DRAFT
Experimentation and Collaboration to Enhance Employment for Persons with
Disabilities: Assessing the Wisconsin Pathways Projects’ Efforts to Explore
Systems Change
Barry S. Delin and Catherine A. Anderson
Stout Vocational Rehabilitation Institute
University of Wisconsin – Stout
Association for Public Policy Analysis and Management Research Conference
Los Angeles, California
November 8, 2008
The authors thank the managers and staff at Pathways to Independence, Office of
Independence and Employment, Wisconsin Department of Health Services for
their cooperation and support. This paper is funded by the Centers for Medicare
and Medicaid Services, Medicaid Infrastructure Grant – CFDA No. 93.768,
Wisconsin Department of Health Services/Pathways to Independence.
The descriptions and interpretations in this paper are those of the authors.
DRAFT
1
Introduction
This is a preliminary report about how an entity called Pathways to Independence
(or for brevity, “Pathways”) has sought to achieve “systems change” for the purpose of
supporting the employment goals of persons with significant disabilities. This policy area
is likely to be one of increasing importance due to both mounting pressure by those with
disabilities for fuller incorporation into American society and the need to find new
workers to replace large numbers of retirees. This paper is the first product of the
“Pathways Interorganizational History Project” which seeks to document Pathways’
overall activity in support of systems change and, in contrast to individual program
evaluations, to assess the long term impact of the unit’s total efforts.
As the phrase “systems change” can be interpreted in myriad ways, our use of
the phrase will reflect that found in Pathways’ documents and how Pathways managers
and staff talked about “systems change” both within Pathways and with external
audiences. Pathways has described systems change in mainly functional terms, that is,
as a set of conditions that would be met when “systems change” had been achieved.
The basic characterization of these conditions has been persistent over time. Systems
change” would be achieved when there was a coordinated and comprehensive return-towork approach for persons with significant disabilities. 1 Program and policies, at all
levels of government, would operate in concert to facilitate better employment outcomes.
Finally, all stakeholders, including persons with disabilities, would have the information
and access to necessary expertise and resources to effectively use the transformed
system. Systems change would certainly involve changes to existing institutions,
policies, procedures, practices and the relationships among these, but Pathways does
not appear to have had a settled doctrine on whether transformation could be produced
through largely incremental adjustments or would require truly fundamental changes to
institutions and policies.
In this paper’s title, we suggest we will be assessing Pathways’ efforts to explore
systems change. At the outset we want to clarify our intent. We are not examining the
extent to which Pathways activity, as a whole, has resulted in employment or earnings
gains for Wisconsin residents with significant disabilities. Similarly, there will not be a
targeted assessment of how far Pathways or Wisconsin has come to implementing a
coordinated and comprehensive return-to-work approach for persons with significant
disabilities, though the issue receives some attention in the final section of this paper.
Our aim in this paper is more modest. We examine collaboration among Pathways and
its various partners in six separate efforts with the aim of elucidating patterns between
the terms of collaboration and the performance of the putative system changing
activities. These case studies are organized into three pairs. The first pair consists of two
demonstration projects that involved both testing an important change in current policy in
the context of more coordinated service delivery. The second pair includes two efforts
1
Pathways has used the term “significant disability” in several ways, but the predominant usage
has been to refer to persons who meet the non-financial disability criteria for qualification to
Social Security disability programs and/or Medicaid or have a high likelihood of doing so in the
future. This reflects both Pathways’ location in a state Medicaid agency and the Centers for
Medicare and Medicaid Services’ loosely defined concept of the target population for efforts
funded through the Medicaid Infrastructure Grants. There are alternative uses of the phrase that
are used within Pathways’ environment, most particularly the use in the contexts of eligibility and
priority for Vocational Rehabilitation (VR) services.
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2
with the goal of increasing the capacity of entities external to Pathways to improve or
increase service provision thought to be necessary components of a transformed
system. The final pair looks at broad priority setting processes aimed at directing effort
and resources to support desired systems change.
It is also important that we, as authors, identify our relationship to Pathways from
the start of this paper. One of us (Delin) performs evaluation work on behalf of
Pathways, but has never had operational responsibilities not directly related to research
implementation. The other (Anderson) is a member of the Pathways management team
and has had either a supervisory or operational role in some of the activities examined in
this paper.
As will be discussed, there is some ambiguity as to the organizational existence
of Pathways to Independence. However, there is no ambiguity about the nature of the
government entity where Pathways is housed, the Wisconsin Department of Health and
Family Services (DHFS). 2 Moreover, due to limits on both its authority and capacity,
Pathways must to a substantial degree use or elicit the cooperation of other parties,
private and public, to attempt to achieve systems change.
In this, Pathways is hardly unusual. Third party administration or, as it is
sometimes called, “government by proxy” is so ubiquitous in the United States that its
presence can almost be viewed as the norm. 3 While not all observers would agree that
the state has been “hollowed out,” i.e., stripped of most or all of the capacity to directly
perform its functional responsibilities, the fact that government entities frequently utilize
third parties to undertake governmental functions or activities is almost no longer worthy
of comment, save when the delegation of the function is novel or there has been a highly
visible and significant failure in performing that function. There is even increasing
discussion of whether the functional location of public authority is gradually moving from
government to a “state of agents” where government is but one partner, albeit usually
the most important one.
Consequently, there has also been greater attention to the various forms that
third party administration may take and the advantages and shortcomings, both general
and situation specific, associated with various forms. For example, third party
administration could be manifested through tight contractual control where the
contracted agent may be under almost hierarchical control of the contracting principal.
Alternatively, the agent, for reasons ranging from the nature of the contracted task to its
strategic use of superior information may develop substantial control over performance
of the function to the extent that the agent becomes effectively the dominant policy
maker. In some cases, the governmental entity and the other parties involved in
2
As of July 1, 2008 the Wisconsin Department of Health and Family Services (DHFS) was
reorganized. The largest component of the former DHFS and the one where Pathways is now
located is the Department of Health Services (DHS). We use the former name and abbreviation
throughout this paper.
3
There is an expansive literature in this area. For the immediate purpose of writing this paper the
authors relied on material from Salamon, Lester M. 2002. “The New Governance and the Tools of
Public Action: An Introduction.” in ed. Salamon, Lester H. The Tools of Government: A Guide to
the New Governance. Oxford UK: Oxford University Press, pp. 1-47., and Frederickson, David G.
and Frederickson, H. George. 2006. Measuring the Performance of the Hollow State. Washington
DC: Georgetown University Press, pp. 11-34.
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3
performing a function may constitute a system of shared influence or power on a
relatively equal basis. There may even be situations where third parties effectively
capture government authority with perhaps the willing cooperation of the governmental
principal. No doubt there are many empirical cases that partially manifest features of
more than one of the examples given; moreover we are making no claim that our
examples represent either an accurate or full conceptualization of “ideal types.”
So where might Pathways fall within the theoretical space of different
manifestations of third party administration and how might that affect the possibilities for
achieving system change? Though this is an empirical matter, one can begin with the
fact that Pathways is atypical for a government entity in that it does not have major
responsibilities for either service delivery or regulatory activity. Pathways is principally
about capacity development and, in a less exact sense, direction setting and R&D
activities. To borrow a metaphor from the proponents of “entrepreneurial government,”
Pathways could be said to have been organized to steer rather than row. 4
Background: a Short History of Pathways
Pathways to Independence can be viewed as an entity composed of staff from
three separate organizations: (1) the Office of Independence and Employment (OIE)
from the Wisconsin Department of Health and Family Services (DHFS), (2) the Waisman
Center at the University of Wisconsin – Madison, and (3) the Stout Vocational
Rehabilitation Institute (SVRI) at the University of Wisconsin – Stout. 5 Pathways staff are
all assigned to OIE as their home office. For analytical reasons we distinguish Pathways
staff from those members of the OIE staff who were transferred from other DHFS offices
in the 2005 reorganization and continued to perform their previous functions, though
there has been some integration of these staff into Pathways systems change efforts. 6
Though the staff is predominately from the University of Wisconsin partners, the
formal management team is composed of one person each from OIE, Waisman, and
SVRI. The OIE member of the management team has, since the 2005 reorganization,
been the Director of that office and is also referred to as the Director of Pathways to
Independence. Before 2005 the Pathways Director had always been the DHFS staff
member with primary day to day responsibility for the Pathways operation, irrespective of
whether there were university partners. Though it is our observation that the Pathways
Director has generally included the other Pathways managers and, to a lesser degree,
other Pathways staff in decision making, the Director has needed to impose a final
4
Osborne, David and Gaebler, Ted. 1992. Reinventing Government. Reading MA: AddisonWesley Publishing Co., Inc. pp. 30 & 32-37.
5
OIE was created through a 2005 DHFS reorganization, which combined the Pathways unit with
some elements of the former DHFS offices serving persons with physical disabilities and
deafness/hearing loss. The current configuration of the Pathways management team evolved
following SVRI becoming a source of Pathways staffing in 2003.
6
For example, there has been some integration of the DHFS service provision function of
providing the aged and those with disabilities access to benefits counseling for the purpose of
establishing and maintaining access to certain public support programs and the Pathways
capacity building activity of supporting work incentive benefits counseling aimed at facilitating
employment.
DRAFT
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decision when there hasn’t been consensus or there has been a directive from those
above the Pathways Director in the DHFS hierarchy. 7 It is also true that most of the
University of Wisconsin system staff view their activities as involving speaking for and/or
acting on behalf of DHFS. Ties to their university units are typically weaker. Indeed, to
date every one of these staff was hired specifically to work at Pathways rather than
being reassigned from other Waisman Center or SVRI positions and duties. 8
The OIE Director’s role as “first among equals” in the management of Pathways
is largely a result of resource flows, proximity to policy making authority, and more
generally, history. Almost all Pathways funding comes through federal grants and
contracts. 9 At present and throughout Pathways’ history, this funding has come through
grants and contracts held by DHFS; no funding, federal or otherwise, has come through
either of the university partners. Early in Pathways’ history the Social Security
Administration (SSA) was the most important source of federal funding. 10 Since about
2004, the Centers for Medicare and Medicaid Services (CMS) has provided the majority
of Pathways funding in the specific form of the Medicaid Infrastructure Grant (MIG).
Moreover, this proportion has tended to grow with each yearly increase in those
revenues. The potential level of MIG funding is contingent on the level of expenditures
for participants in a state’s Medicaid Buy-in, which is administered through DHFS.
Wisconsin’s Medicaid Buy-in has among the largest enrollments in the country. The Buyin program began in 2000 and enrollment grew rapidly through 2005, with slower growth
thereafter. This growth and the associated growth in expenditures have supported a
considerable increase in the Wisconsin MIG’s size. 11
7
This does not mean that University policies do not constrain Pathways operations or the
authority of the Pathways Director or more broadly DHFS. For example, university personnel
policies apply to all University of Wisconsin staff working at Pathways as do budget and
purchasing policies for any monies transferred to the university partners.
8
Waisman and SVRI staff members, not assigned to Pathways, have worked on various
Pathways efforts. Typically, this has been done through release time or through contracts
between OIE and either the university partner or the individual performing the work.
9
OIE retains some state funding from the offices that were combined with Pathways to form OIE.
These monies are not necessarily available for what we view as Pathways activities in support of
systems change. Additionally, OIE retains an ever diminishing portion of the modest amount of
state funding it has had since the late 1990s.
10
Funding from the Robert Woods Johnson Foundation (RWJ) was extremely important to
supporting many of the activities that led to Wisconsin’s participation in the SSA funded State
Partnership Initiative (SPI) and through that the evolution of an identifiable Pathways entity. RWJ
also provided support for research and capacity building activities during SPI in the context of the
Three State Work Incentives Initiative that also included projects in Oregon and Vermont.
11
Medicaid Buy-ins are intended to allow employed persons with disabilities access to Medicaid
when they might not be otherwise eligible due to earnings, assets, or not participating in
programs such as SSI that provide automatic Medicaid eligibility. There are two different types of
Medicaid Buy-ins, each with somewhat different rules and eligibility requirements. However, Buyin participants have to meet and continue to meet the SSA definition of disability, except that
earnings above the indexed Substantial Gainful Activity level do not result in automatic
ineligibility.
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5
With funding from SSA, CMS, and other federal agencies come responsibilities
for both fiscal and performance accountability. As the grants and contracts went to
DHFS and not to Pathways as a multi-organization collaborative, these responsibilities
fell to the Pathways Director as a DHFS agent. These responsibilities, while potentially a
constraint on Pathways activities, also gave the OIE Director a source of authority
unavailable to the university based managers.
Another source of potential leverage for the DHFS based Pathways Director was
that systems change efforts often involved the need for policy changes. Most of these
required approval or acquiescence by federal agencies, the state legislature, the
Governor’s office, DHFS executives, or some combination of these. In general, such
efforts could only be officially initiated through DHFS. The most important example of
these were the Medicaid Buy-in plan, subsequent changes to the rules or
implementation of the Buy-in, and requests for temporary changes to Social Security
disability program rules.
To understand the positional dominance of the Pathways Director it is useful to
examine the early history of Pathways and how it evolved into something that can be at
least plausibly viewed as an entity distinguishable from OIE (or its DHFS organizational
predecessors). The “pre-history” of Pathways involved a series of efforts to first identify
the most important barriers that persons with severe physical disabilities faced in
becoming employed or retaining employment and then to design and pilot an
intervention model to address those barriers. Central to these developmental efforts
were key individuals located at a non-profit service provider (Employment Resources,
Inc. or ERI), the DHFS Office of Disability, and the DHFS administrator responsible for
Wisconsin’s flexible “waiver like” Community Options Program. 12 13 During this period,
this administrator became the head of a new unit in DHFS, the Center for Delivery
Systems Development (CDSD). This unit was charged with developing and piloting a
“redesign” of how Wisconsin would deliver long term care services to the elderly and
The Medicaid Infrastructure Grant is intended to help states develop Medicaid Buy-ins or, once
Medicaid Buy-ins are in place, engage in program development and capacity building efforts that
will result in greater or more effective use of the Buy-ins and/or support broader systems change
efforts to improve employment outcomes for those with significant disabilities. Initial grants are
$500,000 and non-competitive. The larger “comprehensive grants” are competitive with the
maximum amount a state can get limited to 10% of annual Medicaid expenditures for Buy-in
enrollees in the previous year. Presently, there are approximately 12,000 enrollees in Wisconsin’s
Medicaid Buy-in. Wisconsin’s 2008 MIG was about eight million dollars. The 2009 proposal
requests over ten million dollars. MIG funds cannot be spent to provide direct services with the
exception of 10% that may be used to provide benefits counseling.
12
As the Community Options Program was fully state funded, it was possible to use it to support
employment in ways that would not have been possible under Medicaid or a Medicaid waiver
(especially prior to the Medicaid Buy-ins) or to take action without waiting an often lengthy period
for CMS to approve a Medicaid waiver request.
13
Some of these developmental efforts also involved an external research partner, a faculty
member at the University of Wisconsin – Madison, who would then move to the Oregon Health
and Science University. This person’s involvement encouraged Pathways to develop a tradition of
having independent evaluations of at least some of its projects. Her support for having a
Pathways research staff without operational responsibilities almost certainly contributed to
Pathways’ acceptance that this internal research staff should itself design and conduct
independent evaluations.
DRAFT
6
those with physical and developmental disabilities. DHFS chose to place this unit inside
the Secretary’s Office instead of in one of the DHFS Divisions involved in service
delivery or funding. The expectation was this organizational placement would encourage
the development of innovative and more effective methods of service delivery and
coordination. It was hoped that the new methods would support both greater client
(henceforth, consumer or member) choice as well as constrain cost increases through
the application of managed care principles. In short, CDSD was to be about “systems
change;” it would become Pathways’ incubator.
In retrospect, the critical moment in the development of an identifiable Pathways
entity occurred in the first half of 1998 with the submission of grant proposals to the
Robert Woods Johnson Foundation in March 1998 and the Social Security
Administration (SSA) in June 1998. Both proposals had identical titles and very similar
target populations, intervention models, and research designs. Conceptually both
proposals could be seen as expansions of a service approach developed under a prior
Robert Woods Johnson Foundation funded pilot to additional disability groups. 14 That
approach combined work incentives benefit counseling with person-centered vocational
planning to identify barriers to employment and how those barriers might be overcome or
ameliorated. In both cases, participants would connect with and receive services through
existing community service providers external to DHFS. Finally, the proposals
contemplated temporary changes or waivers to federal program rules that would either
allow participants to retain public cash assistance, quasi-cash assistance, and health
care benefits despite higher earnings. The most significant difference between the two
proposals was that the one to SSA involved the Wisconsin Division of Vocational
Rehabilitation far more extensively in the effort than the one submitted to RWJ. Most of
the service, policy, and capacity building approaches used in future Pathways efforts can
be identified in these proposals, at least in nascent form. So too can most of the
recurring types of partners who would make up the networks involved in planning,
governing, or implementing future Pathways efforts.
Both proposals were accepted by fall 1998; the one to SSA as Wisconsin’s
application for inclusion in the State Partnership Initiative (SPI). 15 That SPI project was
soon (re)titled Wisconsin Pathways to Independence, which ultimately became the name
for the unit within the larger Center for Delivery Systems Development. The broad
outlines of the Pathways entity soon became apparent.
First, a distinct group of Pathways staff were hired in the year prior to the
Wisconsin SPI project’s official start in July 1999. Unlike most CDSD staff at that time,
Pathways staff members were hired as neither regular nor limited term DHFS
employees. The current university hiring model was still several years in the future.
Positions were advertised and candidates were interviewed and selected by DHFS.
However, staff were hired and compensated through a rather Byzantine system of
providing funds to a private non-profit organization that would then hire and compensate
14
This was the Dane County Employment Initiative, often referred to as the “feasibility study” for
Wisconsin’s SPI project.
15
To avoid confusion, we will use “Pathways to Independence” and “Pathways” only to identify
the programmatic and staffing entity. The original “Pathways to Independence” demonstration
project will be referred to as “Wisconsin’s SPI project” or just “SPI.”
DRAFT
7
staff through a temporary staffing agency. 16 Nonetheless, there was a separate
Pathways staff with functions and an issue focus, employment and disabilities, distinct
from others in CDSD.
Second, a distinct Pathways management structure soon emerged. Within a
year, this structure included multiple Pathways staff. Though subordinate to CDSD, most
Pathways unit decisions were either made or formulated in this team. While the first
Pathways “lead” was concurrently the Director of CDSD, he operated the emerging
Pathways unit in ways that that were consistent with the development of a separate
organizational identity. Though there were occasional exceptions, Pathways activities
were performed by Pathways staff and Pathways staff members were not deeply
involved in the long term care redesign that occupied the attention of most CDSD. 17
Third, the Pathways unit soon took on activities in addition to the SPI
demonstration project. Concurrently with implementing SPI, members of the Pathways
staff were developing the Medicaid Buy-in program. Though the decision to develop a
Medicaid Buy-in program was motivated, in part, to help some SPI project participants
get or retain access to Medicaid benefits, the Buy-in is in fact a “permanent” Medicaid
eligibility category established through statute that must be available to all state
residents who meet the program’s eligibility requirements. 18 This was soon followed by
the initial MIG application in 2000 and the implementation of the grant the following year.
As a result, Pathways potential reach was expanded from the participants in a relatively
short term demonstration project to the entire population of adults in Wisconsin who
might quality for SSDI, SSI, or Medicaid for reason of disability.
Fourth, as already suggested, the range of partners that worked with Pathways
to develop and implement the SPI project has tended to be involved in many of
Pathways’ subsequent activities. More formally, the long term pattern of those entities
participating in the networks that Pathways uses to plan or implement its activities was
considerably shaped by the network of entities formed through Pathways’ first
programmatic effort. These included the Division of Vocational Rehabilitation (DVR),
16
None of the three parties involved in this staffing arrangement ever acknowledged its actual
role in hiring, supervising, compensating, or terminating such staff. However, there can be little
doubt that DHFS made the decisions. No doubt part of DHFS’ motivation was to obscure the
actual size of its staff in a way acceptable to the political interests of the Department, the
Governor’s Office and the state legislature, though at the (possibly unintended) expense of
employees’ right to know their conditions of employment. None of these parties wanted an
increase in the number of permanent state employees. Employment of staff through the
University of Wisconsin system has largely solved this problem with the added benefit of having
units interested in doing some collaborative work with Pathways.
17
The first CDSD Director took a position at CMS in 2000. The new CDSD Director did not take
an active role in managing Pathways and continued the existing pattern of separation between
Pathways and the CDSD subgroups focused on long term support redesign. It is at this time that
the current OIE/Pathways Director, already a Pathways manager, assumed primary responsibility
for the effort.
18
Medicaid Buy-in programs are conceptualized as much as a work incentive programs as
extensions of public health care. One of the largest barriers to increasing earnings and, at least
subjectively, to employment itself for persons who meet SSA disability criteria is that their
employment activity can result in loss of access to public health care and long term care services.
The Buy-ins are intended to address this concern.
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8
largely non-profit community based service providers, ERI (as a technical assistance
provider), and various fiscal or service delivery entities within DHFS. Additionally, the
networks have typically included a federal partner. For SPI, this was SSA and the agents
it contracted with to provide technical assistance or perform monitoring. Though SSA
remains an important actor in some Pathways efforts, CMS (and its contracted agents)
has become the dominant federal presence in Pathways’ environment. This is largely
due to the size and scope of the MIG.
This is not to say that other entities, stakeholder groups, or individuals were not
involved in SPI or did not become participants in the networks that coalesced around
subsequent Pathways activities. Certainly the range of what could be called both central
and peripheral network participants expanded over time, though the key entities involved
in SPI, as already mentioned, have remained recurring partners.
This expansion in the range of network partners was both related to and
supported by the large and continuing increase in MIG funding between 2001 and the
present. In addition to larger resource levels, a strategic planning process implemented
in 2005 has encouraged Pathways to undertake additional activities in areas consistent
with the strategic priorities identified through that process. 19 The following list is meant to
give a sense of the range of approaches Pathways has utilized. It is not an inclusive list
of actual initiatives. Many of these approaches have either been adopted or its use
expanded as a result of the strategic planning process; for example, greater efforts to
involve employers based on their business needs and to facilitate the transition of youth
with disabilities into the labor market or further education and training.
19
•
Training and technical assistance to support expansion and improvement of work
incentive benefits counseling
•
Policy development of the Medicaid Buy-in, for enhancements to the Buy-in, and
for Medicaid waivers.
•
Integration of benefits counseling and person centered planning in a single
service delivery model
•
Incorporation of person centered planning and/or self-directed services into a
developing managed care (capitated) system for delivering long term support
services
•
Testing benefit offset provisions or enhancements to existing benefit offset
programs
•
Developing efforts to teach self-advocacy skills or resources to promote this
(e.g., an online benefits’ calculator)
CMS had required a strategic planning process for those states holding a comprehensive MIG.
This process involved extensive outreach beyond the core group of entities that had been deeply
involved in Pathways activities. Pathways managers have come to see the process as extremely
valuable for suggesting programmatic needs, identifying potential partners and stakeholders, and
supporting the legitimacy of Pathways’ activities.
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9
•
Developing service strategies and toolkits to support program development in
specific areas, such as transportation or personal assistance services
•
Stigma reduction training or outreach efforts
•
Efforts to build communities of practice among professionals serving persons
with disabilities
•
Building community or regionally based entities to identify needs, potential
solutions, and build support for action
•
Efforts to facilitate asset building and/or self-employment
•
Efforts to utilize these multiple approaches throughout the life cycle with
particular attention to youth and its transition to the workforce
•
Developing resources that allow employers to seek information and resources on
an individualized basis
We have already identified the involvement of the Waisman Center and SVRI in
Pathways operations. Initially their role was mainly that of providing staffing (as an
alternative to the original arrangement) and as a more convenient way to purchase other
services. 20 Over time these two University of Wisconsin units have been increasingly
involved in developing projects in areas where those entities have long conducted
research or service activities. 21 DHFS’ approach to long term care system redesign
(Family Care) resulted in the piloting of managed care entities to provide such services
and has since moved into statewide implementation. Pathways has become increasingly
committed to using Family Care as its primary institutional setting for supporting
employment of persons with significant disabilities. 22 For reasons related to MIG
governance, the increasing saliency of employer needs, and the goal of better
connecting issues of disability and employment to general issues of economic and
workforce development, Pathways has attempted to more deeply involve both the state’s
20
Wisconsin has tightened its purchasing rules in ways that make it more difficult and time
consuming to contract with private entities. These rules do not apply to purchasing agreement
with other state entities such as the University of Wisconsin.
