated with
rehabilitation, i.e., where measurement of outcome should be placed. Status
indicators and activity pattern indicators were developed to describe this
aspect of behavior.
The environment is part of the "means to the end" and as such is seen
as instrumental to change in elicited behavior; it can be subdivided into
units that serve to support or hinder goal attainment. Environmental
Indicators have not yet been developed to the point where "units" of the
environment can be discussed in detail.
Thus, the four types of RI's that have been developed reflect the client
change model and these considerations about useful units of analysis, as well
as the basic starting assumptions: observable, modifiable elements of function-
ing.
H. Defining Disability: Assumptions and Conceputalization
This project's definition of "disability" follows directly from the
definition of the structure of behavior, i.e., B = f(P,E) presented in the
previous subsection. One additional component is needed to define disability
24
impairment. "Impairment" is a structural modification in a person that leads
to functional modifications. Thus, for example, following Nagi (1975), the
damaged brain tissue following a stroke is a person's "impairment"; functional
problems that are based on this structural damage are referred to as "functional
limitations" and "disability" (discussed below). The relationship of impairment
and disability is that the latter is a consequent of the former.
Impairment can be based on physical or mental pathology. An impairment
typically impacts on a person through modifying the person's intrapsychic
variables, including knowledge, goals and skills. The physical impairment
can influence skills through (1) modification of the environment's impact
on experience, (2) modification of the impact of experience on skills and/or
(3) through direct impact on. the skill pool. A physical impairment of structural
damage following stroke, for example, may impact on the person by modifying how
the environment is received to produce the person's experience of it. A stroke
may leave a visual impairment (a field cut) which may serve to filter out part
of the visual environment; it may act in terms of the person's translation of
experience into skills (e.g., a skill that a person learns while not compensating
for a visual field cut may be quite different than the same skill learned when
the person processes the whole field); and it may directly impact on the skill
pool (the stroke may leave the person unable to walk or talk).
With regard to the impact of impairment on skills, two types of impact
need to be differentiated:
1. Because of impairment, skills that people need in reaching goals
will not be developed (or in the case of traumatic impairment will be
removed from the person's skill pool). Impairment can reduce needed
skills.
2. Because of impairment, skills that are maladaptive and hinder goal
attainment will become part of the person's skill pool (and part of
elicited behavior). Impairment can increase unneeded, negative 'skills.'
When reduction of disability through rehabilitation efforts is discussed,
both types of skill problems need to be kept in mind.
The functional consequents of impairment, following Nagi (1975), are
of two types: functional limitations and disability. We define "functional
limitations" at two levels of specificity: skills and behavioral components of
skills (previously discussed on pp. 18-22).
"Disability," on the other hand, is defined within this project's
conceptualization as a function of elicited behavior and expectations or goals
regarding this behavior. Thus, "disability" is located in what the person
does not do, but wants or is expected to do. As Moriarty (1975) points out,
"disability" is relational and cannot be directly seen (see Figure 6 ).
Expectations about functioning
Elicited behavior
Disability
or actual functioning
FIGURE 6
DISABILITY, AS THE RELATIONSHIP BETWEEN EXPECTED
AND ACTUAL FUNCTIONING LEVELS
8. "A physiological, anatomical or mental loss or abnormality, or both" (p.1).
9. Moriarity, J., In Whitten (ed.), op cit, p.15.
25
The expectations about functioning may be the focal person's or may be
society's expectations. "Disability" will, of course, differ when the
expectations differ (over time or in terms of viewpoint) and when the level
of elicited behavior changes over time. In terms of the definitions of
structure of behavior, "disability" can be changed with modification of any
or all of the client variables in the change model: impairment, knowledge,
skills, environment, goals, etc.
In defining disability in this way, we have attempted to differentiate
the two aspects of functioning previously discussed: elicited behavior
(behavior-as-ends) and skills (behavior-as-means). When physical and mental
structures are modified through impairment, the ensuing functional modifications
are complex and the distinction we have made will help maximize the impact
of rehabilitation services. The distinction between behavioral tools (skills)
and elicited behavior is the crucial aspect of this discussion, and is expanded
below.
I. Defining "Needs": Assumptions and Conceptualization
In conceptualizing "needs" this project has defined "needs" differently
than have others. Typically psychologists have viewed "needs" as universally
valued categories of environmental elements which motivate people to work
(expend energy). Thus, people are said to have "physiological needs" in that,
when deprived of food and water, they will work to obtain these relevant items.
"Needs," in typical models, refer to categories of elements in the environment
that will reduce arousal levels associated with an inherently valued state.
For example, the physiological need for food becomes more salient when a person has
not eaten for several hours; the saliency of this need decreases when any food
article is eaten. Also, food is a "need" because continued existence of the
person is valued, i.e., need is based on value.
This type of general model is not very useful in defining the needs of
disabled people, especially if one is defining needs in order to develop a
program of services that is responsive to "needs."
The authors of this proposal take the view that what a person or society
values, provides the context for defining that person's needs. The values
that give rise to needs may be universal or idiosyncratic. This context of
values that give rise to needs may change across situations and time, with the
resultant modification of the person's need.
In order to optimize the attainment of his/her values, each person
operationalizes values into a means/end chain, each link of which is the focus
of a different type of "needs." Below, each of the four linkages of the means/
end chain is discussed. The first part of the discussion is focused on defining
means and ends at each linkage. This is followed on pp.27-29by a discussion of
the "needs" defined at each linkage. (See Figure 7.)
The first link in the means-end chain consists of an "end"--implicit
and explicit values--and a set of operational means. In operationalizing
their values, people tend not to act randomly, but instead tend to establish
longstanding structures and patterns of activity that will provide a continuing
high probability of achieving their values. To optimize value attainment,
people enter statuses (e.g., marriage, employment as a lawyer) and adopt
longstanding patterns of activities within statuses (e.g., performing lawyer-
like activities) or independent of statuses (e.g., seeing certain friends a
26
MEANS
ENDS
LINK
Status, Activity Patterns
Values
First
Skills and Environment
Statuses, Activity
Second
Patterns
Services and Actions
Skills and
Third
Environment
Resources
Services and Actions
Fourth
FIGURE 7:
MEANS-ENDS CHAIN WHICH DEFINES NEEDS OF CLIENTS
27
certain number of times in any given period). Thus, the first link in the means-
end chain refers to status and activity patterns being the major means chosen
to optimize personal values.
FIRST LINK:
STATUS/ACTIVITY PATTERNS
VALUES
The second link refers to the specific constellation of skills and
environmental supports that the person must acquire if he/she is to achieve
the statuses and activity patterns described above. In this link, status and
activity patterns become an "end" and instrumental elements from within the
person (e.g., skills) and from without (environment) are "means" to reach this
"end". For example, to address his/her social and sexual values, a person
may wish to establish a status and activity pattern of marriage. To achieve
and maintain the status and activity pattern, the person must seek an environment
that provides social contact with appropriate persons, must demonstrate certain
instrumental social skills, and must use skills to maintain the marriage, once
attainment has occurred.
SECOND LINK:
SKILLS/ENVIRONMENT
STATUS/ACTIVITY PATTERNS
The third link consists of actions and services that are brought to bear
in a person's attaining skills and in acting on the environment to enhance its
supportiveness. Such actions and services can include the person's own and
those implemented on behalf of the person, e.g., the person taking a course in
English composition, the person's family buying him/her a wheelchiar.
THIRD LINK:
ACTIONS/SERVICES
SKILLS/ENVIRONMENTAL SUPPORTS
The fourth link refers to resources which are necessary if services are to
be provided or actions are to be implemented. "Resources" with regard to
services may include money, training of service providers, information about
service availability and technological/structural adequacy of the service setting.
Resources with regard to individual action may include the client's money,
knowledge of options and ability to sustain an action.
FOURTH LINK:
RESOURCES
SERVICES/ACTIONS
This model depicts four levels at which "needs" can arise. Each of these
types of needs are discussed below.
1. Primary (Status and Activity Pattern) Needs
At the first link, "values" are the "end and "statuses/activity
patterns" provide the "means." If these means are not sufficient to
attain expected ends, "primary needs" are said to exist.
Values are operationalized into expected levels of statuses and
activity patterns (or goals); the actual level the person is able to
attain is a function of these expectations and the constraints provided
28
by the person and environmental variables; the difference between expected
and actual levels defines the person's primary (status and activity pattern)
needs (see Figure 8 ) and is identical to the person's "disability,"
when preceded by impairment.
Values
Status & Activity Pattern:
Expected Level
Actual
Need
Level
Area
Person & Environmental
Variables
Figure 8
To be more precise this difference defines the person's needs to
attain new statuses and activity patterns (the person's primary attainment
needs). Primary maintenance needs refer to those areas where attainment
has occurred, but the person is having difficulty maintaining this level,
e.g., the person is having difficulty holding a job.
EXPECTED LEVEL OF STATUSES AND ACTIVITY PATTERNS
Attained & Maintained
Attained, Not Being
Not Maintained
Behaviors
Maintained
Not Attained
/
TYPE OF
NEEDS
Maintenance
Attainment
Needs
Needs
Figure 9
2. Instrumental (Skill and Environmental Elements) Needs.
Once primary needs have been defined, the means necessary to
addressing these needs must be defined. Instrumental needs consist
of those skills and environmental supports that the person must
acquire (and does not yet have) in order to address primary needs.
It should be pointed out that any single instrumental skill or
environmental support can address more than one primary need. For
example, eating skills can contribute to addressing independent living,
29
social, and vocational goals.
SKILL1
PRIMARY NEED1
SKILL
PRIMARY NEED
N
N
Figure 10
3. Service and Action Options and Resources
Once the client's instrumental needs are defined, many service
options and action options are open to address these needs.
One could define "needs" here as was done at the first and second
linkages by determining what services and actions are necessary in
10
addressing instrumental needs but are not available. However, equifinality
exists at this linkage to a degree not previously found in the needs model.
Thus, if a person does not "enunciate words clearly," many service/
action options may prove to be useful: speech therapy, increased family
supportiveness, psychotherapy, a hearing aid, etc. However, until the
relationship between each option and the instrumental need is known, the
client's service (and resource) needs will not be known, only service
(and resource allocation) options.
The relationships between the different types of means/end needs are
clear: at the first linkage, values are selected and operationalizations of
values are also selected by the person (and stated as expectations); this forms
the context which defines needs at each linkage. "Needs" are the means that
are necessary but not available to the person, given the context of the person's
operationalized values, which define the end. Needs at each level are a function
of the person's operationalized values. As values or operational statements change
within the person, all needs derived therefrom will change.
To this point, definition of needs has been discussed solely from the
individual person's point of view using the individual's adopted values as the
base. But a person's "needs" can also be determined using values selected by
society (and operationalized statements derived therefrom); these might be
labelled the person's societally validated needs. Societal expectations relevant
to functioning can be stated in status and activity pattern terms, but it is more
likely that the expectations will be formulated in general rather than specific
terms.
"Needs" can also be defined during the client-provider service interaction,
where expectations are operationalized into rehabilitation goals. Here client
expectations can be reviewed in the individualized planning context and trans-
lated through consensual validation into operationalized statements: "needs"
and "goals" are derived from consensus of client and provider. Within this
context, societal and client expectations are both used to develop goals toward
10. A systems theory term denoting that many paths to an end are possible and that
there is no one best way to an end.
30
which rehabilitation services and planning will be directed.
Thus, "needs" can be defined from many viewpoints, including those based
on client expectations, those based on society's or those based on both. Each
basis of needs definition will be biased; these biases are discussed in the
context of the purposes "needs" definitions must serve.
Client-based needs (those based on client-selected values and expectations
about functioning) will address a wide range of statuses and activity patterns
the client values and will be quite detailed (e.g., expecting to be a "salesman"
rather than only expecting to be "employed"). These "needs" will closely
parallel "wants." In a world of unlimited resources and completely effective
services, this "needs" list would be the only valid one. However, this "needs"
list is biased, in as much as it does not take into account service limitations
(in terms of effectiveness) and resource limitations (in terms of amount to be
allocated). Determining client-based needs would be a useful starting point in
individualized rehabilitation planning and may be useful as a data base to provide
evidence of important needs not addressed when narrower societal values are used.
Societal-based needs (those based on expectations that a societal agent,
such as a funding agency selects) are limited in that they will tend to be
global rather than specific and will produce a general list of primary needs,
not very useful in generating individualized instrumental needs. Societal-
based needs do not take into account societal resources. However, the bias
exists in that the range of values will be more limited than the client's. To
be useful societal expectations (that will be supported by resource allocation)
need to be stated more specifically and for a broader range of values. These
expectations could be used in surveys of the population where needs of the
disabled are to be defined for program planning purposes.
Needs, defined within a rehabilitation service context (those based on
client values and societal values, consensus being mediated in the service
planning process) are derived from the comparison of goals and the client's
entry functioning. These "needs" are biased by assumptions concerning "being
realistic," "staying within resource limits," "services that are available,"
"client motivation," etc.
From this discussion, it is clear that "needs" are not simple to determine.
"Needs" are of several types and can be developed from several points of view,
depending on the set of expectations being tapped. The major point here is that
"needs" can be defined quite explicitly, given that the purpose of defining
needs is clear.
J. The Structure and Functions of RI's
The preceding conceptual framework has been a review of the project's
definitions of (1) purposes (e.g., defining disability) it can address through
appropriate design of RI's and RI usage models and (2) models of client change
and rehabilitation system processes that impact on clients. Given this framework
the RI product can be described more fully than in pp. 9-11.
Up to this point, RI's at the product level have been described as descriptors
of elements of the client's life that can change during rehabilitation, such
descriptors are infinitely numerous and needed to be sampled and organized before
being useful in addressing such purposes as "enhancing accountability." The RI
31
list of sampled descriptors was developed by first applying two criteria:
"observability" and "meaningfulness." Non-observable elements (e.g., "self-
esteem," "job satisfaction") were discarded, except those that could be directly
operationalized in client behavior (e.g., "remembers own name"). Elements
without direct, functional meaning were also discarded, e.g., "flexes arm."
This sampling approach does not imply that non-observable and/or non-meaningful
elements are unimportant aspects of the client; what is being implied is that
documentation of change must be based on observability and meaningfulness, to
enhance validity and communication.
A key to RI utility lies in the several structural approaches to organizing
descriptors. RI's have been structurally organized for flexibility of use on
the basis of four organizing strategies:
First, RI's are conceptually organized in terms of the four aspects of
functioning (status, activity pattern, skills environment) incorporated into
the client change model.
Second, within each of the four types of RI's, the descriptors are sorted
into content categories (e.g., vocational, self-care, etc.)
Third, the relevance of each indicator to a variety of client disability
categories is being estimated and validated in empirical field testing. The
result will be disability-relevant modules of RI's. (The four aspects of
functioning and the multi-dimensional content may also be seen as bases for
modularizing the total set of descriptors, to increase flexibility of use.)
Within each module of RI's only a sample of possible indicators have been
included. The lexicon cannot possibly contain all of the elements that can be
used in describing all clients' rehabilitation goals, subgoals, needs or
strengths. To describe specific client goals or needs that have not been included
in the lexicon, guidelines for development of "idiosyncratic indicators" will
be included. Such guidelines would define the criteria that were used in
development of each type of indicator, so that users could extrapolate from the
lexicon to describe the client's relevant, but idiosyncratic behavioral or
environmental elements. These idiosyncratic RI's would be used in a manner similar
to that described for standard indicators included in the lexicon.
Fourth, The RI descriptors have been organized into branched levels of
detail. Indicators must be capable of describing behavior at a level of detail
appropriate to the demands of accountability and to the focus of rehabilitation
efforts and must also be structured so that the elements that are not problems,
needs, or strengths may be ignored or easily skipped over and those that are
relevant may be identified in minimum time.
The Skill Indicators, for example, were organized into a three-level
branched structure, by specificity of the skills involved. The first and broadest
level of detail is referred to as a nominal level; it is used solely to organize
and structure skill indicators at more specific levels of detail. The second
level of detail of description consists of broadly defined behaviors and/or
categories of skills referred to as "general skills." A third level of detail,
"specific skills," are components of general skills (e.g., "dries entire body"
is a component of "showers/bathes") or examples of general skills ("opens
envelopes" is an example of "manipulates small objects"). These two types of
specific skills are seen as structurally different, but functionally equivalent.
32
An example of the tri-level branched structure is presented below.
Level of
GENERAL
SPECIFIC
Detail
NOMINAL
SKILL
SKILL
Self-Care
Eats/Drinks
Drinks from cup
Butters bread
Orders a simple meal
Maintains bowel continence
Manipulates small objects
Turns on light switch
Opens & closes drawers
Opens envelopes
Uses key to open door
When the concept of "gating" is added to this branched structure, the client
and service provider can quickly 'reach' the behavioral areas relevant to describing
problems and needs. "Gating" refers to the process of scanning the broadest level
of detail to identify problem areas; a problem at the nominal level acts then as
a gate to the general skill level. For example, if "self-care" is not problematic,
none of the general or specific indicators listed above would be reviewed. The
existence of problems in "self-care" would open the gate to "eats/drinks" which
might open the gate to "drinks from cup." The client and service provider stop
gating when the problem behavior is identified at an appropriate level of detail.
The "gating" operation is useful for saving time during data collection; the gate
structure also lends itself to data reduction (from refined to broad categories)
necessary to serve program evaluation purposes.
The final structural characteristic of RI's that needs to be stated is that
of wide potential application: The RI content is relevant to many types of
disability, including sensory, psychiatric, physical and developmental. Also,
the flexibility and breadth of RI content bodes well for usage within many types
of rehabilitation systems and settings, including State-Federal VR agencies, vocation-
al workshops, mental health centers, medical rehabilitation settings, etc.
To complete the discussion of the RI tool, the functions of indicators (and
Rehabilitation Indicators, specifically) will be discussed.
First, RI's can be used to describe client variables at any one point in
time. Examples: "employment status (at closure): sheltered employment,"
"duration of passive recreation activities (at entry): 60 hrs/wk," etc.
33
Second, RI's can be used to compare client variables at two or more points
in time (i.e., assess change). Examples: "difference between duration of socially
isolated activities at entry into program and at present: 8 hrs/wk decrease,"
"decreased physical barriers in client's home: entry ramp," etc.
Third, RI's can be used to state goals and objectives. Examples: "employment
status to be attained at closure: competitive/wages," "increased frequency of
activities using a prosthesis."
Fourth, RI's can be used to describe problems, strengths, and needs. This
usage combines description of the present level of a client variable and compares
it to a standard or goal. Thus, "types 80 wpm" is a simple description taken
out of context, but is a "strength" when compared to the goal of "employment
status: competitive, secretarial position." Similarly, the fact that someone
has not acquired the skill "washes dishes" may be termed a "problem" or "need"
vis a vis the goal of the self-care status of "independent living."
The fifth use of RI's is to describe client outcomes. Here, RI's can be
used to compare the level of a client variable at closure with a previously
stated goal or objective. Thus, if "washes dishes" has been acquired as a skill
and was a skill objective, the comparison defines a skill outcome.
Before leaving this discussion of the basic uses of the RI tool, it must be
noted that RI's constitute value-free descriptors of client elements; values
become attached to RI's when used to set goals, describe problems, etc; such
values reside in the users of RI's, not in the RI's themselves. In other words,
the relevance and value of each RI to a specific client can only be determined
in the context of each usage situation.
Thus, three contextual dimensions determine the basic uses to which any
indicator may be put:
1. Is the indicator used to describe static functioning (at one point
in time) or dynamic functioning (change over a period of time)?
2. Is value assigned to the description?
3. If change is being described, is the change causally attributed to
rehabilitation efforts?
Figure 11 depicts a terminology system reflecting combinations of these
dimensions. Thus, for example, a "benefit" is a description of change to which
value is assigned and evidence is sufficient to attribute the change to rehab-
ilitation efforts.
The multiple basic uses of the RI tool--description, assessment of change,
goal formulation, problem/strength description, and documenting outcomes--
constitute an additional dimension of RI flexibility. The high degree of
flexibility of the structure and functions of the RI tool allows RI's to be
built into a wide variety of patterns or models of usage. The nature of such
models will also be a function of the purposes which RI's are to address and the
constraints of usage defined by the operational realities of rehabilitation
settings or systems (see Table 2, P. 35).
