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Workforce Infrastructure in Support of People with Disabilities: Matching Human Resources to Service Needs

Letter of Transmittal

January 20, 2010

The President
The White House
Washington, DC 20500

Dear Mr. President:

The National Council on Disability (NCD) is pleased to submit this report, entitled Workforce Infrastructure in Support of People with Disabilities: Matching Human Resources to Service Needs. NCD's purpose is to promote policies and practices that guarantee equal opportunity for all people with disabilities, regardless of the nature or severity of the disability, and to empower people with disabilities to achieve economic self-sufficiency, independent living, and integration into all aspects of society. Under its congressional mandate, NCD is charged with the responsibility to gather information on the development and implementation of federal laws, policies, programs, and practices that affect people with disabilities. This report is a result of that mandate.

Americans with disabilities depend on the disability workforce infrastructure, which consists of health, education, and social services programs. The need for these services is expected to increase significantly in the coming decades as a result of several factors. First, the elderly population of the United States is large and growing rapidly. Since disability rates increase with age, population aging will bring substantial increases in the number of people with disabilities and will have a significant impact on the nation's human service and support needs. Second, improvements in child survival rates mean that more children are born today with birth defects and developmental disabilities than ever before, and many of them will require access to a host of human services and supports throughout their lives. At the same time, large numbers of baby boomers are reaching retirement age, which means that many fewer human service workers will be available. These trends threaten both the availability and quality of future services for people with disabilities.

NCD's research for this report has been undertaken in an environment of significant social, political, and economic change, amid growing levels of unmet demand for services and supports across all sectors of the American workforce. The research has been aimed at better positioning the human resources sector for the future; for example, by providing data and information that organizations can use to understand the supply-demand gaps in the disability-related workforce and to make plans to fill those gaps. The research has also aimed at building industry capability to influence the nature and content of training, as well as capability to manage a sustainable, skilled disability workforce in the future. Finally, in an effort to reflect a holistic view of a community's workforce expectations, the research has been aimed across all relevant segments of the disability workforce, not just at a select handful of human service occupations.

Numerous forecasts based on diverse trends all point to a shortage of qualified workers to meet the needs of the disability population. People with disabilities occupy a strategic place in America's ability to compete. Either their talents and ambitions will be developed into a resource for our society, or they will remain on the margins, battling for shrinking resources.

This report from NCD presents recommendations (with a rationale for each) that call for partnerships among federal departments and agencies, their State counterparts, and the private sector, including organizations involved with education/training, health care, and employment services. NCD calls for policymakers at all levels of government to proactively address these shortages and examine how labor market changes are driving both current and future supply.

We stand ready to work with you and the members of your Administration to improve the nation's workforce infrastructure policies, programs, and practices for all Americans.

Sincerely,

Figure representing Signature of Linda Wetters

Linda Wetters
Chairperson

(The same letter of transmittal was sent to the President Pro Tempore of the U.S. Senate and the Speaker of the U.S. House of Representatives.)

National Council on Disability Members and Staff

Members

Linda Wetters, Chairperson
Patricia Pound, First Vice Chairperson
Marylyn Howe, Second Vice Chairperson

Victoria Ray Carlson
Robert R. Davila, Ph.D.
Graham Hill
Lisa Mattheiss
Heather McCallum
Katherine McCary
Lonnie Moore
Anne M. Rader
Tony Williams

Staff

Martin Gould, Ed.D., Director of Research and Technology
Mark S. Quigley, Director of Public Affairs
Julie Carroll, Senior Attorney Advisor
Joan M. Durocher, Senior Attorney Advisor
Sharon M. Lisa Grubb, Special Assistant, Coordinator of Administration
Geraldine Drake Hawkins, Ph.D., Senior Program Analyst
Anne C. Sommers, Legislative Affairs Specialist
Stacey S. Brown, Staff Assistant
Carla Nelson, Administrative Specialist

Acknowledgments

The National Council on Disability expresses its deepest appreciation to Martha Artiles of Manpower, Inc. Bojan Cubela, and David Vandergoot of CEMS for developing this vitally needed report. NCD also thanks Ray Glazier, Andrew Houtenville, and Peter Mead, who provided critical information, analysis, and research guidance throughout the course of this project.

Acknowledgments

Executive Summary

Section 1. Introduction and Background

Section 2. National Trends, Gaps and Barriers, and Their Implications for People with Disabilities and the Disability Services Industry

Section 3. Disability Services Infrastructure Occupations: Supply and Demand

Section 4. Private Sector Strategies for Building and Maintaining a Sufficient Supply of Disability Infrastructure Occupations

Section 5. Public Sector Strategies for Building and Maintaining a Sufficient Supply of Disability Infrastructure Occupations

Section 6. Recommendations

Appendix A. Literature Abstracts

Appendix B. Supply-Demand Charts of Infrastructure Occupations

Appendix C. Mission of the National Council on Disability

Endnotes

Tables

Table 1. 2006 U.S. Population, by Age, Residence Type, and Disability Status

Table 2. Occupations Projected To Be in High Demand Over the Next 10 Years

Table 3. Legislative Initiatives

Figures

Figure 1. 2006 U.S. Population, by Age Group

Figure 2. 2006 Disability Prevalence Rate, by Age Group

Figure 3. Forecasting and Planning for Future Retirement-Related Talent Deficits

Figure 4. Optimizing Talent Flow

Figure 5. Managing the Talent Pipeline

Executive Summary

Americans with disabilities depend on the disability services infrastructure, which consists of health, education, and social services programs. The need for these services is expected to increase significantly in the coming decades as a result of several factors, most notably the aging of the baby boom generation and declining birthrates. These trends threaten the future availability and quality of services for people with disabilities. As the threat grows, so do the downsides to the American economy and society, which are increasingly engaged competitively on a global basis. People with disabilities occupy a strategic place in America's ability to compete. Either their talents and ambitions will be developed into a resource for our society, or they will remain on the margins, battling for shrinking resources. This report from the National Council on Disability (NCD) presents recommendations (with a rationale for each) that call for partnerships among federal departments and agencies, their State counterparts, and the private sector, including organizations involved with education/training, health care, and employment services. A concerted effort is needed by these sectors to ensure that the projected shortfall in the workforce of the disability services infrastructure entities can be quickly overcome. Unless everyone works together to meet this goal, the quality of life for people with disabilities will be threatened. The gains made over the past two decades in the levels at which people with disabilities participate socially and economically will be lost, and achieving levels of independence comparable to those of people who are not disabled will be pushed farther into the future. The national health care debate, so much a part of the political scene in 2009, as well as the stimulus funds made available by the Obama Administration and Congress, create a unique opportunity to focus attention on the current and future needs of people with disabilities. The potential for refocusing priorities to ensure that the resources are available in the critical areas of employment, education, and health care services for people with disabilities is great and must be realized.

Numerous forecasts based on diverse trends all point to a shortage of qualified workers to meet the needs of people who are disabled. NCD calls for policymakers at all levels of government to proactively address these shortages and examine how labor market changes are driving both current and future supply needs. This six-section report covers the following topics:

Introduction and background
National trends, gaps and barriers, and their implications for people with disabilities and the disability services industry
Disability services infrastructure occupations: supply and demand
Private sector strategies for building and maintaining a sufficient supply of disability infrastructure occupations
Public sector strategies for building and maintaining a sufficient supply of disability infrastructure occupations
Recommendations

Section 1 outlines the strategies used to examine the current and future supply and demand associated with labor markets of the disability services infrastructure. This examination began by identifying organizations and government agencies serving people with disabilities to determine what services currently exist. An extensive literature search identified the best available sources regarding disability service worker shortages and gaps in service delivery. Information from the Bureau of Labor Statistics (BLS) of the U.S. Department of Labor was used to identify specific occupations and future projections. While existing resources help identify trends affecting the demand for future disability services and workers, the supply side has a dearth of resources, requiring more extrapolation and development. The model described in this section and detailed throughout the report provides an expanded research foundation that can be further developed through successive iterations into a tool for guiding policy formation.

Section 2 reviews issues and trends relative to skill shortages in the disability-related service industry as examined by Manpower Inc., including the aging baby boom generation and declining U.S. birthrates. The baby boomers are beginning to retire, thus increasing demands on health care, mobility support, and other services. These demands will generate further restrictions on services available to people with disabilities. This section lays the foundation for the first iteration of a more robust approach to project demand for disability services, which is a key unmet need in policy formation.

Section 3 summarizes data currently available from the Employment Outlook Projections of the BLS related to the supply-demand gap in disability-related occupations. According to the BLS, many infrastructure occupations are projected to be in high demand, particularly those associated with health care. This section suggests ways to increase the supply of disability services infrastructure workers using promising recruiting and retention practices such as increasing salaries and benefits, training to upgrade worker skills, recruiting workers from underutilized populations, and leveraging transferable skills. By developing the discussion of the supply-demand gap and exploring best practices to reduce the gap, this section lays the foundation for a supply management discipline. Such a discipline is mandatory to formulate disability services policy, especially on the national level, where supply management has been conspicuous in its absence.

Section 4 explores recruiting and retention strategies used in the private sector. Public policy affecting the disability services infrastructure cannot be developed in isolation from the private sector. When employers explore current and future workforce demographics to develop workforce management strategies, they are engaging in the private sector version of disability services supply management. Using their data and tools, employers can better identify and target appropriate candidates for disability service positions. These private sector practices provide models and strategies that the public sector can apply as well. In fact, as employers implement workforce management, they may interface with parallel public sector programs. Employers can work with community-based rehabilitation programs and vocational rehabilitation agencies to develop and tap underutilized populations. Such partnerships offer employers a large pool of potential job candidates that can receive job training through vocational services. Another useful strategy employers can explore relates to the successful return to work of injured/ill workers and the prevention of disabilities. Some employers, for example, may develop or hire return-to-work coordinators and case managers to facilitate return to work. Such private sector efforts offer a laboratory for disability services strategies and can provide some of the needed infrastructure that must be addressed through public policy.

Section 5 explores ways in which the public sector can work with the private sector to provide a suitable workforce infrastructure for people with disabilities. Public agencies and programs can establish practices that promote an adequate supply of qualified frontline workers. These public agencies and programs include the State-federal vocational rehabilitation services system, the Department of Veterans Affairs, the Workforce Investment Act and One-Stop Centers, and the Ticket to Work Program. This section also examines how new technologies and Web-enabled tools can improve access to services and information for people with disabilities. In another important discussion, this section identifies problems in health care supply and access for people with disabilities. Proposed solutions in health care reform include the medical home model, with primary care physicians coordinating all care, and electronic medical records to improve efficiency of delivery. In another strategic discussion, the section explores the need for transition services for youth with disabilities that could be met through the postsecondary education system. U.S. community colleges can provide an efficient and accessible link between students and their careers through career and technical education.

Section 6 highlights the recommendations that flow from the discussions in the previous sections. These recommendations include how private sector employers can improve their hiring and retention practices to ensure an adequate supply of workers; how federal and State agencies can target service strategies to enhance the supply of workers; how we can redirect resources in our educational and training establishments to focus on infrastructure occupations; and what we can do to monitor workforce supply and demand so that planning can accommodate unexpected events and redirect resources accordingly.

