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It is suggested that you purchase eight part folders, which will include the following documents and information opened or started in your office:
Section 1:
Section 2:
a) Severity of Disability form.
b) IPE goes on top of Severity of Disability form.
Section 3:
a) All STATE or Tribal VR correspondence goes here - no correspondence should be filed in any other section besides this section. All letters. Note: when reviewing correspondence, if the letter makes any reference to a medical condition, then it should be filed under the medical records section.
Section 4:
Documents filed under this section should be filed in the order received as these records are usually called for in the order of importance as it relates to the client.
a) IEP's (for learning disabled clients this is a school report which reflects
a plan to put student in special education classes). These may be accompanied
by a Psychological Assessment/Report done by school psychologist. This is filed
here as well.
b) Vocational Evaluations.
c) Psychological evaluations.
d) Assessments- these can be done by private contractors. This will sometimes
look like correspondence, but, is a report. Do not put this type of documentation
in the correspondence section.
e) College transcripts. TABE- Test of adult basic education
f) College class schedules- any college documentation other than an invoice
should be filed in this section.
Section 5:
MEDICAL- only medical records go in this spot.
a) hospital records/health facilities
b) medical correspondence which speaks to a client medical condition.
Section 6:
a) Financial- only financial records go in this section
Section 7 and 8:
These sections are used to file State and TVR case notes only.
Which section you use (7 or 8) to file TVR or STATE case notes is unimportant.
The VR process begins with an application and ends with a closure. During this process there are certain milestones, such as application, eligibility determination, IPE, and case closure. As these milestones are achieved, there is a need for management to avoid bottlenecks. The following thoughts are suggestions that hopefully will assist you keep the flow of individuals moving smoothly through your program:
" When you have a signed application and complete the intake interview, do your opening case notes immediately. Then request information or schedule needed diagnostics. Don't wait. The information is fresh and there will be no more convenient time. Get going with your assessment to determine eligibility at this time. Remember, assessment begins when the person walks in through your door.
" Eligibility is next. If you carefully completed the application and assessment, you will have the information you need to make the eligibility determination. The determination should be done in a "reasonable amount of time," usually not to exceed 60 days. In reality, this usually happens sooner than 60 days. It could happen the same day you receive the application if the individual brings the necessary documentation.
"
Assessments (vocational/medical/psychiatric) may be necessary to assist you
and the participant in determining their unique interests, aptitudes, strengths
and preferences. This information will assist you and the individual in establishing
their vocational goal and planning how to get there.
" With the appropriate assessment information in hand, next is the IPE development. The individual and counselor will develop the plan together, which will hopefully carry the individual to successful employment.
" Finally, the individual achieves employment. The individual is then monitored while they are employed and if at the end of a 90 day period the individual and counselor feel that no further services are needed, the case may be closed successfully.
" If problems arise after successful closure, the program can provide "post employment services." This typically occurs within a reasonable amount of time after closure of the case.
" In the case of supported employment, the final phase is normally the "follow along" phase, which can be as long as necessary up to 18 months. This service can be provided by the VR program, a paid provider agreed upon by the individual or their representative, or a natural support system such as family or the employer.
Persons with disabilities who live in rural and remote areas face special employment challenges. These challenges include limited resources, isolation, increased poverty, decreased educational advantages, and greater preponderance of manual labor jobs that are non-conducive to physical and mental impairments.
Statistics show that 2.7 to 3.5 million persons with disabilities between the ages of 16 and 64 live in smaller or rural communities. One author said, "For more than seven decades, we have practiced urban VR in America, forcing the person in need of services to come to us, to be willing to relocate, to give up rural lifestyle. In this decade of empowerment and equality for Americans with disabilities, forcing the urban model is no longer an option. We must be willing to make the necessary adjustment to our programs required to meet the rehabilitation need of those who choose to live in rural areas." (Carney, 1992, p.1)
The positive employment outcome in rural areas does not solely depend on the availability of the labor market. Contributing factors to successful American Indian outcomes include Tribal value system, personal investment in Tribe, Tribal identity, and Tribal acceptance.
Of course, in a rural and remote area, there needs to be creative placement and employment outcome strategies in place. Some helpful hints to developing a strategy that works for your area includes:
" Ask the question, "What skills, abilities, capabilities, and desires
does the participant have?"
"
Think outside the box - sometimes convention can be hindering and creativity
is needed
"
Ask the question, "What services exist in the community?" - knowing
what exists in the community will help determine what is needed
"
Ask the question, "What gaps do those services leave?"
"
Ask the question, "What services do not exist that the community could
use?"
This leads us into the consideration of Self-Employment. Self-employment also takes into consideration the needs of the community. Some possibilities include artist, repair, musician, sewing, carpentry, handyperson, designer (clothing, website), landscaping, janitor, maintenance, or subsistence.