34
DESCRIPTION (Single point) OR CHANGE (Multiple points)
Description:
Change:
Attribution of change to the
rehabilitation system?
Yes
No
Yes
GOAL,
Yes
BENEFIT
GAIN
CRITERION
No
DESCRIPTION
No
OUTCOME
CHANGE
FIGURE 11
CONTEXTUAL FACTORS FOR RI MODELS OF USAGE
K. Models of Usage
Usage of RI's will be discussed in terms of two sets of variables: those
exogenous to the RI use and endogenous variables. Exogenous variables, in
terms of Table 2 , include (a) operational usage constraints and (b) operation-
ally defined problems and needs; these variables define the situation into
which RI's will be placed. Endogenous variables describe the Usage Model per
se: how RI's are used in the setting.
1. Exogenous Variables
The situations into which RI's can be placed can be subdivided into
those where (a) information about specific consumers is obtained (or not)
and (b) a service setting is the site of information retrieval (or not)/
Examples of non-service settings include funding agencies, legislatures,
rehabilitation counselling education programs. Some examples of usage in
non-service settings, include (1) Congress or a funding agency specifying
eligibility standards in RI terms, (2) and using RI's to survey "needs"
in sub-populations of disabled persons. Although these examples point
to important potential usage models for RI's, the more complex usage models
occur in service settings, involving client participation; in Table 2
the exogenous and endogenous variables for this important subset of situations
are outlined.
The situation into which RI's will be placed is defined in Table 2
as a function of type of setting, usage constraints and uses of RI inform-
ation. Thus, for example, RI use could be expected to differ if the clients
in the setting in which RI's are placed are one month VS. one year post-
stroke; or, similarly, if the clients are developmentally disabled vs.
orthopedically handicapped.
RI use would be a function of several setting constraints (1) whether
or not information can be obtained observationally or only from interviewing
clients, (2) the nature of individual service planning, (3) time limits on
contact with clients, etc.
The final set of exogenous variables that affect the nature of the
usage model is constituted of who and how RI information will be used:
For what purposes? Who will be the audience for information? How is such
information to be used in client and/or agency decision making?
EXOGENOUS VARIABLES
ENDOGENOUS VARIABLES
Setting Types
RI subsets used
- Timing of services vis a vis onset of disability
- Functioning aspect (s) (i.e., status, API,
skill, environment)
- Client type
- Content area(s) (e.g., vocational, social)
- Agency goals
- Level of detail (e.g., general, specific)
- State-Federal agency, private facility,
independent living
- Disability-relevant modules (e.g., SCI,
psychiatric)
- Geographic location (urban, rural, etc.)
- Rehabilitation phase (e.g., community-based
Setting constraints
skills
- Present information system's adequacy
Data Collection paradigm
- Receptivity of "utilizers" to new methods
- Timing of data collection (e.g., entry,
closure)
- Present service provision system
- Data source (e.g., client self-report,
- Time limitations on information gathering
significant other, observation)
- Access to clients: interview, observation
- Data collector (e.g., counselor, researcher)
- Data-gathering resources available: computer
- Data recording (e.g., RI forms, client record)
Uses of Information
Data Reduction
- Multiple or single audience: Clients, service
- Computer/non-computer models
providers, evaluators, administrators, funding
agency, etc.
- Level of detail of data reduction
- Purposes of use: Informational, accountability,
Data Uses
evaluation of program, research, service enhancement
- Describe change, outcomes, goal setting, goal
- 'Sophistication' of audience
attainment, benefits, problems, objectives, etc.
- Relationship of information to decision making
- Purposes: accountability, describe functional
limitations, define disability functionally,
program evaluation, program management, etc.
35
VARIABLES AFFECTING
TABLE 2
USAGE MODELS OF RI's
36
2. Endogenous Variables
Usage models per se are defined by which RI subsets are used, the
data collection paradigm, data reduction and actual data usage.
Some usage models may use all RI's; others may include only vocationally-
relevant content, or only skills or only those indicators especially relevant
to a specific disability group. Some usage models might use RI's in sequences
determined by relevance to phases of rehabilitation, i.e., some skills are
only useful when job seeking, some are relevant during institutional phases
of rehabilitation.
Other usage model variables are focussed on RI data-gathering, analysis
and uses of RI data. Such aspects will be complex functions of exogenous
variables, RI characteristics and the conceptual discussion offered above.
This discussion of usage models concludes the exploration of issues relevant
to RI product development and potential for use. The major concluding point is
that the RI tool has been structured to be highly flexible, with broad utility.
The tool is a neutral entity that gains meaning and potential for improving
rehabilitation systems only when placed within an appropriate usage model.
37
1. PROJECT TITLE
Rehabilitation Indicators: A Method for Enhancing Accountability and the Provision
of Rehabilitation Services.
Phase III: Dissemination, Demonstration and Refinement
38
2. R & D ISSUES
A. Introduction
Because the RI tool is an approach to help gather and organize client function-
ing information and, thus, will provide an improved and focussed information base in
rehabilitation agencies, the use of RI's has potential for impacting on many RSA R&D
strategy areas. Although the labels and prioritizing of RSA's R&D issues change
from year to year, several RSA strategy themes have remained constant and have been
addressed by the RI Project since its inception. Development of the RI tool has
been designed to address the following strategy areas:
1. Program planning, program evaluation and program management,
2. Individualized rehabilitation planning,
3. Defining "functional limitations," "disability" and "needs," and
4. Improving the information base for eligibility determination.
Rehabilitation indicators (RI's) have a wide potential to influence the course
of many RSA issues in that they constitute a language of rehabilitation which will
expand the information base to be used by clients, counselors, and other rehabil-
itation professionals in planning and accounting for rehabilitation services. The
many uses to which RI's lend themselves and which determine their potentially wide
influence on R&D Issues are detailed in pp. 9-36, 66-70. The specific ways that
RI's will address the strategy areas listed above are defined in the remainder of
this section.
B. Program Planning, Management and Evaluation
A key aspect of program evaluation is the documentation of the effectiveness
of rehabilitation programs. In that RI's are descriptors of observable elements
of the client's life, their use to document change enhances the face validity of
evaluation data. Also, the defining and organizing characteristics of RI's
(four aspects of functioning, multi-dimensional content, multiple levels of detail
and disability-relevant modules--see pp. 30-32) and the flexibility of basic uses
(description, change, goals, problems/strengths, and outcomes--see pp. 32-34)
allow flexible response to a wide variety of evaluation approaches and foci.
With RI's, program evaluation can focus on an appropriately wide or narrow range
of content to fully reflect the rehabilitation agency's area(s) of accountability--
from "vocational only" to "independent living" to an even more broadly-focussed
content. Thus, multi-dimensional and observable outcomes defined by RI's could
be used to replace uni-dimensional definitions of success/non-success that presently
are used to define "closure" within the VR system. Finally, the RI tool's
structure and organization allows for ease of data reduction to produce evaluation
information suitable to differing audiences. For example, documentation can be
reduced from detailed skill indicators to gross skill areas; also information can
be obtained at relatively gross levels (status and activity pattern indicators)
and/or at relatively specific levels (skills and environmental indicators), with
data collapsed to appropriate levels, as program evaluation needs dictate.
RI's also will assist the process of program management: directly through
personnel supervision and indirectly through better research relating service
inputs to outcome (s). Thus, supervision of counselors, could be enhanced within
RI usage systems that call for documentation of client data closely paralleling
39
the diagnosis-planning-implementation-monitoring process of counselor and client.
The supervisor and counselor both benefit when the information base on which
their interaction rests becomes a more valid reflection of service processes.
In terms of research focussed on the process of service provision, RI's provide
a basic tool for identifying the level of utility of specific rehabilitation
inputs in contributing to client outcomes among specific client groups.
Specifically some RI usage models will lend themselves to research analyzing
causal relationships within rehabilitation processes. When RI usage models in-
corporate the client change model described earlier (see PP. 18-22) and document
changes accordingly, they lend themselves to studies that, in lieu of control
groups, allow partial attribution of client change to rehabilitation system
efforts and services, narrowing ambiguities of interpreting results. Thus, the
model of service delivery and documentation rather than a research design based
on random assignment of clients to treatment and non-treatment conditions forms
the basis for exploring cause of outcome.
Finally, through an information base that is more valid, multi-dimensional
and more relevant, program planning focussed on allocation of resources should
be improved. This purpose directly derives from enhancement of program evaluation
and basic research described above. Such program planning will be improved to
the extent such decisions are based on documentation of effectiveness of services
and to the extent such documentation is enhanced.
C. Individualized Rehabilitation Planning
Certain RI usage models will enhance client participation in service planning
and service provision. Clients can contribute more fully through the generic
language aspect of RI's and through usage systems that encourage clients to state
their goals and problems in terms of observable RI descriptors.
Many usage models will assist counselors and other service providers by
increasing their effectiveness: in gathering and organizing relevant diagnostic
data, in interacting with clients in common language, in developing a plan of
services that evidences high internal consistency (goals correlated with objectives
which are correlated with services) and in documenting results in a style that
complements planning and monitoring.
In general RI's could be integrated into the client-service provider inter-
action in several ways, some of which are described below:
1. RI's could provide a 'standard list' of client elements (statuses,
activities, skills and environmental elements) that may prove useful
as a 'checklist' of crucial sets of variables that need to be considered
while developing a rehabilitation plan: in gathering diagnostic data and
in organizing and translating diagnostic and other data into a form useful
for communicating with the client and with referral agencies.
2. RI's can provide the behavioral, observable content from which suitable
descriptors may be drawn and formulated as goals and objectives.
3. The selected RI's can be used as indicators of change and of rehabilitation
outcomes. The client's progress can be recorded using relevant RI's during
the process of receiving services. This usage lends itself both to program
evaluation and to enhancement of tracking/monitoring purposes.
40
4. The selected RI's help focus the efforts of the counselor in contacting
referral agencies to obtain diagnostic data and feedback regarding progress.
Client-counselor interactions can also become more focussed, enhancing
client participation. Finally, follow-along services and follow-up studies
can also be focussed onto key client elements, defined by RI's.
When integrated into rehabilitation processes, RI's will address the purpose
of enhancing services, as described above. However, such integration is not a
necessary dimension of RI usage. The RI tool will lend itself to many models of
usage, including being used as a data collection device outside the planning,
delivery and monitoring process coordinated by the counselor. This latter model
could be applied to a sample of clients or to all clients who enter a rehabilitation
setting. Thus, a 'data specialist' could collect RI data to be fed back (or not)
into the client-counselor planning process and/or to be used for basic research
and for program evaluation.
D. Defining "Functional Limitations," "Disability" and "Needs"
In our conceptualizing of RI's, this project's framework (see pp. 23-30)
has come to include a conceptualization of "functional limitations, "disability"
and "needs"; the development of RI's addresses the operationalizing of these
concepts. The conceptual definitions of functional limitations and disability
outlined by Nagi (1975) 1 are similar in many respects to the definitions and
conceptualization offered within this proposal. Nagi defines functional limitations
as "the most direct way impairments contribute to disability" (p.2), and allows
that functioning may be limited at many levels (e.g., at the level of cells,
organs, systems, etc.). This project defines conceptually and offers a means for
operationalizing "functional limitations" only at the level of the organism. Also,
the RI Project focusses solely on organismic functioning that is "meaningful,"
e.g., "brushes teeth" not "flexes arm."
Nagi defines disability as follows: "Moving beyond the level of organismic
functioning to social functioning, disability can be defined as a form of inability
or limitation in performing roles and tasks expected of an individual within a
social environment. These tasks and roles are organized in spheres of life activit-
ies involved in self-care, education, family relations, other interpersonal
relations, recreation, economic life, or employment/vocation concerns" (p.2). In
a later chapter based on Moriarty (1975) 2 important implications of the definition
are detailed: (1) "Disability is relational: The definition is rooted in the person-
in-the environment. The relational or interactive character of a disability allows
for considerable fluidity since it is not exclusively a function of the intrinsic
attributes of the individual" (p. 15). (2) "Disability is a discrepancy
between individual performance and average expectable role performance it
is
possible to describe disability as norm-referenced" (p.15). (3) "Disability is
a consequence
to the existence of a physical or mental impairment" (p.15).
The conceptualization of disability developed within this project's activities
is compatible in many ways with these definitional comments. It is agreed that
disability is centered on the discrepancy between "roles and tasks expected of
an individual within a social environment" and the client's level of actual
functioning, that disability is relational and is "not exclusively a function
of the intrinsic attributes of the individual" and that disability is a consequence
of impairment.
1. Nagi, S., ibid.
2. Moriarty, J., op. cit., pp. 15-20.
41
However, in defining client social functioning as the locus of disability,
the idea that normative expectations provide the sole context for defining the
disability discrepancy, is not accepted. Equally valid for some purposes are
sets of individual client expectation or, in some cases, level of client function-
ing prior to impairment. It may be true that normative expectations would need to
be used for locating "the disabled" in the population; however, normative expect-
ations are not maximally or solely useful within the individual client's contact
with rehabilitation services. (See PP. 23-25 for a full discussion of "disability.")
How does one distinguish between "disability" and "functional limitations"?
First, both are consequences of impairment, but this project's conceptualization
would designate "function limitation" as a person variable (or "skill" deficit,
in terms of RI's) while "disability" is a behavioral variable and is a function
of person and environment. "Disability" is an outcome; "functional limitation"
is a mediator; there may be many functional limitations contributing to a
disability (see pp. 23-29). "Needs" are defined within this project's concept-
ualization at many levels of meaning (see PP. 25-29). Using RI's one can define
primary behavioral "needs" (e.g., employment, increased social contact) and
instrumental needs. The type of "needs" most usefully specified are those that
define instrumental skills and environmental elements that are needed in reducing
the "disability discrepancy" referred to above. These two sets of elements
(skills and environmental elements) are what the client "needs" in order to reach
goals set in the rehabilitation service context. Skills and environmental
supports are defined as instrumental to the client's goal attainment. "Needs"
are operationalized with instrumental RI's, defining what 'needs' to be obtained
if the client is to minimize his/her disability. This "need" level is most
useful in that it is the bridge between primary goals (e.g., employment) and
services (e.g., work adjustment training). Skill RI's would define the "functional
abilities" the client "needs" to acquire in order to reduce his/her"disability"
through attaining rehabilitation behavioral goals.
Status indicators and activity pattern indicators provide descriptors which
can be used both to define expectations relevant to functioning and to describe
actual behavior. These indicators are measurable, observable, and multi-dimension-
al, taking into account all categories of roles and tasks mentioned by Nagi in
his discussion of "disability" (self-care, education, family relations, other
interpersonal relations, recreation, economic life, employment/vocational concerns),
as well as transportation and political/legal activities. Thus, in operationalizing
disability the discrepancy between expected and actual functioning that defines the
level of disability would have two components: discrepancies in statuses and in
activity patterns.
Skill indicators and environmental indicators can be used to operationalize
client needs and functional limitations. Thus, operationalizing needs would
follow directly from operationally defining the client's disability: determining
the expectation/actual performance discrepancy ("disability"), which would be
used as the context to define skill and environmental needs to be addressed if
the disability is to be minimized.
E. Improving the Information Base for Eligibility Determination
RI's offer an approach to eligibility determination based on functional
assessment rather than use of medical diagnoses and/or services needed. Thus,
RI's could be used as presently constituted to explicate the person's disability,
limitations and/or needs; in the future, RI's could be used to predict type of
42
outcome from initial assessment data.
F. Other R & D Areas
In addition to the impact on R & D objectives described above, RI's may
have impact on other R&D objectives if adopted as a basic descriptive tool by
other researchers. With better descriptors of client capabilities, problems,
goals, outcomes, etc., being made available to researchers and planners, many
R&D objectives can be addressed better than with presently available tools.
43
3. PROJECT OBJECTIVES
A. Introduction
The overriding purpose of the RI project, which has guided Phases I and II
of its activities and which continues to serve as the overall target, is to
develop a basic tool that will have utility in several ways:
* enhancing accountability through the multi-dimensional definition of
rehabilitation outcomes in terms of four aspects of functioning,
improving processes for individualized rehabilitation planning, through
focussing on observable aspects of client functioning: problems, strengths,
objectives, goals; and by providing a common, non-jargon language for
clients and service providers/counselors.
defining "functional limitations," "disability" and "needs"- for
purposes of identifying the population in need, of differentiating in
the population levels of severity, and of identifying service needs for
individual clients.
improving program evaluation, planning and management through enhancing
the information base relevant to client functioning outcomes and services
provided to achieve such outcomes.
The operational objectives for Phase III of the RI Project (October 1979-
October 1982), are focussed on one key factor: optimizing utilization of RI's
in diverse rehabilitation systems by the end of Phase III, i.e., establishing
sufficient credibility, utility and momentum so that RI's will increasingly be
adopted for use by rehabilitation settings and researchers such adoption becoming
less dependent upon RI Project efforts.
To establish sufficient credibility, utility and momentum, project activities
will be aimed at two types of RI tool dissemination:
1. Demonstration models, in which RI's will be established in a variety of
rehabilitation settings, to be used in a variety of ways, with varying client
populations and to serve multiple setting purposes. Demonstration will
serve two major RI Project needs:
a. Enlarging the RI data pool to address issues of credibility (increas-
ing the methodological foundations of the instrument),
b. Evaluation of a variety of usage models, to enhance credibility and
utility of RI's by analyzing and verifying usage in a variety of models and
settings.
2. Research by others, in which RI's will be used by other researchers to
address their own research questions. The researchers will share their data
with the RI Project and will in effect be evaluating additional usage models.
Dissemination for demonstration and research purposes will address project
needs (a) to expand the number of settings using RI's (to increase awareness
and momentum), (b) to increase the utility of RI's by expanding the number of
tested usage models and by obtaining data to provide a basis for developing
44
second generation RI packages, and (c) to increase credibility through evaluation
of usage models and providing additional evidence regarding reliability, validity
and relevance criteria for RI tool development.
Thus, two interactive routes will be taken to optimize utilization: direct
dissemination and use of demonstration and research feedback to improve product
credibility and utility.
B. Operational Objectives
In order to optimize future utilization, several objectives will be addressed:
1. Demonstration: RI tools, guidelines and training programs will be
disseminated to rehabilitation agencies:
*to expand awareness of and use of RI's,
*to evaluate the impact of RI use on agency parameters (which will
specifically be a function of the usage model established),
*to provide feedback to the RI Project in the form of client RI data,
*to create usage models of wide applicability to other settings, and
*to identify factors necessary to maintain the use of RI's in varying
usage models.
Demonstrations will be designed to fit usage models that are expected
to be widely applicable to other settings. Usage model variables are
outlined in Table 2, pp. 34-36. Two sets of variables are outlined:
exogenous and endogenous. The former are variables describing the situation
into which RI's will be placed:
*Will RI's be used with clients or not?
*Will RI's be used in rehab service settings or not?
*
Type of setting
Usage constraints
Users of information
Endogenous variables describe how RI's are to be used within a given situation:
*Parts of the RI tool used
*Data collection methods
*Data reduction methods
*Uses for RI data
Given these sets of variables, usage models will be developed to be
broadly applicable to the rehabilitation field. Thus, emphasis will be
focussed on models where RI's are used with clients and within settings
(as opposed to non-setting or non-client models). Models will be established
in a diversity of setting types (with at least one state agency and at least
one non-state agency setting, e.g., independent living, medical rehabilitation,
etc.), minimizing contraindicative usage constraints (e.g., low receptivity
among potential utilizers), and serving a variety of information uses (e.g., at
45
least one setting where RI information will be used in client planning
will be selected). Depending on the exogenous and endogenous variables
within specific demonstration settings, evaluation of RI use will explore
the following types of issues:
a. Influence of RI usage on the accountability of rehabilitation
settings:
1) Increased accountability regarding the access of clients
to rehabilitation settings. Service providers can describe
with sufficient specificity the types and severity of disability
of clients who gain access to rehabilitation services and those
who fail to gain access.