The appendices provide detailed evidence that supports the findings in each of the sections and the recommendations. An extensive search of the literature was conducted, and many of the documents that provided an empirical basis for this report have been abstracted and placed in appendix A. Readers who wish to have more detailed information can review these abstracts, which are grouped according to report section. Appendix B contains detailed information and charts on many disability services infrastructure occupations. This information provided the basis for section 3; it is also useful for program planning and as guidance for schools and training programs that offer career and vocational counseling for their students.

All these discussions identify opportunities for public-private sector partnerships to help implement public policy to better manage the nation's disability services infrastructure. Given the overlap between private and public goals and programs, such partnerships are inevitable. This public-private overlap is significant for policy formulation and implementation, because it is based on an even more significant underlying connection. People with disabilities have a shared interest with their nation and government in resolving challenges to disability services infrastructure management; in fact, this population contains an untapped resource to realize a solution to this policy challenge.

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Section 1. Introduction and Background

In many important ways, Americans with disabilities depend on the disability services infrastructure, which consists of health and human services programs. The availability and quality of the services delivered through this important infrastructure affect the health, employment, and social participation of people with disabilities, who number approximately 50 million people, about one-sixth of the overall U.S. population. In fact, this infrastructure is critical to their quality of life. Conversely, barriers and gaps in services, supports, and accommodations negatively affect the lives of people with disabilities.

To maintain the desired levels of service quality, now and in the future, policymakers and planners must anticipate labor market changes as well as the future needs of people with disabilities for services. New service delivery models must be explored and investments made in the infrastructure that supports disability services. The massive baby boom generation is beginning to leave the workforce. Nearly 7 million people in key managerial, professional, and technical jobs will likely retire in the next 10 years. At the same time, owing to declining birthrates, the U.S. economy is about to experience a shortage of young workers. As the baby boomers retire, the "brain drain" of skilled and experienced workers is creating another problem: The new workforce entrants are replacing experience with inexperience. The combination of these trends will create unprecedented competition for talent across all industries, which will further reduce available talent needed to support people with disabilities. In addition, mismatches between available skills and job requirements will continue to widen. Manpower Inc. surveyed nearly 43,000 employers in 32 countries and territories in late January 2008 to determine the extent to which talent shortages are affecting today's labor markets.[1] The results of the third annual Talent Shortage Survey revealed that 31 percent of employers worldwide are having difficulty filling positions because of the lack of suitable talent in their markets.

Today's forecasts predict a long-term shortage of qualified workers throughout the disability services infrastructure. Even more important, a high percentage of this shortage will involve a lack of skills rather than an insufficient number of workers. Therefore, it is essential to examine whether existing competencies and skills in today's occupations are sufficient to address future needs. Skill and competency deficiencies will negatively affect the lives of people with disabilities as much as or even more than a physical shortage of workers. Both shortfalls are critical, and it is imperative to address them in the very near future.

Around the world, Manpower Inc.—in partnership with community organizations and education, business, and government entities—engages in workforce development programs that put people to work. Manpower Inc. has developed a business strategy for dealing with labor shortages. In the current context, this strategy focuses on addressing the short- and long-term labor and talent shortfalls facing the disability services support infrastructure. Manpower Inc. and NCD are seeking ways to correct the imbalance between supply and demand that, if not quickly addressed, will exacerbate the gaps in social and vocational participation of people with disabilities in our society and economy.

Of many potential approaches, one is to ensure that our society fully taps the underutilized pool of workers with disabilities. The agencies and companies serving people with disabilities must begin planning strategically to hire more workers from the very population they serve. The more equitably people with disabilities participate throughout these service programs, the more sensitive and responsive the infrastructure will become to their needs. Their active participation will help alleviate the overall shortages and improve the economy's use of people with disabilities. The nation must tap this pool of talented people.

Before we proceed, it is important to clarify the terms used in this report. This will enhance understanding and facilitate actions needed to overcome the gaps and barriers discussed here.

Disability Services Infrastructure

"Disability services infrastructure" refers to the full range of support services available to people with disabilities, including education; health care; vocational, social, and recreational programs; and other human service programs that affect the quality of life and independent living of people with disabilities of all ages and their families. These programs can be either public or private. They may be developed specifically for people with disabilities or modified for use by people with disabilities. These programs address needs that people with disabilities experience from infancy to old age. The infrastructure supporting these programs is the primary concern in this report: It is currently insufficient to meet the needs of people with disabilities and will likely be even less responsive in the future, as a result of the trends described in the report.

Gaps and Barriers

Regardless of funding source or intended target audience, all services and their resulting outcomes should be engineered to support participation in education, employment, and health care opportunities by people with disabilities to the same extent that other people participate. The gaps and barriers experienced by people with disabilities and their families are documented in the sections that follow; they include environmental, procedural, organizational, legal, social, and political barriers.

Purpose of the Report

The purpose of this NCD report is to reveal the current and future supply and demand associated with labor markets in the disability services infrastructure; to review existing strategies for maintaining balance between needs and services; and to suggest how to transform management and human resources practices for attracting, engaging, and retaining the workers needed in critical occupations. The report also calls for an examination for how the proliferation of new technologies and Web-enabled tools, such as the social networking platforms, can improve access to services and information for people with disabilities. These new technologies have the potential to empower people with disabilities and provide them with opportunities for informed decision making in their lives and careers. Finally, this report reviews how current public and private initiatives and policies affect the soundness of the disability services infrastructure and what can be done to use public resources more effectively.

The current focus of the Obama Administration on economic stimulus and health care reform has created much legislative activity and many policy discussions on these interrelated and very complex issues. Although many factors must be considered to understand the future needs of people with disabilities and the resources available to address them, a firm understanding of health care and economic trends is an important aspect of the discussion if we want to make the most of the opportunities that will result from stimulus legislation and health care reform. The future quality of life for people with disabilities is at stake.

Methodology

NCD took a multifaceted approach to identify the sources that provide the foundation for this report's findings and recommendations. The scope of this innovative project was comprehensive and unique. No clear body of information existed on which to build; therefore, from the outset, it was necessary to cast a wide net and identify as many sources of insight, information, and data as possible.

NCD began by locating organizations related to both the disability and the workforce communities, including government agencies at all levels. We identified contact people and Web sites. Contact people provided information to update print documentation. These contacts informed us of other people and organizations that could provide additional information, so our list of organizations continued to grow through this "snowball" sampling process. These contacts also made important suggestions regarding which occupations in the disability services infrastructure we should include.

NCD compiled a list of key words and phrases that provided a thorough description of the disability services program components. We used the word list to do an extensive literature search to identify the needs of people with disabilities and the service gaps and barriers that prevent them from achieving the same quality of life as people without disabilities. NCD searched for foreign documents as well as those from the United States, as it is likely that solutions discovered elsewhere may be suitable for replication here. The documents obtained through the literature searches were reviewed, summarized, and sorted into appropriate categories corresponding to services provided through the disability services infrastructure, national trends, needs of people with disabilities, gaps and barriers associated with service delivery, and occupational forecasts related to the disability services infrastructure. The literature search was designed to go beyond disability and explore how solutions that have worked with other population sectors might be considered for people with disabilities. NCD was looking specifically for solutions that had a supporting evidence base.

The most useful documents had not only good descriptions of solutions but also data collected through fairly rigorous research designs. Studies with a more rigorous design were accorded more weight in our use of data. We used systematic reviews when they were available (which was infrequently), because they typically provide comprehensive overviews of the highest quality empirical research available. To reveal more detail than is usually captured in an overview of this nature, NCD abstracted documents of particular significance to a topic area, These abstracts are organized by topic in appendix A.

Finally, NCD used published data from the Bureau of Labor Statistics (BLS) of the U.S. Department of Labor to compile forecasts of the occupations identified as part of the disability services infrastructure. This is the most comprehensive and up-to-date source of occupational information available. To supplement the BLS information, which focuses on demandfor workers, NCD contacted associations and organizations affiliated with these occupations to obtain more information, particularly additional forecasts associated with the supply of workers. Appendix B includes charts that show the projected future demand for workers.

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Section 2. National Trends, Gaps and Barriers, and Their Implications for People with Disabilities and the Disability Services Industry

Manpower Inc. has addressed issues associated with skill shortages for many years as part of its core business of providing human resources infrastructure support to companies and governments throughout the world. The company describes the time-tested strategies and tactics it uses in its recently published study Confronting the Talent Crunch: 2008.[2] Manpower is aware of the trends contributing to the imbalances in the human resources infrastructure that will further limit opportunities for people with disabilities to experience the same quality of life and independence as people without disabilities. Data systematically collected over 50 years indicates that people with disabilities have lower high school and college graduation rates, experience greater levels of unemployment and underemployment, have income levels that fall disproportionately below the poverty line, are frequently without any medical insurance, and experience less integration into community life than others. It is also clear that current labor shortages will become worse in the near term unless new approaches are applied. Driving these increasingly critical shortages are the following demographic shifts:

Baby boomers are entering their retirement years and will need a variety of medical and social supports to maintain their quality of life, further burdening the supports available for people with disabilities. As a result of medical advances and scientific developments, boomers will have an increasingly longer lifespan and thus will be competing with people with disabilities for services already in short supply.
At the same time, the falling U.S. birthrate means fewer younger workers to replace the boomers. The late Frank Bowe characterized the baby boom generation as "the pig in the python."[3] The children of this generation constitute a smaller population cohort immediately behind the boomers, which means that the supply of workers will be further weakened and the burden on younger generations to produce the wealth needed to support the retirement lives of boomers will become greater, further straining the ability to adequately meet the needs of people with disabilities of all ages.

Both long-term and short-term solutions are needed. The current disability services infrastructure, already strained, is configured to serve a smaller group while drawing on the large labor pool the baby boom formerly provided. In the future, the burdens on the health care and social support systems will grow, while resources and labor supplies will be stretched ever more thinly. It will take a combined public-private initiative to provide the strategic planning to fully fund and provide for the social and health care needs of all citizens, not just those of older people or people with disabilities. Our society cannot take from one group to meet the needs of others.

Bowe foretells the convergence of interests of the disability and aging constituencies as the first wave of the postwar baby boom generation turns 60 and experiences the gradually (sometimes not so gradually) disabling effects of aging.[4] He makes the point that disability is our common destiny, if we live long enough. Usually, hearing begins to go first, then vision, and then mobility.

A larger proportion of older people will result in a larger percentage of people with limitations and disabilities in the population at large. Bowe says, "The disability community is about to become a lot more central in American life."[5] He notes that in 15 years, 40 percent more Americans will have some degree of hearing loss and vision impairment, and the current 14 percent of adult Americans with moderate to severe mobility limitations will increase dramatically.

As the baby boomers age, Bowe notes, "Accessibility issues will be, for these people, no longer someone else's problems but rather our concern."[6] Seniors are much more likely to exercise their right to vote than younger people. The baby boom generation gave America its first child consumer market (think Davy Crockett coonskin caps and the Mouseketeers) and will continue to drive markets to respond to their changing needs as they age.

In our geographically mobile society, few aging parents can count on their offspring to care for them in old age. Adult children commonly live far from their parents and are already overcommitted, with demanding careers, obligations to merged families, grandchildren of their own, and lives complicated by multiple marriages and two-career couples. And easy access to birth control has made the post-baby boom generation smaller. So who will help the boomers cope with the effects of aging? Today's seniors—and presumably the coming wave—want to remain as active and independent as circumstances permit, preferably aging in place in their own homes.