21
For the Waisman Center this has been mainly in the areas of Developmental Disabilities and
Youth Transition. SVRI interests include vocational assessment and rehabilitation and support for
the community agencies who provide such services and the employers and employees who may
benefit from those services.
22
The Division of Vocational Rehabilitation remains the state’s primary agency for facilitating
employment for those with disabilities. Nonetheless, DVR serves a broader population than just
those using Medicaid and long term care services. As a practical matter, DVR has faced severe
and recurring fiscal problems that meant that the agency has not able to serve all eligible
consumers. Moreover, some of those receiving Medicaid and long term care services may have
employment goals that are more modest than those associated with reimbursement for a
successful DVR case closure. Thus, Pathways and, increasingly, DHFS see Family Care as an
alternative route for facilitating the employment goals of Family Care members who may not be
fully or effectively served through DVR.
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Council on Workforce Investment (CWI) and units in the Department of Workforce
Development in addition to DVR. 23 Finally, starting with ERI, Pathways has developed a
cadre of external contractors and/or technical assistance entities to assist with its work.
Some of this capacity is temporary, some is intermitted, and some, especially that
attached to Pathways funded technical assistance centers, has become continuous and
potentially permanent. 24
Method: Evidence and Analytical Approach
The core of this paper is six case studies describing the terms of interaction
among primary network members in the Pathways efforts examined. There are two pairs
of case studies for each of three domains of Pathways activities. The first domain is that
of demonstration projects to pilot and evaluate changes to policy, service models, and/or
service delivery to support improved employment outcomes for persons with disabilities.
The specific efforts examined are Wisconsin’s State Partnership Initiative demonstration
project (SPI) and the Wisconsin SSDI Employment Pilot (SSDI-EP). The second domain
is that of capacity building efforts to support systems change. The two case studies are
the development and operation of the Wisconsin Disability Benefits Network (WDBN)
and the effort to encourage the use of a person centered planning approach (PCP) to
support the employment goals of those enrolled in Wisconsin’s expanding system of
managed long term care. The third domain is that of processes for identifying
programmatic directions. The cases examined are the annual process of choosing which
projects will be included in the MIG proposal and the process the Managed Care and
Employment Task Force (MCETF) of 2007-08 used to generate its recommendations. 25
The case studies are qualitative in approach using three basic types of evidence.
Each of these six Pathways activities produced a range of written documents.
Additionally, we conducted a number of key informant interviews which were augmented
by summaries of interviews available from evaluations of the demonstration projects. 26
Finally, we have had the opportunity to observe Pathways’ efforts over the past decade
and in our respective roles as manager and researcher were involved in several of the
efforts examined in this paper. 27 Indeed, we anticipated that our dissimilar roles in
23
A subcommittee of the CWI serves as the advisory group for the Wisconsin MIG and, thus,
implicitly Pathways.
24
Existing technical centers include the Wisconsin Disability Benefits Network (WDBN) to
support benefits counseling and WorkSource Wisconsin to support employers potentially
interested in employing persons with disabilities and/or better utilizing such employees. Plans for
a center to support the implementation of person centered employment services through Family
Care are in development.
25
In actuality, a project’s inclusion in a state’s MIG proposal is a recommendation. CMS has the
option of not funding specific projects.
26
The interview summaries from the evaluations of the demonstration projects often included
information about overall Pathways operations.
27
Anderson has had managerial and operational responsibilities at Pathways since 2004 with
direct involvement in the SSDI-EP, WDBN, in the processes for deciding Pathways priorities, and,
to a lesser extent, expansion of person centered planning. Prior to joining Pathways she worked
at one of the community agencies implementing the SPI project. Delin has been at Pathways
since 1998 and has had major roles in evaluating the SPI and SSDI-EP demonstrations. Though
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Pathways would result in some differences in interpretation that we would identify and
discuss.
We begin with the premise that in all of the six cases action involves or is at least
meaningfully influenced by members of a network that includes Pathways and other
actors that each have some span of control fully independent of Pathways. We also start
with a second premise that reflects the limits on Pathways’ authority and capabilities.
None of these Pathways efforts could be performed effectively, if at all, without some
cooperation of external actors, with effectiveness understood in terms of the ability to
pursue a course of action that has a plausible relationship to achieving desired systems
change. We are not committed to any particular definition of network phenomena, but
will use the following statements reference points.
Networks constitute the basic social form that permits interorganizational
interactions of exchange, concerted action, and joint production. Networks are
unbounded or bounded clusters of organizations that, by definition, are nonhierarchical collectives of legally separate units.
Networking is the act of creating and/or maintaining a cluster of organizations for
the purpose of exchanging, acting, or producing among the member
organizations. 28
We have chosen these definitions because we see the members of the networks
involved in specific Pathways efforts and, for that matter, those recurring over multiple
efforts as chiefly organizations. In particular, Pathways networks can be described in
large part based on how organizational partners are “articulated,” that is linked together,
whether by fiscal mechanisms such as grants or contracts, legal requirements, common
goals or frames of reference, professional ties, trust developed through recurring
interactions, and/or political or reputational needs to participate. 29
Nonetheless, it is sometimes ambiguous whether the network partner is really an
organization or an individual holding an organizational position who may be operating
somewhere on a continuum between free agency and serving as an organization’s
tightly constrained “delegate.” Similarly, expectations that network partners always have
legal autonomy and/or that partners, or even the network itself, are not subject to
hierarchical control is at best an approximation and can, in some cases, be seriously
flawed. For instance, some of the partners in Pathways networks are government
entities subject to influence or control by their location in larger bureaucratic entities, by
executives, and/or by legislative bodies. Likewise, control that is technically not
not a Pathways manager, he has been granted the opportunity to observe many aspects of the
management team’s activity.
28
Alter, Catherine and Hage, Jerald. 1993. Organizations Working Together. Newbury Park, CA:
Sage Publications, p. 46.
29
See Frederickson, David G, and Frederickson, H. George. 2006, Measuring the Performance
of the Hollow State. Washington, DC: Georgetown University Press, pp. 8-9, 11-13, & 152-56.
Frederickson and Frederickson emphasize vertical articulations (for example, those between
levels of government or governments and third part agents). However, as the authors observe,
one can also identify horizontal articulations between network partners.
DRAFT
12
hierarchical may be viewed by some network participants as being as essentially
prescriptive as if it were. We will see something of this phenomenon in how some of
Pathways’ “contracted” partners viewed their relationship with OIE.
Evidentiary Limitations
In the very first line of this paper, we characterized this as a preliminary report.
This characterization reflects the quantitative and qualitative limitations of the evidence
we have gathered and analyzed to date. The documents available to us did little to
explicate the alliances among network partners, the conflicts among them, or how those
conflicts were handled and, possibly, resolved. Much was left to inference.
Our key informant interviews provided much better evidence of network
interactions as they were constructed to elicit such information. Interviews began by
eliciting information about the identity and perspectives of key members of the relevant
network and to help us determine how that network was “spatially” organized. 30 The
instrument contained series of items intended to draw out information about initial
agreement, conflicts, and the processes of resolution, successful or otherwise. One of
these series concentrated on direction setting, the other on coordination of project
activities. Informants were also asked to provide information on issues such as the locus
of effective control or influence, duplication or withdrawal of effort, and whether partners
were induced to cooperate through the provision of tangible rewards or “side payments”
unrelated to the goals of network activity. We used questions about the progress made
toward achieving goals and lessons learned on the way to gather information that would
help us assess an effort’s contribution to the larger end of systems change.
Still these interviews may be giving us an incomplete and potentially flawed
picture of how the various Pathways networks operated. To date we have completed not
quite twenty interviews. Even when augmented by interview summaries produced for the
evaluations of specific projects, there are too few for us to be fully confident of the full
accuracy of our descriptions. 31 Moreover, the interviews performed specifically for this
project are disproportionately with current or former members of the Pathways staff.
Thus we are far more reliant on our experiences and impressions as participant
observers (and the private notes and e-mails we have retained) than we would wish to
be. Our goal is to ameliorate these evidentiary shortcomings over time.
30
We do not want to suggest that we used Social Network Analysis techniques. Nonetheless, the
interviews did produce information about who were key partners and the pattern of interaction
among them. In some cases respondents did not perceive anything they would call a single
network, but instead suggested that there were two or more cohesive networks with a connecting
“node” at Pathways/OIE.
31
The interview summaries are chiefly from completed and ongoing evaluations of Pathways
demonstration projects such as SPI and SSDI-EP. There were very substantial numbers of
interviews with non-Pathways staff at organizations that were involved in these demonstrations
and often other types of Pathways efforts. Though the interviews instruments always included
some items aimed at eliciting information about the interactions among what we are calling
network partners that was not the only focus of the interviews. Interviews inevitably concentrated
on the project being evaluated, though they sometimes included (largely by chance) comments
on the overall relationship among Pathways, a non-Pathways organization and others in the
network.
DRAFT
13
Organizing the Evidence
This study does not involve hypothesis testing. The aim, especially in this
formative stage, is largely heuristic. Our expectation was that categories and patterns of
action would emerge from our encounters with the data. Nonetheless, we began with
two working premises based on our experiences working in Pathways and through
reading various project specific reports. 32 The first and more important of these was that
Pathways’ primary mode of action was through networks where membership or
participation was mainly organizational. The second working premise was that the
networks could be usefully described as Pathways centric. By “Pathways centric” we
mean that Pathways had the most important role in organizing and maintaining the
networks and served as the dominant or most frequent node through which
communication flowed and coordination was attempted. Nothing we learned through the
case studies has seriously challenged either of these working premises.
The figure below is a graphic representation of a simple Pathways centric
network. The aim is to give a sense of the spatial organization of the partners, but not to
suggest the type, strength, or directionality of the relationships among partners.
(Community Agencies) ------------------ (Pathways)------------------(Federal Funding Agency)
l
l
l----------------------(State Level TA or Funding Partner)
The configuration illustrated in this example is discernable in all six case studies,
especially those of the demonstration projects and capacity building efforts. The federal
partner and its agents (if any) tend to interact directly with Pathways alone. What does
change across the case studies are the number and types of state level partners and,
less often, the range of local actors (community agencies in the example). The result of
the additional partners is usually, but not inevitably, a large growth in the number of
connections, though the significance of those connections can vary greatly.
More to the point, our working premises shaped not only choices about the types
of evidence we sought but also the framework we used to organize that evidence. We
have already given a sense of this in our discussion of the general areas covered in our
key informant interviews. However the following material provides a more explicit review
as the same analytical framework was applied to the written documents and our
reflections on our experience as participant observers.
Table 1 summarizes our organizing questions and provides some descriptive
information to describe how we tried to apply them to the case study materials. Though
we do not explicitly identify a time dimension in these items, it is important to remember
that networks develop over time and thus the answers to any or all of these questions
can change. Further, we do not present our summaries of case study materials in one to
one correspondence to these items. Instead, we have used the questions to organize
the facts that will be used to spatially place the cases on the continua we identify later in
this section of the paper. Finally, though this study is primarily descriptive, we think that
the answers to the first six organizing questions can inform the understanding of the
32
Some of these were produced by Pathways operational staff or contractors and were at least
as often tools or guidance for project implementation or replication as overall assessments.
DRAFT
14
answer to the final one. That is, the structure and the operation of each
interorganizational network should have some impact on the progress made toward
achieving desired systems change in the area of disability and employment. However,
we are cautious about global claims that strong collaboration is necessarily strongly
correlated with goal achievement. 33
Table 1: Organizing Questions Applied To Case Evidence
Organizing Questions
Notes
Identifying Key Network Partners
The emphasis was on identifying
“organizational” partners with significant
and persistent involvement in the network.
A secondary concern was to identify each
partner’s perspective (e.g. political,
technical, or locally/experienced-based).
Identifying the Purposes/Goals of the
This refers to the nature of the expected
Network
activity or products and its expected
relationship to achieving systems change.
Identifying the Methods and Conditions of
This includes multiple components, such
Network Interaction and Coordination
as: locus of authority (formal or informal),
unity or diversity in perspective or goals,
communication patterns, direct
involvement in joint activities, and the
incentives and sanctions (material or
intangible) utilized or available. It can
include phenomena that are specific to the
network or are products of the external
relationships among network partners.
Identifying the Character and Strength of
In terms of subject matter this substantially
Network Coordination
overlaps the previous item but is different
on two dimensions. The first is that the
focus shifts away from characterizing
partner interactions to characterizing the
network. The second difference is that this
question is posed in ordinal terms.
33
Beyond the obvious caveat of the potential impact of external factors, there is increasing
evidence that when smooth and seemingly effective collaboration is a product of excluding actors
with conflicting priorities from the network there may be reduced progress toward goal attainment
or the goals achieved may be perceived as inappropriate or ineffective by unrepresented
stakeholders. Just as too much conflict may negatively impact network effectiveness (however
defined), so too may excluding conflict or avoiding the task of conflict resolution. See Koppenjan,
Joop F. M. 2007. “Consensus and Conflict in Policy Networks: Too Much or Too Little?” in eds.
Sorensen, Eva and Torfing, Jacob. Theories of Democratic Network Governance. Houndsmilk,
UK: Palgrave Macmillan. pp. 133-152.
DRAFT
15
Table 1 Continued: Organizing Questions Applied To Case Evidence
Organizing Questions
Notes
Identifying Power or Influence over
The exercise of power or influence can be
Agendas, Priorities and Implementation
viewed in terms of single network
participants, alliances among network
partners, alliances involving parties outside
the network, or, hypothetically, the network
losing meaningful control over its activities.
We were especially interested in whether
and how conflicts over goals or activities
were resolved.
Identifying Characteristic or Dominant
This refers to the instrument or means
Policy Tools
used to address the substantive problems
or issues the network seeks to address.
Some have referred to these as the “tools
of public action.” In addition to providing a
basis for the network action in the external
world, these instruments and means can
often provide the source of linkage or
“articulation” that are important to defining
network structure and operations. 34 In this,
the question overlaps with “Methods and
Conditions of Network Interaction and
Coordination.”
Identifying Achievement of Proximate
This refers chiefly to assessing progress
Goals
toward achieving planned “outputs” and
how network operation is related to that. It
can also include assessing the impact of
environmental conditions (including
instability), withdrawal of effort within or
external to the network, and/or the
production of unexpected consequences.
Identifying Progress to Intended Systems
This refers to assessing impact of the
Change
networks activity toward achieving
progress toward desired systems change.
Again the focus is on achieving some
intermediate condition (“infrastructure
development” or “useful learning”) that can
be logically associated with achieving
desired long term systemic outcomes (a
coordinated, comprehensive service
delivery system or better employment
outcomes)
Additionally, though we are not directly engaged in theory development, we
wanted our results to contribute to the evidence available to those who are. Thus, we
sought an existing approach with a strong comparative dimension to help us further
34
Salamon, L. 2002. pp. 19-21.
DRAFT
16
organize and then present our findings. We found this in recent work by H. George
Frederickson and his colleagues. 35
Frederickson and colleagues, through their continuing analysis of federal
agencies and the networks of third parties involved in implementing the agencies’
functions, have identified nine variables that appear to capture important aspects of
network performance. For simplicity, these variables are expressed as continua on a
single dimension, with the authors defining and/or providing examples of extreme
conditions. Federal agencies, based on a “summary” qualitative assessment of their
operations and those of an associated policy network, can then be placed on each
continuum. In turn, agencies’ relative positions can be compared to each other on any
particular continuum. 36 Frederickson et al. have also utilized what could be described as
“spatial cross-tabulations” allowing then to describe interactions between two
variables. 37 In principle, this procedure could be replicated in three or more dimensions.
In our use of this approach, we place projects or efforts on the continua, rather
than agencies. 38 We also limit our use of continua to four of the nine that we think are
best aligned with our organizing questions. These are:
•
•
•
•
the Nature and Quality of Network Articulations
the Level of Goal and Policy Agreement
the Level of Centralization of Policy Implementation
the Level and Character of Client or Stakeholder Support
The other five continua were not used because they were either conceptually tied to a
exclusively “federal centric” perspective on networks, focused on an activity, specifically
performance measurement, not germane to our case studies, or, as in one case, we felt
we could adequately capture one continuum within another. 39 The following diagram
35
See Frederickson, David G, and Frederickson, H. George. 2006, Measuring the Performance
of the Hollow State. Washington, DC: Georgetown University Press and H. George Frederickson
and Dubnick, Melvin J. “Accountable Agents: Goal Congruence and Attenuation in Federal
Networks.” This draft paper was presented at “The State of Agents” conference sponsored by the
Institute for Research on Poverty of the University of Wisconsin – Madison in July 2008. The
authors have graciously given us permission to cite their draft.
36
Frederickson, David G, and Frederickson, H. George. 2006. pp. 28-34.
37
Frederickson, David G, and Frederickson, H. George. 2006. pp. 154-56.
38
Frederickson and colleagues implicitly do this when they compare the operations of one federal
agency (CMS) in the context of one of its major programs (Medicare) to its operations in the
context of another of its major programs (Medicaid). See Frederickson, David G. and
Frederickson, H. George. 2006. pp. 90-94.
39
We did not separately utilize the “Professional Identity” variable as the Pathways staff and
those of most of the major organizational partners are made up of people from multiple
practitioner and/or disciplinary backgrounds. As one of our key informants observed, the more
important distinction is probably between “professionals” and “consumers (clients) and their
natural supports (e.g. family and friends). It was this informant’s opinion, shared by several
others, that consumers had little direct impact on Pathways activities. Therefore, we have chosen
to conceptualize this apparent dominance of a generalized professional perspective in the context
of the Level of Goal and Policy Agreement variable.
DRAFT
17
provides a generalized example of how multiple projects or efforts can be visually
presented.
Project A. Project B.
Project C.
X
X
X
--------------------------------------------------------------------------------------------------------------
“low”
“high”
It is important to remember that a project’s placement on any continuum is an
approximation, especially as location can change over time. A reader may be well
served by picturing a “confidence interval” (of admittedly unknown size) about any
project’s location on a continuum. Table 2 provides further description of the four
continua on which we will use to position each of the case studies and to order our
comparisons across them. The table provides usage notes, including information about
ways in which our practice may be different from that of Frederickson and colleagues.
Table 2: Continua Variables Used to Describe Networks 40
Continuum
Variable Description
Variable
Variable
(Frederickson et. al.)
Extremes
(left to right)
Nature and Quality Continuum focuses on the “remote control” to
of Network
degree of discretion and
“managed
Articulations
latitude third party agents
network”
have. Particular attention
is given to which “tools of
public action” are used to
link network partners.
Level of Goal and
Continuum stresses
“disagreement/
Policy Agreement
agreement within the
incongruence to
principal agency, instead
“agreement/
of across network
congruence”
partners.
Level of
Centralization of
Policy
Implementation
Continuum captures
variation with emphasis on
programmatic
fragmentation and
geographic spread of
implementing agents.
“decentralized,
dispersed, and/or
fragmented” to
“centralized”
Usage Notes for
This Study
Horizontal
linkages are
seen as having
potential to limit
discretion and
latitude.
Emphasis placed
on agreement
across network,
though
agreement in
Pathways is
important.
As most
implementation
is via agents,
differences
reflect level of
central guidance
and constraint.
We also want to mention a particular exclusion of one variable that would seem applicable, the
“Level of Third-Party Implementation.” Frederickson and colleagues define this narrowly in terms
of the ratio of an agency’s budget that supports third party staff to that for agency staff.” We think
this measure is more appropriate to agencies or programs that have the primary function of
providing or, more often, funding direct service provision. As we have stressed, this is not a major
aspect of Pathways’ activities.
40
Material for the first three columns of Table 2 has been drawn from Frederickson, David G, and
Frederickson, H. George. 2006. pp. 28-34. In particular, see Figure 2.1 on p. 29.
DRAFT
Table 2 continued: Continua Variables Used to Describe Networks
Continuum
Variable Description
Variable
Variable
(Frederickson et. al.)
Extremes
(left to right)
Level and
Continuum focuses on
“weak” to “strong”
Character of Client pattern and strength of
or Stakeholder
external support. This can
Support
include competition over
goals and policy among
supporters.
18
Usage Notes for
This Study
Particular
attention to
variations of
support among
network actives
relative to poorly
organized
stakeholders.
Case Studies: Demonstration Projects
The first of the three pairs of case studies consists of two return-to-work
demonstration projects, Wisconsin’s SPI project and the Wisconsin SSDI Employment
Pilot (SSDI-EP). 41 There were several important similarities between the two efforts. In
both cases the target populations were adults in a Social Security disability program,
Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). 42
Both efforts included tests of changes in Social Security policies and involved similar
service models, one emphasizing benefits counseling, consumer choice, and, to differing
degrees, greater efforts at service coordination. In both cases, participants were
volunteers. Additionally, both efforts recruited and served participants through
community agencies. By doing so, the demonstrations more closely modeled the
prevailing decentralized service delivery system than would highly centralized projects.
Though neither demonstration was expected to directly result in systems change, each
was supposed to generate knowledge that could inform systems change. Project
designers anticipated that lessons would be learned as to what combinations of policy
and practice would motivate better employment outcomes and how those could be best
implemented.
Nonetheless, there were important differences between the demonstrations. SPI
focused more on piloting an approach to providing services; the SSDI-EP has
concentrated more on examining implementation of a significant change to federal
policy. Wisconsin SPI’s target population was broader than SSDI-EP’s. SPI enrolled
individuals from both the SSI and SSDI programs. The SSDI-EP was restricted to a
41
The concept of “return-to-work” also subsumes initial “serious” efforts to enter the workforce for
persons with disabilities who have either no work history or one so limited as to preclude eligibility
for the SSDI program.
42
Both the SSI and SSDI programs apply the same disability standards to adult participants. SSI
eligibility includes substantial limitations on assets and income in addition to earnings, SSDI does
not. By contrast SSDI eligibility and the benefit amount reflect each beneficiary’s work history and
payment of Social Security payroll taxes. In Wisconsin, like most states, participation in SSI
provides entitlement to Medicaid. SSDI beneficiaries are eligible for Medicare after two years.
Finally, there are very different work incentives (and thus disincentives) associated with each
program. SSDI beneficiaries with cash benefits less than the SSI benefit level are eligible for
benefits from that program. A result of concurrent SSI and SSDI participation is that two sets of
inconsistent work incentives apply.
DRAFT
19
subgroup of SSDI beneficiaries. It also utilized random assignment, while SPI did not.
Another salient difference is that the number and range of partners involved in SPI
governance and operations was substantially larger than those participating in the SDDIEP, most notably at the state level.
Finally, we want to acknowledge that our presentation of the SPI case study is a
bit lengthy compared to that for the other Pathways efforts. Though this is related to the
sheer bulk of material available for SPI, the justification for the extra attention is the
crucial formative role the SPI project had in Pathways’ creation and in implying the range
and character of its subsequent activities and of the networks associated with those
activities.
The SPI Demonstration
The Wisconsin SPI project (called Wisconsin Pathways to Independence) was
one of twelve funded by the Social Security Administration. 43 The SPI projects were
framed as cooperative agreements. As such, participating states were expected to
engage in substantial collaboration with SSA and its chosen technical assistance agents.
States were given substantial discretion to define both their interventions and their
specific target populations, provided that target population included either SSI recipients
or SSDI beneficiaries. However, SSA exercised fiscal and programmatic oversight,
required projects to have evaluation components, and through its agent, Virginia
Commonwealth University, imposed standardized data collection to support a national
evaluation of the overall SPI effort.
The Wisconsin SPI officially opened in July 1999 and continued through
September 2004; 956 individuals ultimately enrolled in the project. 44 The demonstration
was jointly operated by DHFS (specifically the emerging Pathways unit) and the Division
of Vocational Rehabilitation through September 2003 and by DHFS alone after that date.