2) Increased accountability regarding outcomes of rehabilitation.
Service providers will increase their specificity in describing
observable, multi-dimensional outcomes of rehabilitation (primarily
in terms of goal attainment and sub-goal attainment).
3) An expanded information base for accounting for access and
outcome will also be available to service providers for improved
decision-making at many levels: client and counselor development
of individualized plans, program planners' and evaluators'
formulation of program modifications, and funding sources'
distribution of resources.
4) More precise definition of the relationships between rehab-
ilitation inputs, services and outcomes will be developed using
RI's as a tool to improve decision making.
b. Influence of RI usage on the provision of rehabilitation services:
1) Access of the severely disabled to rehabilitation settings
should be improved, with development of more specific accounting
for access in terms of severity of disability (defined functionally).
2) Individualized planning should become more systematized through
the usage of RI's as an information base for goal selection, for
defining goal-relevant client needs, for setting environmental
and skill sub-goals and for tracking client progress; follow-up
of progress and needs once clients leave active participation in
rehabilitation should be improved using RI's.
3) Enhanced speed and coordination of services, through more
systematic initial planning and tracking of progress.
4) Greater satisfaction of the client and counselor, through
usage of RI's.
C. Influence of RI usage on outcomes of rehabilitation services:
1) The congruence between input/process variables and outcomes
should be increased, given the enhanced RI information base and
a more systematic individualized planning process.
2) The range of goals that is accepted as valid by rehabilitation
systems can be increased to include statuses and activity patterns.
beyond the presently accepted (within the State-Federal VR system),
46
but limited, vocational statuses.
3) Longer maintenance and greater advancement of outcomes of
rehabilitation programs can be attained to varying degrees,
given enhanced planning and optimal implementation of follow-up
mechanisms based on RI's.
2. Tool and Package Refinement: RI materials will be refined to enhance
their credibility and their utility within a variety of usage models:
a. Separate status, activity pattern and skill packages developed
during Phase II will be refined; additionally, all packages will be
integrated into a second generation package of all sets of RI's to
be used concurrently.
b. Training programs appropriate to each RI package will be refined
to better address the needs of varying levels of utilizers.
C. As data are obtained and analyzed (from clients of multiple rehab-
ilitation settings and from normative samples), second generation
indicators will be derived from the present RI descriptors, reflecting
(1) the differential relevance of subsets of RI's for describing
outcomes for selected groups of clients and (2) underlying factors in
changes occurring within descriptor sets.
d. Environmental indicators will be developed to fit criteria utilized
in developing other RI's (i.e., observable, potentially changeable,
relevant to client functioning and meaningful). EI's will be developed
into a separate first generation package and then integrated into the
second generation combined package.
e. As second generation indicators and second generation packages of
indicators are developed, they will be disseminated as described in.
objectives#1 and #3.
f. Models for data analysis and for use of RI's as a mode of communication
will be refined and incorporated into the RI packages.
3. Dissemination: Awareness of RI's--what they are, their potential uses,
and results of field usage--will be expanded throughout the rehabilitation
field (among consumers, counselors, administrators, evaluators, researchers,
educators, funding sources, etc.). Several strategies will be used to
address this objective:
a. A project newsletter (RI Update, see Appendix X) will continue to be
mailed to a wide variety of interested persons, being specifically
focussed on evaluators, administrators, researchers, educators and
consumers.
b. Presentations and publications will be expanded and targetted for
varying audiences: rehabilitation counselors, researcher evaluators,
consumers, and administrators.
C. RI packages will be disseminated to independent researchers for
their use; such researchers must agree to use RI's according to project
47
guidelines and to share resultant data with the RI Project; the
researchers will receive consultation from a project consultation
team, as needed, and will be encouraged to publish their results.
d. Workshops will be offered near the end of Phase III to teams
of agency representatives, where team members represent the key
persons in usage models focussed on in the workshop. The workshops
would be designed to share sufficient RI information with the teams
to create a demand for adopting RI's in the agency. Workshops would
be followed by appropriate Project consultation to assist the adoption
and utilization process in agencies.
4. Defining "Disability" and "Needs"
Use of RI's for defining disability functionally will be evaluated,
in conjunction with the development of second generation (derived) indicators.
Disability-relevant, factored indicators will be used with clients to describe
disability--to analyze the utility of the RI approach compared to other
non-functionally-oriented methods (e.g., medical diagnosis).
48
4., 5. WORK PLAN AND METHODOLOGY
A. Introduction
The purpose of this Section is to define, as far as possible, the RI
Project's strategy for addressing its Phase III objectives and approaches
for implementing the strategy. It is not possible at this time to define
all the tasks needed to address the objectives, the appropriate sequencing
of tasks and methods applicable to tasks, because during Phase III the
nature of demonstration activities will be contingent upon which models of
usage are negotiated through Project/field setting interactions. The Project
is not proposing to evaluate pre-specified designs for using RI's, but
instead to evaluate several usage models (see pp. 34-36). "Usage models"
refers to an approach for using RI's that is setting-specific. Therefore,
tasks needed to implement usage models will be specific to each model. This
provides field settings with the opportunity of aiding in the design of
demonstrations insuring that each demonstration is constructed to fit spe-
cific sets of needs/concerns that arise in the field.
The Project's stance is that developing a pre-conceived research plan
would constitute a weakness in project design and would be counterproductive
in addressing the goal of enhancing future utilization. In our encounters
with field settings, it has been our experience that they "turn off" when
they are asked to march to a researcher's drum; however, when we've incor-
porated into RI usage the setting's needs, data gathering approaches, and
resource constraints, the RI product has been accepted and found useful.
In this proposal, therefore, the issue of a priori "looseness" in being able
to specify tasks and methods has been addressed in three ways, development
of: (a) strategies to accomplish project objectives, (b) using a consultant
and review panel mechanism to monitor strategies as they evolve during
Phase III into specific task-anchored plans and (c) specification of tasks
in those activity areas where such detail is possible.
B. Core and Modular Activities
Given the basic objective of Phase III -- demonstrating the utility
and enhancing the credibility of RI's, to optimize future utilization --
and given the numerous usage models which might be demonstrated, it is clear
that the RI Project cannot implement all important or all possible
demonstrations. If this approach had been chosen, the Project would have
had to establish ten or twenty demonstrations before a broad enough sample
of usage models would have been demonstrated; however, each such demon-
stration will require significant staff resources to establish, to monitor
and to process data emanating from it. Ten or twenty demonstrations would
require a huge staff. Therefore, the Project developed the strategy pro-
posed herein: core and modular activities, with core and modular staff.
Core activities will include (1) establishing several demonstrations,
the number to be limited by staff resources, (2) refinement of the three
types of RI's that have been developed and (3) implementing basic dissemi-
nation activities. Modular activities are those which are equal in impor-
tance to core activities (e.g., development of Environmental Indicators),
49
or of lesser priority (e.g., offering workshops to enhance utilization)
or are demonstrations beyond the number that can be handled by core staff.
The defining characteristic of modules is that the funding of each is
separable from the core: each module can be attached to the core to add to
the total Project effort, but the modules are not necessary to the basic
effort.
The core-and-modules strategy provides a dual advantage: (1) it will
allow the Project to request funding in a way that allows the funding agency
to view the Project as a whole, but fund only those aspects that fit its own
priorities and (2) the Project can phase in as it progresses through Phase
III additional modules of activity -- as new modules are funded or as core
resources are freed up from completed tasks.
C. Expected Progress; Project Staffing
Three inter-related areas of activity will be implemented during Phase
III: demonstration, tool refinement and dissemination. Some general
comments are required before proceeding to discussion of tasks and methods.
First, we need to clarify what project progress is expected prior to
Phase III, in the remaining months of Phase II.
1. A plan, based on a literature review and the canvassing of a Task
Force, will be written regarding development of Environmental
Indicators.
2. Demonstration and dissemination plans will be updated, to reflect
continuing field experience and results of RI data analyses (exploring
validity and reliability issues).
3. Packages of RI's will be produced, in a state ready for intro-
duction into settings for demonstration purposes. Packages will con-
tain the RI tool, guidelines for data collection, simple training
materials and discussions of data analysis as it affects users of
RI's. Separate packages for status, activity pattern and skill indi-
cators, respectively, will be developed, based on the material in
Appendices I-V, but revised in accordance with results of present
field test activities. Each package will be professionally designed
and printed.
Second, the role of respective staff members in implementing Phase
III project activities needs definition:
1. The Project Coordinator (Brown) will be responsible for coor-
dinating and supervising all project activities; this includes the
activities of the Data and Field Coordinators. She will be respon-
sible for negotiating with field settings to establish demonstration
projects and for designing suitable usage models and evaluation
plans relevant to demonstrations. She will be responsible for dissem-
ination activities: coordinating consultation provided to independent
RI users, publication of the RI Update and development of articles and
reports for publication. Finally, she will be responsible for
revising and refining RI materials, coordinating input from the field
and from data analyses. The Project Assistant (Fabian) will assist
the Coordinator in these activities.
50
2. The Research Supervisor (Gordon) (20% time) will serve in the role
of advisor to the Project, Field and Data Coordinators. His responsi-
bility is in the area of research design and data analysis -- insuring
that demonstrations are appropriately designed to address cogent issues
and that data analysis proceeds smoothly and competently in supporting
the Project's objectives. He will conceptualize data analytic questions
and decide appropriate modes of statistical analysis.
3. The Data Coordinator (Farber) will be responsible for all RI data
analysis. She will be responsible for translating project objectives
into data analytic strategies, including assisting in the design of
demonstrations and independent research efforts. She will be responsible
for monitoring incoming data to insure quality control and for providing
feedback to the Field Coordinator. She will be responsible for pro-
viding appropriate input to the Project Coordinator's revision of RI
materials and will assist the Coordinator in concept development and
report writing. She will be assisted by the (half-time) Data Analyst
(Buccheri) who will primarily be responsible for computer programming
and other aspects of data analysis; additional assistance will provided
by two Data Assistants one hired on a consulting basis at the start
of Year 1, the second as a staff member at the start of Year 2.
Consultation will be provided by the Computer Consultant (Lucido) and
by the Research Supervisor.
4. The Field Coordinator (TBH) will assist the Project Coordinator
in establishing demonstration activities and in consultation to inde-
pendent researchers. He/she will be responsible for liaison with
all settings using RI's -- monitoring progress, problems and needs.
He/she will be responsible for training staff of settings to use RI's
and for development and revision of educational materials. The Field
Coordinator will be assisted by a Project Assistant (TBH). Consul-
tation on training and educational materials development will be pro-
vided by the Training Consultant (Randolph).
5. The Secretary (Harris) is responsible for arranging project
meetings and for staff travel, implementing financial aspects of the
project, typing reports and project correspondence, assisting project
personnel in literature reviews and maintaining the project
bibliography.
D. Core and Modular Activity Areas
With these comments regarding general strategies, expected progress
and project staffing, the context has been laid for indicating the activi-
ties that are planned in Phase III to carry out project objectives. The
Project activities can be categorized in terms of core and modules and in
terms of three areas of emphasis: demonstrations, dissemination and RI
refinement. The resulting six categories are presented in Table 3 and dis-
cussed below.
1. Core Demonstration Activities
A six-step process is envisioned relevant to establishing each
demonstration site: negotiation, plan development, plan review,
training, implementation and evaluation. The process is viewed as
cyclic, with negotiation initiating the sequence and also a logical
sequelae of the evaluation phase.
CORE
MODULES
D
E
--Usage Models/Demonstrations:
--Usage Models/Demonstrations:
M
0
1-State-Federal Agencies
1-Additional demonstrations beyond core
2-Private facilities
resources
N
S
2-Computer-based usage
T
3-Using RI's to define "disability," "needs"
R
and "functional limitations"
A
4-Use of RI's in Rehabilitation Counselling
T
programs
I
o
N
D U
-Disseminating RI's to independent
--State Agency Advisory Committee
I T
utilizers, with consultation
S I
-Dissemination - utilization workshops
S L
-Publications ) Basic concepts and
E I
-Presentations. usage models
-Educational program development
M Z
I A
"RI Update" newsletter
N T
A I
--Utilization and Advisory Committees
T 0
I N
o
N
T R
--Status, activity pattern and skill
--Environmental Indicators development
0 E
packet refinement
0 F
L I
-Integration of RI packets
N
E
--Training program refinement
M
E
Data reduction and communication
N
approaches
T
-Second generation RI's
TABLE 3: Phase III Activities
51
52
In preparing for Phase III, two types of settings have been the
focus of negotiations: State-Federal Vocational Rehabilitation
agencies and private facilities. At this point the RI Project is in
the discussion stage with many settings, attempting to develop usage
models that will optimally address Phase III objectives. Our primary
criteria are selecting settings where results of demonstrations will
be applicable to many other similar settings and where potential
utilizers indicate a cooperative spirit at the outset. (It's impor-
tant eventually to address the issue of rehabilitation personnel who
are resistant to using RI's; but addressing this issue at the outset
of demonstration activities seems a poor strategy.)
In attempting to establish demonstrations, we have adopted a
strategy of both responding to contacts initiated by settings and
initiating the contact ourselves. In negotiating with the setting
we state very carefully that we are there to learn what their problems
and needs are in order to design a usage model that will address
setting needs as well as Project objectives. We offer to assume costs
of training, materials, liaison and data analysis for defined (and
limited) usage models in a defined number of settings, clearly indi-
cating that any expanded usage may require the setting's allocation
of resources or the necessity of requesting additional modular funding.
The following is a summary of negotiations up to this point; in
Appendix XVIII, correspondence is included that refers to planning for
future demonstrations.
a. State Agencies: Project staff have met with representatives
of central and/or area offices in Ohio, New Jersey and New York.
In each case several specific ideas have been suggested by the
agency staff and/or administrators regarding possible usage
models and discussed in these meetings. The correspondence to
Roland Sturm (NY DVR), George Chizmadia (NJ DVR) and Mary Nies
(Ohio DVR) in Appendix XVIII incorporates these ideas. However,
they are summarized here to make a point: negotiation has been
an experience of expanding awareness of new ways RI's can be
used -- field personnel have stimulated thinking about how their
needs can be addressed with RI's in novel ways; they have seen
avenues of use and possibilities not previously identified:
1) Analysis of the relationship between RI use and two
approaches to counselling: counselling by objectives and
other. RI's could be used by both types of counsellors;
also included in the research would be a control group
not using RI's.
2) A similar study would focus on the relationship of
RI use or non-use to two other styles of counselling:
counsellor-as-coordinator of services versus counselling
with emphasis on counselling.
3) Using RI's to evaluate SSI/SSDB screening results:
to explore client variables that predict successful
rehabilitation.
4) Use of RI's by counsellors who work with developmentally
disabled persons entering the process of deinstitutinnal-
ization.
53
5) Use of RI's in setting S with multidimensional goals,
such as work activity training centers.
6) Use of RI's to study "homemaker" closures, to define
what gains have been made that would justify a "26 closure."
7) Use of RI's to help define job readiness.
8) Finally, a use mencioned most frequently is use of
RI's by counselors in general offices -- to help improve
client planning working in some settings toward a
computer-based usage model.
With each agency contacted, the agreement has been reached
that the agency and Project continue discussions, leading toward
demonstrations being established, if the respective needs of the
state agency and the RI Project can be incorporated into a usage
model plan and if state agency staff agree to participate (in
Ohio, agency staff initiated contact and, therefore, this latter
requirement has been addressed). In all cases, the possibility
of usage models being implemented appears quite high, in terms
of positive reactions of those participating in the negotiations.
b. Private Facilities: Several private agencies have expressed
interest in using RI's; however, meetings leading toward the
establishment of demonstrations have not yet commenced. Repre-
sentative letters of inquiry are presented in Appendix XVIII.
These settings may be dealt with in one of two ways: (1) pro-
viding consultation to them to establish usage of RI's within
their own design for research or service provision (see Core
Disseminations below) or (2) establishing a demonstration where
the design would constitute a usage model, where RI Project
interaction would be more intense and where the RI Project would
retain greater control of data analysis. In any case, if RI
use is established, settings will be required to feed back to
the RI Project RI and other relevant data.
In order to explore other setting's interest in using
RI's, the Spring 1979 "RI Update" (to be mailed on April 30)
will request settings which have interest in possibly becoming
a demonstration setting to contact the Project.
The purpose of the negotiation step is to see if sufficient
interest exists on the part of the setting and the Project to
continue the process, to clarify what RI's are (and are not),
to discuss possibilities for usage models and to define areas of
mutual and separate responsibility if a demonstration
materializes. If both parties agree to continue, plan develop-
ment follows.
The second step of the process is plan development, an
interactive process between the RI Project and field setting.
Each plan will have three segments: usage model specification,
RI evaluation and agreements. The usage model segment will
specify each of the endogenous variables listed in Table 2,
p. 35: what part of the RI tool will be used, how and by whom
will the data be collected, how will data be analyzed and to fit
what purposes. The RI evaluation segment will define relevant
54
questions concerning evaluation of RI use and its impact on
setting processes, outcomes, etc.. A sample of relevant concerns
is provided in the Phase III Objectives, pp. 45-46. The
evaluation segment will also specify methods that will be used
to address the questions. The third segment of the plan,
"agreements," will clearly describe (1) the calendar of events
including when the demonstration can be expected to start and
RI project involvement terminate, (2) the nature and timing of
training, (3) the nature and frequency of project and setting
liaison, (4) how RI data will be analyzed and fed back to the
setting, (5) how results of the demonstration will be published,
(6) costs to be assumed by each party, (7) processes to nego-
tiate changes in the plans and to negotiate expanded use, (8)
the location of offices and names of staff to be involved in
the demonstration, etc..
The plan will be written by RI project staff after the
groundwork is laid in planning sessions with relevant setting
staff (counselors, supervisors, administrators, etc.) and in
direct observation of present operations. The plan will be
signed by representatives of the RI project and the field
setting.
The third step is Plan Review. At least three members of
the project's Utilization Committee (see p. 85) will be asked
to review the plan. Each member of the review panel will discuss
the plan with project staff and then provide written comments
(critique and suggestions).
The fourth step is training of field setting staff to use
RI's. Project staff will be responsible for this aspect of the
demonstration. We expect to use the Training Consultant to
identify training issues (during the plan development phase),
guide the development of appropriate materials, and implement
a training program. She will be assisted by the Field Coordi-
nator and/or Field Assistant and will phase herself out of
direct involvement as project staff can assume more training
responsibilities. Training will continue, as needed, during
the implementation phase, and is discussed below.
The fifth step is implementation of the plan. Setting
staff will pre-test RI use and with RI staff decide what modi-
fications are needed. Once the usage is stabilized project-
field interactions will occur as defined in the plan; additional
training will be provided by the project if during the liaison
process additional needs are identified. Also, as RI materials
are refined by the project, they may be offered to the setting
for use, if suitable.
The final step of the first iteration is evaluation.
The RI project will gather relevant data into a demonstration
report; the report will identify the number of clients and
providers involved, the uses of data, problems encountered, the
impact of RI use on setting parameters, etc.. This information
will serve as the core of concern in an evaluation meeting
between project and setting staff; the meeting will be used to
55
come to final conclusions and suggestions regarding the
demonstration. If the situation warrants, it will also serve as
the first step (negotiation) of a second iteration of inter-
action between the project and setting. The result of the
meeting will be a written description and evaluation of the
demonstration which may be suitable for publication.
In the core aspect of project activites, a minimum of two
demonstrations will be established, with the probable number
being four or five. The number will be increased past two until
core staff resources are fully engaged; additional demonstrations
would then be developed only as additional funds are acquired.
For those field settings expressing interest in using RI's above
and beyond the core, two avenues of response will be available:
developing modular proposals for funding as a demonstration, or
the project providing consultation on use of RI's as an indepen-
dent effort -- both of these options are discussed below.
2. Modular Demonstration Activities
As discussed above, any demonstrations above and beyond the
number feasible within core resources will be funded as separate
modules. One usage model that intrinsically is beyond core resources
is development of computer terminal-based RI use in a service setting.
Establishing such a demonstration would require modular funding.