When looking at creative placements and self-employment, it is still necessary to do a labor market analysis of your service area. What does the labor market look like on your reservation? Most likely the labor market is extremely slim. Secondly, how does the labor market fit into the participant's choices and options? Finally, how will you and the participant shape the IPE while taking the labor market into consideration?
In conclusion, employment in rural and remote areas depends highly on collaboration between the counselor, participant, and the community. Employment depends on the creativity of the participant, counselor, and community. It is suggested that self-employment and subsistence as employment outcomes be more carefully considered as a VR employment outcome.
OVERVIEW
The guidelines included in this section were developed as a reference for VR staff in decision-making and purchase of medical assessments, goods, services, and treatment. The topics included represent the more common services that are utilized by VR staff and participants. These guidelines are "suggested practices" and not intended to be applied in every case. Every individual brings unique circumstances and needs to the VR process. The type or extent of medical services considered depends on the specific information needed by the counselor and/or the participant's needs.
TRADITIONAL HEALING
The Rehabilitation Act of 1973 as amended has a clause that authorizes the use of "traditional services," which can be interpreted to mean traditional healing practices. Because there are 500 plus Tribes in the US, authors of the Rehabilitation Act wisely did not try to define what "traditional services" are. Therefore, this clause may be interpreted by each Tribal VR program in a manner which best meets the needs of their participants. The end result is that each tribal program is authorized to purchase traditional services as appropriate in their area to meet the needs of participants. These services may be purchased from individuals who meet the programs established standards (Section 121(b)(B)).
MEDICAL CONSULTATION
It is recommended that you consult and/or arrange with a local MD for the following various anticipated services: dental service, psychotherapy or counseling services, cognitive rehabilitation, medication, drivers evaluation, surgery, or when there is a question about the need for or appropriateness of a particular treatment. In addition, your medical consultant may be a valuable training resource in the medical/psychiatric field. Sample medical consultation forms are located under Service Delivery Forms. It is suggested that when you review cases with your consultant you have questions prepared before the meeting. Finally, training is a mutual need. In addition to the consultant training you on medical issues, you need to train the consultant about VR.
Topics covered in these guidelines include:
1) Alcohol/substance abuse evaluation
2) Advanced Registered Nurse Practitioner (ARNP) and Physicians Assistant Certified
(PAC) services.
3) Chiropractic services
4) Counseling/psychotherapy
5) Dental services
6) Eye glass services
7) Payment for missed appointments
ALCOHOL/SUBSTANCE ABUSE SERVICES
If a participant demonstrates behaviors of alcohol and/or substance abuse and you are uncertain whether they are appropriate to receive VR services, you may refer the individual for a comprehensive substance abuse evaluation. The evaluation may be conducted by a Tribal treatment center, a certified Chemical Dependency Counselor (CDC), or a psychologist or psychiatrist with special training in this area. An observed urinalysis may be required, if the circumstances suggest the need.
An alcohol assessment can also be a useful tool in helping a participant identify whether a substance abuse problem is present. The results can be used to assist the participant to look at substance abuse issues and receive professional guidance.
Guidelines:
1) It is suggested that the counselor consider the following elements when
authorizing an evaluation:
* A comprehensive history which describes past treatment and the pattern of
use including issues related to tolerance, abstinence, and withdrawal, consistent
with "Diagnostic and Statistical Manual of Mental Disorders" (DSM-lV).
* A description of the adverse effects of the substance abuse/dependency.
* An indication of loss of control over the substance.
* A description of the functional limitations to employment resulting from
the effects of the abuse/dependency.
* Treatment recommendations and a description of support systems necessary
to ensure continued abstinence (e.g., random urinalysis and/or lab tests or
other appropriate monitoring)
* A description of prescribed medications as a part of the treatment program.
* Identification of the length of time the participant has been drug free.
2) Before entering into an IPE, it is suggested the participant:
* Be alcohol or drug free, or be participating consistently in a treatment
or support program.
* Agree to include terms and conditions on the IPE related to participation
in a certified treatment program or a support program, such as AA or NA, for
maintaining substance-free behavior.
* Receive additional counseling or assessments, if indicated by behaviors that
clearly impact employment potential.
3) Comparable services and benefits are often available through many of the
Tribal Substance Abuse programs for in-patient or outpatient treatment.
4) The participant's continued participation in services or treatment to maintain
sobriety, such as AA, NA, Traditional Ceremonies, or other recognized programs
should be included in the IPE.
5) If at any time in the VR process a counselor is uncertain whether the participant
is clean and sober, the counselor may ask for an assessment to determine whether
the participant is still eligible for VR services. If the assessment indicates
the individual is not maintaining sobriety the case may be closed as ineligible
or no longer eligible.