The Wisconsin SPI was developed over a number of years with the critical step
being a single site feasibility study that utilized a service approach involving the
integration of work incentives benefits counseling with a person centered vocational
planning process. This model called Vocational Futures Planning (VFP) was developed
by the site, Employment Resources, Inc. (ERI), specifically for a population with physical
disabilities. Thus, unlike the later SPI effort, the feasibility study was limited to
participants with a physical disability. ERI was to play an important role in providing
technical assistance for SPI and later Pathways efforts.
The feasibility study had been funded by the Robert Wood Johnson Foundation
(RWJ). Both DHFS and RWJ were interested in testing the approach on a wider stage,
as were parties in Oregon and Vermont. There is also evidence that the Wisconsin
feasibility study and other RWJ funded efforts played a significant role in convincing SSA
to initiate the SPI effort. In these discussions, Wisconsin, several other states, and RWJ
argued that there was a crucial need to test changes to SSA program rules (and other
federal programs) that appeared to have a negative effect on work effort.
43
The Rehabilitation Services Administration funded a smaller number of additional SPI projects.
44
About 600 DVR consumers agreed to participate in a comparison group.
DRAFT
20
DHFS received grants from both SSA and RWJ in 1998 and subsequent years to
fund its SPI effort. However, DHFS would need to provide substantial state funds to
support service provision for project participants due to restrictions on the use of the SPI
funds as match for federal programs.
In preparation for what was to become the Wisconsin SPI project, DHFS began
work on waiver proposals, especially those for Social Security disability programs. These
included a cash benefit offset for those in SSDI, an enhanced offset for those in SSI, and
various means to protect demonstration participants from loss of eligibility because of
work efforts or earnings during SPI. 45 Planning also began for implementing a Medicaid
Buy-in. Additionally, DHFS and ERI planned to organize SPI through largely non-profit
community agencies, replicating the approach used in the single site feasibility study on
a much larger level. These agencies would adopt the VFP model and then enroll and
serve participants with physical disabilities. This structure was significantly modified as
additional state level partners were brought into an expanded network during the
process of developing the proposals to RWJ and SSA.
The first major addition was the bureaus within DHFS that served specific
disability populations. This appears to have happened before the March 1998
submission to RWJ. Several consequences followed. The project would now serve
multiple disability groups and be much larger in size. The DHFS bureaus serving those
with severe and persistent mental health problems (MH) and developmental disabilities
(DD) were already providing technical assistance to support employment support models
other than VFP and not fully compatible with it. In turn, many of the community agencies
serving predominately MH or DD populations and which were ultimately selected as SPI
sites were already committed to using these alternative vocational approaches. Indeed,
for most of SPI’s duration, community agencies were restricted to enrolling participants
from a single disability category. These categories were defined largely in terms of
eligibility requirements for existing state programs which, not coincidently, were those
administered by these DHFS service bureaus.
In retrospect, it is not entirely clear why the emergent Pathways unit sought
participation by the service bureaus nor why the bureaus agreed to participate. Certainly,
for Pathways it was a way to pursue a larger project with the budget and visibility that
went with that. Having a project with broader reach also increased the potential for swift
replication should the intervention approach prove successful. For the DHFS service
bureaus it appears that commitments for additional funding, especially to support
existing staff, played some role in motivating their involvement. Staff from these bureaus,
especially those serving MH and DD populations, would be used to help Pathways train
and provide technical assistance to those project sites designated to serve consumers
from that group. It also appears the bureaus had an interest in having their clients benefit
from the various SSA waivers that Pathways would seek.
DVR became an active network member sometime before the submission to
SSA in June 1998, though we could find no evidence of major involvement in formulating
the RWJ proposal of only three months earlier. There is no clear record as to how DVR’s
entry to the network was accomplished. However, there can be little doubt as to the
45
A cash benefit offset feature provides an incentive for increasing work effort by ensuring that
any reduction in the benefit amount (from that particular benefit program) will always be less than
the marginal increase in earnings.
DRAFT
21
potential attractiveness of DVR participation to Pathways. If the DHFS bureaus
increased the effort’s reach and replication potential, DVR’s involvement would do so by
at least one level greater magnitude. DVR was and remains the state’s main funding
source of vocational services for those with disabilities. Indeed, as DVR was able to
draw down almost four dollars from the federal Rehabilitation Services Administration
(RSA) for every dollar of state matching funds. DVR’s participation would be a powerful
mechanism for further leveraging the limited Pathways funds available for providing
services to SPI participants. It was also thought that DVR counselors could make a
strong contribution to VFP implementation by serving on consumers’ planning teams.
Finally, though DVR had formerly been part of DHFS, there had been relatively little
interaction between DVR and the DHFS units providing long term supports for persons
with disabilities. SPI offered an opportunity to work on a systems problem that was of
concern to staff in all these agencies. Consumers who had successfully used DVR
services to enter employment often found it difficult to gain access to long term services
and supports needed to sustain their employment.
DVR, itself, had multiple reasons for joining the network, though there is less
certainty as to which were most important. At the least, there was interest in insuring that
some DVR consumers would have access to whatever federal waivers Pathways
obtained from SSA and other agencies. DVR was also trying to instill an agency culture
that emphasized consumer choice and some of its managers were increasingly
interested in benefits counseling. Both of these were key features of the VFP approach.
Less certain is whether DVR saw SPI funding as a backup source of match that could be
used to support DVR operations should there be insufficient funding through legislative
appropriations. Finally, it is possible that DVR, consistent with its identity as the state
agency with primary responsibility for working on issues of disability and employment,
felt an institutional need to take part in any large scale demonstration project in this area.
DVR’s ascension to not only having a major role in the SPI effort, but to comanagement status had important consequences for how the project was structured.
Potential participants would have to be already eligible for DVR services or become so
as part of the project enrollment process. No services could be provided without a DVR
authorization. 46 Community agencies operating as SPI sites would have two contracts,
one with DHFS and the second, which provided for payment of benefits counseling and
vocational services, through DVR. 47 Yet, DVR would prove to be something less than an
equal partner in operating the project. Though joint decision making processes were
established, the Pathways office at DHFS had several advantages. The state money that
was used to draw down RSA funds was in fact from DHFS, though this would prove the
least of the advantages. Of much greater importance was the fact that the SSA and RSA
monies that paid for project staffing and the creation and maintenance of training,
technical assistance, policy development, and evaluation infrastructures were in DHFS
hands. Moreover, essentially all of SSA’s interactions with the Wisconsin SPI project
46
There were about ten exceptions to this, HIV positive consumers who did not want to reveal
their status to a DVR counselor.
47
In the first years of the project this was through a negotiated, site specific capitation rate. Some
at DVR and, for that matter, at Pathways thought these rates provided sites a disincentive to
move participants to closure.
DRAFT
22
were through the Pathways office as DHFS was the actual partner in the cooperative
agreement.
Over the next one and one half years and mostly prior to the SPI project’s actual
startup date in July 1999, the network’s structure took something close to its long-term
shape. At the local level, most of the community agencies that would be program sites
were selected through an RFP process. By contrast, local DVR staff did not become
involved in a major way until the months following start up. 48 During this period, the
emerging Pathways unit at DHFS and DVR developed the structure through which they
would co-manage the SPI project through its first four years. However, while the
Pathways unit was able to substantially expand its staff in order to monitor contracts,
provide technical assistance, and implement an evaluation, DVR did not have equivalent
capacity to do so. To a large extent, DVR staff, whether in the central office or in the
field, needed to add SPI related work to their other duties, a situation that increased in
severity as DVR resources shrank, first cyclically and then permanently. 49 Other “state
level” network members of significance were the evaluation staff at Oregon Health and
Science University (OHSU) and key staff at a district SSA office who aided the project in
various ways including policy clarification, troubleshooting participant problems,
expediting access to evaluation data, and, ultimately, administering a benefit offset
waiver. 50
By all indications, network members were sincerely committed to the basic goal
of the project: to test a comprehensive approach to improving employment outcomes for
persons with disabilities. Yet there were important areas where key partners did not
agree on important issues. Disagreements tended to reflect differences in institutional
goals and roles among important state level network members, though these cleavages
could also involve local level network members closely associated with the state level
members. For example, we have already noted that some DHFS bureaus serving
specific disability populations had been providing community agencies technical
assistance in implementing vocational service models other than VFP. Bureau staff from
the DD and, especially, MH bureaus tended to prefer existing models to VFP. Pathways’
response was to suggest incorporating VFP principles more fully into the existing
48
Regional and local DVR staff had considerable operational autonomy. There was considerable
variation in how actively district directors and rank and file counselors became involved.
Sometimes involvement levels reflected personal preferences, sometimes perceptions of
supervisors’ expectations, and sometimes the presence of SPI sites and/or the number of SPI
participants in that region of the state.
49
Initially, DVR committed itself to providing full time staff to help manage the project. The agency
never did so; instead DVR claimed that the part time efforts of both central and field staff met this
commitment. Pathways managers did not agree. In particular, they thought that many SPI
participants were already on DVR counselor case loads or would have been added in the
absence of SPI and thus this did not constitute new, project specific, effort.
50
Though modified over the course of the project, the SPI evaluation plan was primarily the
creation of the individual who had designed and led the evaluation of the “feasibility study.” This
individual moved to OHSU prior to the start of SPI. She and her staff at OHSU remained actively
involved in the Wisconsin evaluation until its completion, working closely with the Wisconsin
based staff “hired” by Pathways. Additionally, this individual was the Principal Investigator of the
RWJ sponsored comparative study of return-to-work demonstrations that included projects in
Oregon and Vermont as well as the Wisconsin SPI.
DRAFT
23
vocational approaches. Though staff from the DD bureau made some effort to
cooperate, MH bureau staff actively resisted. 51 To some extent this conflict was
reflected in the relationships between ERI (in its role as a technical assistance provider
for VFP) and the SPI sites that had been utilized other vocational approaches. The result
was that Pathways ended up sponsoring a range of vocational approaches having
varying degrees of fidelity to the VFP approach, prior to any implementation differences
at the community agency level. 52
There were also important differences in perspective between DVR and
Pathways. These are especially important in that, unlike the DHFS bureaus, the two
entities would have a continuing and sometimes uncomfortable relationship beyond SPI.
Pathways, as a capacity building and R&D unit, was interested in what could be learned
through the SPI project. While unquestionably wanting to improve participants’
employment outcomes, Pathways was comfortable with this happening over what DVR
viewed as an unjustifiably long time period. Pathways also placed value on rigorous
program evaluation, viewing it as more than a SSA imposed requirement. By contrast,
DVR, while not opposed to a service approach that promised better long term outcomes,
retained a strong institutional interest in supporting approaches that could achieve
successful case closures at what it saw as an acceptable cost. Successful closures
result in additional federal reimbursement and better outcomes on federally mandated
performance measures. DVR staff felt that many aspects of SPI were inconsistent with
their service perspective, including the priority given to data collection activities and the
willingness to enroll participants with little immediate interest in pursuing employment.
Over time, the tensions related to these differences in perspective were
exacerbated by events, both within and external to SPI. From DVR’s point of view the
costs of achieving good employment outcomes, specifically the cost per successful DVR
case closure, was simply too high. Indeed, DVR was an agency under fiscal stress.
There were closures of the Order of Selection (OOS) during two substantial periods of
the SPI project because DVR did not have sufficient funds. During a full OOS closure,
DVR stops authorizing services for new cases or additional services for existing ones.
Full OOS closures are typically followed by periods of partial closures when DVR can
only authorize services for the most severely impacted consumers. Though Pathways
could increase the “match” amount it provided to DVR, there was a fixed maximum in the
amount of RSA funding irrespective of the amount of available matching funds. Thus,
DVR staff felt that authorizing what, from their viewpoint, was a less cost-effective
service approach compromised DVR’s ability to serve its non-Pathways consumers and
reduced its performance on RSA measures. 53 DVR’s perceptions regarding SPI’s value
51
The MH bureau staff had the structural advantage of being directly involved in the Medicaid
waiver recertification of some of the community agencies involved in Pathways. The conflict
between these staff and Pathways, which over time became unusually personalized, was
resolved by ending that bureau’s involvement in Pathways TA provision.
52
By itself, this greatly compromised the ability to test the efficacy VFP approach, either in
isolation or in the context of federal policy changes.
53
It is unknown whether DVR counselors were aware that DHFS had provided the match to
obtain the RSA funds used for SPI participants and some number of other DVR consumers. Most
high level DVR managers either knew or had access to this information.
DRAFT
24
was reduced further by concerns about how well the majority of sites were implementing
the VFP model.
Meanwhile, some staff at Pathways and the community agencies contended that
many DVR counselors were either not referring consumers to the SPI program or were
highly resistant to authorizing any services beyond those required through the site
contract in order to insure greater funding for other DVR cases. Whatever the actual
extent of this behavior, it was thought that DVR central management could have done
more to encourage the agency’s field staff to support SPI. There were additional
concerns about DVR’s ability to effectively support the SPI effort. OOS closures delayed
enrollments and postponed service provision, creating concerns about reductions to
project outcomes and having sufficient enrollment to support the evaluation. Additionally,
there was some dissatisfaction at Pathways about the extent that DVR used DHFS
provided matching monies for consumers not participating in SPI. Pathways managers
indicated that in the final year of joint management the effective RSA match rate for SPI
participants dropped to about 1:1, with much of the remaining match going to other DVR
uses. 54 Needless to say, this added a significant irritant to the relationship.
Probably the most important external factor affecting the quality of network
relationships were the delays and failures in obtaining the policy changes that were
expected to be available to SPI participants. 55 The most important of these were
proposed SSI and SSDI waivers, both of which included benefit offset provisions.
Pathways staff, especially the original Director, stressed the significance of these in
recruiting network members, especially the community agencies. Partners generally
believed that even if the waivers were not in place when SPI started enrollment in
summer 1999, they soon would be. Little was done to temper this impression, though
experienced DHFS staff knew that obtaining such waivers is hardly quick work even
when an agency (such as CMS) has standard procedures for processing waiver
requests. SSA did not.
The SSI waiver was finally implemented in May 2001, almost two years after
project start-up. The SSDI waiver was never granted. Though over 300 SPI participants
54
It is likely that DVR and DHFS held different interpretations of the language in their
Memorandum of Understanding about the use and/or return of the match monies from DHFS.
55
There was one major success in obtaining an important and permanent policy change early in
the project. A Medicaid Buy-in was implemented in March 2000. Though the Buy-in initially had
little saliency among network participants outside of Pathways or among SPI participants, it was
intended to deal with an important issue should some participants become so successful as to
leave the Social Security disability programs and ultimately lose the associated Medicaid or
Medicare coverage. Consumers had indicated that loss of access to public health care and/or
long term care services was a greater impediment to working than the loss of SSI or SSDI cash
benefits.
Failure to obtain waivers for non-SSA programs (e.g. subsidized housing) did not prove as salient
as the delays and failures to obtaining the SSA waivers. Indeed, Pathways had largely given
upon the effort to get waivers for non-SSA programs within the first months of SPI operations.
Though this may have marginally added to network partners’ skepticism, that skepticism was
almost always rooted in the perception that Pathways greatly exaggerated its ability to obtain the
SSA waivers.
DRAFT
25
made use of the SSI waiver, it was basically an extension of the existing “1619” feature
of the SSI program. The proposed SSDI waiver was as far more important as the SSDI
program had no cash offset feature; beneficiaries who earned over the Substantial
Gainful Activity (SGA) level lose their entire cash benefit and, unless earning at least
twice SGA, suffer decreases in income despite any marginal increase in earnings. 56
Moreover, there was something of a consensus that SSDI beneficiaries, because of their
previous labor market experience, would, in the absence of the “cash cliff,” be in a
generally better position to increase their work effort and earnings than SSI recipients.
Staff at many of the SPI sites reported they had concentrated on recruiting and
enrolling SSDI beneficiaries over the first year or so of the project in expectation of the
waiver, a claim supported by an examination of actual enrollment patterns. Further, they
conveyed their expectations about waiver availability to consumers. As the program
progressed, staff members at the community agencies were increasingly disappointed.
Some reported that they felt misled by Pathways. More importantly, by trusting that
Pathways would obtain the proposed waivers, they had conveyed inaccurate information
about the project to participants. They argued that this made SPI objectively less useful
to many participants and, more importantly, negatively affected participant trust and
motivation. There were also some indications that other actors such as the DHFS
bureaus and DVR also felt that DHFS/Pathways had exaggerated its ability to obtain the
waivers and were more skeptical of Pathways and the SPI effort as a result.
We turn now to a discussion of the means used to coordinate project activity,
concentrating on the relationships between the dominant state actors, Pathways and
DVR, and the twenty participating community agencies. First, however, we want to
briefly review coordination between SSA and Pathways and between the state level
network partners. As noted, the relationship between SSA and the SPI network was
entirely through Pathways. However, SSA was not deeply involved in the basic design or
management of the project. SSA, and especially Virginia Commonwealth University as
its agent, did exercise oversight and had considerable influence on some activities such
as evaluation. Perhaps the more important interaction was Pathways efforts to obtain
action on the waivers. Though this involved some direct negotiation, SSA decision
making processes were largely opaque. It is possible that political pressure mobilized by
the several SPI projects encouraged SSA to grant the SSI waiver.
The working relationship between DVR and Pathways was spelled out through
annual memoranda of understanding. As noted, there was some divergence of opinion
on how fully the terms of these agreements were met. There were no comparable
agreements between Pathways and the DHFS service bureaus. In reality, irrespective of
the existence of formal agreements, coordination was achieved through largely informal
means and was consequently dependent on the degree of trust, reciprocity, and
common purpose. As indicated these were often strained, but never to the extent that
overall project operations were seriously threatened. Even after DVR officially withdrew
from the SPI effort in late 2003, DVR and Pathways staff continued to meet to work on
SPI related issues. Interestingly, the relationship between Pathways and ERI as its
technical assistance partner was the one most highly structured through a traditional
contract. Nonetheless, a high degree of trust, reciprocity, and common purpose had
developed before SPI (especially through implementing the Dane County Employment
56
SSDI does allow beneficiaries to earn above SGA and keep their full SSDI benefit during a nine
month Trial Work Period.
DRAFT
26
Initiative). Thus, the contract was largely irrelevant as a mechanism to achieve
coordination or control.
Though “intangibles” and personal relationships may have contributed to
coordination of SPI activities at the site level, the main instruments used to achieve
coordination were contracts and an extensive program of technical assistance and
monitoring. The TA efforts involved multiple staff from Pathways, ERI, DVR, and the
DHFS disability bureaus. As contracts were enforced quite gingerly, in large part to
make it less likely that a site would withdraw from the effort, compliance depended
heavily on technical assistance efforts. Even when sites were asked to engage in explicit
remediation activities to retain contracts, technical assistance from the state partners
was critical to this process. In general, technical assistance efforts by Pathways, ERI,
and DVR were mutually reinforcing. To the extent that the technical assistance efforts of
state level partners gave contradictory guidance to the SPI sites, it reflected the
differences between the DHFS bureaus, and the other state level partners, especially
Pathways and ERI, on how far the intervention models used at particular sites could
diverge from the “paradigmatic” VFP approach. In the end there was a compromise of
sort, sites targeting mental health (MH) and developmental disability (DD) populations
were allowed to use service approaches that deviated from VFP in significant ways. The
staff from the MH service bureau that had been most assertive in opposing Pathways
and ERI eventually withdrew from active participation in TA activities.
Despite these extensive technical assistance activities, there were substantial
differences in not only implementation quality but the “program” being implemented. This
applied to aspects as diverse as data collection, participant recruitment, and, above all,
the service approach used. Officially, Pathways sanctioned six service models in
addition to “vanilla” VFP: two mental health models, three developmental disability
models, and a variation on VFP for the sites serving the HIV/AIDS target group.
However, the site to site variation in actual practice models, especially among sites
ostensively implementing VFP, was so large that it sometimes seemed as if most sites
had delivered a unique vocational planning model. Similarly, there was considerable
variation in the delivery of benefits counseling of which, in theory, there was a unitary
model. This variation reflected differences in philosophy as well as skill. Many benefit
counselors placed a higher priority on continued attachment to public benefits compared
to maximizing opportunities for gains in employment outcomes than some of the
participants they served. These differences seemed to be motivated by a combination of
personal preferences and agency culture, though it is a reasonable hypothesis that
these were often closely aligned through hiring and socialization processes.
This discussion brings us to an important question: the distribution of power and
influence in the network. The observed variation in implementation approaches, not just
quality, suggests that the community agencies had substantial influence. Yet based on
interview data and our personal interaction with agency staff, they would tend to deny
this. In this and other Pathways networks involving local actors, staff generally saw most
power and decisions emanating from above. In SPI, this meant Pathways, DVR and
perhaps ERI. More surprising was the typical perceptions of those involved at the state
level. While often seeing “street level” variation as a powerful influence on both
implementation and outcomes, for the most part they did not conceptualize this as an
exercise of power. Though there were exceptions, it was more often portrayed as a
process of almost natural variation that did not involve intent on the part of organizations
or individuals.
DRAFT
27
There was agreement that both Pathways and DVR powerfully shaped project
decisions and actions, though there was less unanimity about the source or level of each
organization’s power. Informants from Pathways never indicated that DVR dominated
decisions. They did observe, that as the intermediary in accessing RSA funding and in
setting the conditions for how services would be funded and, through that, sites
compensated, DVR had a strong voice. 57 Informants from DVR were less sanguine
about the extent of their power. They pointed to Pathways’ ability to dominate technical
assistance provision and having the trump card of an effectively bilateral relationship
with SSA as giving Pathways and DHFS a clearly more advantageous position to shape
project decisions.
The final aim of each case study is to indicate the extent a Pathways activity
achieved its intended goals and to make a tentative assessment of whether and how
that supported systems change, understood chiefly as leading toward development of a
coordinated and comprehensive return-to-work approach available to all Wisconsin
residents with significant disabilities. Whatever the SPI project’s deficiencies, Pathways
and its network partners certainly created a project infrastructure that provided
participants with an intervention that was recognizably what was proposed to SSA.
On the whole, the Wisconsin SPI project could be said to have contributed to
systems change in multiple ways without resulting in any substantial transformation. First
and foremost, a substantial cadre of benefits counselors were trained and gained
practical experience. SPI resulted in the generation of some level of permanent demand
for work incentive benefits counseling from consumers, community agencies and DVR. 58
In tandem, these conditions supported having an ongoing capacity to provide work
incentive benefits counseling beyond the level SSA would support nationally through the
Ticket to Work. Though the SPI experience did not establish VFP (or any of its
mutations) as an ongoing piece of the service delivery system, it contributed to the
development of experience with person-centered employment approaches that would be
available for Pathways, DVR, and others to exploit in other contexts.
Though external to SPI, the creation of a Medicaid Buy-in can be seen as an
essential component of systems change due to its potential to address one of the great
barriers to employment: continuing access to public health care coverage at earnings
and assets levels that would normally preclude continued attachment to either Social
Security disability programs or Medicaid. Given that in the decade since SPI a majority
of states have developed Buy-in programs, it is likely that Wisconsin would also have
developed one without either SPI or an emergent Pathways unit. Still, the early
57
We do not know whether the original system of providing SPI sites a capitation payment for
each participant originated with DVR or Pathways, though this was incorporated in the contracts
between DVR and each community agency. However, when DVR decided that capitation was an
ineffective approach, it exercised its authority to move to a system incorporating a combination of
flat rate fee for service payments and benchmark achievement payments. This approach was
more consistent with how DVR wanted to pay for services, irrespective of whether a consumer
participated in SPI.
58
DVR has tended to favor limiting intensive benefits counseling to when a consumer has
indicated a clear commitment to work above the SGA level and to achieve that in a limited time
period. Other organizations are more sympathetic to providing intensive benefits counseling as a
way for consumers to frame issues and then make informed choices.
DRAFT
28
development of a Medicaid Buy-in, combined with the knowledge and capacity
developed through the SPI project, put Wisconsin in a strong position to exploit the
opportunities afforded by the Medicaid Infrastructure Grant program.