Demonstrations to be included in the core will focus solely on
usage models where the exogenous situation (see pp. 34-36) is defined
by client involvement in rehabilitation settings. Modular demon-
strations, on the other hand, may be developed that include non-
rehabilitation setting use (e.g., in educational program models of
usage) and/or uses where clients are not involved in data gathering
(e.g., specification of eligibility requirements). In this vein,
demonstrations to address the objective of defining "disability" and
"need" functionally will only be developed through modular funding. 1
3. Core Dissemination/Utilization Activities
Two aspects of dissemination will be emphasized: disseminating
the RI product and the RI concept. (See also pp. 61-63 for a dis-
cussion of dissemination/utilization strategies.)
First, RI's will be disseminated to the demonstration setting
as defined above, but also to other researchers and service providers.
These "independent" users of RI's will include some of the present
field test settings that are to continue using RI's (see Table 1,
pp. 3-5) as well as other settings (see Appendix XVIII for some
potential sites). The independent users will follow this avenue of
involvement rather than becoming demonstrations, if establishing and
evaluating the desired usage model is of lesser priority for the RI
project. For example, evaluation of a usage model that gathers data
from clients solely for purposes of program evaluation is not the
highest priority to the project since many such models have been
established and studied during Phase II as part of field testing.
1. The project is also willing to work with state comprehensive rehabilitation programs
in those states interested in I & E development in the RI area, and with other
types of programs in the State-Federal vocational rehabilitation system.
56
The process for establishing RI use with independent users will
be a less time consuming and detailed process than for setting up
demonstrations. Negotiation will largely occur by letter and
telephone. Then the project will provide consultation to the potential
user to develop a plan for use, incorporating many of the points dis-
cussed above, but less formally defined. The plan will focus on the
usage model specification and on agreements about data sharing (which
all RI users must agree to) and publication. The "evaluation of RI
use" plan segment may be developed (or not) but implementation will be
the responsibility of the user not of the project.
If appropriate, training will be provided by the project. During
implementation, RI field staff will maintain liaison largely to monitor
data collection and for trouble-shooting. The product of the dissemi-
nation to independent users will be project and/or user publications
(focussing on or methodologically highlighting RI's) and data, to be
fed into RI tool refinement (see below).
The second aspect of dissemination centers on dissemination of
the RI concept and of evidence regarding use of RI's. Several paths
will be taken here, some aimed at expansion of the level of awareness
and knowledge in a broad cross-section of the rehabilitation community
and some aimed at selected subsets within the community. For example,
in April 1979 a project manuscript was mailed to Evaluation; the paper
(see Appendix XIX) describes the project in general: its historical
context, purposes, product, uses, etc.. This paper is aimed at a
general audience and will be revised to fit other audiences (e.g.,
rehabilitation counselors). Several other papers are presently being
written: descriptions of the client-change model, the accountability
model, and (from field testing) results of the deinstitutionalization
program evaluation (see Appendix XIII), the SCI National Center field
test involvement and the study of pain patients and spouses at the
University of Washington. Now that RI materials are ready for demon-
stration and dissemination to a wider audience, dissemination of the
RI concept to a wide audience through expansion of presentations/
publications has been planned, during Phase III.
An important step will be taken to develop publications suitable
to a rehabilitation counselling/state agency audience:
Members of Project Committees who can "speak the language" of this
large target audience will be asked to co-author relevant papers and
will also be used as co-presenters of papers and talks to relevant
groups (e.g., CSAVR).
Another path to dissemination of the RI concept is the "RI
Update" (see Appendix XII). The project newsletter began publication
in January 1979, with the second edition being mailed on April 30.
It is sent to approximately 1,000 persons, primarily administrators,
researchers, evaluators and all persons who have previously expressed
interest in the project. In the present issue, requests are made for
consumers who wish to be placed on our mailing list, for persons
interested in participating in the Environmental Task Force and for
settings/individuals interested in exploring use of RI's as
57
demonstrations or independent users. Each issue of the RI Update
(four per year) will report on project progress, on availability of
RI materials or other avenues for dissemination and will also discuss
aspects of the RI concept (e.g., how RI's can improve IWRP formu-
lation, how RI's can help in client-counselor and counselor -other
rehabilitation professional communication processes, etc.).
An important activity especially with regard dissemination
and utilization will be the yearly convening of the project's Utili-
zation and Advisory Committees. Each group reviews project progress,
plans and materials to provide a broad-based critique of our course
of action. (Both groups met in recent months, in fact, to provide
advice and suggestions relevant to this proposal's development.)
4. Dissemination/Utilization Modular Activities
Activities defined as modular here are those utilization/
dissemination efforts beyond the basics described above and for which
funding is separable. Three activity areas have been defined at this
point:
First, many issues relevant to dissemination/utilization of RI's
in the State-Federal VR system have arisen in project discussions
since its inception. Although, representatives of several state
agencies sit on the project's committees and task forces, a broader
degree of input will be useful. The project will develop a modular
proposal to request funds to support meetings of a State Agency
Advisory Committee. Ten to fifteen counselors, supervisors and
administrators would meet twice a year to provide input of several
types: (a) general advice relevant to use of RI's in state agencies
(e.g., strategies of approach, possible usage models), (b) how to
create a demand for RI's among counselors and ways the project can
support their attempts to get RI's installed in their agencies, and
(c) critique of RI's as they évolve into derived "indicators" " --- such
critique would be viewed as part of the validation of the degree to
which the derived "indicators" are indicative of meaningful rehabil-
itation progress, from the point of view of experienced service
providers. 1
Second, toward the end of Phase III, to enhance utilization in
selected types of settings, a workshop or series of workshops will
be presented, if modular funding is obtained. Teams of personnel
(e.g., supervisor and counselors, medical rehabilitation teams, etc.)
would be brought together to learn RI usage, benefitting from results
of demonstration and independent use.
Finally, funds will be sought to support the Training
Consultant's producing videotape educational and training materials
for use in state agencies and other settings. These materials, like
the workshop described above, will be distillations of Phase II and
III field experiences.
1. The Project would request assistance of CSAVR in selecting the Committee.
58
5. Tool Refinement: Core Activities
Efforts will be focussed to utilize the large amounts of data
generated in demonstration and independent settings to enhance the
acceptability, and credibility and utility of the RI materials.
Acceptability will be addressed through developing better, less
time-consuming training materials, partially as a function of simpli-
fying RI's per se and partially through using a professional
consultant. Acceptability will also be the key factor in analyzing
RI's to produce better branching systems: to reduce the time needed to
gather data from clients.
Credibility will be addressed through expansion of a criteria
referent system, whereby subsets of RI's will be correlated with other
types of measures (e.g., measures of affect, ADL scales, etc.) to
create a set of anchors of the meaning of RI's. As far as possible,
with core limitations, some RI norms will also be obtained to provide
an additional "layer" of meaning to RI assessment. Increasing the
credibility of RI's is also the purpose of continuing efforts to
increase our knowledge of factors influencing reliability of data-
gathering; project staff also will continue to refine training
programs to address problems that reduce reliability of measurement.
Finally, extensive data analyses have commenced in Phase II (see
pp.
) to study aspects of validity, particularly the sensi-
tivity of RI's to detect change and other types of expectable dif-
ferences in client functioning (e.g., differentiating between types
of disability and between levels of severity).
Utility of the tools will be the focus of a major portion of
tool refinement efforts. The development of an RI package that
integrates all four types of RI's will add greatly to tool flexibility;
development of the integrated set will be based on experience in demon-
stration settings with integrated use. Tool utility will also be aug-
mented through deriving second generation indicators from the simple
descriptions. This development will be a function of obtaining a
large amount of data on diverse populations which can then be sub-
mitted to factor analytic approaches. Development of second gener-
ation indicators will also simplify data reduction and communication
aimed at those outside the client-counselor interaction: present RI's
communicate easily when used by clients and service providers but more
clumsily serve in the role of communicating to outsiders. Derived
indicators will contain larger clusters of meaning and, thus, hold.
promise to be more useful than simple descriptors in conveying
patterns of outcome.
6. Tool Refinement: Modular Activities
A key component of functioning rests in the environment. Envi-
ronmental Indicators are the part of the RI tool that recognizes
this fact. Their development is essential -- to complete the RI
product, but more importantly to insure within the RI tool a set of
indicators that point to the environment's contribution to disability
and rehabilitation. EI's provide a necessary counterpoint, balancing
59
the attention to client factors with factors outside the client.
Inclusion of EI's in an accountability system is necessary if service
providers are to be given adequate credit for their efforts to change
the environment's contribution to disability. Also, service providers
need reminders of the multiple environmental factors -- physical,
social and programmatic environments -- that influence the client's
attainment of goals.
In Appendix VII a modular proposal is presented requesting funds
and outlining tasks for this aspect of tool development and refinement.
60
6. UTLIZATION PLAN
A. Expected R & D Product
The RI Project's expected product has been described extensively
throughout this proposal. In sum, the Project's product consists of RI
packages, the concept of usage models -- with several tested and evaluated,
and the project framework.
RI packages are expected to evolve throughout the course of Phase III;
initially packets will contain single indicator sets (e.g., skill indicators
only), where the "indicators" are really "descriptors" that infer or
"indicate" very little beyond what is directly described. As experience is
gained in using RI sets together, more refined RI packages will be developed
that integrate the indicator sets. Finally, by the end of Phase III,
sufficient data should be available so that derived, second generation indi-
cators can be produced; these "indicators" will be composites derived from
the first generation descriptors. Both types of RI's will, we believe, be
useful in different usage models. As RI packages evolve, the new (and old
versions, as appropriate) will be phased into dissemination.
RI packages will contain not only RI's per se, but also guidelines
and other training materials; these materials will vary according to the
usage models into which RI's are placed.
The concept of usage models is a key aspect of the expected product.
This concept emphasizes flexibility of using RI's and that RI usage
(endogenous variables) is a function of setting variables (exogenous)
(see pp.34-36). This is a crucial point: RI usage in each specific situ-
ation is a function of many variables in the situation; within limits RI's
can be "custom fitted" by the utilizer. The listing of exogenous and endo-
genous variables in Table 2 lists the a priori dimensions of situations that
will affect usage, as well as the dimension of usage per se. Thus, "usage
models" is not an empty concept; the important parameters have been hypo-
thesized and are being explored in Phases II and III to evaluate their
respective influence on usage models.
Not only is the concept of usage models important to the RI product,
but also the demonstration and evaluation of several models is a keystone
of the utlization plan (see below). The project principals believe it is
of highest priority to provide evidence of "good" usage with positive pay-
offs to participants, for the obvious reason that such evidence will lead
to greater utlization, but also to establish positive models for rehabil-
itation settings to emulate -- the "good" models providing necessary and
hopefully sufficient guards against users developing less beneficial usages.
Any tool can be used to the detriment of those it is supposed to help,
RI's included; strong usage models that are beneficial to participants should
help avoid the inappropriate use of RI's.
Finally, the Project Framework completes the RI product. The Frame-
work points toward approaches to enhancement of accountability, to defining
61
"disability" and "needs," to provision of more focussed client services,
and also points toward systematic concepts regarding client functioning
and how change in functioning can be more precisely conceptualized and
measured.
B. Target Groups
Two sets of target groups are envisioned as the eventual utilizers of
RI's. (For an expanded discussion of usage, see pp. 12-36 and pp. 38-42
1. Resource providers
Clients of multiple types of rehabilitation settings in all
disability categories (i.e., sensory, physical, psychiatric and deve-
lopmental disabilities) are included in the target group. It is
expected that the use of RI's by consumers can be either setting-based
or occur outside the context of rehabilitation service provision
(e.g., in consumer surveys of "needs"). The market, using SSA's esti-
mates of disability would be 23,000,000 disabled adults (plus an un-
specified number of disabled children).
The second set of resource providers includes legislators and
others who provide resources to rehabilitation systems.
2. Service providers
Direct service providers, funding agency personnel, and service
planners constitute the second target group. Rehabilitation settings
would include State-Federal VR agencies, independent living settings,
private medical rehabilitation facilities, psychiatric hospitals,
mental health centers, work evaluation centers, workshops for the
disabled, services for mentally retarded persons, etc.. Estimates of
the size of this target group have not been developed.
C., D. Dissemination and Utilization
(See pp. 51-57 for additional discussion of approaches to dissemi-
nation and utilization to be taken by the Project during Phase III.)
Throughout the course of the RI Project, development, dissemination
and utilization have been intertwined concerns. Each area of concern has
been differentially emphasized from Phase I to Phase III, but each has been
influenced by the others. Because utilization of RI's within rehabilitation
settings will require changes in service delivery, service planning and
accountability/evaluation processes, the amount of inertia to be overcome
is large. Thus, at the beginning of Phase I the authors of this proposal
felt that if RI's were to be adopted, development of the product and its
dissemination would need to be heavily influenced by future concerns of
utilization. Similarly, because utilization will require change within
systems, dissemination needed to be carefully planned. Four overlapping
themes have been and will continued to be carried out: (1) inclusion of
62
representatives of the rehabilitation community in all phases and aspects
of project functioning, (2) design of a product to maximize future utili-
zation, (3) development and implementation of a strategy to disseminate the
project concept and project materials, and (4) development and implementation
of a strategy in Phase III to optimize future adoption of RI's.
First, members of the rehabilitation community have been active parti-
cipants in all phases of project activities. The 75+ members of the project
task forces and committees (see pp. 83-89) helped develop the structure and
elements of RI's. (The Environmental Indicators Module -- See Appendix
VIII -- proposes to utilize this process to assist in developing EI's). Not
only in terms of helping the development of RI's but also in terms of
advising the project regarding utilization and dissemination, these repre-
sentatives of multiple viewpoints in rehabilitation have been and will con-
tinue to be crucial to the project's success -- the proposed State Agency
Advisory Committee (see P. 57 ) is an ongoing part of this aspect of
insuring involvement. Additionally, the project will have during Phase III,
in its Utilization Committee, not only a forum to continue to spell. out
strategies and priorities for dissemination/utilization, but also a larger
body of field representatives to act as reviewers of specific demonstration
plans. The Advisory Committee plays a strong part in evaluating project
progress. A newly evolving role has been defined by the project for reha-
bilitation setting personnel who become involved in using RI's: defining
them as "partners in design" of appropriate usage models and "fellow problem
solvers" with regard to improving the RI package. Our message to users is
that although project personnel work full time on RI's and therefore may
"know" more about them, setting personnel who use them with clients gain a
complementary form of expertise -- their sharing their ideas, reactions
and suggestions with us is their contribution to improving and evaluating
RI's. In all of these efforts, the RI Project's goals have been to benefit
from the point of view of diverse rehabilitation "insiders"; to insure the
field's perception that they, too, have been part of RI's; and to expand
the field's awareness about RI's through word of mouth of those who have
had direct contact with RI's.
Second, the RI product has been shaped by the diverse input described
above, to better fit the diverse needs of diverse settings. The concept of
a flexible RI tool set within an appropriate usage model was developed to
enhance potential utilization.
Third, a dissemination strategy has evolved that attempts to optimize
future utilization, while recognizing project constraints -- especially in
terms of speed of progress in developing RI's and limited project resources.
The project has tried to avoid disseminating the RI concept too far in
advance of the RI materials' being sufficiently developed to "make good" on
the promises intrinsic in the concept. Thus, early dissemination of the
concept was funnelled through two media: the participants in project
committees and presentations given to selected (and small) audiences. 1 The
1 Principally, NRA, open paper session, September 1977 (See Appendix X);
American Psychological Association meeting, September 1978 (See Appendix
IX and XIV); Council on Social Work Education, March 1979 (See Appendix
XI); American Orthopsychiatric Association, April 1979; Functional
Limitations Assessment Conference, September 1978; Syracuse Evaluation
Conference, May 1978.
63
emphasis has been placed during Phase I and the early part of Phase II on
a reactive role in dissemination rather than on a proactive thrust.
In preparing for proactive efforts, the project developed "slick"
materials meant to create a visual image for RI's: a stylized phoenix was
selected as a logo; a symbol of regeneration was judged to be a suitable
symbol for the project's efforts to create indicators of rehabilitation.
The "RI Update" is an example of a visually appropriate dissemination
device: it looks professional and will convey the project's message to a
wide audience.
Dissemination in Phase III will take two forms: (1) increasing the
awareness and understanding of the project within a wide audience and (2)
sharing RI materials with a selected and smaller audience of demonstration
settings and independent researchers. Training Consultant, Alice Randolph,
has pointed out that needs of users and potential users of RI's for RI
information varies -- from simply being aware of the project and its major
goals, to understanding the RI concept, to being able to integrate, practice,
evaluate and adopt RI's. Thus, the relationship the person has to RI use
(from none to deciding whether to contact the project for more information
to deciding to adopt RI's for usage) will largely determine the nature of
RI materials that should be disseminated. A second determining factor that
Randolph has highlighted is that of the language of the target audiences:
researchers and service providers use different jargon and respond to
different selling points; our materials must take this into account.
Specific activities to implement the dissemination strategy are
described in pp. 50-57
Fourth, the utilization strategy for Phase III has been defined to
address objectives of increasing the credibility and utility of RI's and
increasing the momentum of RI adoption within field settings. Utility of
RI's will be enhanced through establishing and analyzing several demon-
strations incorporating varying usage models; experiences in using RI's
within the demonstrations will be fed back into RI and usage model
refinement. Additionally, evidence relevant to demonstrations will be
disseminated to specific targetted audiences to enhance awareness and know-
ledge of RI utility. A second thrust of such RI and usage model refinement
is to improve the statistical and technical merits of RI's (e.g., improving
the reliability of data collection, decreasing the amount of time needed to
implement RI's with clients, etc.) in order to increase the credibility and
acceptability of the RI tool relevant to a wide target audience. Momentum,
we believe, will build through establishing a variety of suitable and well-
planned usage models in demonstration and independent research sites; eval-
uation reports relevant to such use will be disseminated to targetted sub-
groups, through presentations, publications, workshops and consultation.
A final aspect of the utilization strategy for Phase III is to include
in the evaluation of demonstrations, activities to determine (1) the
resources needed within settings to support specific usage models and (2)
the elements in settings (and without) that are needed for maintaining RI
usage. These data will help in determining maintenance costs for a variety
of RI usage models: a crucial element in decision-making for potential uses.
64
E., F. Implementation and Commitments
This aspect of Phase III activities is discussed in PP.
, and
Also see Appendix XVIII for correspondence referring to potential
sites of demonstration and other uses of RI's.
G. Indexed Abstract of Proposal
Accountability, Counseling, Rehabilitation Processes, Research,
Planning, Information; Indicators, Behavior, Environment; Independent Living,
Vocational Rehabilitation; Severely Disabled, Disability, Needs.
The purpose of this project is to develop and demonstrate rehabil-
itation indicators (RI's), a generic language of rehabilitation which can
be used to obtain and organize large amounts of information focusing on
client functioning. RI's can be used to account for outcomes of rehabil-
itation and access to services; they can be used to operationalize defi-
nitions of "disability" and "needs"; they also can be used to help define
client strengths and limitations, goals, needs and outcomes within a context
of rehabilitation planning. RI's are descriptors of aspects of the client's
functioning, including statuses, activities, skills and environmental
elements. RI's include vocational/education, independent living, social,
political/legal and economic content at several levels of detail.
RI's are being developed for use within most rehabilitation settings
and with clients of many disability groups: sensory, psychiatric, deve-
lopmental and physical.
This proposal covers the third phase of project development and will
demonstrate RI's and usage models.
65
7. COST-BENEFIT MEASURES
A. Target Groups and Size
The primary target population of this project's product consists of
all disabled persons encountering rehabilitation services during the time
period RI's are used within target rehabilitation systems. All disabled
persons with sensory, psychiatric, physical or developmental/educational
impairment could benefit if served within rehabilitation settings using
RI's. Two groups of disabled persons are not specifically targeted, but
could benefit from use: the culturally disadvantaged and ex-offenders.
The following types of settings and service systems are targeted:
State-Federal Vocational Rehabilitation agencies, medical rehabilitation
facilities, psychiatric hospitals, mental health centers, vocational eval-
uation and training programs, independent living programs, etc.. Direct
service providers, administrators, planners/evaluators, and funding agents
relevant to these types of settings are the secondary target populations.