ADVANCED REGISTERED NURSE PRACTITIONER AND PHYSICIAN ASSISTANT SERVICES
Advanced Registered Nurse Practitioner (ARNP) is an independent practitioner, licensed to evaluate a diagnosis, make referrals, prescribe medications, and provide treatment in a variety of specialized areas. Areas of specialty may include Mental Health/Psychiatry, Family Medicine, Women's Health Care, and Adult/Child/Geriatric Health care. As with any State recognized providers of medical services, they must be certified and licensed, and are held accountable to professional standards of care.
Physician Assistant or Physician Assistant-Certified provides health care services under the supervision/sponsorship of a physician/osteopathic doctor. The supervisor/sponsor is not required to provide signature approval, only availability for oversight and consultation. They may evaluate, diagnose, make referrals, prescribe medications (within the scope of their practice), and provide treatment in a variety of specialized areas as described above. They must be licensed and certified, and they are held accountable to professional standards of care.
CHIROPRACTIC SERVICES
The primary use of chiropractors may be appropriate treatment for the treatment and relief of symptomatic pain as a short-term intervention. This may be effective treatment for acute pain management and a preferred choice of participants.
The use of chiropractic information may be used to determine eligibility only when the information provided is sufficiently comprehensive and confirms the condition reported. When additional information is needed to establish eligibility, chiropractic information may be used in conjunction with diagnostic reports from Medical Doctors, Advanced Registered Nurse Practitioner or Physician's Assistant Certified.
Guidelines:
1) Diagnostic visit (office visit) is suggested to complete an exam, gather
pertinent history, and determine the appropriateness of a short-term treatment.
2) A review of other medical conditions is suggested to assure that the use
of chiropractic treatment is not medically contra-indicated.
3) Recommended that chiropractic treatment be limited to six to eight sessions,
with additional treatment based on substantial improvement.
COUNSELING/PSYCHOTHERAPY
When a psychological/psychiatric impediment to employment is present, VR may provide counseling/psychotherapy services.
Guidelines:
1) If a current evaluation is needed, the evaluation may be completed by a
Psychiatrist (MD), a licensed psychologist (Ph.D.) or an Advanced Registered
Nurse Practitioner (ARNP). It is suggested to request an evaluation report
that includes the following elements, at a minimum:
* Diagnosis
* Prognosis
* How the condition may impact employment
* Treatment recommendations, i.e., type of therapy, length of time
2) A follow-up with the evaluator to discuss the findings as they relate to
employment and rehabilitation concerns may be helpful.
3) When the participant chooses to enter into treatment, a qualified therapist
is selected by the participant. The medical consultant may provide assistance
to verify a therapist's qualifications. As indicated, services must be provided
by qualified service providers.
Typically, these services must be provided by:
* A psychiatrist, licensed to practice in your state, or
* A psychologist, licensed to practice in your state, or
* An Advanced Registered Nurse Practitioner, licensed to practice the specialty
in your state, or
* A certified counselor, holding a Masters Degree plus certification in any
of three categories Mental Health, Marriage and Family, or Social Work
4) In authorizing a treatment plan, it is recommended to provide specific instructions
to the therapist regarding treatment goals, such as:
* Identification of behaviors needing change
* How the behaviors affect employment
* The type of therapy to be engaged (i.e., cognitive, behavioral, psychotherapy,
or other specific treatment techniques)
* The frequency of sessions and duration of treatment
5) The following conditions are recommended when funding treatment:
* Initial authorization of up to twelve sessions or three months.
* A progress report, completed by the therapist, at least midway through the
approved treatment, and a written report following
the final session.
* When authorizing therapy beyond three months, consultation with your medical
consultant is recommended.
DENTAL SERVICES
Dental treatment may be provided by VR when it is directly related to an employment outcome or in emergency situations involving pain, acute infections, or injury.
Examples of disabling dental conditions for which restorative services may be authorized include widespread ulceration of teeth, destruction of tooth surfaces, decay that seriously affects the individual's ability to eat, badly malformed or positioned teeth, or rejection of the individual for employment on the basis of appearance.
Guidelines:
1) A dental examination, including x-rays as necessary, is suggested when
necessary to obtain recommendations and/or a pre-treatment report. Consultation
with your medical consultant is recommended to review the scope of treatment
to assess whether it is appropriate to the vocational needs and to select an
appropriate dentist.
2) The medical consultant may be asked to review the pre-treatment report and
recommended procedures. The medical consultant may consult with the dentist
and/or the participant as necessary, to negotiate appropriate services and
fees with the dentist.
3) A second opinion or dental consultation may be helpful when extensive treatment
is indicated.