The SPI experience, not so much in Wisconsin as nationally, contributed to an
important change in how systems change was thought about, especially in federal
agencies such as SSA and CMS. At the start of SPI, federal agencies regularly talked
about the potential of new work incentives and support programs as ways to reduce the
numbers of people who would maintain long term attachment to federal disability
programs. Other stakeholders tended to frame their arguments in this language to make
it more likely that federal actors would not dismiss their interests or claims out of hand.
During SPI, SSA and CMS gradually moved to the position that while relatively few
persons who qualify for a Social Security program or Medicaid because of serious
disabilities would ever be able to live without some form of public assistance, it would be
of public benefit to assist them in achieving whatever level of self-sufficiency they might
be capable of achieving
Finally, SPI enhanced the potential for systems change through institutional
development. It identified a set of partners that could be usefully networked again to
support future efforts, albeit with some residual level of mutual distrust between key
partners. SPI also resulted in developing a “permanent” institution with significant
experience with policy and program development, training and technical assistance
provision, and evaluation germane to disability and employment issues and strategically
located in a DHFS unit (CDSD) attempting to change how the state delivered long term
services. That institution was Pathways and it would ultimately get a chance to test a
policy change it could not during SPI, a SSDI cash benefit offset.
The SSDI Employment Pilot
The Wisconsin SSDI Employment Pilot (SSDI-EP) is one of four state level
projects that SSA has used to prepare for a national test of a cash benefit offset for the
SSDI program. 59 In all the pilots, the offset rate was 50% ($1 of benefit reduction for
each additional $2 of earnings) applied when monthly earnings rose above SGA and the
beneficiary had completed the Trial Work Period (TWP). This is in contrast to current law
which compels the loss of all cash benefits when monthly earnings reach the SGA level
following TWP completion. SSA also restricted participation in the pilots to adult
beneficiaries who had generated their benefits from their own earnings records and did
not also receive SSI benefits. Most controversially, SSA limited application of the offset
59
The national demonstration is required under a provision of the Ticket to Work and Work
Incentives Act of 1999. It is likely that SSA authorized the state pilots, in part, to meet an already
extended deadline of when the national demonstration was required to start. At the time of
writing, it appears that the national demonstration (the Benefit Offset National Demonstration or
BOND) will start in 2009.
The other three states with pilots are Connecticut, Utah, and Vermont. The Vermont SPI project
had, like Wisconsin, tested a SSI waiver and had unsuccessfully sought a SSDI waiver.
DRAFT
29
to a period ending seventy-two months after TWP completion. All participants would be
volunteers and would be randomly assigned to a treatment or control group. 60
Within this policy framework, SSA allowed the states substantial flexibility on how
to organize the pilots, but retained one critical area of operation. SSA would decide
when the offset would apply, calculate and make adjustments to the benefit check
amount, and engage in “end of year” reconciliation to insure that offset users had
received the right amounts. These functions were performed at the Office of Central
Operations (OCO) at SSA headquarters in Baltimore; there would be no direct
involvement by SSA offices in the pilot states. However OCO did not manage the
demonstration effort, the Office of Program Development and Research did.
Pathways again contracted with local community agencies to implement those
aspects of the effort requiring direct contact with participants, potential or actual. 61 These
agencies recruited and enrolled participants, provided project related services, and
collected information needed to administer the offset and to evaluate the pilot. Of the
twenty-one agencies that took part in delivering the SSDI-EP, fifteen had participated in
SPI. 62 SSDI-EP sites were required to provide all participants, irrespective of whether
they had been assigned to the treatment group, with equal access to project services. All
sites were required to provide benefits counseling services and, as part of doing this,
gather information needed to administer the offset and to troubleshoot any problems that
might arise from offset use. There was no mandated approach to vocational planning or
service provision. 63 The community agencies were expected to operate in a “person
centered” manner and to do their best to help participants access desired services.
Indeed, Pathways had no ability to fund such services, except for a separate Pathways
program that could provide funding for benefits counseling when it could not be obtained
from DVR or other sources. Within SSDI-EP, community agencies would be
compensated mainly for reporting information and engaging in efforts to maintain
60
Thus, to the extent SSA was interested in measuring outcomes through the pilots, it would be
for a population more likely to be motivated to work than the general beneficiary population (or
more properly, that segment that would have met pilot eligibility requirements).
61
Pathways’ decision to use community agencies as the main interface between the project and
consumers reflected the same considerations as in SPI: the goal of testing the intervention in a
context resembling that in which consumers using a statutory offset would get advice and
services and Pathways’ limited capacity to directly implement a pilot over any substantial area of
the state. However, there was another factor at work. Pathways had never stopped attempting to
obtain a SSDI waiver during SPI and following SPI had submitted, in conjunction with Vermont
and Connecticut, unsolicited proposals for a SSDI offset project. Within Pathways, the SSDI-EP
was originally viewed as conceptually linked to SPI. It was hoped that at least half of the pilot
participants would be former SPI participants and it would be possible to test whether their SPI
experiences had prepared them to make better use of the offset. However, that would not
happen. Less than 10% of SSDI-EP participants had participated in SPI.
62
Pathways actually contracted with twenty-two agencies, but one (a former SPI site) never
enrolled a participant. One of the twenty-one sites that had enrolled participants decided to end
its participation midway through the pilot.
63
By contrast to SPI where sites could only enroll consumers within a disability group they were
contracted to serve, SSDI-EP sites were permitted to enroll any participant who they thought they
could serve subject to SSA and any general Pathways eligibility rules.
DRAFT
30
participant involvement. The Wisconsin SSDI-EP started operations in August 2005. It is
scheduled to end in spring 2009. 499 participants enrolled in the program. 64
Pathways, within the constraints of program features and eligibility rules SSA had
mandated, determined the basic rules and procedures that would organize the activities
that the community agencies performed. In retrospect, the most important of these
involved how the annual earnings estimates that SSA would use to calculate the offset
would be collected and amended and how the “end of year” reconciliation procedure
would be implemented. As in SPI, the Pathways staff was involved in training, TA, and
contract monitoring. As the project progressed, staff members needed to spend
increasing time serving as intermediaries between the benefits counselors at the
community agencies and OCO staff in Baltimore. 65 This was due to serious problems
OCO had in generating benefit checks for those using the offset. These were rarely
either accurate or timely. Finally, Pathways housed an evaluation team, which provided
its own training and TA for those at the SSDI-EP sites collecting research data.
While SSA, Pathways, and the community agencies should be viewed as the
most important members of the interorganizational network that implemented the SSDIEP, there were other entities that had significant roles in the effort, especially at the state
level. The Wisconsin Disability Benefits Network (WDBN) had been established following
SPI to insure the continued availability of training and technical assistance to support
work incentive benefits counseling in the state. 66 As benefits counseling was the only
type of service SSDI-EP sites were required to provide, Pathways utilized WDBN as its
primary agent for assuring that sites had appropriately prepared benefits counselors.
Though local SSA offices did not have a formal role in implementing the offset,
they were important as a source of referrals, information needed to assess eligibility, and
to deal with a major side effect of offset use, large overpayments. 67 Staff at the Madison
office proved especially valuable in these areas, both through their own efforts and by
64
Actual enrollment was somewhat higher. Enrollees were retrospectively disqualified if it was
learned that they did not meet eligibility requirements. Most frequently, this resulted from
inaccuracies in the very piece of SSA documentation (the Benefits Planning Query or BPQY) that
sites used to confirm eligibility.
65
OCO opted to communicate only with the entity running the pilot in each state. As the
Pathways staff assigned to supporting site operations were experienced benefits counselors, they
were well prepared to take on this function.
66
The WDBN has been operated out of ERI, the agency Pathways used to provide TA for
benefits counseling (and VFP) during SPI.
67
Persons receiving SSDI and/or SSI benefits are legally responsible for repaying any excess
payments. Given that most participants in these programs rarely have financial resources that will
allow repayment, for many individuals the fear of generating an overpayment constitutes a potent
subjective barrier to improving employment outcomes. Overpayments can happen for many
reasons, including a beneficiary’s failure to provide accurate information on a timely basis.
However, many overpayments result from problems in SSA procedures and data systems
(especially in the SSDI program). This was especially true in the SSDI-EP and other state pilots
where SSA chose to calculate the offset based on annual earnings estimates and then reconcile
the estimates to actual earnings the following year.
DRAFT
31
helping to disseminate information and/or providing assistance to staff at SSA offices
throughout Wisconsin.
Additionally, there was a range of actors indirectly involved due to their
importance as places where persons with disabilities seek information, services, or
establish eligibility for public benefit programs. 68 DVR was the most vital of these as its
role is to be the state’s primary entity for helping those with disabilities enter or return to
the labor force. Though DVR would not be a direct partner as in SPI, Pathways
understood that unless DVR staff had good information about the SSDI-EP and felt
some reason to be supportive, it would be less likely that participants would have access
to vocational services that Pathways could not pay for. Though local DVR staff exercised
substantial discretion in carrying out their duties, strong support by top DVR managers
would provide local staff with cues that would encourage cooperation with the pilot. 69
It is also important to note that there was continuing interaction between the state
pilots about how to implement the project and respond to emerging challenges. This
interaction was encouraged by the project manager at SSA and often used by him to
work through issues rather than through bilateral discussions with the individual pilots. 70
As is often the case, the network partners shared certain key but very general
goals. Most saliently, the partners appeared to fully agree that the SSDI “cash cliff,” that
is, the immediate and complete loss of the SSDI cash benefit when earnings reached
SGA was a significant disincentive to work. Moreover, there was a broadly held
expectation that SSDI beneficiaries would, compared to SSI recipients, have skills and
experiences more likely to support continued employment and earnings above SGA, as
long as doing so did not lead to loss of access to health care and/or long term care
services or create intolerable difficulties to regaining access to SSDI cash benefits
should they be needed again. The partners thought that a well designed SSDI cash
benefit offset would do much to ameliorate these problems and thus favored an effort to
test a SSDI offset provision.
It is also likely that there was agreement among the partners, including SSA, that
many beneficiaries were risk adverse. Most obviously, it is often difficult to prove one’s
eligibility for a disability program and the consequences of losing eligibility are often
severe. Many beneficiaries had limited trust in SSA’s capacity to implement existing
68
Outside of DVR, perhaps the most important of these actors were the emerging system of
capitated managed care organizations providing long term care services (Family Care) and the
county based economic support workers (ESWs). The ESWs were the gatekeepers to the old
system of providing long term care services and to establishing eligibility for Medicaid waivers
and the Medicaid Buy-in. Long term care services are often needed to maintain employment after
a successful entry or re-entry to the workforce.
69
There has been little agreement among stakeholders as to DVR’s overall level of cooperative
DVR has been. There is ample evidence, however about local and even counselor to counselor
variation.
70
This process was facilitated by a staff member at the National Consortium for Health Systems
Development (NCHSD), a TA collaborative that had been formed to aid states in developing
Medicaid Buy-ins and in making better use of the Medicaid Infrastructure Grant program. The
staffer had previously worked for Pathways and had an important role in developing the SSDI-EP.
DRAFT
32
work incentives or to redeem any promise that one would be held harmless for efforts to
work during the pilot, a perception often shared by staff at both the community agencies
and Pathways. Thus, while there was hope that benefits counseling would help allay
participant fears, all parties to the SSDI-EP had an interest in good implementation,
especially by SSA.
Network partners did exhibit some differences in their goals or in the priority
attached to shared goals. Some of these had little or no import. For example, no major
organizational partner, save SSA itself, had a major interest in using the Wisconsin pilot
to prepare for the national demonstration, but this had no effect on their willingness to be
involved in the SSDI-EP. However, there were at least two differences in purpose that
had a significant impact, in part due to their interaction.
SSA is a large agency. SSDI is by most standards a major endeavor, but it is
quite small compared to the retirement benefits component of the Old-Age, Survivors
and Disability Insurance (Title II) program. Compared to SSDI the cash benefit offset
pilots are miniscule. Though our evidence is largely indirect, it appears that there was
strong (and understandable) pressure within SSA to operate the pilots in ways that
would disrupt existing procedures and data systems as little as possible. Additionally,
there has been no consensus within the agency about the desirability of having a
statutory cash benefit offset. Beyond the considerable costs involved in altering
administrative procedures and information systems to accommodate an offset, some
opposed the offset because of their concerns that it would induce additional entry and
reduce attrition from a rapidly growing public benefit program. 71
These institutional purposes were clearly manifested in decisions that SSA made
before the pilots started about eligibility criteria, how the offset would be administered,
and how long those in the treatment group would have access to the offset. Individuals
with concurrent SSDI and SSI eligibility were excluded because applying the offset
would be inherently more complicated and require manual changes in two separate data
systems. Disabled adult children (DACs) and other SSDI (only) beneficiaries receiving
benefits based on another family member’s earnings history also were disqualified to
ease implementation issues. SSA refused to make even modest changes in existing
form letters that might make them more intelligible in the context of the pilots. SSA
decided to calculate the offset using an annual earnings estimate, rather than estimates
or retrospective earnings tied to the monthly period to which SGA applies. For more
than a year, SSA did not have designated OCO staff to perform the non-standard tasks
that processing the offset involved.
However, it appears the single most important decision SSA made from the
perspective of the state and, in Wisconsin, local partners was to limit the use of the
offset to a period starting three months after TWP completion until seventy-two months
71
The Office of the Chief Actuary has been especially vocal about its concerns that a SSDI
Benefit will increase program size and cost. Irrespective of the purchase of such arguments, it is
certain that the size and costs of the SSDI program have been growing steadily and the average
age at program entry has been decreasing. For a brief summary of Social Security disability
program enrollment and cost trends see Wunderlich, Gooloo, S., Rice, Dorothy, P., and Amado,
Nicole, L, eds. 2002. The Dynamics of Disability: Measuring and Monitoring Disability for Social
Security Programs. Washington, DC: National Academy Press. pp. 33-52.
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33
thereafter. Thus, beneficiaries more than seventy-two months past their TWP would be
ineligible for the pilot. By adopting this “seventy-two” month rule, SSA reduced its long
term work load and, perhaps, responded to internal concerns that a permanent offset
would increase program attachment and, consequently, long term expenses. 72 External
stakeholders, including some Pathways staff members, had argued for treatment group
members to have permanent access to the offset as a way to reduce beneficiary fears
that work activity during the pilot would negatively affect their post-pilot SSDI eligibility.
They speculated that such beneficiaries would respond by reducing their work effort
during the pilot compared to what it would be with permanent access. Some also thought
that the “seventy-two” month rule resulted in the exclusion of a sub-group who might
make the most effective use of the offset feature: beneficiaries with long and persistent
workforce attachment but who deliberately kept (“parked”) their earnings under SGA.
By contrast, both Pathways and the community agencies placed greater value on
the offset’s potential to improve participant outcomes and, secondarily, for identifying
which support services might prove more efficacious toward this end. The commitment
to serving participant interests appears to have been especially intense at the
community agencies where staff members had professional relationships with
participants, sometimes of many years standing. This difference in focus and, by
implication, priorities is most clearly seen in the disappointment over the eligibility
restrictions, especially the seventy-two month rule. Most of these restrictions were
announced either during the periods in which Pathways was recruiting potential sites,
attempting to nail down project procedures, or providing community agency staff with
necessary training. As there was a series of such changes, it raised latent but
widespread concerns about SSA’s willingness to test the offset under conditions that
would genuinely examine its efficacy for those beneficiaries believed to be best
positioned to use it.
SSA’s promulgation and (apparent) amendment of the seventy-two month rule
was especially troublesome to state and local network members. In part, their
disappointment was over substantive concerns that have already been described.
However, the announcement of a “final” seventy-two month rule took place almost
immediately before project start-up and reversed a previous understanding of how it
would work.
When Pathways started to recruit potential sites, SSA had indicated that
treatment group members would have permanent access to the offset. This was then
changed to disqualification of all beneficiaries seventy-two months past their TWP.
However key members of the Pathways staff understood this to mean that all those in
the treatment group who entered the SSDI-EP with a completed TWP would still have a
full seventy-two month period in which to use the offset. 73 This was conveyed to the
community agencies, some who were already engaged in recruitment activities. This
interpretation was also given during training that was provided to community agency
72
The concern must have been about creating a precedent. The additional cost, relative to SSDI
outlays, would have been trivial.
73
This interpretation was consistent with SSA’s insistence that the pilots were intended to
produce estimates of participant outcomes. The final version of the rule can result in participants
having as little as one month to use the offset.
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34
staff at the project startup event. SSA staff members from Baltimore were in attendance
and had not objected. Several days later SSA clarified the rule, but at the cost of
damaging SSA’s credibility with community agencies, potential participants, and, to
some extent, Pathways itself.
As noted, administration of the offset provision did not build confidence between
SSA and its partners, let alone with the participants negatively impacted. Finally in late
August 2008, SSA informed the state pilots there would be a final change to the seventytwo month rule. At enrollment, participants were promised that if they were assigned to
the treatment group the offset would be available whenever they completed their TWP.
SSA indicated it would now require certification of TWP completion by a specified date,
otherwise the participant would not be allowed to use the offset. 74 On that conference
call, SSA indicated that the date certain could be as early as December 1, 2008, though
it appears that the agency, at the prompting of the state pilots, is considering a less
draconian date and tying it to the actual TWP completion date. Nonetheless, SSA’s
desire to change the seventy-two month rule can be readily understood in the context of
its concerns about the long term challenges of monitoring offset use. 75 However, it can
be viewed by network members and other stakeholders as a serious breach of trust.
Differences in priorities between the community agencies and Pathways also
seem to have had an effect on network relationships, though a more modest one. Some
at the community agencies found aspects of pilot operations objectionable or
burdensome, such as the use of random assignment or the requirement to have monthly
contact with all participants to gather evaluation data. In their view, random assignment
“harmed” those assigned to the control group, especially those immediately prepared to
make use of the offset. Some saw the monthly contact requirement as a diversion from
effort that could have been put into important service activities, including for those on
their caseloads who were not SSDI-EP participants. There was a second and related
source of difference. Unlike SPI, there was no dedicated mechanism for payment for
service provision. Though SSDI-EP sites did receive payment for data reporting and
other activities, it appears that the lack of an explicit service payment system had some
negative impact on both enrollment and subsequent service provision. 76
74
The time between TWP completion and when SSA produces a letter certifying completion is
highly variable. Thus requiring certification by a date certain rather than the actual TWP
completion date raises an issue of procedural fairness. During an October 9, 2008 conference
call, SSA indicated that December 31, 2008 would be the date certain but that they would be
“lenient” in allowing what was described as a slight bit of leeway in when the certification of TWP
completion had to be on record.
75
Under the current seventy-two month rule it is possible that participants in their early twenties
might not complete their TWPs until nearly four decades after the pilots end. Frankly, SSA’s
decision, whatever its details, will relieve state and local partners of potential future obligations,
albeit largely moral ones. Nonetheless, the details matter. A reasonably long period leading to a
date when all participants must have completed a TWP will greatly reduce the number of people
who will lose access to the offset for reasons beyond their control.
76
Community agencies that did not participate in SPI typically enrolled substantially more
participants than those who had been involved in SPI and had thus received payment for services
through DVR. We hypothesize that the former SPI sites perceived a less generous resource
environment in the SSDI-EP and trimmed back their efforts. Similarly, we think that the new sites
did more planning for how to generate an adequate return from SSDI-EP’s financial
arrangements.
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35
Though the toolbox of methods used to coordinate SSDI-EP were broadly similar
to those used in SPI, contracts were more central to network operations in the newer
effort. SSA used an annual contract to structure its relationship with Pathways instead of
the more flexible cooperative agreement used for SPI. In contrast to SPI, SSA had
clearer ideas about the nature of the primary intervention and what it wanted to achieve
through the state pilots. However, it would be wrong to overstate SSA’s reliance on
contracts to attempt coordination. SSA regularly participated in joint calls with personnel
from all four pilot states. There is also ample evidence that SSA encouraged the states
to discuss and reach a consensus on outstanding issues and to then present their
common position to the SSA project manager. SSA also involved state project staff as
intermediaries to resolve problems with and/or get information from participants.
Of course, Pathways contracted with community agencies during SPI, but the
context had changed in several ways. In SPI, sites, irrespective of the letter of the
contracts, were given substantial leeway to develop and deliver what was essentially a
new product with uncertain characteristics and unknown effectiveness. Though there is
still much to be learned about effective service provision in the area of disability and
employment, by the start of the SSDI-EP Pathways had a knowledge base that allowed
it to be a more savvy “buyer.” Secondly, Pathways was asking the sites to do less.
Finally, the environment was simpler. There would be no separate contract with DVR as
a second project principal and the range of parties providing technical assistance would
be smaller and less likely to act or ask community agencies to operate in ways
inconsistent with what Pathways wanted. Thus specifying and monitoring contracts was
significantly easier in SSDI-EP than in SPI.
Nonetheless, training and technical assistance efforts remained an important
means of coordination. As previously mentioned, the TA providers were limited to
Pathways operations staff, the evaluation team housed at Pathways, and the WDBN.
Unlike in SPI, staff at SSDI-EP sites received consistent and reinforcing messages from
all TA providers throughout the project.
Informants from both state and local network partners provided a consistent
portrayal of the distribution of power and influence in the project, one largely consistent
with that we have observed. 77 SSA is seen, by a large margin, as the dominant actor.
This power is seen to rest more on SSA’s authority over the features of the offset,
primary eligibility criteria, and the processes used to adjust checks, than on its control of
However, this does not explain the generally modest hours of service provision per participant,
relative to SPI, at both the old and new SSDI-EP sites. It is clear that little of the observed
differences result from reduced service provision to control group members. While it is true that
baseline data suggest that SSDI-EP participants were more likely to be employed than SPI
participants at project entry and had more solid work histories, these differences were relatively
small. Most likely, the lack of a dedicated payment system was the predominant factor motivating
site behavior, though the fact that sites had no affirmative duty to provide vocational services (just
to make a good faith effort to arrange access) may also have had a significant impact. Yet this
cannot be the complete explanation. Hours of benefits counseling were also much lower than in
SPI, even though Pathways, through another of its programs, insured that funding was readily
available to the SSDI-EP sites.
77
Unfortunately, we have no information about how network participants at SSA view this matter.
DRAFT
36
project funding. Nowhere has this dominance been more apparent than in SSA’s ability
to make rapid changes in all these areas. As one informant put it, “Plans that were solid
tended to move with alacrity.” Pathways was also seen as having significant power
based on it having made some decisions about project structure and processes,
including how to operationalize the earnings estimates and reconciliation procedures.
Informants, from both Pathways and other network members, saw the SSDI-EPs basic
structure as a unilateral decision on Pathways’ part (though ordered by SSA
requirements). By contrast, it was felt that Pathways, while still making the final
decisions, had sought and seriously responded to community agency input on the
operational issues that came up during the pilot.
To the extent that informants differed in their perceptions about the locus of
power and influence it was over the role of the community agencies. As with SPI, there
was a reluctance to see differences in implementation as evidence of significant
influence over project operations. Even some Pathways staff members seemed to
discount this possibility, seeing such differences mainly as evidence of fudging on
contractual requirements for either fiscal reasons or to devote agency resources to other
activities. Nonetheless, informants occasionally saw more “programmatic” intentionality
in implementation differences. One spoke of his concerns that at some sites there was a
“house” style of benefits counseling that put a far greater emphasis on protecting or
maximizing public benefits than exploring what options were available to improve
employment outcomes or achieve greater independence. As participant-observers, we
have noticed differences across the community agencies in the amount and pattern of
service provision to those in the SSDI-EP. These seem to be correlated with agencies’
service philosophies and practices for all of their consumers.
As with SPI, there can be little doubt that Pathways and the network
implemented a project that was a reasonable approximation of what had been intended.
Indeed, the degree of approximation has probably been closer due to the very simplicity
of the service delivery model. Though enrollment was appreciably less than the hoped
for 800 and disappointingly few of the former SPI participants entered the demonstration,
the numbers were sufficient to support the evaluation plan. Most of the serious
implementation failures that affected the project were concentrated at SSA, which found
it extremely difficult to make the necessary adjustments to offset users’ benefits checks.