Estimating the proportion of the primary and secondary target popu-
lation which would benefit if project objectives were fully met is a simple
task. In that we have no reason to believe that utilizers will not benefit,
we would suggest that 100% of those receiving services and 100% of those
using RI data would benefit, when RI's are used within appropriate usage
models.
To estimate the size of the populations which will benefit is, of
course, much more difficult. Nagi 1 estimates (from a survey conducted in
1971-1972) that the target population for State-Federal VR services is
constituted of approximately 5,000,000 persons "limited in work roles and
activities" and 7,000,000 who are "vocationally disabled"; Nagi based these
estimates on four indices of inability or difficulty in performing work,
housekeeping or school work, because of "disability." The Urban Institute 2
has adopted the SSA's Survey of Disabled Adults' estimate of more than
23,000,000 disabled persons in the U.S. These two estimates of the total
number of persons who might benefit from State-Federal VR services or, in
the latter estimate, from any rehabilitation services received constitute
the pool from which our target population is drawn. However, we have no
estimates available for the number of individuals actually receiving reha-
bilitation services among the total target groups during any one year.
Thus, we have no basis for estimating the size of the actual primary
target group. Also, we have made no attempt to estimate numbers of service
providers, administrators, etc., who work in the type of rehabilitation
settings listed above, the secondary target group.
1
Nagi, S. Estimates of Target Population for State Federal Rehabilitation
Programs, Unpublished paper, July 10, 1974, P. 3-4.
2 Urban Institute, Comprehensive Needs Study, 1975, p. 72.
66
B. Expected Benefits
Two approaches are offered in describing expected benefits to the
target populations: (1) The individual and non-personal benefits, listed
in section 4010.25 of the R & D Guidelines, that are likely to occur with
full use of RI's are listed first. Since these terms are not defined in
the Guidelines and the meaning of some are not clear, we have not priori-
tized the benefits. (2) The project principals, as part of developing the
project framework, have specified the expected payoffs for each target
group. These expected benefits are described in this Cost-Benefit Section
(see Table 4).
1. RSA Benefit Terms:
The following terms from Section 4010.25 of R & D Guidelines
describe possible individual direct benefits from use of RI's:
Quality of service delivery; coping behavior; counselling, education
and training; containment of personal cost; adaptive behavior; client-
initiative; expanded potential for benefit from services; client
awareness and expectation of service; consumer participation; under-
standing rights and obligations; and service containment.
The following terms describe possible non-personal direct
benefits from use of RI's:
Legislative impact; program improvement tactics; improved evaluation
of programs; service process refinement; improvement of provider's
efficiency and effectiveness; cost effectiveness and benefit/cost;
improved information systems; improved productivity of tax expen-
ditures; validation of benefits; more effective planning processes;
expanded R & D potential; improved data quality; and improved and
more flexible administration.
2. Project-Defined Payoffs from Use of Rehabilitation Indicators:
Use of rehabilitation indicators will provide payoffs to
resource providers (clients and funding sources) and to service pro-
viders (counselors, physicians, planners, etc.); the nature of the
payoffs is a function of the usage model into which RI's are placed.
Some of the potential payoffs outlined below will be empirically
tested during Phase III. The results will help determine final
development of training programs, using model guidelines and the
final utilization plan.
a. Resource Providers. The clarified language of rehabili-
tation indicators within appropriate usage models will make
possible the following enhancements for rehabilitation resource
providers (clients and funding sources):
1) Clients:
a) Reasons for not gaining access to rehabili-
tation services should be more clearly stated to
applicants refused services; the rationale could
67
be detailed in terms of status, activity pattern,
skill, and environmental relationships.
b) The logical relationships among rehabilitation
variables should be more clearly and directly shared
with the client through use of RI's; in other words,
the means-end chain could be explicated: the
rationale for specific services being chosen, to
address identified skill and environmental needs
which, if alleviated, could enable specific goals
to be reached. The client's clear understanding
of the rationale for the services being offered
should speed up the rehabilitation process.
c) The client's role as an equal participant in
rehabilitation plan development and implementation
should be enhanced. With the focus of rehabili-
tation planning placed on factors and events that
the client understands, e.g., "walking," "visiting
with friends," "being employed in a workshop," and
with avoidance of jargon which can hinder mutuality
in planning, the client can understand actual and
projected levels of functioning and can see progress
as clearly as the rehabilitation professional: the
client knows where he/she "is" in the rehabilitation
process at any point in time.
d) Rehabilitation planning should improve and goals
and sub-goals of rehabilitation should be attained
more quickly, when the need for specific rehabili-
tation services is based on identification of client
instrumental needs; the service plan would be based
on identification of the environmental factors and
skills that need to be the targets of rehabilitation
efforts, if primary goals are to be reached.
e) Client satisfaction and understanding also should
be increased when the locus of needs is explicitly
specified, whether client-centered/behavioral or
external/environmental.
f) Rehabilitation goals should become more syntonic
with the client's capabilities, interests and needs,
leading to increased satisfaction.
g) The multi-dimensional content of RI's should
broaden the target areas of rehabilitation efforts:
a wider primary goal range can be validated by the
resource provider and a wider range of instrumental
skills and environmental factors can be targeted.
In the past, too narrow a focus in goal selection
and particularly in need identification has hindered
the attainment and sustention of rehabilitation
success and have prevented clients from maximizing
their potential within formal rehabilitation programs.
68
h) The client's role as an evaluator should be
enhanced in that the information necessary to judge
the service provider's use of resources is improved.
i) Whenever direct service providers have access to
RI's, duplicated services and other information-based
errors should decrease.
2) Funding Sources:
a) In that the benefits and payoffs of rehabili-
tation can be more clearly, specifically, and broadly
defined, cost/effectiveness evaluation can be uti-
lized more rationally in funding decisions.
b) Funding sources can define priority of access to
rehabilitation systems in terms of functional disa-
bility levels of clients, a more meaningful measure
of severity than "diagnosis" or "number of services
used." Evaluation of actual access to the system
would be possible through use of RI's.
c) Improved research regarding access, process, and
outcome, using RI's as a basic tool, will give
funding sources improved information relevant to the
their decisions about these variables.
d) Funding sources will have in R.I's a language to
define multi-dimensional success, in that the lan-
guage of RI's provides additional observable out-
comes which are key factors in expanding the client's
quality of life.
e) The four types of RI's provide a powerful tool
to define "disability" and "needs" of disabled
people. Needs would be defined multi-dimensionally,
with two primary foci, the environment and client
skills. This approach to defining need will provide
objective data that can be used to enhance resource
allocation decisions.
b. Service Providers. With use of RI's in appropriate usage
models, the following enhancements are probable for direct
service providers and service planners, respectively:
1) Direct Service Providers: This group includes reha-
bilitation counselors, physical therapists, psychologists,
physicians, social workers, etc.. The main function of
direct service providers vis a vis clients is to coor-
dinate and/or directly provide rehabilitation services.
69
a) Developing the written rehabilitation plan should
be an easier, more systematic process; the content
that would be included in the plan would be found in
the lexicon of RI's.
b) Record keeping could become simplified in that
rehabilitation efforts would be more precisely
focussed through RI's used in appropriate usage
models.
c) Expanding the categories of outcomes and foci
(environmental and behavioral) that can be dealt
with in rehabilitation, should increase the direct
service provider's satisfaction, in that clients
can be worked with more nearly as 'wholes,' rather
than as undimensional 'parts.'
d) The set of RI's that are incorporated into the
client's goals and sub-goals provides a useful
tracking device, to better follow the client's
progress, by focusing on the change within critical
behaviors and on progress made in modifying or
adapting to external barriers. This allows better
feedback into goal setting, which can be a cyclic
process.
2) Service Planners: This group includes those who plan
and evaluate resource allocation, training, staffing,
service development, etc.
a) All planning processes can be improved through
implementation and use of basic input/process/out-
come research that helps clarify relationships
among these rehabilitation client and service
variables. RI's provide an excellent tool for this
purpose.
b) Evaluators within rehabilitation settings (in-
house evaluators) will have better information, both
in client records and within special data collection
devices, to perform better formative and summative
evaluation.
c) The language of RI's should assist in the
training of service providers, its being a directed,
outcome-oriented language understandable to a broad
range of providers.
REHABILITATION
REHABILITATION
REHABILITATION
ACCESS
PROCESS
OUTCOMES
Rationale for access
Rationale for plan development
Goals and client strengths
More participation, avoidance
more syntonic
of jargon
Expanded goal range
Services more focussed and
CLIENT
direct
Problem locus is clear:
behavioral vs. environmental
Client as evaluator
Avoidance of duplicated
services
Priority in access can be
Better research will rationa-
Better defined outcomes
stated in functional
lize access, process and
improve evaluation of
FUNDING
terms
outcome expectations
services
SOURCE
Resource allocation improved
through better "need"
definition
DIRECT
Plan development a more satis-
Expanded outcomes allow
SERVICE
fying process
working with client as a
PROVIDER
Simplified record keeping
'whole'
Tracking of client progress
SERVICE
Planning processes improved through basic research
PLANNERS
Better evaluation information
Training programs become more outcome-oriented
TABLE 4
Expected Benefits to Rehabilitation Participants with RI's
In Appropriate Usage Models
70
71
8. BACKGROUND
A. Project Staff/Committee Organization Chart
Advisory
Utilization
Environmental
Committee
Committee
Task Force
Co-Directors
Wilbert Fordyce, Durand Jacobs
Leonard Diller
Research
Project
Consultants:
Supervisor
Coordinator
Computer, Training, etc.
(W. Gordon)
(M. Brown)
(Lucido, Randolph, etc.)
Field
Data
Coordinator
Coordinator
(TBH)
(J. Farber)
Field
Project
Data
Assistant
Assistant
Analyst
Secretary
(TBH)
(A. Fabian)
(G. Buccheri)
(B. Harris)
Data
Data
Coder
Assistant
(TBH)
(TBH)
Advisory Relationship
Supervisory Relationship
72
B. Staff Qualifications
1. Leonard Diller, Ph.D., Co-director
Dr. Diller has been actively involved in rehabilitation psychology for
nearly 30 years as a researcher, clinician, educator and consultant, and
has served as chairman and member of numerous professional organizations,
some of which are described below.
Dr. Diller is presently Chief of Behavioral Science Research at the
Institute of Rehabilitation Medicine, and Professor of Clinical Rehabilitation
Medicine at New York University Medical Center. Formerly he served as Staff
Associate for the Association for the Aid of Crippled Children (1963-1964)
and Chief Psychologist and Assistant Chief of Psychiatric Services at New York
University Medical Center, Institute of Rehabilitation Medicine (1951-63).
He has served as research consultant for several organizations including United
Cerebral Palsy, New York City (since 1961) and is a member of their Professional
Advisory Committee (since 1967); he is also a Member of the Professional
Advisory Committee of the New York Chapter of the March of Dimes. Other con-
sultantships and memberships include Human Resources Corporation (1957-60),
Association of Rehabilitation Centers (1960-1961), Psychology Advisory Committee
of the Social and Rehabilitation Service Administration (1968-1970), and the
spinal cord research program, RSA (1975- ).
Dr. Diller has held office in several professional organizations:
President, Division 22 of the American Psychological Association (1964-65);
Chairman (1962-63), Research Awards Committee, American Personnel Guidance
Association; Board of Governors' of International Neuropsychology Society
(1975- ); and Executive Board of the New York State Psychological Association
(1970- ).
Dr. Diller's publications and presentations in the field number nearly
200. Those most relevant to the issues to which this project is addressed
include:
Diller, L. Evaluation of the physically handicapped and psychological assess-
ment of the brain damaged. Georgia Psychol. Assn., Atlanta, March 1957.
Diller, L. Research in Trehabilitation. In D. Martin (ed.) Whither diagnosis:
evaluation of the atypical. University of Colorado, 1959.
Diller, L. Prognostic strategies in rehabilitation. American Psychological
Association Convention, Cincinnati, September 1959.
Diller, L. Psychology and rehabilitation. Conference of Rehabilitation Centers,
California, 1960.
Diller, L. Olient-Counselor relationships to counseling in rehabilitation process.
In Jacobs, Jordan, and DiMichael (eds.)
Bureau of Publishers,
Teacher's college, Columbia, 1961.
Diller, L. Pre-vocational unit in a rehabilitation center. Institute of
Physical Medicine and Rehabilitation Monograph, New York, 1961.
73
Diller, L. Hemiplegia. In Garret, J., and Levine, E. (eds.), Psychological
practices with disabled. Columbia University Press, 1962.
Diller, L., The psychology of activities of daily living in stroke. AMA Stroke
Conference, Chicago, 1964.
Diller, L., Rehabilitation and behavior psychology. Division 22 Bulletin,
American Psychological Association, 1965.
Diller, L., The psychopathology of activities of daily living. N.Y. Society
of Clinical Physical Medicine and Rehabilitation, New York City, January,
1966.
Diller, L. Ben Yishay,Y. and Haas, A. Development of objective psychometric
predictors of recovery rates and duration of rehabilitation in hemiplegic
patients. Congress of Physical Medicine, Montreal, August, 1968.
Diller, L., Ben Yishay, Y. and Gerstman, L. Prediction of rehabilitation
outcomes from psychometric parameters in left hemiplegia. Journal of
Consulting Clinical Psychology, 1970, 34, 436-441.
Diller, L., Ben Yishay, Y., Weinberg, J., Goodkin, R., Gerstman, L., Gordon, W.,
Mandelberg, I., Shulman,D and Shah, N. Studies in cognition and rehab-
ilitation in hemiplegia. Final Report, SRS, RD-2666-P. July 1971.
Diller, L., & Goodkin, R. Reliability among physical therapists in diagnosis
and treatment of gait deviations in hemiplegics. Perceptual & Motor Skills,
1973.
Dembo, T., Diller, L., Gordon, W., Sherr, R., & Leviton, G. A view of
rehabilitation psychology. American Psychologist, August, 1973.
Diller, L., Powell, R., & Grynbaum B. A follow-up study in hemiplegia.
J. of Genetic Psychology Monog., 1976
Gordon, W., Freidenbergs, I., Diller, L., Hibbard, M., Rothman, L., Wolf, C.
and Ezrachi, 0. Assessment of psychosocial problems of cancer patients.
American Psychological Association Convention, San Francisco, 1977.
Freidenbergs, I., Gordon, W., Diller, L., Hibbard, M., Rothman, L., Wolf, C.
and Ezrachi, O. Problem-oriented record in psychosocial assessment/
intervention with cancer patients. American Psychological Association
Convention, San Francisco, 1977.
Diller, L., Gordon, W., Freidenbergs, I., Hibbard, M., Rothman, L., Wolf, C.
and Ezrachi, 0. The relationship between rehabilitation goal, ADL status
and psychosocial problems in cancer patients. American Congress of
Rehabilitation Medicine, Florida, 1977.
Diller, L., and Gitler, D., Evaluation and management implications of cognitive,
attentive, behavioral and functional deficits in children. American
Congress of Rehabilitation Medicine, Florida, 1977.
Diller, L. & Gordon, W., RI's: A home for ADL. American Psychological Association,
Toronto, August 1978.
Gordon, W., Friedenbergs, I., Diller, L., et al, The Psychosocial problems of
cancer patients. American Psychological Association, Toronto, 1978.
74
Diller, L., Rehabilitation indicators as a system for accountability. Conference
on Functional Limitations Assessment, Alexandria, Va., September 1978.
2. Wilbert Fordyce, Ph.D., Co-director.
Dr. Fordyce has been a prominent figure in the field of rehabilitation
psychology for many years: as professor, researcher and clinician. Since
1970 Dr. Fordyce has been Professor of Clinical Psychology in the Department
of Physical Medicine and Rehabilitation, University of Washington School of
Medicine, Seattle, and previously was Associate Professor (1964-70) and
Assistant Professor (1959-64).
He has served as member and officer in numerous organizations and
committees and has served on several editorial boards. These include the
American Rehabilitation Foundation (Vocational Psychologist Committee, 1963-70;
Chairman 1967-70), the Association of Rehabilitation Centers (Long-range
Planning Committee, 1961; Research Committee, 1963-64; Education Committee,
1967-68, Board of Directors, 1967-68), the American Congress of Rehabilitation
Medicine (Professional Development Committee, 1967-72; Vice President, 1973-77),
and International Association of Rehabilitation Facilities (Executive Board,
1969-72). Dr. Fordyce has been active in several divisions of the American
Psychological Association (12, 18, 22,25,38) and has served as a member on the
Council of Representatives (1970-1972), as President of Division 22,
Rehabilitation Psychology (1973-1974), as Chairman, Section on Health Care
Research (Division 18), 1976-1978; and on the Fellows Committee of Division 38
(1978-1979).
Dr. Fordyce has served on the editorial boards of the Archives of Rehab-
ilitation Medicine (1969- ), and the Journal of Program Evaluation (1972- ).
From Dr. Fordyce's numerous publications we have selected those which reflect
his interest and commitment to the issues addressed in this project. These
include:
Parsons, J.R., Fordyce, W.E., Thorne, J., & Gronewald, D.H. Studies of public
assistance referrals to vocational rehabilitation: I. Administrative
effectiveness. II. Predicting vocational rehabilitation outcomes.
Report, Office of Vocational Rehabilitation, School of Social Work,
University of Washington, 1961.
Fordyce, W.E. Assessment and management. In Handbook of physical medicine
and rehabilitation. Philadelphia: F.H. Kinsen, F.J. Kottke, P. Ellwood,
W.E. Saunders Co., 1965. pp. 137-164
Fordyce, W.E. On behavior theory applications in a medical rehabilitation
context. Bulletin, Division 22, APA (July), 1967.
Fordyce, W.E. Psychology and rehabilitation. In Rehabilitation and medicine.
New Haven, Conn.; S. Licht; published by Elizabeth Licht, 1968.
Fordyce, W.E. Behavior control systems to increase socialization behavior in
the elderly. Bulletin, Division 22, APA (March), 1969, 50, 11-16.
Sand, P.L., Fordyce, W.E., Treischmann, R.B., and Fowler, R.S. Behavior
modification in the medical rehabilitation setting: Rationale and some
applications. Journal of Rehabilitation Research and Practice Review,
1970, 1, 11-24.
75
Fordyce, W.E., Fowler, R.S., Sand, P.L., Treischmann, R.B. Behavior systems
analyzed, Journal of Rehabilitation, 1971, 37, 29-33.
Fordyce, W.E. Behavioral method in rehabilitation. In Neff, W.S. (ed.),
Rehabilitation psychology, Washington, D.C.: APA, 1972, 74-109.
Bonica, J., Fordyce, W. Operant conditioning for chronic pain. In Bonica, J.,
Procacci, P., and Pagni, C.A. (eds.), Recent advances on pain pathophysiol-
ogy and clinical aspects. Springfield: Charles C. Thomas, 1974, p. 295.
Fordyce, W.E. Chronic pain as learned behavior. Bonica, J.J. (ed.) Advances
in neurology series, Vol. 4., New York: Raven Press, 1974, pp. 415-422.
Fordyce, W.E. Behavioral science and rehabilitation. Rehabilitation Psychology,
1974, 21, 82-85.
Fordyce, W.E. Research on influencing level of patient participation in the
rehabilitation process. In Fifrer, M.J. (ed.), Selected research topics
in spinal cord injury rehabilitation. Houston, Texas, 1975, 55-69.
Fordyce, W.E. Behavioral methods in chronic pain and illness. St. Louis:
C.V. Mosby Company, 1976.
Fordyce, W.E. A behavioral perspective of rehabilitation. In Albrecht, (ed.),
The sociology of physical disability, Pittsburgh: University of Pittsburgh
Press, 1976.
Fordyce, W.E., Brena, S.F., Holcomb, R.J., De Lateur, B.J., and Loeser, J.D.
Relationship of patient semantic pain descriptions to physican diagnostic
judgements, activity level measures and MMPI. Pain, 1978, 5, 293-303.
Fordyce, W.E. and Brockway, J.A.: Pain and its management. New York: McGraw-Hill,
In Press, 1978.