What we are seeing is a coalescence of the need for help by both seniors and people living with disabilities. People with disabilities already enjoy some community access features and in-home supportive services that enable them to be active citizens engaged in community life and aspiring to or achieving full-time competitive employment. These services, if preserved and extended, will also sustain the baby boom generation as it ages. It is critically important to see how these mutual needs and supports can be integrated even better, so that none of our citizens in either group misses out on the quality of life that people who are younger and free of disabilities enjoy.

Recent data, primarily from the Census Bureau, can be used to forecast the expanding population of people with disabilities over the next 20 years. Any staff shortages or gaps in the disability services infrastructure that exist now will be exacerbated not only by the aging of the population but also by the increase in the number of people with disabilities.

Population Growth. The U.S. Census Bureau estimated the U.S. population at 306 million on March 1, 2009,[7] and projects an increase to 336 million by 2020 and 364 million by 2030.[8] In other words, the population is expected to increase by 35 million (10.4%) from 2007 to 2020 and by 63 million (17.3%) from 2007 to 2030. According to the Census Bureau's 2006 American Community Survey (ACS),[9] 15.7 percent of the population reported a disability. Applying this percentage to the population projections suggests that the population with disabilities will be 53 million by 2020 and 57 million by 2030. (This estimate is for people ages 5 years and older, but the exercise assumes that the percentage is the same for all ages and constant over time.)

Disability, Age, and the Baby Boom

The baby boom generation, born between 1946 and 1964, has created a demand for increased government services at each stage; for example, the need to build more public schools in the 1950s and 1960s. Figure 1 shows the U.S. population by age group in 2006, when the boomers were 42–60 years old. As this generation continues to age, the demand for disability services will increase.

Figure 1. 2006 U.S. Population, by Age Group

Source: U.S. Census Bureau (see note 7).

The connection between age and disability is well known and is graphed in figure 2. For example, the disability prevalence rate among the youngest baby boomers (42-year-olds) was 11.9 percent, while the rate among the oldest boomers (60-year-olds) was 25.2 percent. As the boomers age, the population with disabilities will increase.

Figure 2. Disability Prevalence Rate, by Age Group

Source: U.S. Census Bureau (see note 7).

Institutions

It is important to note that a portion of the population with disabilities lives in institutions. As shown in table 1, in 2006, 5.7 percent of people ages five and older with disabilities lived in institutions, compared with 0.7 percent of people without disabilities. And the percentage of people with disabilities living in institutions increased with age: 2.3 percent for those aged 5–20; 3.6 percent for those aged 21–64; and 9.8 percent for those aged 65 and older. The degree of institutionalization will likely affect the demand for social services. Unfortunately, current data does not distinguish between privately and publicly funded institutional care.

**Table 1. 2006 U.S. Population, by Age, Residence Type, and Disability Status**
Age/Residence Type	Total	Disability Status
Age/Residence Type	Total	Disability	No Disability
Ages 5 and older	279,019,603	43,755,805	235,263,798
Living in the community	274,896,047	41,247,284	233,648,763
Living in an Institution	4,123,556	2,508,521	1,615,035
Percentage living in an institution	1.5	5.7	0.7
Ages 5–20	66,645,996	4,411,409	62,234,587
Living in the community	66,361,958	4,311,751	62,050,207
Living in an institution	284,038	99,658	184,380
Percentage living in an institution	0.4	2.3	0.3
Ages 21–64	175,179,720	23,217,180	151,962,540
Living in the community	172,961,160	22,381,523	150,579,637
Living in an institution	2,218,560	835,657	1,382,903
Percentage living in an institution	1.3	3.6	0.9
Ages 65 and older	37,193,887	16,127,216	21,066,671
Living in the community	35,572,929	14,554,010	21,018,919
Living in an institution	1,620,958	1,573,206	47,752
Percentage living in an institution	4.4	9.8	0.2
Note: "Living in the community" refers to households and noninstitutional group quarters. Source: American Community Survey 2006

Type of Disability

Disability is a complex concept and includes numerous types. The American Community Survey (ACS) collects data in several broad disability categories: sensory, physical, mental, self-care, go-outside-home, and employment. (Survey respondents may report more than one category). These categories are useful to understand the types of disability services needed. According to the 2006 ACS, among people with disabilities ages 5 years and older, 28.9 percent had a sensory disability, 63.3 percent reported a physical disability, 40.2 percent reported a mental disability, 22.5 percent reported a self-care disability, 32.6 percent reported a go-outside-home disability, and 59.3 percent reported an employment disability.

Needs, Gaps, and Service Barriers

Appendix A provides abstracts highlighting the needs of people with disabilities in critical areas: education, employment, health care, independent living, and quality of life. Our focus is this report was to identify broad issues affecting the entire population of people with disabilities. The major issues in each need area are summarized below.

Education

Students with disabilities at all levels of education have experienced greater degrees of integration and opportunity. Yet difficulties and inequities still exist:

Graduation rates for students with disabilities lag behind those for other students.
Younger students with disabilities experience more behavior problems and have less developed social skills than other students.
Older students with disabilities tend to have lower self-esteem, to participate less in school activities, to feel somewhat isolated, and to be fearful about their future prospects, including employment, than other students.
More students with disabilities are enrolled in postsecondary schools than in the past, but the numbers are still comparatively low and support services are frequently lacking at colleges and universities.
Students with disabilities who are part of immigrant families face additional difficulties. Cultural differences may lead to misunderstanding, and parents often do not know how to navigate the educational system and or how to access available supports.

Employment

Across the board, people with disabilities have lower employment rates and earnings.
Transition-age youth with disabilities are getting greater access to employment support services, but they need more work experience opportunities while in school.
Although corporate America is offering more opportunities for workers with disabilities, many companies have not yet developed corporate cultures that are open to disability and diversity.
The employment success rates of people served by vocational rehabilitation agencies have not improved appreciably.

Health Care

Funding for specialized health care services for people with disabilities is not adequate to meet the need.
Treatment services are often inaccessible or not adapted to the special needs of people with disabilities.
Health care burdens and costs are greater for families of people with disabilities than for families that do not have a member with a disability.
There is a growing gap of unmet need for care providers in the workforce.

Independent Living and Quality of Life

Physical accessibility to transportation, recreation, and other important venues remains a problem, particularly in minority communities.
Recreational opportunities are limited for people with disabilities.
Accessible housing and transportation are limited almost everywhere in the nation.
Income supports for people with disabilities are falling behind the growth of income of other population sectors.
A greater proportion of people with disabilities falls below the poverty line.

Summary

The number of people with disabilities will increase over the next 10 years, and many of them will be over 60 years of age. The double impact of age and disability will strain the service infrastructure for older people and siphon off services for younger people unless additional resources are directed at the increased needs. The current needs of people with disabilities, although receiving increasing attention, are multifaceted and often unmet. Existing shortfalls and expected increases in demand for services require immediate consideration if service gains are to be sustained and needs properly addressed.

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Section 3. Disability Services Infrastructure Occupations: Supply and Demand

This section summarizes information about current and future supply and demand associated with disability services infrastructure occupations.

The data comes primarily from the Employment Outlook Projections of the Bureau of Labor Statistics (BLS) of the U.S. Department of Labor.[10],[11],[12],[13] Appendix B provides detailed information about these occupations, including workforce estimates, future demand, educational requirements, salary levels, and competencies that may be transferable among disability services infrastructure occupations. The BLS uses available data to estimate current supply (i.e., the number of people employed at the time the study was completed) and to project demand 10 years into the future. Where possible, the BLS projections incorporate expectations about future supply from other sources, primarily professional and industry associations. These projections can help policymakers, administrators of education and training programs, employers, and the counseling profession make decisions that will ensure an adequate future supply of workers for these occupations, which are critical to the well-being of people with disabilities.

The projections consider both expected growth in demand and replacement needs owing to workers retiring or leaving their jobs. Education and training pipelines are not systematically tracked, but the best estimates assume that occupations with the largest gap between current supply and future demand will require special attention. This is a central concern: to manage supply over time to ensure that it is sufficient to meet the future needs of people with disabilities.

This discussion of supply and demand is based on research that extrapolates data from the past into the future. The biennial BLS study encompasses a 10-year period; its projections assume that current trends will likely continue as the future unfolds.[14] However, the prediction models used in 2006, for example, did not anticipate the protracted economic downturn that began in late 2007 and continued through 2009. Likewise, the comprehensive stimulus plan proposed by President Barack Obama and enacted by Congress may alter current trends that affect projections. In fact, some components of the stimulus plan are directed at supply-demand imbalances, particularly in health care occupations, so the future reality may bear little resemblance to current projections. In addition, other unforeseen events and forces might affect the balance between supply and demand, such as natural disasters, flu pandemics, terrorist acts, expanded or new wars, and prolonged economic turmoil. This section will highlight stimulus plan provisions intended to address future shortfalls.

However conditional the predictions are, they are still useful. The current balance between supply and demand points the way to what should be given the most attention moving forward, with a careful eye on events that might require a corrective response. These projections provide a baseline for a capacity-planning process that can be modified and improved on a continuing basis in future years as services infrastructure leaders learn more about planning for the future. In this initial effort, both the private sector and all levels of government must focus on how education and training resources, including those of employers, should be aligned for the future.

Occupations with Future High Demand

The BLS projects that certain occupations will require at least a 15 percent rate of growth over the next 10 years to respond to increases in demand. These occupations will require the most additional support through policy, publicity, and resource allocation. Table 2 organizes these occupations into four areas of need for people with disabilities: employment, health care, quality of life, and education.

Table 2. Occupations Projected To Be in High Demand
Over the Next 10 Years
Area of Need	Occupation	Projected Increase in Demand
Employment	Rehabilitation counselor	23%
Health Care	Home health aide	48.7%
	Medical assistant	35.4%
	Substance abuse counselor	34.3%
	Mental health counselor	30%
	Physical therapy aide	28.9%
	Occupational therapy aide	27.9%
	Physical therapist	27.1%
	Physician assistant	27%
	Registered nurse	23.5%
	Occupational therapist	23.1%
	Respiratory therapist	22.6%
	Pharmacist	21.7%
	Massage therapist	20.3%
	Emergency medical technician	19.2%
	Medical records technician	17.8%
	Medical and health services manager	16.4%
	Psychologist	15.3%
	Radiology technician	15.1%
Quality of life	Social and human service assistant	33.6%
	Social and community service manager	24.7%
	Social worker	22.2%
	Child care worker	17.8%
Education	Sign language interpreter	23.6%
	Clinical, counseling, school psychologist	15.8%
	Special education teacher	15.4%
Source: Author

Workers in the health and medical services will be in greatest demand over the next 10 years, and the extent of the demand is very strong. The three occupations in which demand is projected to increase most are all in health care. The single highest increase in demand—for home health aides—directly affects the quality of life of people with disabilities.

Employment opportunities will be plentiful in the high-demand fields listed in table 2. Schools, colleges, community organizations, and employers should expand their offerings accordingly, and guidance counselors might encourage youth to consider careers in these fields. Vocational rehabilitation agencies and programs should inform consumers about opportunities in these high-demand occupations.