Yet the contributions of the SSDI-EP toward achieving systems change,
particularly in Wisconsin, appear to be modest. Certainly, the effort has already
generated a great deal of information about the implementation problems that SSA and
its primary contractor, ABT Associates, will face in implementing the national
demonstration (BOND). In addition to the challenges of processing the cash benefit
offset identified at SSA, experience in Wisconsin and the other pilot states indicate that
offset implementation greatly benefits from having a local infrastructure to support
beneficiaries’ use of the feature. At minimum, this is likely to require some form of
benefits counseling service and support to troubleshoot problems. It is also likely that
such support will have to be provided in ways that allow the development of a continuing
relationship with beneficiaries, given their fears about their ability to maintain access to
needed public benefits and their generally low levels of trust in SSA. While a statutory
offset would probably result in useful changes to SSA data systems, procedures, and
DRAFT
37
form letters that will reduce offset administration problems, this is still unlikely to
completely obviate the need for locally provided support. 78
Within Wisconsin, the contributions of the SSDI-EP toward systems change are
harder to discern. Certainly, as with most major endeavors, there has been some
learning that can be applied in novel contexts. For example, the SSDI-EP provided
services in a far more flexible manner than in SPI. This experience could inform efforts
to provide services through DHFS’ Aging and Disability Resource Centers or through
Family Care Managed Care Organizations. However, the SSDI-EP does not appear to
have resulted in the development or the significant refinement of any service approach,
though, should an offset be available in the future, the project probably has contributed
to developing “best practice” in how to intervene to resolve difficulties that offset users
may face. 79 The SSDI-EP may have contributed to the maintenance and expansion of
benefits counseling capacity at particular community agencies, though by the project’s
inception there were alternative means for accomplishing this goal.
Comparing the Demonstrations on Four Continua
In the methods section of this paper we indicated that we would place our case
studies on four continua for the purpose of identifying possible relationships between
network operation and the contribution to Pathways’ system change activity. These
locations are tentative. This is not only because of current limitations in our evidence, but
also the lack of clear benchmark values for the end points of each continuum. Though
we hope our frames of reference are similar enough to those used by Frederickson and
his colleagues to be of at least heuristic value, our placements are strongly influenced by
our perceptions (or intuitions) about the relative positions of these and other Pathways
efforts on these dimensions. Lastly, the placements are always “Pathways centric,”
irrespective of whether Pathways is legally the agent of some federal principal.
Figure 1: Nature and Quality of Network Articulations
SPI
SSDI-EP
X
X
--------------------------------------------------------------------------------------------------------------
“remote control”
“managed network”
Figure 2: Level of Goal and Policy Agreement
SPI
SSDI-EP
X
X
--------------------------------------------------------------------------------------------------------------
“disagreement/
“agreement/
incongruence”
congruence”
78
In our view, it certainly hasn’t for the 1619 feature of the SSI program.
79
It appears that Wisconsin will be one of the ten geographical areas in which BOND will operate.
DRAFT
38
Figure 3: Level of Centralization of Policy Implementation
SPI
SSDI-EP
X
X
--------------------------------------------------------------------------------------------------------------
“decentralized, dispersed
“centralized”
and/or fragmented”
Figure 4: Level and Character of Client or Stakeholder Support
SPI
SSDI-EP
X
X
--------------------------------------------------------------------------------------------------------------
“weak”
“strong”
On every one of these continua, SPI’s placement is to the left of SSDI-EP,
implying a significantly more decentralized and potentially contentious environment. Yet
it is clear that the SPI project contributed more to the Wisconsin systems change effort
than the later demonstration. Certainly, SPI was first and, in most respects, more
ambitious. We turn to the other case studies to get a sense of whether SPI is typical or
the exception. There is another possibility. As important as these continua may be for
explicating phenomena that Fredrickson and colleagues were interested in
(implementation of performance measures and the relative attention given different
conceptions of accountability), they could have little purchase on the relationship
between network activity and achieving large scale, even transformational, change in the
policy environment the network seeks to affect.
Case Studies: Capacity Building Efforts
Demonstration projects are temporary and relatively small scale. Systems
change requires substantial and relatively permanent change to structures and
processes on a much larger scale. Though demonstrations often produce valuable
learning and build some capacity, there needs to be means to refine and then apply
these products more widely through existing institutions or the creation of new ones.
One general approach toward achieving this end is capacity building, where there are
extensive and focused activities to transfer information, skills, and resources into real
world settings. Pathways, in part because of the expertise developed through SPI, in
part because of the infusion of resources provided through the Medicaid Infrastructure
Grant (MIG), increasingly turned to capacity building activities as a primary instrument
for encouraging systems change.
Though Pathways increased the range of its capacity building efforts as MIG
funding levels rose, we focus on two major capacity building efforts which have deep
roots in the activities that led to SPI. The first is the effort to maintain and expand
capacity to provide work incentive benefits counseling through a technical assistance
entity, the Wisconsin Disability Benefits Network. The second capacity building effort
examined is the effort to achieve the widespread incorporation of person centered
employment planning services (PCP for short) into Family Care, Wisconsin’s emerging
DRAFT
39
system for providing those with physical and developmental disabilities (as well as the
elderly) with long term support services.
It is important to note that Pathways has and continues to view increasing
capacity in these domains as essential to building a system that would facilitate
significantly better employment outcomes for persons with disabilities. High quality
benefits counseling was viewed as a necessary service to support truly informed choice
by consumers, by distinguishing real barriers from illusory ones, and identifying ways to
overcome or ameliorate them. A person centered planning approach had long been
seen as a logical adjunct to benefits counseling, both to help individuals articulate their
long term vocational goals and to identify actions that could help them realize their goals.
During SPI, Pathways viewed DVR as its primary partner for institutionalizing benefits
counseling and a PCP approach to vocational planning and service planning. Following
SPI, for reasons that will be described in the second capacity building case study,
Pathways increasingly viewed Family Care, which is located within DHFS, as likely to be
a more effective point of intervention for promoting systems change.
The Wisconsin Disability Benefits Network
Because of SPI there had been a large increase in the number of work incentive
benefits counselors and their availability across Wisconsin. 80 Prior to SPI, benefits
counseling had been available through less than five organizations with the number of
counselors barely larger. By September 2003, Employment Resources, Inc. (ERI), as
Pathways’ TA partner, had trained an additional seventy benefits counselors to work at
the participating community agencies; there had been an approximately fivefold increase
in the number of agencies offering the service. Though the Social Security funded BPAO
program would insure that there would be a small amount of residual capacity,
Pathways, by 2002, had begun to pay attention to sustaining and ideally expanding
benefits counseling after SPI. 81 Though part of the challenge would be to identify ways
to fund benefits counseling services, there would also be a need to train new benefits
counselors and to provide technical support and continuing education to those in the
field. The Wisconsin Disability Benefits Network (WDBN) was established to meet this
need.
The WDBN grew out of discussions between Pathways managers, the ERI
Executive Director, and other key staff. For the most part, those involved in the
discussions shared a common vision about the role of benefits counseling and a high
degree of mutual trust that had developed through SPI and the activities that had
preceded it. 82 ERI was awarded a contract to house WDBN in late 2002. 83 By the end of
80
In Wisconsin, the term benefits specialist in the preferred job title for those who provide benefits
counseling services.
81
The BPAO (Benefits Planning Assistance and Outreach) program fulfilled a requirement of the
Ticket to Work and Work Incentives Act of 1999. It has since been reorganized as WIPA (Work
Incentive Planning and Assistance).
82
One Pathways manager was concerned that WDBN, as envisioned by ERI and most Pathways
staff, would lead to an excessive professionalization of benefits counseling. This manager felt that
it would both decrease the availability of the service and, more importantly, reduce the
consumer’s control of the process relative to that of a professional who might have different
priorities.
DRAFT
40
the following year substantial work on planning a curriculum, training and technical
assistance provision, and outreach activities was completed and WDBN commenced
operations shortly thereafter. Planning and operations were carried out mainly by ERI
staff with some involvement by experienced benefits counselors from other agencies.
However, there was ongoing input and oversight by Pathways managers.
Over time, additional partners have become associated with the network, though
not in all cases directly involved in WDBN operations. This included the benefits
counselors who most directly utilized WDBN services and the entities that employed
them. Initially this category included mainly work incentive benefits counselors and the
community agencies where most have been employed. 84 However, WDBN, almost upon
its inception, also began to provide training and technical assistance to those engaged in
benefits counseling primarily to help those with disabilities to establish and maintain
access to public benefits. Such benefits counselors currently work in both private and
public entities, including the DHFS sponsored Aging and Disability Resource Centers
(ADRCs). 85 According to our informants, most benefits counselors and their employers
have restricted their involvement to making use of WDBN activities and products and
then voicing their satisfaction or concerns.
Nonetheless, though such stakeholders have connected to the WDBN network
mainly as customers (though largely non-paying ones), a non-profit advocacy group,
Disability Rights Wisconsin (DRW), has been directly involved in WDBN governance and
operations. DRW’s participation is significant as attorneys from that organization have a
supervisory role in the Disability Benefits Specialist (DBS) program. 86 The entities that
oversee benefits counselors providing similar services for the elderly are only recently
becoming active in the network. Indeed, as the Elderly Benefits Specialists perform
similar functions to the DBSs and often work at ADRCs and Family Care Managed Care
Organizations, there is increasing interest at DHFS in using WDBN to train and provide
technical assistance for this constituency. Should this process continue, it suggests that
direct involvement in network governance by an entity parallel to DRW would almost
certainly follow. 87
Staff from local SSA offices had an important role in insuring that the curriculum
has been accurate. Much of the curriculum content is focused on SSI and SSDI rules
and processes. WDBN has also made use of external content experts. In particular, the
83
WDBN has never had a corporate existence. An existing organization has been contracted to
house and operate WDBN (to date ERI) under terms of a contract with DHFS and with the
oversight of an advisory board that included stakeholder representatives.
84
A few benefits counselors are self-employed.
85
As the name suggest the ADRC is involved in providing information and making referrals.
However, the ADRC is increasingly the point of entry to establish Medicaid eligibility and access
to long term care services.
86
Additionally, the DHFS position with primary responsibility for the Disability Benefits Program
was transferred to OIE, the unit where Pathways is housed, in 2005.
87
Current involvement is focused on developing a code of professional conduct for all three types
of benefits counseling. The WDBN is facilitating this process.
DRAFT
41
University of Wisconsin – Stout has deepened its involvement as WDBN explored the
issue of professional certification. 88 Those staffing WDBN maintain regular contact with
units in the state’s Department of Workforce Development (DWD). Despite differences
between DVR and WDBN’s primary partners as to when and for whom intensive benefits
counseling is most appropriate, DVR continues to be a major purchaser of benefits
counseling services. It thus has a continuing interest in WDBN activities and has
representation on the WDBN advisory board. Disability navigators are also regularly
consulted. Their jobs require that they know when to refer their consumers to benefits
counseling services and WDBN has provided the training that allows them to perform
this function. 89 Unusually for a Pathways effort, this network does not involve a
significant federal partner (excluding Wisconsin based SSA staff). WDBN has been
funded through a combination of state and federal sources, but without any single
predominant source of federal funding.
Once again, network partners agreed on the overall goal of the effort. Benefits
counseling was seen as a vital service. There was also strong agreement that a capacity
building entity that could provide training, technical assistance, and outreach on a
sustainable manner would be an effective means of maintaining and expanding access
to benefits counseling. Unlike many other Pathways efforts, there were few underlying
differences in institutional interests that could made operational decision making more
difficult. The only truly significant difference of this sort was between DRW and the two
other main partners in WDBN governance, ERI and Pathways. As noted, there is an
important difference in the focus of work incentive benefits counselors and those with the
primary function of helping persons with disabilities establish or keep program eligibility
that the law entitles them to. Disability Rights Wisconsin also expressed some concerns
about the possibility of a programmatic merger between the two types of benefits
counseling that would prove disadvantageous to those unable or not interested in
working. Nonetheless, the parties found ways to achieve reasonable accommodations to
these differences through operational decisions, for example creating curriculum
modules that distinguished between common and specialized subject material and
scheduling training so that each type of benefits counselor can receive training in
specialized subject matter with their peers. DRW’s fears regarding programmatic merger
seem to have been assuaged by “institutionalizing” a separation through making DRW a
formal sub-contractor in the WDBN effort.
Despite the close association between ERI and Pathways, there were some
meaningful differences between these partners concerning how the WDBN should
operate. In the early years of WDBN these differences were largely in three areas. The
first was the use of computer technology and/or staff at organizations other than ERI to
provide training and TA at reduced cost to Pathways and to make it easier for
organizations far from Madison (where ERI was located) to use WDBN services. ERI
88
This is in addition to the UW-Stout employees attached to the Pathways staff who monitor the
WDBN contract.
89
The Disability Navigator program is funded by the U.S. Department of Labor; the navigators are
generalists helping person with disabilities to utilize the systems that provide services to the
disabled, especially those parts relevant to seeking or maintaining employment. To a certain
extent, the Disability Navigator program can be seen as a response to the documented problems
that the Workforce Investment Act mandated “One Stop” Job Centers have had serving those
with disabilities.
DRAFT
42
had concerns about the quality of such efforts. The second concerned the value of
having a full time WDBN manager which ERI favored, but Pathways thought diverted
resources from programmatic activities. Finally, though both Pathways and ERI favored
some form of professional certification for benefits counselors, there were differences
over how to do this. Over time, these differences narrowed, generally in the direction
preferred by Pathways. Some informants reported that this outcome reflected a change
of leadership and staffing at ERI. One added that to a large extent the Pathways/DHFS
preferences had always been embedded in contract language. The new leadership at
ERI was described as not being interested in resisting Pathways’ preferences in the
formerly contested areas. 90
More recently, there was some conflict over how to make progress toward
sustainability, as Pathways is unlikely to be in the position to provide large subsidies for
WDBN indefinitely. Though both ERI and Pathways have discussed the possibility of
moving gradually to a fee structure, Pathways has successfully opposed doing so to
date. Pathway management’s position is that it pays for essentially all WDBN activities
and that by doing so it has paid for the training and technical assistance already. Indeed,
as many organizations have objected to the indirect costs (time and travel) associated
with training and TA for their staffs, Pathways has been concerned that moving to a fee
structure will retard the availability of benefits counseling and negatively impact the
operations of a number of Pathways efforts (including the SSDI-EP). ERI and others
associated with WDBN, including some Pathways staff, argue that at some point service
users will have to bear a substantial portion of the cost and that it is better to move in
this direction incrementally.
Generalized support for most WDBN activities is very high across the range of
network stakeholders. Even an entity like DVR that has a somewhat different
perspective on benefits counseling than ERI or Pathways has been highly supportive.
Nonetheless, the support for concrete activities has been somewhat less. As already
noted, entities employing benefits counselors have had decidedly mixed feelings about
the time and travel costs participation in training and technical assistance entail. There
have also been mixed feelings about the development of a certification regime, which
may increase benefits counselors compensation and, thereby, the effective cost of
providing benefits counseling services.
Though outwardly the WDBN appears to be an effort that is tightly structured
through contractual arrangements, such a portrayal would be misleading. Pathways and
ERI choose WDBN’s priorities in a largely collegial fashion, based upon trust developed
through joint Pathways and ERI activities over more than a decade. ERI has been
allowed considerable discretion, reflecting Pathways management confidence in ERI’s
technical expertise and performance record. Moreover, the two entities’ perspectives
about the purpose and value of work incentive benefits counseling have been largely
identical. These social and ideological bonds are strengthened by a strong tendency by
Pathways to hire staff that had worked at or been trained by ERI. The Pathways staff
members most directly involved in WDBN operations had formerly been ERI employees;
their supervisor had received benefits counseling training from ERI during SPI. Overall,
this relationship appears to one that fits well under the concept of relational contracting,
where the terms of the contract are mainly embedded in the mutual expectations of the
90
Leadership change was also reported as a factor that contributed to easing tensions between
DRW and management at Pathways and ERI.
DRAFT
43
parties and are rarely explicit enough to be enforced by the courts or other third
parties. 91
On the whole, day to day coordination in the network appears to have been
achieved largely through inter-group communication among the agents of the
organizations participating in the network. This appears to apply somewhat less to
Disability Rights Wisconsin than the other key members. DRW was the only major entity
that was brought into the network following its establishment. More significantly, DRW
has a greater interest in provision of a type of benefits counseling that concentrates
more on eligibility issues than in facilitating employment. Interestingly, two informants
report that DRW’s inclusion in contractual arrangements has allowed it to participate in
the network in terms that more closely resemble those of the Pathways/ERI relationship.
It is also likely that Pathways’ increasing involvement with ADRCs and Family Care has
encouraged Pathways to view disability benefits counseling as more closely related to its
core business.
Available information about the distribution of power or influence appears to
correspond with our information about coordination. The WDBN “network” is generally
characterized as one in which power has been shared on a roughly equal basis, though
with DRW as definitely the junior partner. Yet some observers have reported their
perception that Pathways is in a dominant position vis-à-vis ERI. Their claim rests on
Pathways’ control over funding. Nonetheless, if we have correctly interpreted their
remarks, the exercise of this power is quite restrained. It has been manifested through
the slow and persistent shaping of agency priorities such as suggested by the resolution
of differences over computer training and certification approach. The most direct
exercise of fiscal power has been in Pathways’ insistence that WDBN continue to
provide training and other services to its “customers” for free.
Relative to other Pathways efforts, WDBN has been especially successful in
achieving its proximate goals. To date it has trained approximately 135 work incentives
benefits counseling, plus a sizable number of disability benefits counselors. This 135
represents a nearly 200% increase from the 2003/04 period when WDBN began
operations. Accomplishing this required the development of a formal curriculum that was
flexible enough to address the distinct needs of both work incentive and disability
benefits counselors. WDBN has provided ongoing technical assistance for benefits
counselors, both to insure they are up to date on changes to relevant state and federal
programs and aware of emerging best practice in delivering service. Moreover, WDBN
has engaged in extensive outreach efforts, including providing stakeholders either basic
information about benefits counseling or a greater level of information to support
activities such as making informed referrals to benefits counseling services or hiring
persons likely to develop into effective benefits counselors. 92 It is also fair to say that
91
See Jones, Candace, Hesterly, William S.., and Borgatti, Stephen P. 1997 “A General Theory
of Network Governance: Exchange Conditions and Social Mechanisms. Academy of
Management Review, 22(4). pp. 911-45. While other Pathways efforts involving contracts exhibit
elements of relational contracts, the contractual relationship between ERI and Pathways
(technically DHFS) for operating the WDBN comes the closest to fitting the archetype.
92
Employers have not found it easy to identify “good” hires, though certainly standardized training
has made the task somewhat easier. The problem is that there are relatively few experienced
benefits counselors on the market. Compensation has not been particularly high. Thus
experienced benefits counselors advance their careers by moving into positions where they no
DRAFT
44
WDBN has made considerable progress toward defining the criteria that a desirable
professional certification system will need to meet.
The only area where WDBN has failed to make major progress is finding a
business model that will allow it to sustain its operations when it is no longer heavily
subsidized by Pathways. There is also uncertainty as to how well WDBN will be able to
serve two different approaches to benefits counseling. Some observers think that the
differences are modest enough that the approaches can easily co-exist and that one
benefits counselor may be able to effectively use either approach as the circumstances
warrant. Yet, excessive “risk adverseness” in how work incentive benefits counselors
perform their functions has been a continuing concern since the SPI demonstration. This
issue may grow in saliency to the extent that a greater proportion of work incentive
benefits counseling is provided through the managed long term care system, a result
that is far from certain.
The WDBN’s activities in themselves probably do not constitute systems change,
but can be viewed as important to building the necessary infrastructure toward the end
of creating a system that provides a coordinated and comprehensive process for helping
persons with significant disabilities to return-to-work, maintain employment, and then to
make economic gains not dissimilar to the general population. One’s assessment of
WDBN’s contribution to systems change is dependent on whether benefits counseling
services are in fact a necessary condition for a return-to-work process that meets system
change criteria. Pathways, ERI, and most partners in the networks associated with
WDBN and other Pathways activities would strongly agree with this claim, though
empirical evidence adequate to either support or challenge this claim is far from being
adequately developed. There is also the reality that while Wisconsin probably has a
larger cadre of benefits counselors than any other state, the number is still small
compared to the size of the population that might reasonably use services.
Person Centered Planning for Employment
Just as Pathways was concerned about maintaining and expanding the benefits
counseling capacity developed during SPI, there was also interest in ensuring the further
development of Person Centered Planning (PCP) for employment. 93 Employment was
longer provide direct service. This puts a premium on identifying and hiring persons who are
especially likely to become excellent practitioners after training and some months of practice. An
important part of WDBN’s outreach is helping those who employ benefits counselors increase
their probability of making a good hire.
93
Pathways was also interested in a related approach called Self-Directed Supports (SDS). In
SDS the consumer (or the consumer’s family) has primary responsibility for identifying and
contracting the necessary services, including those that support employment. Besides the
obvious relationship this has to consumer choice, it was included as an option in Family Care to
insure that CMS’ requirement that consumers would have alternatives to the Managed Care
Organizations for access to long term care services. SDS implies a need for substantial technical
assistance for consumers and those elements of the long term care system that would assist
consumers to identify service providers and to contract with and pay those providers. Those at
Pathways involved with building PCP capacity through Family Care have also been deeply
involved with SDS. They tend to see the distinction between PCP and SDS capacity building as
largely artificial. Nonetheless, for simplicity, we have decided to focus this case study on PCP
alone.
DRAFT
45
understood as work compensated at least at minimum wage, preferably in the general
labor market than in settings restricted to persons with severe disabilities. 94
However unlike benefits counseling, there would be no easy consensus within
Pathways, let alone across the wider range of stakeholders, on what form capacity
building efforts should take, whom they would be targeted toward, or, initially, what
minimally qualified as a PCP approach that Pathways could support. Even today the first
two issues are not fully resolved, but Pathways’ capacity building efforts in this domain
have increasingly focused on incorporating a PCP approach to employment into the
Family Care Managed Care Organizations (MCOs). 95 While exploratory efforts started as
early as 2002, it would be difficult to argue that Pathways placed as high a priority on
these as, for example, benefits counseling until the Governor of Wisconsin committed to
statewide expansion of Family Care in 2006. With DHFS’ adoption this year of most of
the recommendations of the Managed Care and Employment Task Force (see the final
case study), the MCOs and the associated Aging and Disability Resource Centers
(ADRCs) appear to have become the single most important focus for Pathways’ efforts
for the next several years.
During SPI, Pathways had concentrated on building capacity to implement
multiple person centered vocational planning models at the community agencies
participating in the demonstration. Even before the demonstration ended, many
stakeholders, including DVR and ERI staff, perceived the effort as somewhat ineffective.
While such perceptions were incorrect in the sense that SPI produced statistically
significant gains in employment rates, earnings, and gross income, there were
reasonable concerns about the cost-effectiveness of the approaches, especially at
DVR. 96 In the post-SPI environment, it would be DVR that would continue to be the main
94
This understanding included self-employment, even if it did not immediately generate income
equivalent to even the minimum wage.
95
In our experience, Family Care managers and staff, whether at DHFS or the MCOs, claim that
all individual level service decisions are made, or at least should be made, through a person
centered process where the member (or the member’s proxy) is actively involved. Thus, it is
important to note that our use of “person centered planning” or “PCP” is always in the context of
employment unless specifically noted otherwise.
As noted, after SPI there was some uncertainty even at Pathways as to the minimum requirement
that a PCP approach would need to meet beyond it being consumer driven. The basic answer
was to maintain the values upon which the Vocational Futures Planning (VFP) approach had
been founded, but adopting means appropriate to the organizational and resource context. PCP
would have to be serious and open-ended enough to support thoughtful goal identification and
revision. It also needed to be designed to result in (and allow amendment of) an action plan for
realizing desired outcomes.
96
See Delin, Barry S., Reither, Anne E., and Drew, Julia A., and Hanes, Pamela P. 2004. Final
Project Report: Wisconsin Pathways to Independence. Menomonie, WI: University of Wisconsin –
Stout Vocational Rehabilitation Institute, pp. xiv-xvi and 131-140 (for outcomes) and pp. 119-120
(for cost, particularly for a successful DVR closure). ERI’s concerns were different. Management
at that organization indicated that their proprietary VFP model did not receive a fair test because
most SPI sites either did not have to use the model or, when they were required to use VFP, were
not adequately pressed by Pathways to faithfully implement it.