Fordyce, W.E. Environmental factors in the genesis of low back pain. Advances
in pain research and therapy, Vol. 3. In Bonica, J.J., Liebeskind, J.C.,
and Albe-Fessard, B. (eds.), New York: Raven Press, In Press, 1978.
Fordyce, W.E. Behavioral methods in the rehabilitation process. In Eisenberg,
M.G., and Falconer (eds.). Treatment of the spinal cord injured: An
interdisciplinary perspective. Charles C. Thomas, Springfield, IL:
Charles C. Thomas, 1979.
3. Durand F. Jacobs, Ph.D., Co-director
Dr. Jacobs is Chief of the Psychology Service of the Veterans Administration
Hospital, Loma Linda, California; he is also lecturer at the University of
California, Riverside. Until 1978 he was Chief of Psychology at the V.A.
Hospital in Cleveland and Associate in Psychology at Case Western Reserve
University (1965- ) and Adjunct Professor, Psychological Clinic, Kent State
University (1968- ).
Dr. Jacobs' professional activities have included participation in several
aspects of the American Psychological Association: 1) Division 22--President (1976);
2) Chairman, Standards Committee (1966- ); 3) Chairman, Legislative Committee
(1972- ); 4) Member, Task Force on Specialty Criteria; and 5) Member, Health
76
Care Committee. He also has participated in other organizations, such as
Task Force on Standards for Service Facilities, Chairman (1971-75); Northeast
Ohio Rehabilitation Association, President (1969-70); Ohio Rehabilitation
Association, Board of Trustees (1973-74); Advisory Board of the Bureau of
Vocational Rehabilitation, Region II Ohio (1962-74); and Advisory Board of
the Vocational Guidance & Rehabilitation Programs, Cleveland (1967-73).
Dr. Jacobs has been consulting editor to the Journal of Counseling
Psychology (1962-75), the Journal of Rehabilitation Psychology (1970- ),
and the Journal of Drug Issues (1972- ). Dr. Jacobs was also (1976) Trustee,
Ohio Academy for Education & Research in Professional Psychology and APA
representative to the White House Conference for Handicapped Individuals.
Dr. Jacobs' publications and presentations relevant to project issues include:
Jacobs, D.F. (ed.) Rehabilitation of the emotionally and mentally disabled
veteran: Workshop proceedings. Division of Vocational Rehabilitation,
Indiana, 1955.
Jacobs, D.F. and Trollinger, A.B. A hospital-community team approach to
vocational rehabilitation. V.A. Program Guide, 1956 G-8, M-2,Pt. X,
28-30.
Isaacson, L.E. and Jacobs, D.F. An inter-agency multi-discipline approach
to rehabilitation. Journal of Counseling Psychology, 1958, Vol. 5,
No. 4, 300-304.
Jacobs, D.F. Vocational rehabilitation of the psychiatric patient: a
hospital-community problem. Personnel and Guidance Journal, 1960, 38,
642-647. Reprinted: Hope for the mentally handicapped, Employment
Security Exchange, Govt. Printing Office, 1960, No. 17, 13-15.
Jacobs, D.F. Motivation to work. Toledo: U. of Toledo Press, 1963.
Jacobs, D.F. Rehabilitation indicators symposium. American Psychological
Associations Convention, Toronto, August 1978.
4. John R. Barry, Ph.D., Chairman, Field Testing Task Force: Member,
Steering Committee.
Dr. Barry has accrued a broad and extensive range of professional
experience and accomplishments over the last 30 years. Only those which
particularly reflect his interest in the issues and methods related to this
project are described herein. Since 1966 Dr. Barry had been Professor of
Psychology at the University of Georgia (Athens) and Consultant for Research
to the State of Georgia Dvision of Vocational Rehabilitation. Since 1968 he
has been Coordinator of Graduate Education in Psychology at the University of
Georgia. Prior to this appointment Dr. Barry was Director of the Regional
Rehabilitation Research Institute and Professor of Psychology at the University
of Florida (1962-66).
Dr. Barry has been a member and officer of numerous professional psychology
and rehabilitation organizations, including the American Psychological Association
(Division of Consulting Psychologists: President (1964-65), Research Awards
Committee (1967- ), Executive Committee (1973-76); Division of Rehabilitation
Psychology, President, 1972-73; APA Council of Representatives, 1966-69, 71),
77
American Association for the Advancement of Sciences (Fellow), National
Rehabilitation Counseling Association (Professional Member), and the American
Personnel and Guidance Association (Association for Measurement and Evaluation
in Guidence, and ARCA--Professional member, and Chairman of Interest Group on
Aged.) Dr. Barry is Consulting Editor for the Journal of Gerontology (1977- ),
Journal of Rehabilitation (1978- ) and the Journal Supplement Abstract Service
Catalog of Selected Documents in Psychology (APA) (1977- ). Previously he
acted as consulting editor to the Georgia Rehabilitation Bulletin (1967-74),
the Rehabilitation Counseling Bulletin (1962-67), and the Journal of Criminal
Justice and Behavior.
Some of Dr. Barry's present consultantships are to the Human Interaction
Research Institute (since 1966; Member, Board of Directors since 1975) and the
Veterans Administration (1963- ). Other professional activities include
participation as APA representative at the Regional Planning Meeting for the
White House Conference on Handicapped Individuals (Atlanta, 1976) and as APA
representative at the 15th Annual Conference of the U.S. National Commission
for UNESCO entitled "Environmental Education, the Last Measure of Man" (1971).
Over the last 25 years Dr. Barry has had published and has presented
numerous papers; those that relate to issues, purposes and methods of this
project include:
Barry, J.R. Research design in rehabilitation, basic and applied. Annual
Meeting of the American Personnel and Guidance Association, Minneapolis,
1965.
Barry, J.R. Rehabilitative approaches. In I.A. Berg and L.A. Pennington (eds.).
An introduction to clinical psychology. New York: Ronald Press, 1966,
685-713.
Barry, J.R. Dissemination and utilization of rehabilitation research information.
National Conference of Joint Liaison Committee, Miami Beach, 1966.
Barry, J.R., & Fulkerson, S.C. Chronicity and prediction of duration and outcome
of hospitalization from capacity measures. Psychiatric Quarterly, 1966,
40, 104-121.
Barry, J.R. Predicting results of vocational counseling. Annual Meeting of
American Psychological Association, Washington, D.C. 1967.
Barry, J.R. Research utilization and œerations research in state rehabilitation
agencies. Regional Conference on Research Utilization and Dissemination,
Atlanta, 1968.
Barry, J.R. Non-standard data utilization in the rehabilitation setting.
Conference on Planning and Program Development as it Relates to
Rehabilitation Data Management, Atlanta, December, 1969.
Barry, J.R. Rehabilitation and data management. Conference on Planning and
Program Development as it Relates to Rehabilitation Data Management,
Atlanta, 1970.
Barry, J.R. Behavioral classification of the physically disabled. Report
to the APA Task Force on Behavioral Classification. Psychological
Aspects of Disability, 1971, 18, 136-142.
78
Barry, J.R. The physically disabled. In D. Spiegel and P. Keith-Spiegel (eds.),
Outsiders, USA, San Francisco: Rinehart, 1973, 99-115.
Barry, J.R. Program evaluation in vocational rehabilitation agencies. Fall
Conference on VR Region IV Research, Warm Springs, Georgia, 1974.
Barry, J.R. Program evaluation and accountability. Symposium at Annual
Meeting of American Psychological Association, Chicago, 1975.
Barry, J.R. The costs of mental health, institutionalization VS. independence.
Georgia Conference on Aging, Atlanta, May 1976.
Barry, J.R. Symposium on program evaluation: Positive and negative aspects.
American Psychological Association Convention, Washington, 1976.
Brown, M., Diller, L., Fordyce, W, Jacobs, D., Barry, J.R., Gordon, W., &
Mayer, J. Accountability: Definitions, problems, and the response of
Rehabilitation Indicators. Annual Meeting of National Rehabilitation
Association, Washington, 1977.
Barry, J.R. Barriers in the rehabilitation of SSI and SSDI referrals. Training
Staff Conference, Georgia Division of Vocational Rehabilitation, Athens,
December 1977.
Barry, J.R. Counselor and program evaluation methods in vocational rehabilitation,
HEW Region IV Training Conference, Orlando, Florida, January 1977.
Barry, J.R. Use of reports for monitoring in the State-Federal vocational
rehabilitation program. New directions in program evaluation. San Francisco:
Jossey-Bass, 1978, No. 3, 37-44.
Bozarth, J. and Barry, J.R. Impact of selected psychosocial research on
rehabilitation services. In Annual Rev. Rehab., 1, New York: Springer,
1979 (in press).
5. Margaret Brown, Project Coordinator
Ms. Brown's major experiences prior to becoming Coordinator of the RI
Project in 1974 has been in health program analysis and project development, as
well as in research and teaching. In 1973-74 she was Project Analyst for the
Mid-America Comprehensive Health Planning Agency, Kansas City, Missouri, being
responsible for project analysis relevant to health services, manpower and
research funding applications and for liaison with the agency's review committees.
In 1972-73 Ms. Brown served as Coordinator for Project Development for the Kansas
Regional Medical Program, formulating procedures, policies and guidelines
relevant to the development and review of project proposals. Previously, as a
program evaluator with KRMP (1969-72), she was responsible for the management
of several project evaluations.
While at the University of Kansas (1965-68), Ms. Brown participated in
research studies as a U.S. Public Health Service Trainee under the supervision
of Beatrice Wright, Franklin Shontz, Gerald Siegel and Roger Barker. Ms. Brown
received an M.A. with honors in Social Psychology from the University of Kansas
and is presently a Ph.D. candidate in the Community Psychology program at
New York University.
79
In the past few years she has served on Advisory panels., for several projects
and research efforts: Functional Limitations State of the Art Review, Indices,
Inc.; (Select Panel) Taxonomy and Nomenclature Task Force, RR&T Centers National
Association; Feasibility Study for Evaluation Methodologies for Cost-Benefit
Analyses of Restoration Services in Rehabilitation, Rehab Group, Inc.; and Weight-
ing Case Closures, Arkansas RR&T Center.
Relevant presentations include:
Brown, M., Diller, L., Fordyce, W., Jacobs, D., Barry, J., Gordon, W., & Mayer, J.
Accountability: Definitions, problems and the response of rehabilitation
indicators. National Rehabilitation Association meeting, Washington, D.C.,
September 1977.
Brown, M., Diller, L., Fordyce, W. and Jacobs, D. Rehabilitation indicators:
An overview of the RI Project. Program Evaluation for Rehabilitation
Agency Personnel Conference, Syracuse University, May 1978.
Brown, M., Caplan, J. and Swirsky, J. Rehabilitation indicators: An overview.
American Psychological Association, Toronto, August 1978.
Brown, M. Rehabilitation indicators: A method for enhancing rehabilitation
services. American Psychological Association, Toronto, August 1978.
Gordon, W., Brown, M. & Sherman, B. Evaluating the impact of perceptual
remediation. International Neuropsychology Society, New York, February 1979.
Brown, M. The use of indicators to study the rehabilitation process. Council
on Social Work Education, Boston, March 1979.
6. Wayne Gordon, Ph.D., Research Supervisor
Dr. Gordon is Assistant Clinical Professor of Rehabilitation Medicine and
Supervisor of Research in Behavioral Sciences at the New York University Medical
Center, Institute of Rehabilitation Medicine. As such he is responsible for
development of research programs, including the conceptualization of research
problems, experimental designs, and designs for data analysis. As a rehabilit-
ation methodologist, Dr. Gordon integrates the tennets of experimental design
with concepts of rehabilitation and realities of clinical research to develop
evaluation techniques suitable for rehabilitation programs. As staff consultant
to this project, Dr. Gordon has participated in Task Force, Co-director and
other project meetings, where he advises the project on methodologic and analytic
issues; he will assist the Coordinator in supervising ongoing data analysis and
in planning field operations.
In addition to his role as project manager to this and other projects in
the Behavioral Sciences, Dr. Gordon is a member of an in-house research review
committee at the Institute which reviews all proposals from all departments for
purposes of peer review and quality control. Dr. Gordon is a frequent consultant
and reviewer: consultant to the National Exercise & Heart Disease project (1972-73)
sponsored by the Social and Rehabilitation Service and to the Brooklyn V.A.
Hospital; grant reviewer for the Epidemiology Study Section of the National
Heart-Lung Institute, the Behavioral Medicine Study Section of NIH and the Special
Section on Psychological Precursors to Cancer, and reviewer for the Journal of
Behavioral Medicine and Archives of P M and R. Also, he presently chairs the
Liaison Committee of Division 22 of APA. Dr. Gordon has contributed many public-
ations and presentations relevant to rehabilitation and educational psychology;
80
those which relate to project issues include:
Diller, L., Ben-Yishay, Y., Weinberg, J., Goodkin, R., Gerstman, L.J., Gordon, W.,
Mandelberg, I., Schulman, P. and Shah, N. Studies in cognition and rehabil-
itation in hemiplegia. Final Report, SRS, RD-2666-P, July 1971. Reprinted
as Rehabilitation Monograph #50, 1974.
Gordon, W. Public relations and rehabilitation: The patient as a consumer.
Second Symposium on Public Relations and Rehabilitation, Athens, Greece,
September 1972.
Gordon, W., Gertler, M., Diller, L., Leetma, H. & Gerstman, L. Behavioral
correlates of coronary proneness. Eastern Psychological Association,
May 1973.
Dembo, T., Diller, L., Gordon, W., Sherr, R. and Leviton, G. A view of rehabil-
itation psychology. American Psychologist, 1973, 28, 719-722.
Gordon, W., Gertler, M., Diller, L., Leetma, H. and Gerstman, L. Behavioral
correlates of the coronary profile. J. of Clinical Psychology, 1974,
343-347.
Gordon, W., Freidenbergs, I., Diller, L., Hibbard, M., Rothman, L., Wolf, C.
and Ezrachi, O. Assessmant of psychosocial problems of cancer patients.
American Psychological Association, San Francisco, 1977.
Freidenbergs, I., Gordon, W., Diller, L., Hibbard, M., Wolf, C. and Ezrachi, O.
Problem-oriented record in psychosocial assessment/intervention with
cancer patients. American Psychological Association, San Francisco,
1977.
Diller, L., Gordon, W., Freidenbergs, I., Hibbard, M., Rothman, L., Wolf, C.,
and Ezrachi, O. The relationship between rehabilitation goal, ADL status
and psychosocial problems in cancer patients. American Congress of
Rehabilitation Medicine, Florida, 1977.
Athelstan, G., Dexter, N., Gordon, W., Harasymiw, S., Mayclin, D. and
Thompson, D. Psychosocial-vocational research project. American
Spinal Injury Association Convention, April, 1978.
Gordon, W., Freidenbergs, I., Diller, L., Hibbard, M., Rothman, L., Wolf, C.,
Lipkins, R., Ezrachi, O. and Francis A. The psychosocial problems of
cancer patients. American Psychological Association, Toronto, 1978.
Diller, L., and Gordon, W. Rehabilitation indicators: A home for ADL.
American Psychological Association, Toronto, 1978.
Diller, L., Gordon, W., Freidenbergs, I. Psychosocial factors in the rehabilit-
ation of people with cancer. Cleveland Cancer Center, December 1978.
Gordon, W., Brown, M. and Sherman, B. Evaluating the impact of perceptual
remediation. A case study. International Neuropsychology Society,
February 1979.
81
7. Joan Farber, Data Coordinator
Ms. Farber expects to complete all Ph.D. requirements in June 1979, in
Social Psychology, City University of New York. Her experiences include
appointment as Instructor in Psychology Hunter College and serving as consul-
tant in evaluation research to the Board of Education, New York City. She
has gained experience in rehabilitation and health issues in research assist-
antships with David Glass and Irwin Katz. Relevant publications include:
Katz, I., Glass, D.C., Lucido, D.J. and Farber, J. Ambivalence, guilt and the
denigration of a physically handicapped victim. J. Personality, 1977,
45, 419-429.
Katz, I., Farber, J., Glass, D., Lucido, D. and Emswiller, T. When courtesy
offends: Effects of positive and negative behavior by the physically
disabled on altruism and anger in normals. J. Personality, 1978, 46.
Katz, I., Ludido, D., Farber, J. & Glass, D. Ambivalence and amplification of
response to the physically handicapped. Manuscript submitted for public-
ation.
8. Gino Buccheri, Data Analyst
Mr. Buccheri is presently completing requirements for a Ph.D. in Social
Psychology at the City University of New York. His experiences include serving
as consultant in program evaluation to the New York City Board of Education,
being assistant to the Chief Psychologist at St. Francis Hospital, Roslyn, New
York, and conducting independent research regarding varying perspectives of
disability. He has gained a working knowledge of SPSS and MLIN and extensive
experience in computer use for data analysis.
9. Abbe Fabian, Project Assistant
Ms. Fabian was graduated in 1977 from Connecticut College with a B.A.
in Psychology; she was elected to Phi Beta Kappa and graduated summa cum
laude. As an undergraduate she participated in faculty research and conducted
her own research project as part of an honors thesis. Prior to being hired
by the RI Project, she worked at Rockefeller University in the Department of
Immunology.
10. David Lucido, Programming and Data Analysis Consultant
Mr. Lucido is presently completing requirements in the Social Psychology
Ph.D. program at the City University of New York. He has obtained much
experience in programming and data- analysis in several positions at CUNY:
Consultant to the Physician Payment Project at the CUNY Research Foundation;
Graduate Fellow, serving as computer consultant to faculty and graduate students;
Instructor of Computer Statistical Software; and Research Assistant to Leonard
Kogan and Irwin Katz. (For relevant publications, see Farber, above.)
82
C. Each of the Co-directors and other key project members are affiliated with
and have access to a variety of rehabilitation institutions and organizations
throughout the country (these have been highlighted in the preceding biographical
sketches). Associations of project principals with rehabilitation networks
provide potential sites for demonstration and channels for dissemination of RI's.
In addition, Task Force and Committee members represent many professional
and consumer organizations and institutions. (See Table 5 , p.83, for a
complete list of all project participants and their affiliations).
Another contributing factor in this project's potential success is its
being located at the Institute of Rehabilitation Medicine (RT Center 1),
New York University Medical Center. This location provides access to 1) consult-
ants and specialists in rehabilitation medicine, psychology, homemaking, occup-
ational therapy, physical therapy, vocational rehabilitation, bio-engineering,
architectural re-structuring, research methodology and data analysis; 2) computer
terminals and programing/key punch; 3) medical and university libraries; and
4) other resources in the metropolitan New York area (e.g., ICD Resource Center,
National Paraplegia Association) including a wide variety of rehabilitation
programs.
D. NOT APPLICABLE
83
TABLE 5 PARTICIPANTS IN PROJECT
COMMITTEES
1
1.
STEERING COMMITTEE
Leonard Diller, Ph.D.
Chief, Behavioral Science Dept.
Co-Director
Institute of Rehabilitation Medicine
New York University Medical Center
New York
Wilbert Fordyce, Ph.D.
Professor of Clinical Psychology
Co-Director
Dept. of Physical Medicine &
Rehabilitation
University of Washington
School of Medicine
Seattle, Washington
Durand Jacobs, Ph.D.
Chief, Psychology Service
Co-Director
Veterans Administration Hospital
Loma Linda, California
John Barry, Ph.D.
Professor of Psychology
University of Georgia
Athens, Georgia
2
2.
ADVISORY COMMITTEE
John Cobun, Ph.D.
Asst. State Superintendent in
(representing CSAVR)
Vocational Rehabilitation
DVR, Baltimore
Anne Crumpton
Project Director
Services for the Blind, Knoxville
Anthony DeSimone
Director, Office of Rehabilitation
(resigned)
Services
DHEW, Region II
New York
Fred Fay, Ph.D.
Asst. Director of Research & Training
(resigned)
Tufts-New England Medical Center
Boston
Fred Francis
Director, Division of Policy, Evaluation &
Development
OVR, Albany, New York
Lex Frieden
Houston, Texas
Pamela Gunnell, Ph.D.