Supply Issues

There are no general surveys or studies of trends in supply as there are for trends in demand. In the absence of hard data, we can look at the principles driving supply trends. One driving principle, as long as the economic climate remains difficult, is that people are likely to hold on to the jobs they have. Therefore, one might expect replacement needs to be lower than currently projected. The economic downturn and the higher Social Security retirement age mean that older workers are likely to stay employed longer. These trends may provide a "softer landing" from projected shortfalls in supply, especially in the higher skill jobs held by many older workers. But supply shortfalls are already appearing and will be felt especially in new occupations and entry-level occupations, such as home health aide.

Labor markets are not static. Organizations react to changing conditions by responding to the reality confronting them. When employers feel the pressure of a shrinking supply of workers to meet increasing demand for services, they will create training and career development opportunities to keep existing workers on the job and improve their capabilities. Employers are also likely to increase wages in these occupations to entice workers to remain and to attract new hires to fill vacancies. It is uncertain to what extent such employer efforts will narrow the supply-demand gap, because they may be offset by the impact of extended or enhanced unemployment benefits currently under consideration. Enhanced benefits could influence unemployed people to stay on the rolls rather than seek or accept new employment. It is hard to estimate the relative strength of countervailing trends such as these, but identifying them is a starting point.

The health care sector has a history of high turnover among long-term personal care workers and aides. Over a 6-year period from 2000 to 2006, the actual wages of these workers decreased when adjusted for inflation.[15] This situation will only worsen as the trends mentioned above become stronger. To keep these workers on the job and provide daily care for older people and those with disabilities, employers will have to increase salaries and benefits, and provide training to upgrade skills.[16] A recent four-State demonstration project sponsored by the Department of Health and Human Services using these and related strategies showed a significant decrease in turnover among these important caregivers. [17] But while this demonstration shows how to increase employee retention in a high-demand occupation, it does not address the challenge of recruiting new workers to reduce the supply-demand gap.

Employers must adopt new recruitment strategies, including recruitment among underutilized populations. People with disabilities, who are often consumers of vocational rehabilitation (VR) programs, can be valuable recruits for companies experiencing worker shortages. VR programs should seize this opportunity and help people enter these occupations at whatever level possible. Because they are well-versed in many disability issues as a result of their own experience, these people are ideal recruits. The list of high-demand occupations includes some for which people with disabilities could be trained quickly, such as the medical records technician and aide occupations. People with disabilities have long been an underutilized sector of the labor market. Section 5 will describe more strategies to increase the supply of workers in these critical occupations.

Graduates of training and education programs constitute a large proportion of the workforce supply in the disability services infrastructure, and this area of the supply channel is at risk. It is expensive to expand education and training capacity. A recent study of the supply of general surgeons indicates that no increase is occurring in medical school enrollment, and physician shortages are predicted through the mid-21^st century.[18] Similarly, a study sponsored by the American Association of Colleges of Nursing indicates that a lack of funds to hire adequate numbers of faculty is limiting enrollment of nursing students.[19] A recent study found that the current supply channel for rehabilitation counselors is inadequate to meet retirement replacement demands, let alone the additional demand from increasing caseloads.[20]State VR agencies expected to hire more than 3,700 counselors between 2002 and 2007, but the graduation rate from rehabilitation counselor programs over the period was only a little more than a third of that total. It is not yet clear how distance learning technologies might mitigate the lack of resources inhibiting growth in traditional education and training facilities.

Finally, the federal and State governments need to act quickly to increase the flow of money to move the economy out of the recession that began in December 2007. Stimulus money includes funds directed at jobs in the disability services infrastructure, such as primary care physicians and frontline caregivers, and will most certainly influence the supply of workers for these jobs. It is difficult to anticipate what will happen to the supply-demand balance as a result of these funds and later, when the funds are spent.

American Recovery and Reinvestment Act (ARRA) of 2009

The stimulus package introduced by the Obama Administration in 2009 includes a time-limited infusion of new funding that responds to the projected limited supply of service providers in the areas of health, education, employment, and quality of life. In addition, Congress has introduced numerous bills and passed legislation designed to enhance education, recruitment, and hiring in key infrastructure occupations, thus making them more attractive and worthwhile for prospective students and workers. Most of these new and proposed laws focus on increasing funding for education, or recruiting and retaining workers in needed areas. Although the goal of the stimulus funds is to increase employment in the near term, the longer term impact is much less certain. Some bills are unlikely to make it out of Congress, but enough have been proposed in both the House and the Senate to indicate that Congress is aware of workforce shortage concerns.

The Obama Administration has said it will address specific disability issues germane to the needs described here. In education, the focus is on early screening, transition from school to work, and expanded higher education opportunities. Regarding employment, the emphasis is on enforcing the provisions of the Americans with Disabilities Act (ADA) and providing resources to help employers accommodate workers with disabilities. In health care, the goal is to require insurance plans to cover preexisting conditions and improve mental health care.

What the Administration and Congress will be able to accomplish is unknown, but whatever they implement will affect the supply-demand balance in the disability services infrastructure. Some current initiatives in Congress are listed in table 3, to illustrate what Congress and the Administration are considering.

**Table 3. Legislative Initiatives**
Legislation	Occupation, Field, or Population Impacted	Needs of People with Disabilities
Legislation	Occupation, Field, or Population Impacted	Employment	Health, Safety, Well-being	Education	Independent Living
Passed
S.AJMDT.799	Medical professionals		X
S.AJMDT.802	Medical professionals (veterans)		X
Title I Pt. A of IDEA	Teachers			X
Proposed
S.750	Gerontology		X		X
S.811, HR2066	Psychology		X
S.790, HR1946	Health professionals		X
S.502	Older workers	X
S.999, HR1932	Child mental health		X	X
HR 1928	Nursing		X
HR 1457	Geriatric		X
S.497, HR2043	Nursing		X
HR 2273	Nursing		X
HR 1581	Health professionals		X
HR 1011	Mental health		X
HR 724	Nursing		X
HR 795	Social work		X
HR 1930	Dentists		X
HR 1161	Teachers			X
HR 2350	Physicians		X
HR 349	Autism		X	X
S.2933	Older workers	X
HR 468	Geriatric		X
HR 2832	Nursing		X
HR 2388	Physicians		X
Source: Author

One of the two passed Senate bills, S.AJMDT 799, establishes a reserve fund to address systemic inequities of Medicare and Medicaid reimbursement that lead to access problems in rural areas. The second, S.AJMDT. 802, provides a Veterans Health Administration reserve fund to ensure that the supply of professionals serving veterans is appropriately prepared to meet their needs.

The ARRA has specific implications for people with disabilities that parallel the goals of the Administration:

States: enhanced funding for the Individuals with Disabilities Education Act (IDEA).
Social Security Administration: funding to reduce the backlog of disability claims.
State-federal vocational rehabilitation program: $540 million for services.
Centers for Independent Living: $140 million to enable people with disabilities to live in their communities.
Public Housing Capital Fund: $250 million for energy retrofits to supportive housing for people with disabilities, making these units more energy-efficient.

Numerous bills are proposed and awaiting action. They are categorized below, although bills often include multiple funding vehicles that spill over categories. The largest category funds training and education programs to increase the supply of qualified professionals in the disability services infrastructure (primarily health care).

S. 750 – Caring for an Aging America Act. Geriatric and Gerontology Loan Repayment Program; nursing education grants for those who complete specialty training in geriatrics or gerontology and elect to provide nursing services to older adults.

S. 811, H.R. 2066 – Graduate Psychology Education Act. School grants to encourage specialized training, including services to veterans with posttraumatic stress disorder (PTSD).

S. 790 – Health Access and Health Professions Supply Act of 2009. Expansion of loan repayment programs; matching State grants for the operation of State Health Workforce Centers; National Health Service Corps Scholarship Program for Medical, Dental, Physician Assistant, Pharmacy, Behavioral and Mental Health, Public Health, and Nursing Students in the United States Public Health Sciences Track in Affiliated Schools.

H.R. 1928 – Home Health Care Nurse Promotion Act of 2009. Training grants to nursing schools and associations; scholarship and loan support for home health care nurses.

H.R. 1457 – Geriatric Loan Forgiveness Act of 2009. Considers each year a person is enrolled in a geriatric training program as a year of obligated service under the National Health Service Corps Loan Repayment Program.

H.R. 724 – America's Partnership for Nursing Education Act of 2009. Grants for States experiencing explosive population growth with a significant projected shortage of nurses to increase the number of qualified nursing faculty in college and university nursing programs.

S. 497, H.R. 2043 – Nurse Education, Expansion, and Development Act of 2009. Grants to schools with nursing programs that promote accelerated degrees in nursing.

H.R. 1930 – Primary Care Dental Academic Workforce Development Act of 2009. Loan repayment for full-time faculty of dentistry programs.

H.R. 1185 – Primary Care Volunteer Incentive Act of 2009. Limited loan repayment for part-time primary care volunteer doctors at community health centers.

Other bills, including the following, focus on retention or career enhancement of professionals already in the disability services infrastructure:

H.R. 1161 – Keep Teachers Teaching Act of 2009. Grants aimed at teacher retention, to be applied toward professional development, teacher mentoring, advanced certification, research or travel opportunities, and pairing teachers with industry professionals.

H.R. 795 – Dorothy I. Height and Whitney M. Young, Jr. Social Work Reinvestment Act. A commission to advise Congress on recruitment and retention in the field of social work.

S. 502 – Older Worker Opportunity Act of 2009. Employer tax credits to employ persons 62 years and older.

Other bills, including the following, pursue alternative methods of increasing the capacity or quality of the service delivery channel:

H.R. 1581 – Patient-Focused Critical Care Enhancement Act. Appropriations for augmented delivery of critical care services to rural settings via telecommunications; National Health Service Corps Loan Repayment Program recruitment efforts for providers of critical care services.

H.R. 1011 – Community Mental Health Services Improvement Act. Funding for technical support and personnel training in the National Health Information Infrastructure to address the needs of providers of mental health and substance abuse treatment services; grants to address behavioral and mental health workforce needs in professional shortage areas.

Table 3 shows how the legislative priorities of the Administration and Congress intersect with the disability services infrastructure, especially the health care occupations. If several of these bills were passed, signed into law, and fully funded, the supply of health care workers, such as nurses and physicians, would come into better balance with demand, as would the supply of workers in education-related occupations. Passage of these bills would address workforce shortages in fields that affect the lives of people with disabilities, with substantial effect on supply shortages in the mental health profession. However, the legislative intent is primarily targeted to broader concerns of the overall population or of groups such as older people and veterans, which include significant numbers of people with disabilities. In one example of legislation directly intended to provide resources to the disability services infrastructure, the ARRA included funding for State VR agencies to build infrastructure that will enhance the VR system's ability to help people with disabilities become employed. It is not known as of this writing which bills will become law, so it is important to track them to anticipate the impact on supply and demand, and plan accordingly.

Competencies in Demand

Employers rely on transferability of skills to ensure that they can quickly develop an adequate supply of workers by recruiting those with similar skills to workers in occupations that are experiencing shortages. Typically, on-the-job programs can quickly train these workers to levels of competence. However, specialization is becoming increasingly prevalent, and with it comes credentialing standards that require licensure by a regulating State agency or certification by a professional association. To obtain these gate-keeping credentials, people must have specific degrees and experiences that cannot be attained on the job. Unfortunately, many of the disability infrastructure occupations with strong future demand characteristics have such credentialing requirements. Insofar as these requirements ensure a high level of service quality, they must not be weakened or compromised. However, developing new ways to achieve the proper competencies and credentials would turn transferable opportunities into viable solutions to shortages. Workers who have already demonstrated successful tenure in related occupations should not be discouraged from pursuing opportunities in infrastructure occupations.