DRAFT
46
source for funding vocational services for consumers at most of the community
agencies. 97 To the extent that DVR continued to support person centered planning
approaches, it would have to be on terms that agency found acceptable. Though in the
waning days of Pathways, DVR experimented with a fee for service schedule for paying
for an integrated package of PCP and benefits counseling services; DVR terminated this
experiment within several months. 98 Though DVR has continued to make consumer
involvement and consent a central value in its service planning process, since SPI it has
given limited supported to any approach that Pathways staff would consider a formal
PCP approach. Lastly, there was an additional reason why Pathways saw DVR and the
community agencies as a difficult setting for long term efforts to foster PCP. DVR has
continued to face funding shortages and, consequently, has had to institute waiting lists
for protracted periods.
By contrast, Family Care MCOs would increasingly be seen as an attractive
setting for increasing capacity to provide PCP. Family Care is Wisconsin’s redesigned
system for providing long term care services to the frail elderly and adults with
developmental or physical disabilities. “Members” participate through Managed Care
Organizations that can be organized on either a single or a multiple county basis. MCOs
are not directly operated by DHFS; instead, MCOs operate under contract to DHFS with
some (contested) level of autonomy provided they achieve the outcomes specified in
their contracts. MCOs are funded on a capitated basis. They may directly provide
services, but often pay for services provided through other entities. Membership requires
that individuals are judged to require a certain level of care as determined through a
functional screen and to meet financial eligibility criteria. 99 The associated Aging and
Disability Resource Centers (ADRCs) do not have equivalent service delivery
responsibilities, but are instead a point of entry to the MCOs and provide information and
referrals to potential sources of service for those not eligible for MCO membership.
There were multiple features that made Family Care a potentially attractive
setting for capacity building efforts. First, it is a DHFS program closely tied to Medicaid.
As such, Family Care has a prima facie justification for taking the lead in serving this
population and Pathways for facilitating those efforts. Indeed, as DVR has neither the
mission nor resources to provide long term care services to support employment, it
would be reasonable to expect that DVR would be agreeable to Family Care taking on
this role. Second, Family Care claims that all decisions about services are made through
a person centered process. Moreover, Family Care claims it is holistic in focus and
seeks to support members in fulfilling their full range of needs and aspirations, including
the fullest possible inclusion in community life. Thus, Family Care could, in principle, be
highly amenable to a person centered planning approach to employment services. Third,
Family Care was intended to eliminate the waiting lists associated with the existing long
term care system. In principle, a MCO, unlike DVR when it is in an Order of Selection
97
More precisely, Pathways would no longer be contributing to the state match for RSA funds
and thus would be in a far weaker position to influence DVR’s purchasing behavior.
98
99
Delin, et al. 2004. pp. 108.
With few exceptions MCO members under 65 will be Medicaid eligible for reasons of disability.
However, Medicaid eligibility does not automatically result in Family Care eligibility.
DRAFT
47
closure, could provide PCP and other employment related services when they were
most needed by the member. 100
Actual capacity building efforts began in 2002 in the context of mental health
rather than of Family Care and the disability populations it served. It should be recalled
that Pathways had been located in the unit, the Center for Delivery System Development
(CDSD), which had primary responsibility for the long term care redesign. Though
Family Care would not include a mental health eligibility group, CDSD staff did not see
that target population as outside its charge. Also, the Pathways manager who initially
had the greatest interest in exploring incorporation of PCP in managed care settings had
previously worked for a community agency serving a mental health clientele. However,
shortly thereafter small scale efforts began at the first group of MCOs. These efforts
involved a small cadre of staff at Pathways, CDSD, and a well positioned supporter at
DVR. Through these initial efforts, work was started on answering three key questions.
What did PCP for employment actually require? How would capacity building efforts be
organized? How, in the context of managed long term care service provision, would
employment be defined? These questions would be dealt with in the context of the
institutional perspectives of the members of an expanding interorganizational network.
The effort to incorporate person centered planning employment services at the
MCOs would eventually result in a network that is at least the size of that associated with
SPI, but one where the partners have more autonomy, at least vis-à-vis Pathways. With
the exception of the very first efforts, Pathways efforts have been funded through the
Medicaid Infrastructure Grant, making CMS, putatively, the chief federal partner.
However, CMS did not take an active role in participating in or managing the network. 101
Pathways was of course a key player, though Pathways managers, as a group, gave
only intermittent attention to the area until the go ahead for Family Care statewide
expansion. Instead, a small cadre in Pathways, which included a gradually expanding
group of external consultants, took the lead, especially in developing and engaging in
capacity building activities. 102
Those in DHFS involved in developing and, increasingly, monitoring and
regulating Family Care were of course important partners. Originally this effort was
housed in CDSD and then integrated into the customary DHFS organizational structure
100
Nonetheless, MCOs still rely on DVR as a critical source of resources until the member has
achieved closure. Even then, there is the possibility that members can utilize DVR services in the
future, just not for long term support needs.
101
By contrast, CMS had and continues to have a very important role in Family Care operations.
Family Care operates on various CMS granted waivers, which places some limits on the authority
of DHFS over the MCOs. Among other things, CMS granted permission to extend service
provision authorized for one eligibility population under a pre-existing Medicaid waiver program to
all Family Care eligibility groups. Thus services that could previously be used to support
employment for one sub-group within the developmental disabilities (DD) population could be
extended to the entire DD and physical disability populations who were eligible for Family Care.
This feature of Family Care goes a significant way toward removing a structural barrier to building
the coordinated and comprehensive system Pathways and others desired.
102
As noted, there was from the start a “champion” for the effort on the management team.
Additionally, and unusually for Pathways, graduate students were deeply involved in the capacity
building efforts and the efforts to identify effective practice.
DRAFT
48
as the Office of Family Care Expansion. Other interested, though less actively involved
parties in DHFS, included the units with responsibility for ADRC expansion and service
provision to specific disability groups. By 2006, these units and Pathways, with the main
exception of those focused on mental health, had been brought into a common DHFS
unit, the Division of Long-Term Care. Division managers would become increasingly
involved with issues of whether and how to expand employment services, particularly in
the context of the Managed Care and Employment Task Force (MCETF).
The Managed Care Organizations were of course important participants in the
network. It is important to note that until 2006 there were only five Family Care MCOs, of
which only four served persons with disabilities under the age of sixty. Early capacity
building efforts concentrated on these MCOs, thus resulting in substantial differences
between these MCOs and the newer ones in their experience in providing employment
services. The MCOs, in turn, are tied to a range of parties who might be involved in
employment related service provision, coordination, or funding. These include
community agencies, employers, school districts, “organized” MCO members and,
inevitably DVR. With the exception of some involvement of these parties through the
MCETF, network involvement has generally been intermittent and modest. DVR has
been something of an exception to this pattern with a particular staff member having
direct involvement in some of the capacity building efforts.
However what was truly distinctive about the network associated with the effort to
build PCP capacity into Family Care was the formation of genuine multi-partner work
groups to facilitate the effort. In most Pathways efforts this has been limited to advisory
committees or to governance groups limited to two or three key entities, for example
Pathways and DVR during SPI and Pathways, Employment Resources, Inc., and
Disability Rights Wisconsin for the WDBN. One of these work groups was the Selfdetermination and Integrated Employment Workgroup (SDIE) which included staff from
various DHFS entities, the MCOs, and the ADRCs. The second was the Managed Care
and Employment Forum where participants were mainly MCO staff and the Pathways
staff and consultants directly involved in technical assistance activities. SDIE provided a
setting where participants sought ways to identify and strengthened the connections
across separate DHFS activities that supported greater independence and community
inclusion for persons with disabilities. The “Forum” was a setting where MCO staff could
take the lead in identifying and discussing ways to promote their members employment
goals. Finally, the effort to incorporate PCP into Family Care was unusual in the extent
that it deliberately sought to expand the range of input from external stakeholders in
ways likely to maximize its visibility and impact. We are referring again to the Managed
Care and Employment Task Force. Again, while Pathways had long used a variety of
ways to elicit stakeholder input, it had never done so in a way that assured that the input
would be aggregated and disseminated substantially unmediated by either Pathways or
DHFS. 103
103
Pathways made a deliberate choice to allow the MCETF to adopt and disseminate its
recommendations in a largely autonomous fashion, both to make the effort more attractive to the
“high level” participants Pathways wanted and to have the recommendations taken seriously. Top
management in the Division of Long-Term Care concurred and, more importantly, subsequently
acted in ways consistent with their commitment.
DRAFT
49
Compared to the other Pathways efforts examined in this paper, PCP capacity
building has exhibited the least agreement on even overarching goals among those
actively participating in the relevant network. 104 At most, consensus has been limited to
agreement over the desirability of supporting the employment goals of those who are
willing and able to work in competitive employment in integrated settings. However,
reaching common ground on other goals has taken effort. For example, there still is little
agreement on the likely proportion of MCO members with serious disabilities who may
want employment in competitive settings and, thus, what priority should be given to
building capacity for PCP and/or contracting employment related services. Similarly
there is no agreement about whether competitive employment should be viewed as the
“standard” goal for those capable of pursuing it or simply one possible goal of many with
equal standing.
Unusually, there was some goal conflict, if generally latent, within Pathways
beyond the difference over the priority that should be given to PCP capacity building in
the pre-statewide expansion environment. 105 The original champion for the effort in the
Pathways management team favored approaches to developing natural supports
involving families, friends, employers, and other community institutions to supplement or
serve as an alternative to approaches, including ones that were strongly person
centered, that were highly dependent on professional staff working in specialized
organizations for their implementation. Though efforts to expand PCP capacity at MCOs
intrinsically involved professionals, this manager and the working group he assembled,
while utilizing standard techniques of top down training and technical assistance
provision, also sought intervention strategies where the MCO staff would have a
significant role in defining and implementing capacity building activities. For example,
Pathways has provided MCOs with grants, with relatively few restrictions, to undertake
largely MCO identified efforts at capacity building specific to employment and/or
experimenting with how to best operate within a PCP framework.
Though these small scale projects did not generate any real opposition from
other Pathways managers, some informants reported there was some lack of
understanding of their efforts. In point of fact, from SPI forward the dominant mode of
Pathways TA provision has been top down. The effort to build capacity for PCP was
Pathways first significant experience of placing at least equal emphasis on bottom up
methods. Though Pathways has increasingly used this combined approach in other
contexts, there remains tension, quite possibly a creative one, on the relative value of
104
In this material we have decided to concentrate on differences within Pathways and, especially
between Family Care and Pathways. There are other organizationally based differences in goals
or purposes that are important. One important example is that external service providers may
have a vested interest in continuing service patterns that were profitable under the pre-Family
Care long term care system but are not well aligned with the MCOs’ charge to support member
defined outcomes. While not inherently opposed to changing their operations, they want
assurance that new service patterns will be fiscally supported. By contrast, MCOs feel under
enormous pressure to use currently available services to respond to members’ preferences in the
absence of better alternatives.
105
One informant reported that in 2005, when there were substantial doubts about Family Care’s
continuation, Pathways came very close to ending its efforts at capacity building at the MCOs.
DRAFT
50
top down and bottom up approaches. 106 For example, in the case of continuing efforts to
incorporate PCP at the MCOs, this tension is being played out within Pathways as to
whether to focus on establishing a TA center reminiscent of WDBN or to give increased
resources to MCO driven efforts. For the time being, Medicaid Infrastructure Grant (MIG)
funding is sufficient to support both types of efforts.
Of greater import were differences in purposes and goals between Pathways
and, respectively, the Office of Family Care Expansion (OFCE) and the MCOs. At this
time, we are uncertain as to whether these are better characterized as differences in
emphasis or will prove, especially as efforts to fulfill the Managed Care and Employment
Task Force (MCETF) recommendations go forward, to be rooted in major differences in
organizational interests. At the least, OFCE and some MCO staff have expressed
concerns about the pace that Pathways has wanted to ramp up the ability of MCOs to
engage in PCP and to see a substantial increase in the number of members entering
competitive employment in integrated settings. OFCE and MCO staff have argued that
while these are reasonable goals, the speed with which they are pursued need to be
calibrated to the pace of the much larger and more critical tasks of establishing each
MCO, developing and fine tuning the infrastructure and processes at OFCE needed to
manage Family Care, and the challenges of moving from five pilots to statewide
operations in a five year period. Beyond this, OFCE staff has pointed to challenges
related to limits in the current availability of jobs in competitive settings and both the lack
of local service providers and of adequate service capacity among existing providers to
support the placement of many members in the types of employment settings they might
prefer. As MCOs have a strong obligation to help members attain their desired
outcomes, in the short run this can result in greater utilization of sheltered workshops
and other segregated settings than Pathways or Family Care might prefer. 107 Moreover,
some in Family Care have argued that members and their families often prefer such
settings.
However, there is a case that the Office of Family Care Expansion and at least
some at the MCOs do not place as high a priority on supporting members’ employment
goals for reasons in addition to the practical challenges of implementing Family Care. In
particular, an assessment of the level of Family Care’s interest in vigorously helping
members to pursue competitive employment goals depends on one’s understanding of
when an expressed preference is a reasonably informed one. Given that persons with
disabilities have faced substantial policy, environmental, and cultural barriers to pursuing
competitive employment or, beyond that, career development, there is good reason to
106
One of the thorniest issues raised by the use of bottom up strategies is that it leaves
Pathways vulnerable to criticism or political attack for actions not under its control.
107
Indeed, there is evidence that MCOs are more likely to provide or purchase employment
related services for those with developmental disabilities than physical disabilities, in part
because the former and/or their surrogates are more accepting of placements in a sheltered
workshop or segregated environment. See Williams, Eva M., Sievert, Ann, Neugart, Jennifer,
Wisnewski, Debra, and Rearick, Kyle. 2007. “Integrated Employment: Why it’s important, what
gets in the way, and how to make it work!” Madison WI: Pathways to Independence, University of
Wisconsin – Madison Waisman Center and Wisconsin Department of Health and Family
Services. p. 4.
DRAFT
51
believe that many have internalized the external barriers to at least some degree. 108 This
raises the difficult issue of whether the first preference expressed about employment
goals is a reasonably informed one. 109 The very point of a person centered employment
process is to give the individual the time and space to articulate goals and to make
choices. However, some at Family Care have argued that there is a good reason not to
make employment a more salient part of general efforts to elicit member preferences.
They contend that robust use of a PCP approach places undue pressure on members or
their surrogates to indicate they want to participate in competitive and integrated
employment. They caution that, at the least, all parties should wait until Family Care has
better techniques to assess whether members are satisfied with their outcomes. 110
In addition, some at OFCE and the MCOs have observed that employment is
well down the hierarchy of needs for most persons using or needing long term care
services. While regrettable for those members who may wish to pursue “high-level”
employment goals, giving greater attention to other types of issues better serves most
members’ interests. Although, there is no evidence that this is a majority position, this
point of view has been offered frequently enough to suggest that it has a continuing
presence in Family Care’s internal discourse.
The distinction we have rendered between a modal Pathways and Family Care
perspective may be somewhat overdrawn. One OFCE manager asserted that
employment has always been an important part of Family Care’s charge and that
progress toward helping members achieve their goals in this area would have happened
with or without Pathways’ involvement. Without gainsaying this observer’s point of view,
we think a stronger argument can be made that Pathways’ efforts to incorporate PCP at
the MCOs has gradually increased the number of staff convinced that it is possible to
support employment in competitive and integrated settings and have developed a
commitment to doing so. We have heard this not only from current and former Pathways
staff, but from sources at MCOs and other entities outside Pathways.
We turn now to reviewing the primary means Pathways used to coordinate the
activities designed to build capacity for MCOs to a person centered planning approach to
108
See Bandura, Albert. 1997. Self-efficacy: The Exercise of Control. New York, NY: W.H.
Freeman. Self-efficacy is viewed as specific to behavioral domains such as employment.
Particularly salient consequences include the relative balance between approach and avoidance
behavior and the degree of persistence in the face of obstacles or barriers.
109
For a brief but cogent discussion of this issue, albeit one sympathetic to the position that
initially expressed preferences do not necessarily coincide with those developed over time and
thus should not have the same standing, see Mills, C. Wright. 1959. The Sociological
Imagination. London, UK: Oxford University Press, pp. 8-13. Also see Connolly, William E. 1974.
The Terms of Political Discourse. Lexington, MA: D.C. Heath and Company, pp. 62-76.
110
How to best identify members’ employment goals and to get evidence of their achievement
has been an area of disagreement between the Office of Family Care Expansion and Pathways.
In particular, Pathways has made a substantial financial contribution to the development of a
Personal Experience Outcome Integrated Interview and Evaluation System (PEONIES). Yet
OFCE has been resistant to having PEONIES include an item that focuses directly on
employment, rather than the current, more general approach of asking whether members feel
they do things that are important to themselves.
DRAFT
52
serve their members’ employment goal. To do so, it will help to identify important
differences between the environment in which this capacity building effort took place and
those in which Pathways conducted the two demonstration projects and the capacity
building effort already discussed. While Pathways could not compel participation in these
efforts, it was in a strong position to insist that participation would, at least on paper, be
on Pathways’ terms. In the demonstration projects, the community agencies that were
the primary local partners could only be part of the project by accepting the contractual
terms offered by Pathways and, for SPI, DVR. The agencies had to agree to the basic
service model and to accepting the technical assistance those contracts mandated. For
the WDBN, the contract arrangement between ERI and Pathways was mainly relational,
with close collaboration reflecting a high level of mutual trust and consensus on goals.
Meanwhile, the community agencies which were the main employer of work incentives
benefits counselors had strong incentives to participate on Pathways’ and ERI’s terms.
Benefits counseling had become an important service for which there was no local
alternative to WDBN training and technical assistance. Most benefits counseling was
funded by either Pathways or DVR, both of which required that benefits counselors had
training and technical assistance comparable to that provided through WDBN. 111
In marked contrast, Pathways was in a far less dominant position in the “PCP
network.” Unless the Office of Family Care Expansion (or those higher up OFCE’s DHFS
chain of command) demanded cooperation, MCOs were free to accept or reject
Pathways’ involvement as the MCOs saw fit. Thus, from a Pathways-centric perspective,
the network more closely resembled the default condition of being a “…non-hierarchical
collectives of legally separate units.” 112 Though, as previously noted, there has been
something of a debate in Pathways about the relative emphasis that should be given to
supporting PCP capacity building efforts in a bottom up fashion, it is not yet clear how
much this was informed, especially before 2006, by an explicit understanding of
Pathways’ limited reach.
Pathways’ early efforts to support PCP, unlike the demonstration projects and
WDBN, were small scale and focused on a single or small number of organizations at
any time. 113 While these projects utilized some traditional top down provision of
technical assistance, they typically involved grants where the recipients had a great deal
to say about how the grant monies were used. Rather than having MCOs compete for
grants, Pathways’ modus operandi was to essentially guarantee the grant if the MCO
would work with Pathways staff or consultants throughout the process from initial
proposal to finalizing deliverables. Additionally, Pathways staff made considerable effort
to assess both the grant activities and progress toward better use of a PCP approach
through the eyes of the MCO staffs. Assessment reports went beyond simply using
information from the MCO staffs, but highlighted their thoughts on both problems and
best practice as a privileged perspective for identifying future courses of action. Beyond
an intervention approach that validated the MCOs’ abilities to identify their own needs,
111
Indeed, some of these agencies participated in other Pathways sponsored efforts (such as the
SSDI-EP) that required the agency to use WDBN training and TA.
112
113
Alter, Catherine and Hage, Jerald. 1993. p. 46.
In this the pre-2007 efforts to expand PCP capacity were typical of the majority of MIG funded
efforts. This paper has concentrated on the larger Pathways efforts.
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53
the grants were also valuable in that MCOs did not have another funding source to
support capacity building efforts in the area of employment. 114
A second, though later, feature of Pathways’ efforts was the formation of working
groups, the previously identified Self-determination and Integrated Employment
Workgroup (SDIE) and the Managed Care and Employment Forum. It appears that each
of the two groups, which had partially overlapping membership, tended to reinforce the
influence of the other. The SDIE group was disproportionately from within DHFS
including Family Care and Pathways staff and provided a setting to share information
and achieve greater understanding among those participating. Though this does not
always insure the development of good will and a basis for cooperation, it seems to have
in this case. The Managed Care and Employment Forum was a group dominated by
MCO staff and thus its agenda reflected their needs directly. Our informants at both
Pathways and the MCOs noted that this workgroup gave MCO staff a chance to share
best practices and discuss issues on their own terms. This peer process tended to
confirm the value of the information and advice that had been provided by Pathways
staff and consultants, thereby increasing their credibility. Participation in the workgroup
also helped to deepen MCO staff members’ commitment to PCP. They began to
consider what MCO based resources could best help generalist caseworkers support
members employment goals. 115
With an increasing number of MCOs and with DHFS largely adopting the MCETF
recommendations, Pathways is increasingly considering top down capacity building
approaches to make use of the current window of opportunity for deeply entrenching
efforts to support competitive employment into Family Care. Pathways’ efforts to build
capacity at the MCOs will expand considerably provided CMS approves the funding
requested for such activities in the 2009 MIG proposal. One idea under serious
consideration is creating a training and technical assistance center akin to WDBN.
Another approach is to encourage the Office of Family Care Expansion to change MCO
contract language to be more prescriptive about how MCOs support members’
employment goals. Indeed, there is a more general movement in DHFS to have MCOs
operate on more of a franchise model than, as originally intended, being subject to
relatively few rules provided they can achieve contract specified outcomes in a manner
consistent with core Family Care values and legal requirements.
As both the distribution of power and influence and the policy tools Pathways
used has been explored in the preceding discussion of coordination methods, we’ll turn
to considering the role that the PCP capacity building effort has played in pushing the
systems change agenda forward. At the very least, the idea that Family Care has a
significant responsibility for helping members achieve employment outcomes has
achieved a measure of permanence and institutionalization. In 2002 when Pathways’
capacity building efforts started the responsibility was largely a theoretical one
114
This was largely true for any “discretionary” capacity building. According to one Family Care
staffer, Pathways essentially had the field to itself. This was also true for the MCO forums or work
groups that we discuss next. Though there were several that focused on business and
operational issues, the only ones dealing with particular domains of service provision were those
Pathways “staffed for employment and the related issue of Self-directed Supports.
115
One example of this type of idea that is being implemented at several MCOs (and others have
expressed interest in) is having a full time employment coordinator. We do not know whether this
idea was originally developed through discussions in the Managed Care and Employment Forum.
DRAFT
54
subsumed in a general obligation to help members stay and participate in their
communities in terms members find meaningful and satisfying. Employment has become
a distinct and salient area where MCOs are expected to take targeted and ongoing
action to achieve better outcomes. Most likely, the Managed Care and Employment Task
Force has played a role in this, but the seriousness with which both the MCETF process
and recommendations have been taken can also be understood as indicating the
success of the bottom up approach Pathways utilized. In a very real sense, the
combination of small-scale grants for MCO specific capacity building, the particularly
collaborative style of technical assistance associated with the grants, and the use of
practitioner directed workgroups, did much to build legitimacy and support for PCP
approaches to employment within the MCOs.
Pathways management is aware that there is presently a window of opportunity
for using the long term care system as the setting in which very significant progress can
be made toward having a coordinated and comprehensive return-to-work approach for
persons with significant disabilities. The availability of a strong PCP process and a
substantial funding stream for employment services at the MCOs and, potentially,
benefits counseling through the ADRCs would mean that systems change efforts could
positively impact tens of thousands, rather than only several hundred, consumers.
Potentially, the size and visibility of the effort might encourage change in the operation of
other important system actors such as service providers, DVR, and the cluster of entities
engaged in school-to-work transition efforts.