Coordinator of Research & Evaluation
Wyandot Mental Health Center
Kansas City, Kansas
1. Participants include project staff.
2. Participants include the Steering Committee, Chairman of the ADL Task Force,
RSA Project Office (N. Ed Acree) and project staff.
84
Douglas Inkster, Ed.D.
Director, New York Infirmary
Center for Independent Living
New York
Adriano Marinelli
Chief of Program Planning & Evaluation
New Jersey Office of VR
Trenton
Marion Martin
Asst. Commissioner of VR
(resigned)
New York State Office of VR
Albany
Esther Montanez
Asst. Director
(resigned)
Fountain House, Inc.
New York
Essie Morgan
Chief, Socio-Economic Rehabilitation
& Staff Development
Dept. of Medicine & Surgery
Veterans Administration
Washington, D.C.
Louis Nau, Ph.D.
Assistant Director, OVR
Springfield, Illinois
John Nelson
Tufts-New England Medical Center
Boston
Thomas Porter, Ph.D.
Professor of Special Education &
Rehabilitation
Memphis State University
Memphis
Maxine Prescott
Director, Mentally Retarded Adolescent
Delinquency Project
Piscataway, New Jersey
Robert L. Robinson
Consultant
American Foundation for the Blind
New York
Stanley Sadofsky
Research & Development Specialist
Rehabilitation Services Administration
Region II
New York
Denise Sherer
Center for Independent Living
Berkeley, California
Douglas Watson, Ph.D.
Director of Service Research
Deafness Research & Training Center
N.Y.U. School of Education
New York
85
3
3.
UTILIZATION ADVISORY COMMITTEE
Gerben DeJong
Tufts-New England Medical Center
Boston
Stefan Harasymiw, Ph.D.
Rehabilitation Institute of Chicago
Chicago
John Muthard, Ph.D.
Professor of Rehabilitation Counseling
University of Florida
Gainesville
Alice Randolph, Ph.D.
Kent State University
Ohio
Kenneth Reagles, Ph.D.
Associate Professor of Rehabilitation
Syracuse University
Syracuse, New York
Robert Struthers, Ph.D.
OVR, Lansing, Michigan
Roland Sturm
OVR, New York, New York
Richard Walls, Ph.D.
Associate Professor of Educational
Psychology
West Virginia University
Morgantown
4.
ADL TASK FORCE⁴
R. Rembert Aranda
Director of Research (resigned)
Center for Independent Living
New York
Paul Corcoran, M.D.
Tufts-New England Medical Center
Boston
Lenore Daniels
Dept. of Speech & Hearing
Tufts-New England Medical Center
Boston
Therese Fitzpatrick
Dept. of Physical Medicine &
Rehabilitation
Tufts-New England Medical Center
Carl Granger, M.D.
Pawtucket Memorial Hospital
Chairman
Pawtucket, R.I.
3. Participants include Steering Committee, ADL Task Force Chairman, RSA Project
officer, project staff, and the following members of the Advisory Committee:
Cobun, Francis, Marinelli and Sadofsky.
4. Meetings attended by Co-director L. Diller and project staff; this Task Force
is no longer functioning.
86
Glen Gresham, M.D.
Tufts-New England Medical Center
Boston
Arnold Gross
Graduate School
for Advanced Studies in Social
Welfare
Brandeis University
Waltham, Massachusetts
Lauro Halstead, M.D.
Texas Institute for Rehabilitation &
Research
Houston
Ellen Jones (Resigned)
Center for Community Health & Medical
Care
Harvard University School of Public
Health
Boston
Sidney Katz, M.D.
Michigan State University
East Lansing
Robert A. Keith, Ph.D.
Director of Research
Casa Colina Hospital for Rehabilitation
Medicine
Pomona, California
Maude Malick
Director of Occupational Therapy
Harmarville Rehabilitation Center
Pennsylvania
Cairbre McCann, M.D.
Director, Rehabilitation Medicine
Rhode Island Hospital
Providence
Barbara McNitt, Ph.D.
Center for Community Health & Medical
Care
Harvard University
Boston
John Melvin, M.D.
The Medical College of Wisconsin
Curative Workshop of Milwaukee
Milwaukee
Harold Remmes
Project Director, Advocacy Project
Massachusetts Counsil of Organizations
of the Handicapped
Boston
Herbert Schoening, M.D.
Director, Rehabilitation Medicine
St. Mary's Hospital
Minneapolis
87
Clarence Sherwood, Ph.D.
John Jay College of Criminal Justice
City University of New York, and
Project Consultant to
Fall River Housing Authority (FRHA)
Fall River, Massachusetts
Sylvia Sherwood, Ph.D.
Director of Social Gerontological
Research
Hebrew Rehabilitation Center for Aged
Rosindale, Massachusetts
5
5.
ENVIRONMENTAL TASK FORCE
Lee Meyerson, Ph.D.
Professor of Psychology
Arizona State University
Tempe
William Moldt
New Jersey Dept. of VR
Trenton
Charles Reeder, Ph.D.
Director, Institute on Attitudinal,
Legal and Leisure Barriers
George Washington University
Washington, D.C.
Marilyn Saviola
Dept. of Rehabilitation Counseling
Goldwater Hospital
New York
Angela Thompson
President, Disabled in Action
New York
6.
6
FIELD TESTING TASK FORCE
John Barry, Ph.D.
Professor of Psychology &
Chairman
Coordinator of Graduate Education in
Psychology
University of Georgia
Athens
John Muthard, Ph.D.
Professor of Rehabilitation Counseling
University of Florida
Gainesville
Kenneth Reagles, Ph.D.
Associate Professor of Rehabilitation
Syracuse University
Syracuse, New York
Richard Walls, Ph.D.
Associate Professor of Educational
Psychology
University of West Virginia
Morgantown
5. Meetings chaired by Co-director L. Diller; attended by project staff
6. This Task Force has been integrated into the Utilization Committee.
88
7
7.
SOCIAL TASK FORCE
Howard Kaplan, Ph.D.
Professor of Psychiatry
Baylor College of Medicine
Houston, Texas
Edwin Willems, Ph.D.
Associate Professor of Rehabilitation
University of Houston
Houston, Texas
8.
VOCATIONAL TASK FORCE I⁸
Jim Bertram
Executive Director
Skills, Inc.
Moline, Illinois
Monique Bruns
CCDPA Western District Office
Chicago
Stanley Crow
VEWAA Research Director
Washington, D.C.
Richard Erickson
Director of Vocational Rehabilitation
Unit
Institute of PM & R
Peoria, Illinois
Robert Granzeier
Division of Vocational Rehabilitation
Springfield, Illinois
Michael Haswell
Raleigh, N. Carolina
Edward Hester, Ph.D.
Goodwill Rehabilitation Center
Chairman (Resigned)
Chicago
Robert Lee
Goodwill Industries of San Antonio
San Antonio, Texas
Alex Levis, D.Sc.
Systems Control, Inc.
Palo Alto, California
Fred McFarlane, Ph.D.
Assoc. Professor of Rehabilitation Cslg.
San Diego State University
Rehabilitation Center
San Diego
William Rabucha
HRS Vocational Rehabilitation
Tallahassee, Florida
John Roberts
Goodwill Industries of Toledo, Inc.
Toledo, Ohio
7. Meetings also attended by Co-director Wilbert Fordyce and project staff; this
task force is no longer functioning.
8. This task force was constituted by Dr. Hester with sub-groups meeting three times
prior to Dr. Hester's resignation as Chairman. This task force is no longer
functioning.
89
Charles Robinson
Rehabilitation Director
Vocational Development Center
Manchester, New Hampshire
Arnold Sax
Materials Development Center
Department of Rehabilitation &
Manpower Services
University of Wisconsin-Stout
Menomonie, Wisconsin
Harold Taylor
Division of Vocational Rehabilitation
Mt. Prospect, Illinois
9
9.
VOCATIONAL TASK FORCE II
Gary Athelstan, Ph.D.
Professor of Rehabilitation Counseling
Vocational Rehabilitation Unit
University of Minnesota
Minneapolis
Arthur Bradley, Ph.D.
Veterans Administration Hospital
Minneapolis
Rene Dawis, Ph.D.
Professor of Counseling Psychology
University of Minnesota
Minneapolis
Fred McFarlane, Ph.D.
Associate Professor of Rehabilitation
Counseling
San Diego State University
Rehabilitation Center
Duane Sermon
Director of Research
State of Minnesota DVR
St. Paul
9. Replaced Vocational Task Force I in February 1976. Meetings chaired by Co-director
Durand Jacobs; also attended by project staff. This task force is no longer
functioning.
90
E. 1. Staff Commitments:
Current employees include Brown, Gordon, Farber, Fabian, Buccheri and
Harris. Current consultants include Lucido and Randolph.
To be hired during the current project Phase (i.e., May 1979) is the
Field Coordinator. This staff person will be responsible for liaison between
the Project and all demonstration and satellite users: he/she will assist
in setting up and monitoring demonstrations and will be a member of the
dissemination consulting team. He/she will be responsible for development
and implementation of training programs, in conjunction with the training
consultant. The person is expected to have several years' experience in
providing rehabilitation services as well as experience in educational
materials development.
To be hired three months into the first year of Phase III is a Project
Assistant to assist the Field Coordinator in implementing training programs,
in monitoring data collection, and in providing feedback to settings. To
be hired at the start of the second year of Phase III is a Project Assistant
who will assist the Data Coordinator and Data Analyst. It is projected that
data feedback to the Project will increase rapidly by the second year, generating
a need for greater capability in data analysis. Both Project Assistants will be
B.A. level people with suitable rehabilitation and research experience.
E.2. Other and Prior Approaches
The approach of this project is unique in that what we are developing is
a multi-dimensional, multi-faceted language of descriptors that is conceptually
compatible with serving multiple purposes within diverse models of usage. Other
researchers (see pp. 92-95) have developed less flexible tools, focussing on
only some aspects of functioning (e.g., "competencies," not tied to other
functioning variables) or on single purposes (e.g., improved outcome measures).
Some approaches to assessment are also based on observable elements of functioning
and are quite comprehensive (e.g., Crumpton, 1975; SKILS, 1978), but are not
intended for use in many types of rehabilitation settings and with diverse groups
of disabled persons. Other approaches often form a patchwork of data demands
that can be awkwardly placed on a rehabilitation setting or system; none we
have found provide an integrated approach where data gathering is incorporated
into the planning of client services and only then is used for extrinsic
accountability, evaluation purposes.
RI's avoid the jargon that resides in some other approaches to rehabilitation
assessment and RI's provide for flexible use; the development of demonstrated
usage models is seen as crucial to RI product development.
Other assessment tools that provide more detailed functioning information
have been developed (e.g., SKIL, 1979); such tools that focus on observable
client elements are often compatible with RI's, simply defining more levels of
detail. RI's provide a "medium level" of detail: useful in individualized
planning, in tracking progress and in program management--an approach that
ties together client behavior, skills and environmental assessment.
91,
F. Potential Users
In Appendix XVIII, copies of correspondence between the Project and potential
users is provided. Plans to involve these settings and individuals in Project
activities are discussed in pp. 50-57
G. Implications for Legislation
RI's provide better means for multi-dimensional outcome measurement. Such
potential could lead to the development of sophisticated evaluation paradigms
being applied in settings for severely disabled people: providing better inform-
ation to resource providers (e.g., Congress) as to benefits accruing to disabled
clients of independent living centers and other similar settings.
Also, environmental indicators should provide detailed information relevant
to environmental elements that hinder, or prevent or assist client goal attain-
ment. These data could provide the ammunition for stronger legislation relevant
to environmental supports and barriers.
92
9. REVIEW OF APPROPRIATE LITERATURE
A. Introduction
A review of the literature can serve many purposes, including providing
a history of the research of others from which the focal research is derived,
comparison and differentiation of other approaches relevant to the focal
research, and review of research results directly utilized in the focal re-
search. Our discussion here will not be lengthy, although the Bibliography
of materials reviewed (see Appendix XVII) is quite extensive. This brevity
is due to the fact that our approach is basically orthogonal to most others
of which we have become aware and is not derived from a history of prior
published developments (although recent developments are relevant and are
discussed herein).
Basically we have reviewed the literature with four purposes in mind:
1. Discovery of descriptors and environmental barriers/supports
that other researchers have utilized in describing, assessing or
measuring aspects of the client's life,
2. Ensuring that this project's framework accounts for relevant
conceptual developments of others (e.g., defining "needs", "outcomes",
"disability", etc.),
3. Ensuring that the RI tool and usage model does not duplicate
the work of others, and
4. Analyzing related work relevant to outcome measurement.
The remainder of this Review will discuss each of these purposes in turn.
B. Review of Literature Useful for RI Content Development
1. Self-care/Independent Living
To help develop RI's related to self-care, we began by reviewing
the major ADL scales (e.g., Donaldson, Wagner & Gresham, 1973;
Granger, 1974; Schoening and Iverson, 1968; Katz and Lyerly, 1963)
and scales of functional life activities (e.g., Sarno, Sarno, &
Levita.., 1973; Scranton, Fogel & Erdman, 1970). Forms and check-
lists used in several medical rehabilitation facilities were also
reviewed for the purpose of determining the behavioral components
of "activities of daily living" that could be translated into
skill indicators (e.g., "Household activities chart", Institute
of Rehabilitation Medicine; "Physical self-maintenance scale",
Philadelphia Geriatric Center, Lawton, 1965). In order to des-
cribe skills associated with specific disabilities, literature on
the rehabilitation of people with mental retardation, hearing, and
speech impairments were consulted (e.g., Gold, 1963; Wolfsenberger,
1967; Porter, 1975; Sarno et al., 1973). "Household activities"
were based on a draft provided by Maude Malick, a member of the
ADL Task Force.
93
Several adaptive behavior scales and checklists were utilized in
the development of indicators in the area of social ADL. These were
a) the Camelot Behavioral Checklist (Foster, 1974), b) AAMD Adaptive
Behavior Scale (1974) and c) the Adaptive Behavior Checklist (Schwartz
& Allen, 1974).
All of the materials from which we directly drew ideas for in-
dicators are asterisked in the Bibliography.
In addition to the ADL Scales and checklists, we reviewed some
major developmental efforts of multi-dimensional behavioral description,
including the approach of the Knoxville Functional Capacity Areas project
(Crumpton, 1975), the Colorado Master Planning Guide, the Nebraska
Client Progress System (Hansen, 1974), the work of the Portland
Habilitation Center (Thiel, 1975), and SCIL (Hannah, et al., 1977).
Each of these are impressive efforts to describe client behavior in
self-care, social and vocational terms. Each, however, takes a develop-
mental approach where skill descriptions are used as behavioral anchors
on scales of and/or curricula for developmental progress and growth.
2. Vocational Assessment
The literature in this area is abundant. The basic objective of
our review in this area was to analyze and then behaviorize constructs
such as "work adjustment" and "employability" to help in developing
specific, observable and objective skills related to vocational
functioning. These included job-seeking and interview skills (Walker,
1969; Lumsden and Shard, 1974), job-related personal-interpersonal
skills (MDC Behavioral Identification Format, 1974), career planning
skills (Smith, 1959; Willings, 1959; Calhoun, 1946) and job-specific
skills (DOT, 1965).
Other efforts to make vocational planning more behavioral and goal
oriented (Esser, 1972; Houts, Scott and Leaser, 1973) and other
multi-dimensional vocational evaluation systems (e.g., Hester
Evaluation Systems; Controlled Environmental Laboratory Evaluation)
were reviewed as well as vocational scales such as the JVS Employability
Scale, San Francisco Vocational Competency Scale (1968) and several
scales of work adjustment. All scales and other published resources
used in development of RI's are asterisked in the Bibliography. An
important recent publication (Walls, et al., 1978) is being reviewed
by RI staff to insure our coverage of areas defined by Walls and his
coworkers.
3. Social/Leisure Behavior
After an extensive review of the literature exploring relationships
between rehabilitation variables and social/leisure outcomes, one
reference (Chapin, 1974) proved to be particularly useful in develop-
ing the content of the activity pattern methodology. Other literature
in the area of social behavior took approaches less consistent with
the project conceptualization, (e.g. focussed on affect); Chapin's
work is aimed at exploring how people use time and space. His activ-
ity categories were used as the basis for development of activity
categories. listed in Appendices II - IV.
94
It should also be pointed out in this context that the work of
Willems and his colleagues at TIRR (cf., Willems et al., 1977) was
influential (through Willem's participation in the Social Task Force
of this project) on the direction taken by the RI Project in
developing activity pattern indicators.
C. Relevance of Literature Review to Project Framework
Unfortunately most of the literature was not relevant to the develop-
ment of the RI project's framework. Briefly outlined below is the research
and work of others that has been influential in conceptualizing RI's:
1. Relevant to defining "disability" and "needs", only the chapters
by Moriarty and Nagi in Whitten (Ed., 1975) proved useful and
consistent with our own approach.
2. Kennedy, Hamilton & Galliers (1972) provides a useful model for
program planning, which could be used with RI's as content.
3. Jones' (1974) work on patient classification provided us the
concept of "level of detail", which has become integral to RI's.
Much of the project's framework was developed by the project staff,
interacting with the project's Task Force/Committee structure and
informal contact with colleagues.
D. Duplication of Others' Work
The RI approach (RI's and usage models, within a project framework)
overlaps with the work of others but does not duplicate it. Most of the
work of others that is most relevant to issues to which the RI approach
is responsive addresses only parts of what the RI project has "taken on."
Thus, some efforts focus on measuring outcomes in vocational rehabilitation
agencies (e.g., Westerheide and Lenhart, 1975; Reagles, Wright and Butler,
1970), some efforts focus on defining (in great detail) client competencies
and skills (e.g., Theil, 1975; Crumpton, 1975; Hannah, et al., 1977), some
assessment systems are focussed on single types of disability. None of
the approaches we've encountered have taken the RI approach:
- A basic, flexible tool.
-
To serve multiple purposes:
- Outcome measurement
- Assisting in client plan development
- Defining disability functionally
- Etc.
-
Focussing on several, conceptually integrated aspects of functioning:
- Statuses
- Activity patterns
- Skills
- Environment
95
-
Applicable in multiple types, of rehabilitation agencies
- State-Federal VR
- Private facilities
- Independent living
-
Useful with many disability groups
- Orthopedic and other physical disabilities
- Sensory disabilities
- Developmental disabilities
- Psychiatric disabilities
- Where information is focussed through "branched"or "gated" levels
of detail.
E. Review of the Literature on Prediction of Rehabilitation Outcome
(This review was developed as part of project efforts in relation to
the client change model, see pp. 16-22 , and is included here because of
the relevance of methodological outcome studies to the RI Project efforts.)
Several reviews, bibliographies and discussions of the literature on
prediction of rehabilitation outcome are available (Rubin and Salley,
1973; Bolton, 1972; Westerheide and Lenhart, 1974; Walls and Tseng, 1976;
Grigg, Holtmann and Martin, 1970; IRI Prime Study Group, 1974; Hammond,
Wright and Butler, 1968, and Sankovsky, 1968). Based upon Rubin and
Salley's (1973) annotated bibliography and some additional references,
this review includes those studies that used physically disabled persons
as subjects and/or where the study is methodologically interesting in the
context of this proposal's client change model. In these studies,
predictors include demographic, disability and experiential variables,
e.g., age, sex, level of education; psychological measures, e.g., anxiety,
self-concept; cognitive measures, e.g., WAIS; environmental variables,
e.g., availability of jobs; service variables usually are formulated
in terms of employment; occasionally an outcome such as independent
living is utilized.
Most studies reviewed have used a simple model of one set of variables
to predict one set of outcomes. Two exceptions are Barry, Dunteman and
Webb (1968) and Arnholter (1962). Both of these studies used a range
of predictors (psychological and/or demographic, disability, functional,
or service variables) to predict employment outcomes which were viewed
as mediated by motivation (Barry et al) or by a decrease on a rigidity
measure (Arnholter). No studies were located that postulated a wide
range of mediating outcomes (e.g., increased skills, increased mobility)
as does the client change model.