Many of the high-demand occupations have career tracks that permit workers to move up as they gain education and experience. Therapy aides and social services program aides, for instance, have skills related to credentialed therapy and social services, which are high-demand occupations in the health care sector. Facilitating career advancement for people in lower tier jobs will require creative approaches to overcoming credentialing barriers. Employers, credentialing agencies, and education and training programs should consider the development of creative alternative credentialing opportunities. Gaining credentials for higher level jobs through education and training while on the job would be one approach. Professions, schools, employers, and credentialing agencies will need to collaborate, and they may need to partner with State legislatures or Congress to ratify alternative credentialing ladders.

The following abilities underlie many of the in-demand occupations in the disability services infrastructure. People who have gained these abilities from previous work experiences are likely to be good candidates for transferring their skills and assuming infrastructure jobs with proper on-the-job and learning experiences.

Transferable skills include the ability to do the following:

Work comfortably with people and put them at ease in difficult circumstances.
Identify, evaluate, and address the needs of others through information and personal assistance, often by providing direct care.
Obtain needed information by interviewing, assessing, and reviewing records.
Assist people with decision making and problem solving.
Recommend strategies and solutions for managing personal issues.
Communicate well verbally and in writing.
Provide information and education to individuals and to the public.
Use equipment to provide diagnostic and treatment services.
Collaborate with other service and treatment providers and organizations.
Follow policies and prescribed procedures when providing treatment and services.
Ensure privacy and confidentiality of personal information.
Use electronic recordkeeping systems and equipment so that information is valid and secure.
Maintain work areas in a safe, clean, and organized manner.
Work as a member of a team to provide coordinated services and treatment.
Refer individuals and families to appropriate service and treatment providers.

In addition to these competencies, many experienced workers assume managerial and administrative responsibilities that entail the following additional abilities:

Plan, direct, coordinate, and supervise the work of others in providing services.
Ensure that all operations of the organization are done in compliance with laws and regulations.
Manage budget and fiscal procedures to balance costs and revenues.
Provide resources for needed operations involved in service provision.
Ensure that staff have the necessary skills and knowledge to serve individuals and families.

Many of these competencies are required by high-demand occupations, suggesting that transfer of skills can be a potential solution to balancing supply and demand in the future. Overcoming credentialing barriers that prohibit movement of skilled workers across infrastructure occupations should be a high priority.

Return to Table of Contents

Section 4. Private Sector Strategies for Building and Maintaining a Sufficient Supply of Disability Infrastructure Occupations

Given the likely shortfalls in the supply of workers in disability infrastructure occupations over the next 10 years, it is essential to distinguish long-term solutions from the policies and practices that look promising right now. Because of the shortages, infrastructure employers will have to work harder to attract and maintain the workers they need. Unless something is done quickly, citizens with disabilities will fall further behind economically and socially in spite of new policies, new legislation, and increased funding for services. This reality is crucial for the companies in the private sector that provide services as part of the disability services infrastructure. Without adequate staffing, many of these companies may fail, thus adding to the shortage of available resources. Many frontline infrastructure jobs are low-salary positions. Because of the impending shortages, wages will probably increase in these jobs. Higher pay will help attract new workers; then the focus will be on retaining them. In this section, we outline management strategies to improve retention over the next decade.

The section explores efforts undertaken by the private sector to ensure an adequate workforce through recruitment and retention strategies. These initiatives hold promise for correcting supply-demand imbalances in the disability services infrastructure. NCD strongly believes that no source of talent can be ignored moving into the second decade of the 21^stcentury. That means that workforce management strategies and practices will have to change.

Workforce Management

NCD partnered with Manpower Inc. to prepare this report. In a recent study, Manpower surveyed the status of the existing workforce and identified opportunities.[21] NCD believes that the findings of the Manpower survey are particularly relevant with respect to the disability services infrastructure. The current difficult economic climate, which has persisted since the end of 2007 and is likely to continue for some time, might actually help the situation in the short term. Workers who are close to retiring or have already retired might decide that the uncertain times require a delay of retirement or a return to work. This will mean that more workers than previously expected are still on the job, at least initially, and will allow more time to put new strategies in place to address the longer term shortfalls. In any case, employers need to recognize that encouraging early retirement and offloading older workers because of their higher salaries are no longer viable business strategies. In fact, salary increases and benefits that promote flexibility (which are as important to older workers as they are to workers with young children) should be considered as part of the new mindset of keeping older workers as long as possible, well beyond traditional retirement years.

NCD and Manpower do not believe that a strategy of importing workers from other countries is likely to work. For many years, our economy has turned to immigration to ensure adequate numbers of workers in certain jobs. However, supply shortages of critical disability infrastructure occupations are occurring globally, not just in the United States. These workers will find opportunities in their home countries, and the increasing demand will likely drive up wages, reducing the allure of working in the United States. U.S. employers should focus on training, not only for new employees but for longer term employees as well, to improve productivity and provide opportunities for career advancement.

Figure 3 summarizes a general strategy for dealing with shortages through a multifaceted approach that NCD believes will also benefit disability services infrastructure companies. The strategy involves identifying the current demographics of the workforce and forecasting how things will change over the coming decade.

Figure 3. Forecasting and Planning for Future Retirement-Related Talent Deficits

Source: Manpower (2007). The New Agenda for an Older Workforce. Milwaukee,WI: Manpower, Inc.

A demographic-based forecast will provide clues to help identify workers who are likely to consider retirement and those who will need to focus on elderly parents or young children. Tracking turnover trends will allow employers to understand replacement needs as well as the reasons workers leave. Inadequate pay is the reason for much of the turnover, but it is not the only reason. Family responsibilities are significant factors in different ways, depending on the employee's age and gender. These assessments will suggest how employers can revamp benefit plans to attract and retain employees. Meanwhile, employers need to study their markets and forecast what the demands are likely to be—not just the number of workers but the skill sets employees must have to ensure that the company is competitive. Once these supply-and-demand projections are in place, employers can decide which recruiting, training, and retention strategies will be most successful. Too few employers engage in these strategic planning activities and thus are unprepared to deal with worker shortages.

For employers that do plan strategically, the next task is to consistently recruit and prepare a competitive workforce. Figure 4 summarizes this process.

Figure 4. Optimizing Talent Flow

Source: Manpower (2007). The New Agenda for an Older Workforce. Milwaukee, WI: Manpower, Inc.

Proactive companies will partner with local schools and postsecondary education institutions to allow students to see firsthand what opportunities are available and to provide experiences for them to learn about the world of work. Students need to have realistic perceptions of careers early on so their career decisions are informed and aligned with their values, interests, and needs. Too few employers engage with schools, teachers, and students in their local communities.

Career development should involve all employees. For new hires, employers need to demonstrate the long-term career potential and set them on a path to acquire skills through training and development. Employees should have individualized plans for developing their careers with their company, including internal and external learning opportunities for which they and their employers share responsibility. For employees in mid-career, the focus should be on ensuring that skills and knowledge are upgraded to mesh with changes in the marketplace. Workers should have a clear understanding that their companies do not want them to become obsolete; rather, the company wants them to remain as valuable as when they were first hired. Companies should collaborate with older workers to assess the needs of the company and the worker, and should offer flexible approaches that are mutually advantageous. The key to lowering turnover rates and keeping workers is to demonstrate to employees that they are valuable assets, and that the company wants to retain and promote them. Offering ongoing skill-building opportunities, accommodating employee needs, and rewarding workers according to their productivity are beneficial strategies for all.

Employers can take many other steps to ensure that their employees become more productive and remain with the company. Employers need to establish an open and accepting corporate climate to ensure that workers from diverse cultures, including those with disabilities, feel welcome and have equal opportunities to fulfill their and their families' needs. This includes the following:

Offering performance-based compensation that rewards accomplishment, not just tenure.
Treating employees with respect and expecting workers to treat each other with respect.
Specifying expectations in a way that is clearly understood. This may require different approaches for different people.
Ensuring that everyone has a sense of belonging and is welcomed.
Treating all workers the same way.
Providing access to equipment, tools, information, and other supports and resources to enable workers to efficiently accomplish their assigned tasks.
Training workers to do their jobs and to adapt their skills and knowledge to changing circumstances; and using online technologies to provide training in a more timely and efficient way.
Implementing a consistent, fair, and regular feedback system for workers, including two-way communication and flexible channels. The system should inform them about their strengths and weaknesses, and result in a plan they can implement to increase their productivity.
Using teamwork approaches wherever possible so that workers understand how they fit in and contribute.
Recognizing workers' contributions in tangible ways.
Providing opportunities for advancement.
Helping workers plan a gradual transition to retirement.
Keeping workers informed about the company's progress and success in the marketplace.
Giving workers as much assurance as possible about their job security.

By demonstrating their will and skill in accommodating the needs of workers with disabilities, employers send an important message to all workers. Besides recognizing the potential of workers with disabilities, broadly disseminated guidelines about accommodations often become best practices, driving productivity enhancement for all workers.

In the future, employers will face much greater challenges to ensure an adequate supply of qualified workers. Employers will have to provide proactive and flexible work arrangements for all employees and be much more sensitive to their needs. Flexible work schedules have already created some opportunities for women with children, but they are important for older workers and those with disabilities as well. Similarly, training should be a constant concern for workers at every stage of their careers.

Recruitment Strategies

The purpose of recruitment strategies is to identify and target the right people and bring them into the company. This requires a clear understanding of the skills and abilities that will be needed in the future to replace retiring workers and succeed in a changing marketplace. Figure 5 illustrates the strategy of balancing recruiting and retention to match future needs.

Figure 5. Managing the Talent Pipeline

Source: Manpower (2007). The New Agenda for an Older Workforce. Milwaukee, WI: Manpower, Inc.

It will become increasingly critical for employers to identify potential workers with the skills that will yield a competitive advantage. In addition to skills, however, infrastructure companies need to recruit workers who have the attitudes and values that are the hallmarks of those who serve people with disabilities. By practicing the proactive workforce management strategies outlined in this section, companies can solidify their reputations as employers of choice, and improve their recruiting and retention efforts. In light of the economic constraints most companies are experiencing, a good reputation can help overcome the inability to offer attractive financial packages to new recruits who have high potential.

To link recruitment and workforce management, companies can partner with the education and training pipelines that provide entry-level and advanced skills to new and current workers. Partnering with these resources will help them equip students and trainees with appropriate skills, and provide connections for their graduates. Adding work experience and internships to the partnerships allows all parties to assess the quality of the fit between recruit and employer. This strategy can help eliminate trial-and-error in the hiring process.

Another partnership opportunity for employers exists with community-based rehabilitation programs and the State vocational rehabilitation agencies. These organizations and agencies are willing to train new workers with disabilities specifically for partner companies, often at no cost to the companies. The workers are then provided with ongoing assistance, as needed, to ensure their long-term success and retention. And employers can take advantage of tax credits for hiring these workers. This strategy can reduce labor shortages and employ people with disabilities at the same time.

Companies must clearly define the skill sets needed by their infrastructure workers. For each job description, they need to specify essential job functions and list the experiences that typically provide opportunities to learn these skills. Clearly defining skill sets enables a company to assess whether applicants have the entry-level skills to begin productive service and what training they still need to gain increased productivity. Beside skills, companies need to have interview procedures in place that will reveal an applicant's values and whether they are compatible with the company's mission to serve people with disabilities. Without skills and values, the match is not likely to be successful.