4) If full mouth extraction and replacement with upper and lower dentures is
authorized, it is recommended that you case note that the participant has consented
to full mouth extraction.
5) The medical consultant may be asked to review the treatment recommendations.
Usual dental practices apply the following order of priority in developing
a treatment plan. First priority is usually given to reduction or elimination
of pain, reduction or elimination of pain, reduction or elimination of disease,
stabilization of dental health or condition, cosmetic, the dental condition
is such that it negatively impacts the individuals ability to obtain employment
due to appearance or speech. Long term dental care plan procedures or treatment
to be covered by the participant at some future date, after employment, and
case closure.
EYEGLASSES
Guidelines:
1) When an eligible individual needs glasses to accomplish their IPE, the
participant should be sent to an Ophthalmologist or Optometrist for examination
and recommendation.
2) If the participant is found to be in need of visual correction to pursue
their vocational goal or complete their IPE, glasses or necessary visual correction
should be purchased or secured. If unsure of the diagnosis or prescription,
the medical consultant should be consulted.
V. Comparable Benefits and Services
Finding and utilizing alternate resources or comparable benefits is a requirement of the Rehabilitation Act. Through the use of comparable benefits and resources available to the individual, the program can recognize a significant saving of resources that will stretch your program dollars. It is also another way in which the individual can be brought into the rehabilitation process as a partner. Securing comparable benefits requires effort on the part or the counselor and the participant. In this manner, the individual is able to help pay for their plan and invest in their own future.
The following information comes from Section 101(a)(8) the Rehabilitation Act and from the 34 CFR 361.53 and 34 CFR 371.21(h) regulations. Section 101 of the Act refers to the State VR Plan and 361.53 are the federal regulations referring to the State VR program; however both are more descriptive than the Tribal regulations in 34 CFR 371 and are appropriate to follow.
Comparable services and benefits are services or benefits that are similar to services Tribal VR would provide that are available at no cost to the individual from other sources. For example: IHS or Tribal programs such as medical or dental services, education and training, financial assistance, child care services, or private resources such as, health insurance, or another employee benefit program.
Not all Tribal VR services require similar or comparable benefit to pay the first dollar. The following VR services are provided without a determination of comparable services and benefits:
" Assessment services
"
Assistive technology services
"
Assistive technology devices
"
Counseling and guidance services
"
Independent living services, including assessments, when provided directly
by a VR counselor
"
Referral services
"
Job placement and job retention services
"
Rehabilitation engineering services
"
Post-employment
A determination of comparable services and benefits is not required before you begin providing VR services if: (a) The delay of service would place the individual at extreme medical risk (Extreme medical risk means a likelihood of death or a functional impairment that will substantially worsen if medical services, including mental health services, are not provided quickly); (b) Would hinder or interrupt an immediate job placement; or (c) Unduly slow progress toward achieving the employment outcome identified on the IPE.
You may complete the determination of comparable services and benefits while the individual receives VR services if it is expected that services and benefits exist and could be used at a later time without resulting in a delay. If comparable services and benefits are available, you must pursue them with the individual.
Tribal VR does not pay for a service that is available to the individual as a comparable service or benefit. If the individual should choose not to apply for or use comparable services or benefits that the VR counselor has determined are adequate to meet the need, the individual will be responsible to pay for them.
Awards and scholarships based on merit are not considered as comparable services and benefits.
References: Section 101(a)(7) and 101(a)(35) of the Act and 34 CFR 361.18
Application to Tribal VR:
For several years, State VR has been struggling with the issue of CSPD, however there have been no formal policies concerning the Tribal VR programs. At present the issue is being discussed by CANAR and RSA.
The current thought is, in regards to qualifications of professional personnel for the Tribal VR programs, the greatest priority is to employ local individuals who are part of the Tribal community and understand the culture. To compensate for any lack of VR background, programs have been encouraged to complete a plan of professional development for their staff to build the necessary VR skills. When no local individual with a VR background is available the counselor should meet some basic qualification.
Thought is being given to basic core competencies within VR, which may or may not be part of a degree program. Presently, several universities offer distance education graduate programs in VR counseling and there are some offerings for undergraduate and/or certificate work.
The CSPD regulations that exist in the Act and 34 CFR 361 are very broad and would not be reasonable for a Tribal VR program. However, there are some components that may be incorporated into the Tribal VR regulations and should be considered by the programs even though the regulations may not be in place at present. These are:
1. At present most States consider that basic qualifications for a VR counselor is a Masters degree and eligibility to sit for the national examination to qualify as a Certified Rehabilitation Counselor (CRC) or,
2. A BA in VR or a related field plus a written plan for continuing education or staff development which will assist professionals and paraprofessionals in your program to stay up to date with necessary rehabilitation skills and issues. This should be individualized for each of the staff members.