Most of the studies reviewed use "obtaining employment" as the sole
criterion variable (Zuger, 1971; Mesch, 1976; Weisbroth, Esibill, and
Zuger, 1971; Burnstein, Soloff, Gillespie, and Haase, 1967; Goss, 1968;
Taylor, 1963; MacGuffie, 1970; MacGuffie, Janzen, Samuelson and McPhee,
1969; Tseng, 1972; Salomone, 1972; Tosi and Vesotsky, 1970; Clayton,
1970; DeMann, 1963; McPhee and Magleby, 1960; Miller and Allen, 1966;
Gressett, 1969; Schwartz, Denner11, and Lin, 1968; Warren, 1961, and
96
Gilbert and Lester, 1970). Three studies vary from this pattern and
must also be noted: Ben-Yishay, Gerstman, Diller, and Hans (1968) used
length of stay and functional outcomes as criteria; Novis, Marra and
Zadrozny (1960) focussed only on "pre-rehabilitation outcomes";
Bowman and Micek (1973) included congruence between vocational goals
and vocational outcomes.
Others look at outcomes in addition to "obtaining employment":
Neff, Novick and Stern (1968) focussed on percent of time worked;
Arnholter (1962) measured change on Rorschach as a mediating outcome;
Barry, Duntemann, and Webb (1968) obtained ratings of motivation,
potential functioning efficiency and satisfaction; Lorei (1967) assessed
number of days not hospitalized; Miller, Kunce and Getsinger (1972)
studied employment-related outcomes, such as "job stability"; Greenblum
(1977) measured post-rehabilitation earnings; Clark (1973) assessed
employment-related outcomes, independent living, and ratings of success;
Siegel (1969) included schooling as a rehabilitation outcome category;
Nadler (1957) included several measures of work-related functioning, e.g,
punctuality; Ayer, Thoreson and Butler (1966) looked at occupation level
and upward mobility ratings; Hawryluk (1974) utilized a standardized
gain score constituted of hours of work per week, weekly earnings, work
status, economic dependency, and psychological well-being; and Olshansky
and Beach (1974) focussed also on job stability.
With regard to predictor variables, most studies analyze demographic
and disability variables. Westerheide and Lenhart (1974) concluded,
after reviewing several reviews of demographics as predictors (Sankovsky,
1968; Hammond, Wright and Butler, 1968; Day, Cummings, Anderson, and
Iverson, 1969; Grigg, Holtman and Martin, 1970), "demographic data have
not been shown to bear any consistent relationship to outcome" (p.13).
Some of the studies also use psychosocial and cognitive assessment
to predict outcome. For example, Weisbroth, Esibill, and Zuger (1971)
found that communication abilities related to employment for right hemi-
plegics, while WAIS block design differentiated return and not return to
work for left hemiplegics. Warren (1961) found that supervisors'
ratings of personality and social characteristics of clients predicted
employment. Nadler (1957) found significant correlations between WAIS
and Bender-Gestalt and a criterion constituted of the number of jobs
the person was capable of, productivity, steadiness of work, punctuality,
independence from supervision and work quality. Barry, Duntemann and
Webb (1968) found that favorable attitudes toward self, similar real and
ideal self images, interest in people and attitudes of social restraint
could predict levels of motivation and return to work. Gilbert and
Lester (1970) found that WAIS full scale, WAIS performance and MMPI
hypochondriasis and depression measures correlated with rehabilitation
success. Westerheide and Lenhart (1974) conclude, "The value of psycho-
logical tests in predicting rehabilitation success seems limited
Psychological factors may play an important role in the client's
rehabilitation, but they have proven difficult and time-consuming
to define and measure" (pp. 14, 16).
97
Of lesser emphasis have been studies that have included environmental,
service and client functioning variables as predictors of outcome.
Lorei (1967) found that a client's relatives' attitudes toward mental
illness could predict the client's employment and living in the
community. McPhee and Magleby (1960) found that a "healthy family
relationship' would predict "substantial employment". Mesch (1976)
found that employment opportunities and employer cooperation correlated
with employment; Clark (1973) found that none of the predictor variables
(demographic, psychological, cognitive, etc.) correlated with employment
and independent living of mentally retarded subjects, but that availability
of jobs in a rural setting accounted for variance. Burstein et al. (1967)
found a positive correlation between psychomotor performance measures
and discharge employment status. Ben-Yishay, et al (1970) found that
client functioning levels predicted (with other variables) self-care
and ambulation at termination. Mesch (1976) also suggests that the
patient's communication abilities will correlate positively with employ-
ment outcome. Weisbroth, Esibill and Zuger (1971) found that ambulation
and upper limb functioning correlated with employment. Tseng (1972) and
Arnholter (1962) correlated work behavior ratings and vocational outcomes.
With regard to service variables, Arnholter (1962) found that group
counseling participation did not correlate with criterion variables.
Neff, Novick and Stern (1968), however, found that counseling predicted
vocational adjustment; Bruell and Simon (1960) found that early entry
into physical therapy correlated with recovery among hemiplegics.
McPhee and Magleby (1960) found that obtaining more vocational training
correlated with their outcome category of "substantial employment".
Hawryluk (1974), however, found a negative correlation between rehabili-
tation service expenditures and rehabilitation gain. Bowman and Micek
(1973) found that three service variables (less vocational training,
completing the rehabilitation plan and number of contacts between
referral and plan formulation) correlated with congruence between
vocational goals and outcomes among 114 "26 closures".
In terms of the methodology of outcome studies, one might conclude
that none of the work reviewed depicts a complex model of rehabilitation
services and client/environment change. Findings are not reproduced
consistently and in much of the work, the utility of the findings to
service planners and providers is questionable.
98
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and Adults, 1974 Revision.
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with the MMPI and demographic data. Personnel and Guidance Journal, 1966, 40,
634-637.
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tation. Journal of Counseling Psychology, 1968, 15, 237-244.
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outcomes from psychometric parameters in left hemiplegics. Journal of
Consulting and Clinical Psychology, 1968, 34, 436-441.
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outcome. Rehabilitation Counseling Bulletin, December 1973, 100-109.
Bruell, J.H. and Simon, J.I. Development of objective predictors of recovery in
hemiplegic patients. Archives of Physical Medicine and Rehabilitation, 1960,
564-569.
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discharge of mental patients by psychomotor performance: partial replication
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for clients with hearing loss. Rehabilitation Counseling Bulletin,
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103
10. PROGRESS REPORT
A. Changes in Plan
All changes in plan have been detailed in prior progress reports (see
Appendix VI, pp. 4-7, and Appendix VII, pp. 5-8), except for one change in
the plan outlined on p. 22 of Appendix VII. In a discussion of planned
activities in the Progress Report for Year 2, it was stated that by the end
of Phase II the project would expand its conceptual discussion of
"disability," "needs," etc. and develop a plan to operationalize such
concepts. Instead these activities will be aimed at producing a modular
proposal rather than a plan for action in Phase III (implying core activity).
B. Progress Report
The last report of progress was written in January 1979 (see Appendix
VII). Progress since that date has been discussed in several parts of this
proposal. One aspect of progress remains to be described: activities of
project staff centering on analysis of RI data.
Studies have been conducted in three major areas of concern: a)
reliability, b) tool refinement and sampling procedures, and c) validation.
1. Reliability.
Test-retest reliability of the weekly inventory (NYU) form of
API's was studied; the form was administered twice to a sample of non-
disabled adults. Correlation methods were applied to both frequency
and duration of occurrence of activities in each of 12 activity cate-
gories (e.g., Vocational, Educational, etc.) across the two points of
measurement.
Analysis of these data indicated that for both frequency and
duration, ten of the 12 correlations between the sampled weeks were
significant (p < .05). The probability of obtaining this proportion
of significant correlations by chance is less than .02. This suggests
that activity patterns were consistent in this sample from one
"typical" week to the next, providing evidence that the inventory form
is reliable over time.
2. Tool Refinement and Sampling.
The following study was conducted to serve two purposes: (a)
to examine the comparability of two API forms currently in use (weekly
inventory (NYU and daily timeline -- see Appendices II and IV,
respectively), and (b) to begin to determine the best sampling
procedure to use with the timeline for obtaining a two-or three-day
record that adequately represents a full week:
Seven daily timelines, as well as the two weekly activity inven-
tories mentioned above (one of which covered the same week as was
sampled using the timeline) were administered to 20 nondisabled adults.
104
Comparability of the two API forms was examined by correlating
the summed activities of the seven daily timelines with the inventory
form for the same week. The two API forms were significantly cor-
related on nine of the 12 activity categories for frequency and on 11
of the 12 for duration (p = .003). Thus, duration more than frequency
was highly comparable across the two API forms. The timeline form
appears to provide a more complete description of an individual's day,
thereby providing a more accurate and reliable view of what transpires.
Despite these differences, however, this study of a small sample pro-
vides evidence that the inventory and timeline forms are significantly
comparable.
The timeline data were further examined by making multiple
internal comparisons of data subsets: individual days, composites of
weekdays,
weekend composites and the total week. In these ana-
lyses, it was found that:
a. For both frequency and duration, the composite of the five
weekdays correlated significantly with the sum of all seven
days on all 12 categories. The composite of the two weekend
days correlated significantly with the total week on 11 of the
12 categories for frequency and on 10 of the 12 categories for
duration. While the weekday and weekend composites each cor-
related significantly with the total week, they only correlated
significantly with each other on four out of 12 frequencies and
three out of 12 durations. (Individual weekend days and week-
days tended to correlate negatively with one another or not at
all.)
b. Out of 48 correlations (12 activity categories X 4 other
days) of each of the five weekdays with every other, the maximum
number found to be significant for any one day was 29 for fre-
quency and 26 for duration. However, the proportion of signif-
icant correlations was much greater for comparisons between
individual days and the total week, and between individual days
and the weekday composite. For frequency, Monday and Tuesday
correlated significantly with the total week on all 12 cate-
gories, Wednesday and Thursday on 11 out of 12, and Friday on
10 out of 12. For duration, Monday correlated significantly
with the total week on all 12 categories; Tuesday, Wednesday
and Friday on 11 out of 12. (Thursday correlated significantly
with the composite week only 9 out of 12 times). Individual
weekdays also correlated well with the weekday composites. For
frequency, Monday, Tuesday, Wednesday, and Friday all correlated
significantly with the weekday composite on all 12 categories,
and Thursday on all but one out of 12. For duration, Monday and
Wednesday correlated significantly with the weekday composite on
all 12 categories, Tuesday and Friday on 11 out of 12, and
Thursday on 10 out of 12.
C. Saturday and Sunday correlated significantly only six out
of 12 times with each other, and only eight out of 12 and seven
out of 12 times respectively with the composite week for
frequency. However, Saturday correlated significantly 11 out of
12 times and Sunday ten out of 12 times with: the composite weekend.
For duration, Saturday and Sunday were significantly correlated
105
only two out of 12 times, and each was significantly correlated
with the composite week only eight out of 12 times. However,
Saturday was significantly correlated with the composite
weekend ten out of 12 times, Sunday 11 out of 12 times.
These findings suggest that weekdays and weekend days are not
sufficiently correlated, indicating a need to sample at least one of
each in order to obtain an accurate representation of an entire week.
Furthermore, timeline days were strongly correlated with the composite
week, indicating that sampling a single day to represent all week days
is supported by this evidence.
Two additional sets of analyses on these data are in progress:
1) the similarity of activity category means, for both frequency and
duration, on the two forms will be tested in order to cross-validate
the correlation studies; 2) within subject activity pattern consistency,
both over time and across API forms, is also being examined in order to
clarify the group patterns observed.
3. Validation
A number of data analyses, some completed, others in progress, provide
information regarding the sensitivity of RI's to differences in client
populations, varying along dimensions such as type and severity of disability,
type and phase of rehabilitation, and status. Table 1, pp 3-5, summarizes
these studies:
1. IRM, Cancer Research Project: An early inventory form of the
API's was used in a longitudinal study of the impact of problem-oriented
intervention programs on the psychosocial rehabilitation of breast
lung, and skin cancer patients. Intervention and Control patients 1
were tested within 48 hours of hospital admission (T1), at hospital
discharge (T2), three months post-discharge (T3) and six months post-
discharge (T4). The API form (an early version) was used to measure
frequency of participation in various social-leisure and family-role
activities. At T4, Intervention patients more frequently (p <.05)
participated in Household Business Activities away from Home (grocery
shopping, bill paying, errands, etc.) than did Control patients. The
frequency of participation in Solitary Activities at Home (reading,
TV watching, napping) was constant from T1-T4 in the Intervention
but, increased significantly (p < .03) in the Control group. There
were no activity pattern differences specific to cancer-site. These
measures indicate the greater activity of those in the Intervention
group, and that the effects of intervention were associated with active
patterns of activity.
2. IRM, Psychosocial-vocational Research Project: API data (NYU form,
see Appendix II) gathered from 85 spinal cord injured individuals, 1-5
1. "Controls" received regular psychosocial services rather than the special
intervention program.
106
years post-injury, were available for analysis. Ten cases (not
wheelchair bound) were eliminated from the analysis; it was felt that
the difference in mobility status would have skewed the data base,
rendering interpretation (at this point) difficult. Thus, the data
from 75 SCI individuals were examined in order to determine how API's
varied as a function of disability [paraplegic (N = 25) VS. quadri-
plegic (N = 75)], vocational status [working (N = 25) VS. not working
(N = 75)], sex [male (N = 60) VS. female (N = 15)] and marital status
[married (N = 23) VS. single (N = 52)], and duration of disability
[years post injury: 1 (N = 12), 2 (N = 20), 3 (N = 16), 4 (N = 16),
5 (N = 11)]. All data were collapsed into 12 activity categories for
each individual and then were analyzed using analysis of variance
procedures; the Tukey-B procedure was used to test the significance
of all post-hoc comparisons. These analyses indicated:
a. The categories of API's were sensitive to the effects of
disability. This was observed in several ways: a) The para-
plegics participated in many more different activities than
the quadriplegics (p <.004). b) The greater diversity of
activities was also reflected in the area of transportation
(p < .02). Thus, the paraplegics appeared to venture out more
and use transportation to do more different activities. c)
The paraplegics more frequently participated (p < .05) in
Household Business activities (shopping, banking, etc.) for
longer periods of time (p <.03). The paraplegics also spent
more time in Home Maintenance Activities (p < .05). These
activities were especially underrepresented in the reports of
the C4 quadriplegics (p .001).
b. The categories of API's were sensitive to the effects of
vocational status. As would be expected workers engaged in
more different (p < .001), more frequent (p < .001) and more
time (p < .001) in vocational, educational and transportation
activities than the non-workers. In contrast, those who were
unemployed spent more time engaged in rehabilitation (p < .01)
and recreational (p < .001) activities compared to those who
were employed.
C. The categories of API's were sensitive to gender differences.
The data indicated that the women were more active social parti-
cipants than the men. This was observed in several ways: a)
the greater diversity of recreational activities (p < .01) and
communications (letters/phone calls) (p < .04) ; and b) the
greater frequency of social activities (p < .05). In addition,
the women spent more time (p < .03) in personal care activities
than did the men.
d. The categories of API's were sensitive to marital status
differences. Thus, married people more frequently participated
in child-centered activities (p < .001) for longer periods of
time (p < .002).
107
e. The categories of API's were sensitive to duration of
disability, in that those who were one year post injury engaged
in more different rehabilitation activities than those who were
three or five years post-injury (p < .05),
Following these analyses, the focus of data analysis was switched
to individual activities. It was reasoned that even though categories
of activities differentiated between groups, use of categories in the
analyses would be blunting the sensitivity of API's to group differences.
It was hypothesized that individual API's would be the source of dif-
ferences and that category means might be similar but the ways in which
activities were distributed within a category might differ. The latter
situation is analogous to two individuals having similar WAIS full-
scale IQ scores, but based on differing patterns of subscale performance.
In order to examine the utility of this approach for future analyses,
the items in the social, recreational, social interaction, relaxation
and housework categories were examined.
It was noted in the category analysis that unemployed subjects
spent more time in recreational activities than did persons employed.
Examination of the specific activities added meaning to this finding:
the recreational activities selected were largely passive in character.
Specifically, non-workers more frequently watched TV (p < .03) or read
(p < .05), for longer periods of time (TV, P < 001 reading p < .007)
than did workers. The greater passivity of the non-workers is also
noted in their social interactions: they more frequently (p < .07) and
for longer time (p < .02) were visited by family members (a more active
form of social interaction would be the Ss visiting family) than
workers.
It was seen in the analysis of activity categories that women
were more socially active than men, which is accounted for by their
greater participation in such activities as dining out (frequency,
p < .05), going to museums (frequency, p L .05; duration, P <. .01),
going to the theater (frequency, p 4 .001; duration, P .003),
wheeling (duration, p is .03) and interacting when friends visit
(frequency, p < .07).
Individual API's were much more sensitive to the effects of
marital status than were the activity categories. Single people more
frequently visited (p < .06) and spent time with friends (p < .02)
than those who were married. In contrast, those who were married
spent more time attending meetings of clubs and organizations (p (..02).
Also, those who were single spent more time listening to the radio
(frequency, p < .01; duration, P < .001).
These analyses indicate that the API's are sensitive to statuses
which act as major channels of behavior. Further analyses are planned
during Phase II and III to: (a) explore the external correlates of
activity patterns, and (b) explore ways of clustering items so that der-
ived "indicators" of such factors as mobility, isolation, etc.,
emerge.
108
3. IRM, Vocational Department, Summer Work Program. This study
derived from an interest of the Vocational Department at IRM in evalu-
ating the effects of a summer placement program for young adults and
teenagers. Using the NYU form of API's, pre- and post-placement, with
an N = 9, no consistent immediate changes in patterns of activity were
found. A request for R & T Center funds to continue the evaluation
over a longer time span was rejected, and therefore no further activi-
ties are planned by the RI project in this evaluation.
4. IRM, Electronic Device Research. A cross-sectional study of quadri-
plegics was conducted for the purpose of evaluating the impact of
devices on activity patterns and other variables within this population.
Preliminary analyses have been completed and are presented in Appendix
XX.
5. UCP, PIPP. RI data (API's and Status Indicators) were obtained on
over 30 developmentally disabled persons at two points in time: pre-
and post-deinstitutionalization, as part of a longitudinal evaluation
study of the Post-Institutional Placement Project, sponsored by United
Cerebral Palsy of New York. A report of this study is included in
Appendix XIII. Overall, the results revealed large, expected pre/post
differences, pointing towards increased activity levels, diversity of
activity, independence, and mobility after deinstitutionalization.
6. Altro Health and Rehabilitation, Evaluation Research: A. 2 X 2
cross-sectional study of 20 psychiatric clients at entry and at closure
was conducted, using either the NYU or timeline API forms. By
inspection of the data, it was found that the two API forms did not
differ greatly on either frequency or duration within the activity
categories and therefore these two cells were collapsed for the analysis
of clients at entry and at closure. It was found that: a) clients at
closure engaged in rehabilitation activities more often and for longer
duration than did clients at entry; and b) clients at closure showed
less variance in their responses than did those at entry. It is un-
clear whether the latter finding reflects greater similarity in actual
activity patterns, less measurement error or both.
These findings and a report of field test experiences in this
psychiatric setting were the focus of a presentation by Joan Mayer
Caplan, a former staff member, and Celia Benney, Research Dierector
at Altro, at the April 4, 1979 meeting of the American Orthopsychi-
atric Association.
7. University of Washington, Chronic Pain Research: This is a longi-
tudinal study of chornic pain patients and their spouses. API's are
being used in conjunction with several other measures: the MMPI, acti-
vity diaries, an activity checklist, and a health care utilization
measure. Data analyses are focussed on describing the API's criterion
referrent systems.
109
8. University of Washington, Hemiplegia Research and Other Research:
An exploratory study of hemiplegics and their spouses, and a similar
study of a heterogeneous sample of disabled patients have been
completed. The use of API's in those two studies was descriptive.
Expected activity pattern differences among subsamples were found.
(See Appendix XVI.)
9. University of Washington, Spinal Cord Injury Research: In another
ongoing longitudinal study, medical and functional capacity measures,
and API's are being administered to spinal cord injured patients.
Correlations among these measures, and the relationship between indi-
vidual and functional capacity and changes in activity patterns will
be examined. Results are not yet available.