However windows of opportunities are often open for short periods. In particular,
the final year of the Medicaid Infrastructure Grant is 2011. It is not yet known whether
the MIG program will be extended or replaced by another federal effort that can be used
to support systems change efforts. Part of Pathways’ ability to get cooperation from
Family Care and the MCOs has been its ability to provide funding in a context where
discretionary funding is extremely scarce. Given the general tightness of state revenues,
there is no guarantee that Family Care can or will support substantial capacity building
activities in the area of employment. Yet the MCOs current capacity to implement a PCP
approach remains very modest, no more so than at the new MCOs, some of which have
yet to open. Small scale efforts at the grassroots level have proven effective, but they
are small scale and, from a Pathways perspective, resource intensive. Top down efforts
have the potential for much greater reach, but it is not clear how to organize a top down
approach that will elicit commitment in a context where Pathways has very little
authority. Thus, Pathways has to make difficult choices about how to exploit its window
of opportunity and what combination of top down and bottom up activities are likely to
prove most effective.
Comparing the Capacity Building Efforts on Four Continua
The placements of the two capacity building efforts, WDBN and PCP, on the four
continua are very different from each other. The scale of that difference is somewhat
more than that estimated for the two demonstration projects. Again, as with the
demonstration projects, when a case is closer to one extreme of the axis for one
continuum it is also so for the other three.
We again emphasize that our placements are made based on conceptualizing
Pathways as the network’s principal. Of course, in none of the efforts we looked at is this
legally true. The money always comes from elsewhere. For example, from a CMS
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55
perspective (i.e., the federal funding source) the WDBN would appear much less
controlled and centralized than we portray it. Readers wanting to review the meaning of
each continuum and how to interpret placements can review the material on pages
sixteen through eighteen.
Figure 5: Nature and Quality of Network Articulations
PCP
WDBN
X
X
--------------------------------------------------------------------------------------------------------------
“remote control”
“managed network”
Figure 6: Level of Goal and Policy Agreement
PCP
WDBN
X
X
--------------------------------------------------------------------------------------------------------------
“disagreement/
“agreement/
incongruence”
congruence”
Figure 7: Level of Centralization of Policy Implementation
PCP
WDBN
X
X
--------------------------------------------------------------------------------------------------------------
“decentralized, dispersed
“centralized”
and/or fragmented”
Figure 8: Level and Character of Client or Stakeholder Support
PCP
WDBN
X
X
--------------------------------------------------------------------------------------------------------------
“weak”
“strong”
We would add two points of clarifying information about these placements, both
relating to the WDBN. The WDBN’s placement toward the extreme right on Nature and
Quality of Network Articulations continuum reflect the extremely close association
between Pathways and ERI that supports what must be viewed as a relational contract,
whatever its written terms. The WDBN’s placement somewhat toward the center of the
Level of Goal and Policy Agreement continuum (substantially to the right of its placement
on the other continua) reflects the role of Disability Rights Wisconsin and the issues that
arose out of differences between in how to provide training and TA for “disability”
benefits counseling. Finally, it is interesting to note that reasonable claims can be made
that both capacity building efforts contributed to systems change efforts. Thus, it does
not appear that there is a simple relationship between placement on these continua and
an effort’s potential for supporting systems change. More interestingly, we observe that
each of the two capacity building efforts and, for that matter, each of the demonstration
DRAFT
56
projects occupies approximately the same territory on all four continua. We wonder
about the implications for an effort that is located in substantially different positions on
two or more of the continua.
Case Studies: Priority Setting
The final pair of case studies focuses on two priority setting efforts. Both
examinations concentrate on how basic directions were set, rather than the specific
project proposals or recommendations that each effort generated or the outcomes that
followed from those choices. There is no material about implementation per se, though it
is evident that concerns about how goals could be implemented were to varying degrees
considered in these direction setting efforts.
The first of these efforts is the process Pathways used to make its annual
request to the Centers for Medicare and Medicaid Services (CMS) for Medicaid
Infrastructure Grant (MIG) funding. The annual request identifies the specific projects
that will be funded through the MIG, the amounts of expenditure that will be devoted to
each, and, at least implicitly, the approach or approaches that Pathways will be using to
make progress toward systems change. Pathways first funding proposal was for 2001
and it has submitted a new proposal for every subsequent year.
The second case study, the Managed Care and Employment Task Force
(MCETF), was a priority setting effort that took place over a much more constrained
period in 2007-08. Its focus was more limited, how Wisconsin’s redesigned long term
care system could best provide support for the employment goals of the persons with
disabilities who use that system. Technically, the MCETF was a Division of Long-Term
Care effort, but it was largely instigated, organized, and staffed by Pathways.
Medicaid Infrastructure Grants
The Medicaid Infrastructure Grant (MIG) is authorized through the Ticket to Work
and Work Incentives Improvement Act of 1999. These federal grants can go to state
Medicaid agencies (or their agents) for the purpose of supporting efforts that will
facilitate better employment outcomes among persons with disabilities, especially those
who are Medicaid eligible or may become so. There are two types of grants. The basic
version is for $500,000 and is meant to be used to establish or further develop a
Medicaid Buy-in program or to expand the availability of personal assistance services.
The second type, the “comprehensive employment systems” grant is intended to support
broader system change to eliminate barriers to employment, especially by building
lasting capacity or infrastructure. A state can apply for grants up to 10% of its spending
in the previous year on Medicaid services for participants in its Medicaid Buy-in program,
though it is CMS’s decision as to how much a state will receive. There are few limitations
on how the grants can be used, the most important being that grant monies cannot be
used to provide direct services except benefits counseling or to supplant funding from
other sources. 116
116
Only 10% of the grant may be used to pay for providing individuals with benefits counseling
services.
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57
Pathways prepares the Wisconsin MIG proposal and administers the funds. After
the initial grant, Pathways has always sought and received a comprehensive grant.
Since the end of the State Partnership Initiative in 2004, the MIG has been the primary
funding source for the unit. 117 It has also been a rapidly expanding source. For example,
the 2005 grant was roughly $2.5 million, the 2008 grant nearly $8 million, and the 2009
request is for more than $10 million. 118 Deciding what should go into each year’s
proposal is probably the single most important decision Pathways makes each year.
Each proposal, even the first, included multiple projects. Over the years the number of
funded projects has greatly expanded. Nonetheless, in any given proposal, it is possible
to discern emphases or themes that change over time. For example, the 2009 proposal
emphasizes projects that are related to implementing the MCETF recommendations.
The network involved in MIG decision making can be described as truncated
compared to the others. Though we have found all of the case studies to be strongly
Pathways centric, this one is unusually so. Our evidence strongly supports a conclusion
that most discussions about what should be included in the MIG proposal were held
within the Pathways unit and most decisions effectively made there. Informants were far
more likely to talk about the roles of specific Pathways staff or groups thereof than about
Pathways’ role as a unit. Still, there have been other actors in this network, some clearly
important, some potentially so. However, evidence about the involvement of other actors
is less consistent across our sources than usual.
CMS is certainly in a powerful position to affect MIG priorities by their decisions
about what projects to fund and which to reject. However, Pathways managers could
only identify a single occasion when CMS explicitly denied a specific project. CMS has in
some years approved less funding than was requested, but generally has left it to
Pathways to decide which activities would have to be scaled back or eliminated. To the
extent that CMS has worked to explicitly shape Wisconsin MIG priorities it mainly has
been through the cues it provides to all comprehensive grant states through the yearly
grant announcements or through technical assistance activities. For example, if CMS
announced that it was particularly concerned about youth transition services or the
employment support needs for those with mental health issues, Pathways would include
additional activities in those areas in its next proposal. CMS has also required those
states with comprehensive grants to undertake a strategic planning process to help the
states guide their future efforts. 119 In short, CMS has allowed Wisconsin and presumably
other states a great deal of latitude about how to work toward systems change. CMS
117
Ironically, Pathways management was initially reluctant to apply for MIG, because it feared
that it would divert staff effort from the SPI project.
118
Pathways, or rather OIE, has lost much of its state funding, in large part because DHFS
executives are aware of the increasing levels of MIG funds and can, depending on circumstance,
reprogram the state monies to other units’ uses or have OIE disproportionately contribute to
spending reductions demanded by the Governor’s office.
119
Pathways undertook extensive strategic planning activities in 2005, completing the plan the
same year. While it has not formally updated the plan since, it has engaged in a variety of
activities, ranging from public listening sessions (held in the context of other activities including
the MCETF) to ongoing involvement by a MIG advisory body which is a committee of the state’s
Council on Workforce Investment.
DRAFT
58
appears to have chosen a fairly peripheral role in this network as either a matter of policy
or limited capacity to monitor efforts.
A second, more active cluster of actors have been from other units in DHFS.
Typically, the most active and important of these actors were those from the Division of
Long-Term Care (DLTC). 120 This included DLTC executives, other units in the Bureau of
Aging and Disability (where Pathways is housed), and other DLTC units such as the
Office of Family Care Expansion (OFCE), those units serving specific disability groups,
and the advisory councils associated with those units.
While both authors of this paper would agree that the impact of these DHFS
entities on the overall shape of MIG priorities was ultimately modest, we came to
different interpretations of the extent that these entities have generated proposals with
tenuous connections to the purposes allowed by the MIG’s authorizing legislation. One
viewed the phenomenon as significant enough, especially during the first years of the
MIG, to deserve mention. The other author saw the incidence of such requests as too
rare to deserve attention. Still, when DLTC (or prior to that, CDSD) executives asked for
Pathways funding, it put Pathways management in a difficult position whenever it wished
not to include the request in the MIG proposal. Moreover, the cooperation of these units,
especially OFCE, has been necessary for Pathways to pursue its programmatic activities
However, it is important to note that such requests were often well aligned with the
Pathways mission or could be with some fine tuning. Additionally, some DHFS offices
outside DLTC have also requested MIG funding on occasion. 121
Other entities, mainly at the state level, have been involved in attempting to
influence MIG priorities, largely as potential claimants. These include the Department of
Public Instruction, multiple units in the Department of Workforce Development, disability
advocacy groups, and Pathways’ university partners. Two parties merit more detailed
identification, though neither party’s involvement in the network was primarily aimed at
obtaining resources for specific projects it favored. The first of these was the Division of
Vocational Rehabilitation (DVR). Its goal was chiefly to have good information about how
MIG activities might touch upon its activities and jurisdiction, especially on what DVR
saw as its primacy in engaging employers on return-to-work issues. The second was a
120
DHFS (DHS since July 1, 2008) has undergone multiple internal reorganizations over the
decade of Pathways’ existence. The names and their organizational placement in this material
reflect current conditions.
121
Ironically, of all the non-DLTC units, it has been the Division of Health Care Financing (DHCF)
that has had the strongest impact on Pathways decision making, though it never directly sought
MIG funding. DHCF administers Medicaid, including the Medicaid Buy-in program. It is in the
position to effectively veto requests for changes to rules and procedures that come from
elsewhere in DHFS. Pathways has a strong interest in shaping Medicaid Buy-in rules and
administrative procedures to make the program a more effective work incentive. DHCF has a
strong interest in having standardized administration across Medicaid programs and, as far as
possible, constraining program costs. In particular, DHCF has been opposed to further changes
to economic eligibility requirements that might further advantage Buy-in participants relative to
other groups of Medicaid recipients, a position that has strong resonance across DHFS.
Pathways has consciously chosen not to press for certain types of changes to the Buy-in program
or to use MIG funds to engage in activities to explore such changes. DHCF has recently changed
its name to the Division of Health Care Access and Accountability.
DRAFT
59
committee of the state’s Council on Workforce Investment (CWI) that Pathways chose
as its advisory board in 2004 several years into the MIG effort. It is important to note that
CWI (like DVR) was housed in Department of Workforce Development and thus outside
DHFS control.
As usual, the partners in this network shared agreement on a high level goal.
MIG resources should be used to motivate better employment opportunities and
outcomes for those with disabilities. Beyond this, those seeking to influence MIG
priorities often had parochial interests they hoped MIG could serve, usually but not
always related to the overarching goal. Again it is important to be aware that MIG
represented a substantial and increasing money flow in an increasingly impoverished
environment. Claimants faced a temptation to use MIG resources to maintain staff and
valued activities. Pathways, in turn, needed to find ways not only to have projects that
were employment relevant, but that also contributed in some way to systems change.
Further, it needed to do this in a fashion that did not seriously alienate the prospects for
future cooperation and support, especially within DHFS.
We have already asserted that Pathways was largely able to keep most MIG
decisions within the unit. This depiction will need to be modified by addressing when and
how Pathways allowed external claims or considerations to influence MIG priorities and
the converse, when and how Pathways was able to resist those claims. At the outset, it
should be noted that former Pathways managers and staff were understandably more
willing to talk about this subject than those currently working at Pathways. Without
making any judgments about the relative veracity of different informants’ accounts, this
means that we have more information about how conflicts between internal preferences
and external claims were mediated from early in Pathways’ history than for recent years.
Pathways staff have never had problems identifying projects that could be MIG
funded. They also had no difficulties in identifying key partners such as DVR or the units
in DHFS that would be involved in providing long term care services. The challenge has
been to find a unifying approach or cluster of approaches toward supporting systems
change which could be used to choose among different projects. This need was
especially felt in the early years when Buy-in enrollments and, thus, the potential size of
the MIG were, by subsequent standards, modest. Informants, especially those still at
Pathways, report that two major unifying approaches emerged, though often differing as
to when this happened. The first approach is that of emphasizing work incentive benefits
counseling to support informed choice by consumers, use of the Medicaid Buy-in and
other work incentives, and service planning. The second unifying approach is the
importance attached to involving Family Care in providing services that would support
members seeking to enter or remain in competitive employment in integrated settings. 122
Further, the two approaches were seen as highly complementary, as informed choice by
MCO members is one of Family Care’s guiding principles.
Nevertheless, while this material allows one to reasonably infer the relationship
of specific projects in the most recent MIG proposals to these two overarching systems
change approaches, there is something of a “just so” quality that suggests the
approaches were to some degree retrospectively identified. There have been periods of
122
By implication, this would also include whatever units implement the anticipated redesign of
mental health long term services.
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60
enthusiasm for other unifying approaches that, while remaining among MIG funded
activities, have receded considerably in their centrality. 123 Yet, the decisions to shift
focus appear to have been reasonable ones based on project performance and changes
in opportunities (especially the Governor’s 2006 decision to take Family Care statewide).
It is also a fact that the Pathways Strategic Plan does not specifically identify benefits
counseling and developing employment supports through the managed long term care
system as the overarching strategies that Pathways will use to achieve systems change.
Instead the Strategic Plan puts forth six broad priority areas, of which only one points
strongly to the approaches described in the previous paragraph.
Informants within Pathways have given reasonably consistent accounts as to
how decisions to include projects in the MIG were made. It has been described as highly
participatory and collaborative process, with the Pathways management team, especially
the Pathways Director, rarely needing to impose decisions. Though Pathways staff might
not find the comparison flattering, we see some resemblance between MIG decision
making and the practice of “logrolling” observed in legislative bodies. In describing this
process, we will for the moment ignore the power dynamics and pressures that can
accompany funding requests made by actors outside Pathways. 124
The first criterion is whether a proposed activity supports competitive
employment for disabilities that is in some important way different from existing efforts. If
so, the proposal will get serious consideration. Since 2005 decisions must be made with
reference to the Pathways strategic priorities, but these priorities are so broad that it is
unlikely that any advocate within Pathways would propose a project that could not fit. 125
Instead, the strategic priorities operate more as a reminder of what priorities may have
“insufficient” activity and thus may serve to advantage proposals in “underserved” priority
areas. 126
123
One recent example has been a project aimed at developing regional coalitions to identify
issues of regional importance and localized strategies to address those issues. The “Regional
Initiative” was seen as a promising way to address the problem of post-MIG sustainability of
systems change efforts through creating regional actors with interest and capacity to sustain
whatever they had helped to organize.
124
In this context, we view requests from some actors technically external to Pathways, but with
continuing involvement in or access to Pathways’ internal decision making processes, as being
internal for all practical purposes. For example, a request for a benefits counseling related project
from ERI would be of this character.
125
Though Pathways sought input for its Strategic Plan from multiple constituencies and using
multiple information gathering approaches, some observers have argued that the input was
processed to validate what Pathways wanted. Be that as it may, there is no doubt that the broad
concerns identified in the strategic priorities are real in that subsequent information gathering
efforts, formal and informal, have found the same stakeholder concerns. Nonetheless, the
strategic priorities did not represent a sea change in Pathways’ priorities, though they did
emphasize some areas (employers, universal design) where Pathways had not been very active.
126
It appears this practice is reinforced by how the Pathways advisory body sees its role. It
typically attempts to identify areas where there needs to be greater emphasis rather than offering
opinions about which particular projects should be included in the MIG proposal.
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61
In particular, small scale efforts have had a very good chance of inclusion if they
had advocates on the Pathways staff or among those with ongoing involvement in
Pathways operations. 127 In general, Pathways management looked kindly on
experimentation, especially when there was past experience or empirical work that
suggested the proposed activity had promise. In a very real sense, Pathways has
viewed itself as being in the business of knowledge generation, especially knowledge
that can be readily used by practitioners. Moreover, the very growth of the MIG has
made this practice possible, with the additional benefit of reducing conflict within the staff
by giving almost everyone “a piece of the action.” Indeed there is some evidence that
Pathways managers who wished to undertake work in certain areas intentionally hired
staff with the ability to design and advocate efforts in that area. Not coincidentally, this
also added another in-house advocate for the effort.
Larger efforts naturally received greater scrutiny. This is where Pathways
management made reference to current views as to its priorities and opportunities and to
the degree of interest and support among external stakeholders, especially superiors in
DHFS. Additionally, large scale efforts that fell outside the current emphases on Family
Care and benefits counseling may have been given more consideration when they
addressed underserved strategic priorities. For example, three of the six strategic
priorities addressed employer needs directly, while a fourth mentioned workforce
development. It was not by chance that Pathways soon began to devote considerable
MIG resources to supporting an employer driven technical assistance center.
Making decisions about continuing projects over multiple years, especially those
originally expected to last a single year raised additional considerations, including
whether CMS would see continuations as evidence of performance deficiencies or
management difficulties. Failure to produce promised deliverables and/or to identify
additional project goals, activities, or deliverables increased the chances for nonrenewal. Still, our observation is that Pathways has been relatively slow to terminate
MIG funded projects.
As a general rule, Pathways had significant ability to defer external demands for
MIG funding that it did not think justified. The main exception was requests that came
from or were strongly supported by those directly above the Pathways/OIE Director in
the DHFS hierarchy. For instance, a former Pathways manager spoke of a $200,000
request made in an early grant cycle that, in his view, was intended mainly as a form of
recompense for a unit that had undergone recent facility closures. Any contribution
toward building capacity for employment would be modest. Nonetheless, his main
objection was that the proposal would consume a large percentage of that year’s total
grant. In the end, Pathways acceded to the request from up the chain of command; the
informant conceded it was prudent to do so. However, he also claimed that it gave him
an impetus to find means to more effectively resist such demands in the future.
Of course, as long as external requests were relatively modest, the increasing
size of Medicaid Buy-in expenditures and, in most circumstances, the MIG, gave
Pathways the option of avoiding conflict by incorporating external requests into the MIG
proposal. All of the Pathways staff we discussed this issue with agreed this had been the
case to at least some extent. One was, however, adamant that the issue was largely
127
For example, this is how the work incorporating PCP at the MCOs started. The projects were
small and there was a champion on the Pathways staff.
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62
hypothetical insofar that the main form of response had been to modify the requests in
ways that better served Pathways’ and CMS’ goals. A former Pathways manger
observed that Pathways had deflected some requests by claiming that the proposed
project violated conditions of the grant, such as those prohibiting fiscal supplantation or
direct service provision. Pathways’ authority to interpret the grant conditions, at least in
his experience, had never been challenged.
The Council on Workforce Investment (CWI) committee that serves as the MIG
advisory body provided another resource for withstanding external demands. Again, it
was a former Pathways staff member who most vigorously made this claim, asserting
that CWI was sought as the advisory body’s location because CWI provided a separate
but equally legitimate expression of the Governor’s intent as did the DHFS hierarchy. In
any case, there is general agreement among our sources that Pathways wanted
connection to a relatively independent actor within the Department of Workforce
Development’s sphere of influence, one that would both symbolize and help to
substantively connect issues of disability and employment to broader concerns about
economic and workforce development. As previously noted, the CWI based advisory
body has played a useful role in suggesting areas the MIG can better address without
significant interference in Pathways decision making processes or day to day
operations. 128
Nonetheless, while Pathways has some ability to insulate itself from DHFS
demands for MIG funds, that ability is far from complete. From time to time, Pathways
management has had to make the judgment that there was too much to either gain or
lose by not complying. As one informant noted, all of Pathways’ grant monies flow
through DHFS. While Pathways may have the upper hand in deciding what goes into the
MIG, DHFS supervisors can usually assert their authority to get what they want. A
corollary of this is that when the interests of the two are aligned, it allows Pathways to
have substantial influence in areas it might not otherwise. The current support of Division
of Long Term Care executives increases Pathways’ chances of implementing Managed
Care and Employment Task Force recommendations in Family Care.
We conclude our examination of MIG priority setting by considering the
contribution of MIG toward systems change over eight grant cycles. A sizeable number
of projects and activities have been funded. The 2001 grant supported six or seven
identifiable efforts, the 2008 grant at least twenty-nine. 129 The sheer amount of activity
and the resulting learning generated and then made available for dissemination would
appear to be impressive. Yet, the evidence for its impact remains mixed.
We are aware of examples where what has been learned through MIG funded
efforts has been replicated elsewhere in Wisconsin. We have already identified the
128
Some concern has been raised both within and outside the advisory body about its
chairperson’s use of the position as an extension of his legislative office. It is reported that this
use has, in the view of some, diminished the body’s cohesiveness and its ability to perform its
function.
129
The count of twenty-nine fails to include the various grant funded efforts within some of the
MIG projects. This tally, for instance, includes neither the grants given to MCOs to engage in
MCO specific capacity employment capacity development efforts nor the seven very different
projects funded under the grants component of the Pathways Regional Initiative.
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63
spread of PCP capacity at the MCOs. Other important examples are materials
developed for youth transition and transportation projects that have found wider
application. In some cases, the replication was outside Wisconsin. For example, an early
and very expensive MIG effort was building an online benefits calculator that had
localized content and the ability to make sophisticated non-linear income projections.
The effort was not sustained, as it proved expensive to keep the system up to date and
there were unresolved disputes as to how to incorporate the system into benefits
counseling practice. However, the effort made substantial technical contributions to
developing a viable calculator in California. Additionally, MIG has served as the launch
pad for potentially sustainable technical assistance centers such as WDBN or the
employer oriented WorkSource Wisconsin.
Yet there have been many MIG funded efforts that did not produce useful
products or learning. In making this assertion, we are not referring to projects that didn’t
have their intended effects as much can be learned from apparent failure. Instead, our
concern is with the efforts that were not really implemented or usefully assessed. In this
last case, we want to make it clear we are talking about information that program
planners or practitioners might have used about what was done, what challenges were
faced, and what did or did not work. 130 Finally, there is also the question of how many
within Pathways are aware of or interested in the ways that MIG funded activities might
reinforce each others impact on system change. One of us believes that few staff
members have thought seriously about this; the other is more optimistic on this point.
We are less concerned about the current lack of evidence that MIG efforts have
improved employment outcomes for those in Wisconsin with significant disabilities. The
efforts have been modest compared to the need. The issue is whether they can be
ramped up to meaningful scale. That is one reason that the Managed Care and
Employment Task Force recommendations and DHFS’ seeming commitment to
implementing them is important. In short, the effort has potential as both a method of
expansion and sustainability. This cannot be said for other MIG (or Pathways) efforts
and implies the inability to sustain or replicate efforts may be the Achilles heel of the MIG
funded efforts and their potential for driving systems change. Nonetheless, this comment
may prove overly pessimistic. Even when there isn’t substantial or direct replication at
the project level, there is always some likelihood that parts or features of those efforts
may be used as components of either future MIG projects or of existing state programs.
Some of this has been observed in the areas of vocational service planning, benefits
counseling, and youth transition efforts.