Successful Return-to-Work Strategies

This section explores employer programs to prevent disabilities from occurring in their workforces and to manage the return to work of injured or disabled employees. These programs help retain good workers, minimize the long-term impact of injuries and illnesses, and demonstrate that the company values its workers with disabilities. When a disability infrastructure company uses these strategies, it contributes to the supply of infrastructure workers and provides employment for people with disabilities at the same time.

Most employers have disability management (DM) programs to retain current employees who have suffered a disabling injury. Disability management is driven by the need to comply with government mandates, reduce the cost of providing employee benefits, and retain the skills and knowledge of valuable employees.

DM programs are typically offered by external vendors for eligible employees as a benefit of employment. The process of verifying eligibility for benefits is usually much simpler than in public sector services. Compared with public sector services, the workers in these programs often have better prospects for successful return to work: They have been off work for only weeks or months and most still have jobs to return to. Consequently, these DM programs often use different staffing approaches and resources than public sector programs, reducing potential competition between the two systems over the supply of disability management occupations.

DM programs, particularly those that are administered internally, may employ a master's level professional with certification credentials who oversees programs for large work sites or multiple sites, or is used on a contract basis. A lean staff performs a reduced set of functions in-house; many functions are outsourced to insurance companies or other vendors. Two functions, however, are frequently part of an employer's in-house staff: the return-to-work coordinator and the case manager.

Return-to-work (RTW) coordinators work with all stakeholders (medical, insurance, supervisors, co-workers) to develop and implement an RTW plan for an employee after an injury or the onset of a temporary disability. RTW coordinators are most common in manufacturing, utilities, construction, and other industries where employees perform physical work. RTW coordinators may have earned specialized credentials through a professional association with continuing education requirements. They may be experienced employees who have no formal rehabilitation credentials but have returned to work themselves after a significant disability event and have received on-the-job training in the RTW process.
Case managers orchestrate compliance with insurance or medical requirements during the RTW process and facilitate information exchange between the employer and medical providers. Case managers are used in virtually all industries and professions. Most medical case managers are registered nurses with an additional credential; those who manage insurance cases may need only the case manager credential.

Research has found that successful DM programs usually include the following components:

A strong commitment throughout the workplace to health and safety.
An employer who makes early, considerate contact with injured/ill workers.
An employer who offers work accommodation to facilitate RTW.
An RTW plan that supports returning workers without disadvantaging co-workers or supervisors.
Supervisors who are trained and included in RTW planning.
The use of an RTW coordinator or case manager.
Exchange of information between the employer and medical providers.

This list does not explicitly include ergonomic evaluation because most ergonomics goals are achieved through the work accommodation offer, which often can be developed in an interactive process with the returning worker without incurring the expense of a master's level ergonomist to perform a full evaluation. Employers typically focus on returning injured/ill employees to their original job, perhaps with a modification to accommodate temporary or permanent impairments.

Most employers who are active in groups such as the Disability Management Employer Coalition (www.dmec.org) acknowledge that there is room for improvement in their DM programs, including efforts to identify employees at risk for disability and systematic early intervention to prevent disability. These efforts could reduce the number of disability claimants moving from the employment sector to social services.

Private sector return-to-work and disability management programs are a useful complement to the public sector disability services infrastructure. Progressive employers actively seek to prevent or reduce disability claims, thus reducing the number of people who lose employment and apply to the public sector for services. The private sector does not aggressively compete with the public sector for disability services professionals. The private sector uses master's level professionals conservatively and relies extensively on credentials or designations that have a commercial insurance focus that is not necessary in the public sector, where greater efforts are expended on verifying eligibility for benefits. NCD encourages the public sector to use the recruiting, retention, and workforce management strategies of private sector organizations to reduce the gap between supply and demand in the disability services infrastructure.

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Section 5. Public Sector Strategies for Building and Maintaining a Sufficient Supply of Disability Infrastructure Occupations

In this section, we describe how the public sector, in partnership with the private sector, can support the nation's efforts to provide a suitable workforce infrastructure for people with disabilities over the next 10 years. "Public sector" refers to the tax-supported federal, State, and local education, health care, and employment programs that serve people with disabilities. The term also includes programs and systems that serve the overall population, including people with disabilities. All these service providers must ensure that they have an adequate supply of qualified personnel to help people with disabilities become labor market participants, improve their overall quality of life, and gain greater access to opportunity.

Publicly funded programs not only require a suitable workforce to meet the increasing demand for their services, they also can lead by example by hiring people with disabilities. The Equal Employment Opportunity Commission, for example, employs people with disabilities at a rate that is nearly 2.5 times higher than the average for all federal agencies. The Social Security Administration has a "Schedule a Hiring" initiative with simplified hiring protocols that make it easier to hire people with disabilities.

Public agencies and programs can establish practices and services that ensure an adequate supply of workers, hire qualified people with disabilities as part of their frontline workforce, and equip workers with the ability to provide high-quality services. These workforce goals can be approached using multiple strategies. First, public sector agencies can adopt the workforce planning management practices already in use in the private sector (outlined in the previous section) to recruit, hire, and retain a sufficient workforce. Second, the mission of many of these programs is to focus on the employment needs of people with disabilities and to provide them with competitive, marketable skills so they gain greater financial independence and improved quality of life. These programs can promote careers in the disability services infrastructure by providing information, education, skill training, connections, and on-the-job support to their consumers. People with disabilities are underemployed and, because of their knowledge and personal experience, are well-equipped to work in the disability services infrastructure. Publicly funded employment programs need to focus on the opportunities available to people with disabilities in their own services infrastructure. This section will provide an overview of potential opportunities in the public sector. Some of the data presented can be used as benchmarks or performance indicators of outcomes achieved in public sector programs. These measures can give us a sense of the quality of services provided, which we can then use as a baseline to assess improvements anticipated over the next 10 years. It is not enough to have an adequate number of workers; we need an adequate supply of qualified workers.

Employment Services for People with Disabilities

State-Federal Vocational Rehabilitation Services System

The flagship of employment services for people with disabilities in the United States is the State-federal vocational rehabilitation (VR) program. Eighty programs, under the leadership of the Rehabilitation Services Administration (RSA) of the U.S. Department of Education, exist throughout the 50 States. Some States have two agencies: one to serve the general population of people with disabilities and a second to serve people with vision impairments. A primary goal of these agencies is to help people with disabilities become more independent through employment.

Each year, these agencies serve more than 600,000 people with disabilities; more than 200,000 of these people obtain jobs in the community. According to 2006 data, more than 205,000 people with disabilities were placed in jobs that year as a result of receiving services from the VR program. Of these, it is estimated that more than 28,000 (14%) were placed in disability services infrastructure jobs. Although this is a fairly high proportion, it can be even higher, as the demand is likely to be much greater in the foreseeable future.

VR agencies and programs need to focus on outreach strategies to infrastructure employers so that connections to jobs are more readily available to consumers of VR programs. Private-public partnerships for training and placing people with disabilities with infrastructure employers have been successful and should be expanded, and on-the-job training has been a consistently successful strategy for employing people with disabilities. Formal training and education programs for preparing people for infrastructure jobs funded through the VR system also need to be expanded to accommodate the increasing number of referrals from the VR.

In June 2009, the unemployment rate for people with disabilities was 14.3 percent, while the overall rate was 9.5 percent. A month later, in July, the unemployment rate for people with disabilities jumped to 15.1 percent, while the rate for those without disabilities remained at 9.5 percent. Given the high demand for infrastructure positions, many employment and long-term career opportunities should be available in this sector for people with disabilities. Many people with disabilities are placed in entry-level jobs that pay low wages,[22] but this is true for the population in general. However, these jobs need to have career potential so wages can increase and people can attain their desired quality of life.

Studies point to the need to focus on services that build an employer-consumer connection before placement, so doors will open more readily for people with disabilities.[23] Finding a job should not be left to chance; direct support services are needed to help a person get that first placement. Ongoing support and training during the early stages of holding a job also appear to be valuable contributing factors to long-term success. Developing services to help employers hire people with disabilities—such as accommodation support, job-matching, on-the-job support services, and disability management—can also benefit the employment prospects of people with disabilities. VR programs need to build their capacity to be direct intermediaries in the labor market so that many more people with disabilities obtain jobs with career potential.

In 2007, the Government Accountability Office (GAO) analyzed the State-federal VR system's ability to serve beneficiaries of Social Service Disability Insurance (SSDI) who were seeking to return to work.[24] The results were uneven, but the report identified certain factors that seemed to achieve desired outcomes. They included the following:

Close ties to the business community.
Collaboration with other agencies.
Spending a greater proportion of their funding on training.

Agencies with a higher proportion of certified counselors were more likely to help beneficiaries become employed and independent of SSDI income supports.

NCD conducted a review of State VR agency programs for youth with disabilities transitioning from school to work and offered recommendations to improve services and outcomes (NCD 2008).[25] The NCD report concluded that transition-age youth were definitely becoming more of a focus for the VR agencies and that programs should concentrate on the following:

More rigorous research and evaluation are needed. It was not clear which services contributed to the desired outcomes, because the research base did not have adequate methodologies to establish evidence-based practice guidelines.
VR agencies should establish specialized units of professionals dedicated to serve this population, and should devote training resources to this area.
VR agencies should continue to build on their collaborations with schools and other community-based organizations to serve these youth.

Finally, GAO conducted a review of the overall performance of the State-federal VR system.[26] The review analyzed how well the system monitored its own performance so that ongoing improvements could be made on the basis of feedback. Conclusions included the following:

Monitoring was not timely and needs to be speeded up.
Outcomes for specific populations, including transition-age youth and SSDI beneficiaries, are not tracked; thus, it is difficult to measure the success of policy initiatives undertaken for various groups of people with disabilities.
The extent to which the VR system meets the needs of the population it is intended to serve is not clear. Although the system serves a large number of people each year, it is not known how many more people need the service.
No incentives or sanctions exist to help VR agencies focus efforts on improving their performance in desired directions.

Department of Veterans Affairs

The Department of Veterans Affairs (VA) offers a vocational rehabilitation program to veterans with disabilities. GAO conducted a review of this program in 2008 and prepared a report to Congress.[27] The reported concluded that the VA VR program was improving by having service tracks tailored to the different needs of veterans but that the focus on employment services, as opposed to training and education, was lagging behind. The report recommended that incentives for veterans to attend schools and training programs be extended to veterans who were on track for direct placement into jobs. The VA was commended for collaborating with other programs in pursuit of direct employment, but GAO believed that more could be done.

In particular, the VA VR program was encouraged to continue building on its collaboration with State VR agencies, primarily to take advantage of the employer networks these agencies have in place. The VA VR program was encouraged to build its own relationships with employers to improve direct employment opportunities for veterans with disabilities. Finally, GAO commented that the VA needed to engage in strategic planning to determine its workforce needs, because too many regional offices lack the necessary staff to fully implement the direct employment service program. This is increasingly important as the wars in Iraq and Afghanistan create increasing numbers of veterans with disabilities.