Managed Care and Employment Task Force
The Managed Care and Employment Task Force (MCETF) was convened in May
2007 by the DHFS Division of Long-Term Care (DLTC) Administrator. It was “…charged
with recommending a comprehensive strategy to expand work options for adults who
rely on the community-based, long-term care system.” 131 Though convened by DLTC
130
Though we would also argue that too few efforts were formally evaluated, we consider this a
secondary issue.
131
Managed Care and Employment Task Force. “Final Report.” 2008. Madison, WI: Wisconsin
Department of Health Services, Division of Long-Term Care, p. 5.
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and chaired by the unit’s Deputy Administrator, Pathways staff and consultants took the
lead role in organizing and providing staff support to the task force. Funding for this
support came from the Medicaid Infrastructure Grant (MIG). The Pathways Director saw
the task force as a golden opportunity for prompting increases in Family Care’s efforts in
support of competitive employment in integrated settings far beyond what had been
facilitated by Pathways’ smaller scale efforts at building capacity for person centered
planning approach (PCP) for employment services at the Family Care Managed Care
Organizations (MCOs).
The MCETF Final Report suggests that it was convened as a “blue ribbon”
commission for exploring how to take full advantage of the combination of managed long
term care expansion and the Medicaid Infrastructure Grant (MIG) to offer persons with
disabilities greater employment opportunities. 132 While there is truth in this
characterization, it obscures a crucial factor. Disability advocacy groups had been
complaining to DHFS, elected officials, and the media that the Family Care MCOs,
despite the rhetoric of choice, had done less to meet the preferences of members
wanting competitive employment than had the “inadequate” system that was being
replaced. The MCETF was convened in large part to respond to this political problem.
Nonetheless, the DLTC Administrator was insistent that the MCETF’s business would
have to be conducted in a public and transparent fashion. The task force was
responsible for fulfilling its charge, not for providing DHFS cover or issuing
recommendations that would reflect DHFS inclinations. By all accounts, this was exactly
what took place.
Pathways hired the MCETF lead staff member, deliberately choosing an
individual known as a strong advocate without ties to DHFS. The new lead staff member
with the aid of Pathways staff recruited twenty-seven members from a wide range of
organizations and stakeholders that were involved in the areas of long term care and/or
disability and employment. Efforts were made to identify and recruit highly
knowledgeable and widely respected participants. The twenty-eighth member was the
only one from DHFS, the aforementioned DLTC administrator who would serve as the
chair. 133 The aim was to be as inclusive as possible, both to insure a diversity of
perspectives and to increase the probability of external acceptance of the task force’s
recommendations. Informants report that this was achieved, though one felt that it would
have been useful to have had more employers. This individual’s main concern was that
as a consequence of the lack of employers the MCETF found it much harder to work
through issues of how to “incentivize” employers to hire and retain workers with serious
disabilities.
MCETF members began with a consensus on several broad issues. First, those
persons who wanted competitive employment in integrated settings should receive
adequate support. Second, the current system was not doing this well and, in particular,
that MCOs had a programmatic obligation to provide needed support. Aside from this
there was little agreement. In addition, the MCETF included participants from entities
132
133
Managed Care and Employment Task Force. 2008. p. 10.
There was no member from the Office of Family Care Expansion (OFCE). While there were
members from MCOs, these entities are legally outside DHFS and there were issues on which
there were major differences between OFCE and the MCOs.
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65
with some history of interorganizational conflict and distrust, including distrust as to
whether DHFS would allow the task force full control over the contents of its final
report. 134 Nonetheless, MCETF staff report that this history had little effect on the
MCETF’s work. Members demonstrated a strong commitment to discuss issues and to
work toward compromise; mutual trust appeared to increase over time.
The most important area of conflict was over what the DHFS policy on
employment should be, as this would guide what the Office of Family Care Expansion
(OFCE) would require of MCOs. To some extent, this conflict resembled that described
in the PCP case study. One group within the task force favored an “employment first”
policy. 135 While MCO members would never be required to work, MCO staff would be
expected to operate from the premise that working in competitive employment in
integrated settings would be the norm. The second perspective was that of viewing
competitive employment as just one choice among many. Proponents of this perspective
feared that too much emphasis on competitive employment would generate unjustified
pressure on MCO members and their families to conform. One of our informants
identified a third perspective, “cultural comfort,” one that in this context suggested similar
policy implications as the second. Some individuals prefer to work in settings with others
they consider peers, in this case persons with a disability or a certain type of disability.
Eventually, a compromise formula was reached. All positions would be recognized as
valid, but “…the managed care long-term care system should support integrated
employment as the preferred employment option.” 136
Other issues where task force members began the processes with significant
differences included how rapidly and to what degree to phase out the use of sheltered
workshops, and how to insure the most effective and efficient coordination of resources
external to MCOs (for example, those from The Division of Vocational Rehabilitation).
Many of these issues remain to be fully resolved, but in general the MCETF was
successful in “contextualizing” the issues in ways that established a framework for future
resolution. Still, it would be inaccurate to suggest that there were many unresolved
issues. The MCETF Final Report contains over seventy actionable recommendations.
Though, as noted, the MCETF membership proved deeply committed to its task
and was not pressured by DHFS to shape recommendations to the department’s liking,
this is not to suggest that Pathways and the MCETF chair did not carefully organize the
task force’s work. The members of the core planning group were the DLTC Deputy
134
Pathways staff, the MCETF chair, and the DLTC Administrator were all aware that some task
force members were concerned that DHFS would edit or even remove recommendations and of
the history that gave credence to such fears. We have reports that there was some “lobbying” in
DHFS to actively shape MCETF deliberations and recommendations, but cannot substantiate the
reports. In any case, the MCETF chair and the DLTC Administrator did not intrude. If they faced
any pressure from within DHFS, they successfully resisted it.
135
One informant reported that the position task force members took on disputed issues did not
generally reflect the type of organization or stakeholder group they were from. Thus, the word
“group” refers here to those members who shared a perspective on any given issue, not a
coalition reflecting association with or employment by organizations sharing common interests or
perspectives. This informant added that members did not typically see themselves as
organization representatives, a view another informant vigorously disagreed with.
136
Managed Care and Employment Task Force. 2008. p. 20.
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66
Administrator who had been designated the MCETF chair, the Pathways contracted
MCETF lead staff member, and the Pathways/OIE Director. The group appears to have
focused on structuring the task force and its operations in ways intended to have strong
payoffs in three areas. The first was that MCETF members would see themselves as
engaging in a credible and meaningful process where they would have ultimate control
over the products. The second area would be important to both the task force and
DHFS; that is, having a process that would produce a competent and potentially
actionable report. The third area was to insure that there would be a strong chance that
the recommendations would be implemented. Instead of viewing these as objectives that
would be met successively over time, the core planning group appeared to have seen
concurrent progress in these areas as important. For example, the fact that there would
be MIG funds available to implement some of the recommendations helped to get some
MCETF members to join, others to take the effort seriously.
We have already examined the care taken to constitute the task force
membership and to hire a lead staffer who would be widely viewed as independent of
DHFS. Having the DLTC Deputy Administrator as chair served several purposes. Her
status made it more likely the report would be taken seriously within DHFS, especially at
the Office of Family Care Expansion which was in her division. To the extent she could
demonstrate that she took MCETF independence seriously in how she performed her
duties, it would ease fears that others, whether in DHFS or elsewhere, would be able to
interfere with the MCETF’s deliberations and recommendations. Finally, this individual
had an established reputation for being a skillful, even-tempered facilitator.
The core planning group took care to insure that the MCETF had access to a
broad range of background materials and expertise, including bringing in nationally
recognized experts to make presentations. To provide additional stakeholder input into
the process, focus groups and listening sessions were held at locations across the state.
This outreach was performed both early on to gather information about needs and
potential responses and late in the process to get feedback on the draft
recommendations.
Probably the most important choices the core group made were those about how
to organize the MCETF’s work processes. One crucial choice was the decision to
constitute seven issue committees, each led by a MCETF member. Besides providing a
setting for intensive discussions, the issue committees allowed entrée to both additional
stakeholders and technical experts, including from Pathways and Family Care, into the
discussions. All told, approximately seventy persons participated in the issue
committees.
The issue committees were also vital to the process of moving toward
recommendations that could be widely supported in the task force. The approach was
highly iterative. Draft documents were produced at both the task force and issue
committee level. They were circulated and discussed, and then subjected to multiple
rounds of redrafting and deliberation. This process was supported by taking and
distributing extensive notes at each step. Both the task force and issue committee chairs
were careful not to force decisions in the absence of consensus. The final report, itself,
was drafted largely by the lead staff member with significant input from the others in the
core planning group. Even so, the full task force had multiple opportunities to provide
input or to amend the document before it gave final approval.
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Those whom we interviewed about their MCETF experience or whom we have
informally spoken with about it have stressed that they felt that it was an open process
with widely shared influence. They see the Final Report as an accurate reflection of the
group’s work. Among those interviewed, there was awareness of how much the process
had been structured, but they saw the structure as one that facilitated both the quality
and independence of their work. Still, there was awareness that some persons had a
greater impact on the process, even beyond the chairperson and staff director. For
example, the member who was a Division of Vocational Rehabilitation (DVR)
administrator was credited with being unusually influential. Though there was a general
understanding that a recommendation that impacted DVR operations and which that
agency opposed would almost certainly not be implemented, this member’s influence
rested more on the quality of his participation than perceptions of DVR’s power. Task
force members from MCOs provided another example. Their views on the challenges
MCOs face and the types of resources that would be needed to provide effective support
for MCO members wanting competitive employment were articulate and, probably as a
result, accorded substantial deference.
At the end of each case study we have reviewed each effort’s outputs or
products and the implications for achieving systems change. The MCETF had a product,
its final report, which was clearly responsive to the DLTC charge. As noted, Family Care
provides a setting with the potential to provide a large proportion of Wisconsin adults
with serious disabilities something much closer to the coordinated and comprehensive
return-to-work approach envisioned by, among others, those who designed what was to
become the SPI project. As of fall 2008, Pathways was completing a workplan to begin
implementation of many of the MCETF recommendations.
Comparing the Priority Setting Efforts on Four Continua
Assessing priority setting efforts on the four continua involves some special
problems as there were no activities that were immediately carried out by a principal
and/or its agents aside from choosing the priorities themselves. It is particularly difficult
to apply a concept such as “the level of centralization of policy implementation” in a
conventional fashion when there is no clear distinction between a decision and a
subsequent action. So we have interpreted effective influence or control over the
decision as equivalent to implementation in this context. This observation might also
apply to the area of “network articulations” as well. Perhaps so, though we would reply
that methods of insulation from external influence are themselves a form of articulation.
We have not shown the continua for MIG and MCETF activities here, as in the
next section of the paper we display the placements for all six case studies. As might be
anticipated, those for MIG are consistently toward the right hand side of the line for each
dimension. This reflects Pathways’ substantial ability to maintain control over decision
making. We faced more difficult decisions in thinking about how, not simply where, to
place the MCETF on the continua.
On one hand, Pathways had substantial control over how MCETF work
processes were structured, though we have no evidence to suggest substantial
disagreement with these among task force members. However, it was the MCETF that
not only approved the recommendations but largely generated them. Thus, even though
it is clear to us that Pathways as a sort of principal got, more or less, the
recommendations it desired, Pathways staff had, in collaboration with the MCETF chair,
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set up a process where the task force, i.e., the agents, had enormous independence. 137
Thus, working from a Pathways centric perspective, our placement for MCETF on each
continuum is well to the left of that for MIG priority setting.
Discussion and Next Steps
The original Director of both the Center for Delivery Systems Development and
Pathways often told his colleagues that “systems change is tough stuff.” The
organizational change literature certainly suggests that “transformational” change within
a single large organization is typically a result of many years of committed effort. 138
There is no reason to believe that the task is any easier across a system involving
multiple organizations.
If substantial increases in average earnings, employment rates, and other
employment outcomes are the primary metric of successful systems change, then there
is little evidence of significant progress in Wisconsin. Census products, such as, the
annual American Community Survey, describe essentially static employment outcomes
for those with disabilities over the 2003 through 2006 period. 139 Pathways has
commissioned a yearly evaluation report on the Wisconsin Medicaid Buy-in since 2001.
Though Buy-in enrollment continues to increase, there has been a general downward
trend in average and median earnings among program participants. 140
137
Again, Pathways was not a principal in any technical sense. We use the term to connote that
Pathways was playing a role much as one would expect a principal to play.
138
For an example of the supporting literature see Nadler, David A., Gerstein, Marc S., Shaw,
Robert B., and Associates. 1992. Organizational Architecture: Designs for Changing
Organizations. San Francisco, CA: Jossey-Bass Publishers, pp.148-54. In their view, five to
seven years is a reasonable period for fully transforming an organizational culture.
139
These data are compiled by the Cornell University Rehabilitation Research and Training
Center on Disability Demographics and Statistics and disseminated through the annual “Disability
Status Report.”
140
The annual “Medicaid Purchase Plan Annual Reports are prepared by APS Healthcare, Inc.
The first report was issued in 2001. The most recent (March 2008) contains data for 2007. The
decrease in average and median earnings appears to reflect two interacting factors. The first is
that while the Wisconsin Medicaid Buy-in generally requires participants to be employed, there is
no minimum requirement for either work hours or earnings. Indeed, compensation can be in-kind.
Second, there was a change in the typical characteristics of enrollees. As the number of enrollees
increased, the proportion entering with relatively high cash earnings decreased.
Additionally, Pathways has also started to track systems level changes in employment outcomes
through comparisons between samples of Medicaid Buy-in enrollees and others on Medicaid for
reason of disability. Samples are drawn in January of every year and followed over a two year
period. Though the first samples were drawn in 2005, initial employment rates and earnings for
both types of cohorts have not changed significantly over the next three draws. For a description
of this MIG Outcomes Tracking System see Delin, Barry S. and Sage, David. 2008. “Tracking
Outcomes for a Touched by MIG Population: An Opportunistic Approach from Wisconsin.” New
Orleans, LA: MIG/DMIE Employment Summit, April 2008.
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69
However, it would be reasonable to expect some, perhaps considerable, lag time
in improving employment outcomes. 141 If so, perhaps evidence of substantial change in
organizational and interorganizational goals, and improvements in the processes and
coordination mechanisms used to effect those goals would be enough to conclude that
major progress toward systems change has been achieved. The answer to this surmise
is implied by the very existence of a Managed Care and Employment Task Force. As the
MCETF noted in its final report:
…the Managed Care and Employment Task Force (MCTEF) was convened in
May 2007 by Division of Long-Term Care Administrator Sinikka Santala and
charged with recommending a comprehensive strategy to expand work options
for adults who rely on the community-based, long-term care system. The Task
Force, composed of 28 members representing a wide range of interests and
expertise, analyzed the challenges and identified best practices from Wisconsin
and elsewhere for overcoming these challenges. 142
In short, if systems change had been already substantially in place there would have
been no need for either the MCTEF or the Division Administrator’s charge. Additionally,
we think that most of the material in the six case studies confirms the limited progress
that has been made toward achieving the envisioned coordinated and comprehensive
return-to-work system for persons with significant disabilities.
Still limited progress is not the same as insignificant progress. In every one of the
six studies there is evidence that something valuable has been learned or some useful
capacity has either been established or expanded. One of these efforts, the WDBN, has
been particularly successful in building capacity, in this case for work incentives benefits
counseling, though our informants think the availability of the service is still inadequate
to meet current, let alone, potential needs. 143 We have also described the strong
potential that person centered planning (PCP) in support of employment goals might
have for motivating systems change, should high quality PCP services become readily
available, especially if provided in concert with benefits counseling and changes to
public program rules that encourage work effort. This is the course the MCETF has
urged DHFS to pursue through the Family Care MCOs and which Pathways is now
working to find ways to implement.
One of our goals for this first report of findings from the “Pathways
Interorganizational History Project” was to produce case studies of what we felt were
important and characteristic Pathways efforts. Though one of our aims was to simply
document these efforts, we also wanted to examine the terms of collaboration among
Pathways and its various partners with the aim of elucidating relationships between the
141
Moreover, if, as it now appears, the United States has fallen into a serious and prolonged
recession, it is likely the employment and earnings effects of a genuinely successful systems
change effort would remain obscured for some period of time.
142
143
Managed Care and Employment Task Force. 2008. p. 5.
This capacity could, in principle, be further expanded if disability benefits specialists at the
Aging and Disability Resource Centers began to provide even limited work incentives benefits
counseling as part of their normal activities. They receive significant training in this area as part of
the WDBN training for new benefits counselors.
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70
observed patterns of network structure and processes and each networks’ ability to carry
out activities that would support systems change. We hoped to identify patterns that
suggested terms of collaboration that were associated with higher levels of progress
toward systems change and which might then inform Pathways’ future efforts to
effectively steer itself and its partners toward that end. 144 More specifically, we wanted to
see if the locations of the projects on the four continua would reflect relative success.
However, we were not able to perform this kind of analysis due to a lack of
variation across the case studies. We think the evidence supports a claim that every one
of the Pathways organized networks accomplished something that was supportive of
systems change. Further, none of these efforts, with the possible exception of the
WDBN, has yet had sufficient impact to support even a limited assertion that a major
element of systems change is either substantially or permanently in place. If all the
efforts examined in our case studies made reasonable progress toward both their
proximate and ultimate goals, would that necessarily mean that the terms of network
collaboration, at least within the ranges observed, were not very important? 145 While this
is a logical possibility, it is equally reasonable to ask whether it is possible that different
network environments require different terms of collaboration for the network to be
effective. While we cannot settle this issue, we think there is more evidence that is
consistent with the latter possibility than the former.
Figures 9 through 12 show the locations of all six case studies on each of the
four continua. Two things are notable. First, there seems to be a high degree of
consistency between the location of a case study on any one continuum and the other
three. Indeed, even when there is noticeable variation in the location of a particular case
study, it is almost always remains on the same side of the dimension. 146 For example,
the location of the SSDI-EP on the “Centralization of Policy Implementation” continuum
is much closer to the center position than on the other three continua, but still clearly on
the right hand side.
Figure 9: Nature and Quality of Network Articulations
MCETF
MIG
PCP
SPI
SSDI-EP
WDBN
X
X
X
X
X X
--------------------------------------------------------------------------------------------------------------
“remote control”
“managed network”
144
Osborne, David and Gaebler, Ted. 1992. p. 32.
145
As we noted earlier, we lack clear benchmark values for the end points of each continuum.
146
The only exception to this pattern is on the Level and Character of Client or Stakeholder
Support continuum, where two case studies, MCETF and SPI have placements slightly to the
right of the continuum’s midpoint. Still, the placements are well to the left for the other members
of the respective pairs (MIG and SSDI-EP).
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71
Figure 10: Level of Goal and Policy Agreement
MCETF
SSDI-EP
PCP SPI
WDBN MIG
X
X X
X X X
--------------------------------------------------------------------------------------------------------------
“disagreement/
“agreement/
incongruence”
congruence”
Figure 11: Level of Centralization of Policy Implementation
MIG
PCP
SPI
MCETF SSDI-EP
WDBN
X
X
X
X
X X
--------------------------------------------------------------------------------------------------------------
“decentralized, dispersed
“centralized”
and/or fragmented”
Figure 12: Level and Character of Client or Stakeholder Support
MCTEF
SSDI-EP
PCP
SPI
MIG WDBN
X
X X
X X X
--------------------------------------------------------------------------------------------------------------
“weak”
“strong”
We were not entirely surprised to learn that each of the case studies is similarly
located on the four continua. Though we would argue that each continuum captures an
analytically separate phenomenon, all four dimensions involve distinctions between
relative uniformity and diversity. Additionally, we were only mildly surprised to find that
each member in all three pairs of case studies, respectively, demonstration projects,
capacity building efforts, and priority setting efforts, is positioned quite differently from its
corresponding partner across all four continua. If one member of a pair is to right on a
continuum, it will be to the right on all the other continua. Moreover, the distances will
usually be substantial enough that we are highly confident that the differences are real,
despite the fact that our placements are far from precise. For example, the WDBN
“capacity building” effort is always to the right and its match, PCP, is always to the left.
With only six case studies, this finding might be a chance result. However, what
was quite unexpected was that we did not find extreme differences between each pairs’
members in their overall contribution toward systems change. For example, aside from
the scale of impacts to date, we did not find major differences between WDBN and PCP
in their contributions. Indeed, should the MCETF recommendations be followed, there is
a real possibility that PCP in the post MCETF environment may ultimately have the
greater impact. Moreover, lest it be thought that a difference in the scale of impacts is
the factor that structures location to a particular side of each dimension, the SPI and
SSDI-EP serves as a counterexample, as it is certain that SPI has had the larger impact.
With SSDI-EP in its final months, that judgment is unlikely to change.
Figures 13 through 15 display the location of the case studies in a space defined
by their location on two continua. We have shown only three of the six, as all the two-
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72
way diagrams exhibit the same basic pattern. In all three of the diagrams shown below,
the case studies cluster into two groups arranged on a diagonal. The cluster that
appears to the upper right in all cases includes SSDI-EP, WDBN, and MIG. The second
cluster is always to the left and below the first. It contains SPI, PCP, and MCETF.
Moreover, except when Client or Stakeholder Support is one of the dimensions, each
cluster of cases is located in diagonally opposed quadrants of the diagrams.
Figure 13: Case Study Locations, Nature and Quality of Network Articulations by Level
of Goal and Policy Agreement
GOAL AGREEMENT
(MORE)
MIG
SSDI-EP
WDBN
(LOOSER) ARTICULATIONS
(TIGHTER)
MCETF
SPI
PCP
(LESS)
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73
Figure 14: Case Study Locations, Level of Goal and Policy Agreement by Level of
Centralization of Policy Implementation
CENTRALIZATION (MORE)
MIG
WDBN
SSDI-EP
(LESS) GOAL AGREEMENT
(MORE)
MCTEF
SPI
PCP
(LESS)
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74
Figure 15: Case Study Locations, Nature and Quality of Network Articulations by Level
and Character of Client or Stakeholder Support
STAKEHOLDER SUPPORT
(MORE)
WDBN
SSDI-EP
MIG
MCETF
SPI
(LOOSER) ARTICULATIONS
(TIGHTER)
PCP
(LESS)
If we are correct in thinking that each case study represents a reasonably
successful network in terms of facilitating action supportive of progress toward systems
change, it implies that each network was at least minimally functional in the environment
in which it operated. This suggests a next step in this project; one beyond continued
data collection to rectify whatever errors of fact or interpretation we have made due to
the limitations in our evidence. 147 The next step would be to inquire into which aspects of
network operation, that is, what we have called the terms of collaboration, are more
likely to prove effective depending on how heterogeneous the network environment is.
147
See page twelve of this paper.
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Indeed, as we have noted, each of the four continua can be understood as expressing
different types of relative homogeneity and heterogeneity in the network environment.
The challenge would then be to identify a range of structures, processes and means,
presumably from the extant literature, and then examine how well they might explicate
the relationship between the networks’ history and known outcomes. Though, at the
moment, we see this as an essentially qualitative and interpretative task, we would
certainly hope there will be some opportunities for quantification and formal hypothesis
testing to support whatever “story” emerges from such analysis.
Finally, a new and exceedingly practical goal resulted from the process of writing
this paper, though it was always implicit in the work. At present, Pathways is still both
expanding and deepening its efforts to achieve systems change. Nonetheless, the clock
is most assuredly running. Following 2009, there will be only two more years of MIG
funding available. There is little expectation that DHFS or the State of Wisconsin, more
generally, will have any appreciable ability to fund continuing efforts. It is likely that will
require substantial federal help, whether through extension of the MIG or from other
federal efforts. Many of the MIG funded and other return-to-work efforts undertaken in
Wisconsin and other states have been reasonably well documented and/or assessed.
What, to the best of our knowledge, has not been done is to attempt a summative
assessment of progress toward systems change. Yet, such information might be helpful
for convincing Congress and relevant executive branch officials that additional effort and
funding is justified.
In the first paragraph of this paper, we wrote that the goal of the Pathways
Interorganizational History Project was to document Pathways’ overall activity in support
of system change and, in contrast to individual program evaluations, to assess the long
term impact of the unit’s total efforts. The first part of that statement has always been
true, but the truth of the second part has emerged from our experience in putting
together this preliminary study.