Another significant workforce opportunity is the VA's new Post 9/11 GI Bill of 2008, which took effect in August 2009, creating new education benefits for service members who have been on active duty for 90 or more days since September 10, 2001. These benefits are tiered on the basis of number of days of active duty, which gives currently and previously activated National Guard and Reserve members the same benefits as active duty service members. The benefits include the following:

Up to 100 percent tuition and fee coverage.
A monthly housing stipend.
Up to $1,000 a year for books and supplies.
A one-time relocation allowance.
The option to transfer benefits to family members.

It is hoped that the VA will use these generous benefits not only to assist veterans with their career needs but also to connect them to the vocational possibilities of the disability services infrastructure, including the workforce needs of the VA itself.

Ticket to Work of the Social Security Administration

No discussion of employment programs for people with disabilities is complete without mentioning the Ticket to Work and Self-Sufficiency Program based in the Social Security Administration. The program has potential, but to date it has not met expectations as far as helping SSI and SSDI beneficiaries replace benefits with employment.

Several trends offer hope that the Ticket program will improve on its past performance. In July 2008, SSA implemented new rules making the program much more attractive to private sector employment networks (ENs) that serve consumers. The new rules provide a much more favorable environment for collaboration between State VR agencies and ENs. These infrastructure improvements are expected to increase the number of ENs providing services from the 1,200 enrolled in 2008 to 5,000.

The Ticket program is not based on a fee for service. Rather, providers are paid only if they generate employment outcomes leading to termination of SSDI benefits. Many EN providers are private sector nonprofits already participating in other government programs to serve people with disabilities. Some are for-profit companies that have streamlined methods to secure job placement, which is to be expected under an outcome-based program.

The Ticket program and other SSA initiatives could change the economics of disability insurance and disability services in the United States. While State VR agencies have a mandate to serve people with significant disabilities, the Ticket program makes it more profitable for ENs to serve people with less significant disabilities. Ideally, the Ticket program can secure employment for these people and reduce the numbers of SSDI and SSI beneficiaries. In turn, this would reduce the demand on the Social Security Trust Fund, which is an important goal.

In addition, private sector disability insurance carriers routinely seek to place their long-term disability beneficiaries on SSDI to reduce the carriers' own costs. While many of these people are entitled to SSA disability benefits, the Ticket program could be modified in ways that would motivate insurance carriers to maintain a longer term commitment to help people return to work, thus reducing their own costs over time. SSA has an early intervention demonstration project that would essentially use a return-to-work attempt as part of the disability determination process, with protocols aimed at both VR agencies and ENs. In addition to reducing the rate of approval for SSDI benefits, this program could change the disability culture at SSA into a more employment-focused culture. Many people in the insurance industry and the general public perceive SSDI as a "permanent and total" workers' compensation claim, yet SSDI need not be a direct route to permanent disability status.

Among the quality-monitoring improvements in the new rules, the Ticket program rewards EN providers that help people stay employed for 5 years or more. SSA is also researching other improvements to work incentives that could give beneficiaries a more favorable benefits scenario for seeking employment.

Any public-private partnership of this magnitude—based in an agency as large as SSA, which has other primary goals—is bound to face challenges. But the new Ticket program rules and other efforts at SSA, combined with private sector investment in serving people with disabilities, are beginning to address those challenges.

Workforce Investment Act (WIA) and One-Stop Centers

Another key program serving people with disabilities is the One-Stop Center created by the Workforce Investment Act of 1998 (WIA). The WIA is designed to integrate the entire workforce development system funded through the Federal Government in each of the States. One-Stop Centers are the hub of this effort—they provide comprehensive services to job-seekers and employers on a local basis throughout the nation. Included in this network of employment services are the Employment Service and the Unemployment Insurance program. The State-federal VR program is also a mandated partner.

State and local Workforce Investment Boards are in place to ensure that services address local needs. These boards must have a majority of private sector representatives as well as representatives from human services agencies, including educational systems. One-Stops are required to collaborate and integrate services with the local offices of the State-federal VR system. This can go as far as co-locating staff from the two systems to ensure coordinated planning and allocation of resources at both the organization and individual consumer levels. GAO studied exemplary One-Stop programs; the findings suggest that One-Stops need to incorporate the following components into their services:[28]

Seamless access to all services.
Services for employers, with dedicated staff to ensure that employers' needs are considered.
Strong collaboration with other community-based programs that increase and focus resources on workforce development.

However, in spite of the intention of the One-Stops to increase accessibility, a recent study indicates that access issues remain for people with disabilities.[29] These issues include physical access, in that One-Stop locations are not within reasonable distance for many people with disabilities; inaccessible space; and difficult internal program referrals. A 2007 GAO study found that fewer States reported VR co-location sites than in an earlier study, although more reported having electronic referral capabilities.[30] Another study identified the following limitations in One-Stop services for people with disabilities:[31]

Inaccessible locations.
Inaccessible computer equipment, which WIA consumers are expected to use.
Automatic referral of people with disabilities to the VR program without first providing WIA services.
WIA outcome measures focused on employment, earnings, and credentials of those who exit the programs. This emphasis may be a disincentive for One-Stops to serve people with disabilities, who, as a group, tend to have lower employment and earnings rates. However, this is one of the very issues WIA programs are designed to address.

Given the problems in recognizing the service needs of people with disabilities, the WIA One-Stops are not likely to be sensitive to the disability services infrastructure. Although these issues may be alleviated to some extent as time goes on, a more deliberate emphasis and focus on the employment and service needs of people with disabilities seems warranted.

New Technologies, New Opportunities

VR and employment programs need to take advantage of new technologies to assist people with their employment needs. Using these technologies, it is possible to imagine new ways to empower people with disabilities to access many more labor market opportunities. VR agencies need to be on the cutting edge of how to use these technologies for the benefit of people with disabilities. Many innovations are being driven by Web 2.0 technologies, which hold great potential to improve work opportunities and quality of life for people with disabilities everywhere.

New software and computer network technologies, and their broader acceptance and use in our daily lives, suggest a good business case for rehabilitation uses. The new breed of inexpensive, fast, reliable Web-based solutions is empowering persons of all backgrounds to take greater control over their lives, and they are environmentally friendly as well.

The growth of Internet and other technologies, driven by the reduced costs of global communication, is changing how we think, socialize, shop, and learn, and influencing how we will work in the future. Technological innovation is driving change—behavioral change in particular. The change is good news for people with disabilities, and it is here to stay. Trends worth highlighting include social networks built on Web 2.0 technology, and SaaS (software-as-a-service) and Cloud Computing, which enable companies to bring transformative innovation to the world of work.

Social networks are having a huge impact on how people socialize, gather information, stay informed, and solve problems. As this new medium gains wider acceptance and adoption in both personal and work environments, it can be further customized to focus on particular subsets of populations, targeting their specific needs and wants. We can explore new applications of social network platforms to create communities specific to people with disabilities, in which people with similar interests and needs can exchange volumes of useful information instantly and at minimal cost.

To see how this might work in practice, consider www.myvetwork.com, a fast-growing social network platform, custom-designed for persons associated with the U.S. military (active duty or veterans) and their spouses, families, and friends. (Compliance is not required of nongovernment organization Web sites, but the Internet sites mentioned here should comply with Section 508 of the ADA. The degree of compliance may change at any site at any time.) Recognizing this group's unique needs and challenges, MyVetwork is creating a unique, independent, trusted source of information driven by its members' collective interests and desire to stay in touch.

The second trend is the proliferation of technologies that hold the promise of changing how work is done or—even more important—where it is done. The advent of the Internet makes it possible for work to come to us. The barriers to flexible work have been removed, benefitting both workers and the companies they serve. People have the freedom to structure their time around family and other needs. Workers are empowered and new opportunities exist for those who have traditionally been left out of the workforce. People with disabilities, retirees, stay-at-home moms, dislocated workers from industries that permanently left local communities—these people have a vast array of skills, and now they can offer their services to companies that are increasingly looking for talent that may not be available in their local labor markets.

The opportunity for cost savings and improved productivity for corporations is tremendous, and they are starting to adopt the new mindset. Industry leaders in SaaS and Cloud Computing are developing technologies that enable them to link corporations looking for talent with "virtual workers" and home-based workers who prefer to work flexible hours or work from a distance. It is all about options and choices benefiting both individuals and the corporations that employ them. People with disabilities can make those choices on a large scale for the very first time, as much as any other group of workers, and they can realize the benefits of working from home or from any other location they desire.

A technology platform that provides services to both employers and teams of employees is called www.livework.com. LiveWork offers employers high-quality work and accountability, and independent workers (referred to as "experts") gain an infrastructure and the option of working for multiple companies. Both the companies and the experts can count on efficiency and community. With LiveWork, companies can outsource work to communities of virtual workers without the need to sign lengthy contracts with outsourcers. Any business can advertise its need for virtual workers and workers can find projects, as well as promoting their own services. Each worker's profile includes information about his or her work history, reputation, and so on.

LiveOps (www.liveops.com) has developed the leading on-demand contact center platform, which it uses to operate a virtual work community of 20,000 independent agents in the call center space. LiveOps is in a unique position to take this concept to the next level and create the next-generation technology platform that could revolutionize the world of work: an online marketplace that enables teams of free agents to sell their expertise and services to buyers of labor. This networked community of workers is a central market where buyers and sellers can convene, create work teams, converge, and transact business.

LiveOps intends to do for the world of work what eBay did for commerce, and technology has advanced to the point that such an endeavor is possible. At the same time, three worldwide trends are converging to create a perfect environment for a global labor market: ever-increasing productivity, globalization, and environmental stewardship.

A nondiscriminatory virtual employment market is further supported by the corporate trend of using talent management and applicant tracking software (also delivered as SaaS) to automate recruitment, assessment, hiring, and on-boarding processes. The automation helps employers with compliance while at the same time having a positive effect on employment of special groups. It is a win-win situation for employees and employers. People with disabilities need to have access to these technologies so they can participate competitively in these new labor markets.

Health Care for People with Disabilities

Access to health care is a major concern of people with disabilities everywhere.[32] Studies describe either the lack of access to appropriate treatment or the receipt of inappropriate or perhaps even harmful treatment as a result of the lack of knowledge and experience of treatment providers.

One solution being considered in health care reform is the "medical home model," built around the relationship between the primary care physician and the patient. The physician is expected to get to know the patient and his or her needs, and coordinate all needed care with other treatment providers. If this approach is successful, it will help ensure that people with disabilities get the treatment they need, at the right time and from the right provider. However, there are not enough primary care physicians to met current and future demand, especially if this model is introduced as part of health care reform.

Electronic medical records are touted as a technology that can improve the quality of services and reduce costs at the same time. These systems have the potential to provide substantial benefits to physicians, clinic practices, and health care organizations. They can facilitate workflow and improve the quality of patient care and patient safety. The Institute of Medicine has identified the application of information technology as a primary means to improve the quality of health care. However, health care IT professionals are in short supply. Recognizing this, the Administration and Congress included the Health Information Technology for Economic and Clinical Health Act (HITECH) as part of the American Recovery and Reinvestment Act (ARRA), and provided $19 billion for health IT. Not only is this investment potentially significant for the health of people with disabilities, it presents career opportunities for them that the VR and education systems need to pursue.

The current health care reform debate (fall of 2009) is of central importance to everyone who is concerned about the health of this significant population. The debate seems to focus primarily on the costs associated with various reform proposals rather than on the quality of care provided. Of course, cost is a factor in quality, but it is not the only factor.

ARRA and the various health care bills being debated all include investments in the quantity and quality of health care personnel at all levels of the continuum. To illustrate, on July 28, 2009, the Department of Health and Human Services announced that $200 million in ARRA funding was available for the training and financial support of health care professionals. These funds will be used for scholarships, loans, grants, primary care training programs, and increasing the diversity of the professional workforce, among other purposes. Another $300 million in ARRA workforce funds will be used to expand and develop the Health Resources and Services Administration's (HRSA's) National Health Service Corps. When health care reform becomes a reality, it is likely that more services will be needed to meet the increased demand. Given that a shortfall in personnel is projected under current scenarios, any increase in services will only increase the supply-demand gap. Using ARRA and health care reform funding not only to expand but also to improve the quality of services will be imperative, if costs are to be controlled and outcomes improved.

It is not clear how the anemic economy will fare in the next few years; however, evidence exists of increasing demands on the Medicare system as applications for SSDI benefits rapidly escalate. This is to be expected, with many people nearing retirement age or being laid off. Under more favorable circumstances, they might continue working despite health conditions. But with no work available, these conditions can be used to obtain SSDI along with Medicare. Even before the economic downturn, it was clear that Medicare funding streams would not be sufficient for future needs. Now the recession is likely to bring more beneficiaries into the system, with a corresponding shortfall in tax revenue owing to high levels of unemployment, putting Medicare funding in a vise.

A core issue in the current debate is that providing more services to more people will increase the pressure on the health care system and will continue to drive up costs, as demand outstrips supply. Depending how the issue of cost is resolved, many different things could happen. If more costs are shifted to employers, they might lay more people off or keep wages low, thus further reducing the supply of disability service workers. If costs are moderated by controls placed on what health care providers can charge, incentives to enter the field will be diminished, thus contributing to a future imbalance between supply and demand. Until health care reform becomes a reality, it will be difficult to anticipate and plan for sufficient infrastructure staffing. Many administrators of health care and social service programs hesitate to use stimulus money to hire staff, because the funding is only temporary and the means to maintain these new staffing levels are not likely to emerge in the current economy. Thus, whatever programming can be done in the short term with stimulus funds to train and upgrade the skills of current health care personnel would seem to be a wise investment. Similarly, reducing the costs of entering the health care field by providing funds for tuition and related education/training costs, including improving access to needed credentials, would likely entice more people to pursue health care careers and mitigate the projection of an imbalance between supply and demand.

Education and Youth with Disabilities

The education system focuses on providing the foundation for students to become productive, independent citizens. For most, this means pursuing postsecondary education and training, or becoming employed. Employment for youth with disabilities is a concern for the VR system and for the schools, but in spite of efforts over the past decade to increase collaboration between VR agencies and schools, improvements in outcomes are lagging. In general, unemployment rates for youth ages 16 to 19 years are about three times higher than the rates for older workers. For those 19 to 24 years old, the rate improves somewhat but is still about double the rate of other age groups. Of course, employment rates are lower because many in these age groups are in educational and training programs. It is well known that early employment experiences and successful completion of academic and training programs translates into long-term gains in employment, financial independence, and quality of life. It is important that youth with disabilities become engaged in personally productive activities, such as further education and employment, to whatever extent possible after they leave secondary education.

One national study presents an exceptionally robust and useful window on the impact of education on employment-related experience of youth with disabilities. Longitudinal research sponsored by the Department of Education and conducted by SRI International has followed a nationally representative sample of more than 11,000 special education students since 2000. A 2009 report presented findings describing the experiences of these youth, who had left high school by 2005.[33] In some instances, data collected from them was comparable to data collected from youth in the general population. Comparisons of the data enable us to measure the similarities in the post-high school experiences of youth with and without disabilities. Much of the effort in policymaking and practice innovations over the past 30 years has been devoted to providing accommodations to youth with disabilities so they can compete with their peers when they reach adulthood. The following are some of the more salient peer comparison findings from the 2005 data (unless otherwise noted, these results refer to youth with disabilities):

Forty-five percent of youth with disabilities continued on to some postsecondary education within 4 years of leaving high school, while 53 percent of youth without disabilities did so.
Fewer were likely to be attending 4-year institutions (8% vs. 29% of youth without disabilities).
Fifty-five percent of those who were identified as having a disability during their secondary education did not consider themselves as having a disability during their postsecondary experiences.
Of those who reported their disability status to their postsecondary institution (37%), fewer received accommodations than when they attended secondary schools (24% vs. 84%).
A large majority who received accommodations believed that they were helpful and that they were getting the right assistance.
Almost 90 percent of the students reported that they were pursuing a specific degree or certificate.
Seventy-two percent reported having worked at some time since leaving high school, with some holding up to three jobs. Of the latter, 58 percent reported working full time at one of their jobs.
Of those who held jobs, 19 percent reported that their employers were aware of their disabilities and 3 percent reported receiving accommodations.
A majority of working youth reported liking their jobs (85%), being well treated (87%), and receiving good pay and advancement opportunities (67% and 78%, respectively).
Eighty-five percent had been engaged in employment, postsecondary education. or training since leaving high school.
Approximately 20 percent did not complete high school. Differences between them and their counterparts who finished high school showed up almost immediately.
Noncompleters were less likely to enroll in postsecondary education (51% vs.17%) and more likely to have engaged the criminal justice system.

These findings show that a high proportion of youth with disabilities actively prepare for their futures in positive ways, in numbers that are comparable to those for youth without disabilities. However, certain evident disparities—in completing secondary education and moving on to postsecondary opportunities, particularly 4-year programs, and in access to accommodations during postsecondary education—require ongoing attention. Any gaps at this early stage of career building and community participation will be more difficult to make up as time goes on.

Community Colleges

The system of community colleges throughout the United States is the perfect resource to help youth with disabilities transition to productive adulthood. Community colleges are increasingly seen as the key link between students and their careers. One of their strengths is their focus on career and technical education (CTE), which often directly connects students with work experiences.

The College and Careers Initiative, sponsored by the U.S. Department of Education, funds programs that link high school students with career tracks that extend to associate or bachelor's degree programs, or certification programs. These programs make direct connections between high school and postsecondary curricula, eliminating the problem students often face of having to take courses that are irrelevant to their career pursuits. The programs also strive to eliminate the problem of transfer credits between 2-year and 4-year colleges.

CTE programs include employers as partners to ensure that students acquire needed skills and experiences, and that job opportunities are available when students complete their programs. The goal is to keep students involved all the way through to completion and to connect them with high-demand jobs. This is a highly promising approach to address the workforce imbalance in the disability services industry. The career pathways pioneered by community colleges should be adopted as a workforce development strategy. For example, in the health care industry, a career pathway would enable youth to become nurse aides, then practical nurses, and eventually registered nurses or even nurse practitioners.

Summary

In the three critical sectors of education, health care, and employment, major efforts to provide opportunities to people with disabilities are meeting with success. Many people with disabilities are participating in life arenas of their choice because they took advantage of a disability services infrastructure that offered a continuum of opportunities. And many businesses, educational institutions, and community-based organizations are providing needed accommodations, enabling all of society to benefit from the contributions of people with disabilities. But although many positive signs and trends are apparent, discrepancies in key quality-of-life areas remain to be overcome. Positive momentum is threatened by workforce shortages that were projected even before the current recession.

Near-term efforts are needed to engage the political process to do the following:

Maintain current services.
Invest now in accommodating current and future workforces.
Strategically plan how public and private sectors will work together to engage all people with disabilities in economic and social infrastructures.

This can be the era when the United States moves from a gaping patchwork of programs to a strategically driven disability services infrastructure, staffed by highly qualified workers.

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Section 6. Recommendations

This NCD review indicates that the disability services infrastructure has grown stronger over the past 20 years and has addressed serious deficiencies associated with the quality of life of people with disabilities. However, most of the indicators suggest that quality of life for these people still lags behind that of others in our society. The infrastructure must be enhanced, both in terms of the number of workers needed to fill the required positions and in terms of the skill levels, tenures, and organizational supports provided to them, including wages and benefits. Data indicates that the need for these services will increase, especially as the baby boomers age into their retirement years, increasing the demands on infrastructure resources. Couple the increased demand with the boomers' withdrawal from the workforce, and the imbalance between supply and demand is inevitable. Knowing in advance that this will happen compels a proactive response as soon as possible. We should not let any difficulties deflect us from the goal of ensuring that all services and their expected outcomes support participation by people with disabilities to the same extent that they support the participation of other citizens in any social enterprise. The following recommendations focus on actions that should be considered in this light.

Recommendation 1:

Establish a mechanism to track ongoing economic, social, labor market, and professional developments so that new information can be used to redirect planning and actions in support of the disability services infrastructure. The reality of the future workforce may bear little resemblance to the projections provided here, and unforeseen events and forces might change the balance between supply and demand. These events and forces must be identified and accounted for quickly. The Departments of Labor and Education should partner to provide leadership to the nation on this issue.

Recommendation 2:

Currently, not all occupations specific to the disability services infrastructure are tracked by the Bureau of Labor Statistics (BLS), which makes it difficult to plan for shortages. In addition, these occupations are not well known to the general public, because information about them is hard to find. More definitive coverage of these occupations in the BLS data system would be very useful in overcoming workforce supply and demand imbalances.

Recommendation 3:

Among its many potential labor sources, our society needs to fully tap the underutilized pool of workers with disabilities. The infrastructure agencies—including the State-federal vocational rehabilitation (VR) system, the Department of Veterans Affairs (VA), and private sector companies that serve people with disabilities—must begin planning strategically to hire more workers from the population they serve. Accommodations are critical to making this happen. Infrastructure buildings and transportation systems need to be fully accessible if significant employment gains are to be made by people with disabilities. The Department of Transportation should be in the forefront, leading the way to resolving transportation issues.

Recommendation 4:

Ensure that partnership opportunities are encouraged between the public and private sectors. Combined public-private initiatives will be required to provide the strategic planning to fully fund and provide for the social, educational, and health care needs of all citizens, not just those of older people or people with disabilities. Given their presence in communities in each of the 50 States, VR agencies and Workforce Investment Act (WIA) One-Stops are ideally positioned to ramp up collaboration with each other and with local employers and education-training programs.

Recommendation 5:

Establish systematic efforts to acquire information on the supply of infrastructure workers. Collect data from universities, training programs, professional organizations, and unions to track current and future workforce supply. The private sector and all levels of government must pay attention to how education and training resources, including those of employers, should be realigned for the development of the future workforce. Supply pipelines for infrastructure occupations need resources to expand current education and training programs, and to create new ones. Facilities and faculty/trainers need to be available quickly and in sufficient numbers. The National Institute on Disability and Rehabilitation Research should establish appropriate data collection systems.

Recommendation 6:

Promote opportunities to encourage new entrants into critical infrastructure occupations, such as home health aide, personal care assistant, mental health worker, and rehabilitation counselor. Publicize career opportunities in these and related infrastructure occupations through a variety of media channels, including social networking media. Target school- and college-age youth, educational institutions, and community employment support agencies. Schools, colleges, community-based organizations, and employers should expand their offerings, and career counseling personnel should encourage youth to consider careers in these occupations. In particular, vocational rehabilitation agencies and programs need to inform consumers with disabilities about opportunities in these occupations. Again, the federal Departments of Labor and Education should share the lead in this effort.

Recommendation 7:

Infrastructure employers will have to increase the salaries and benefits, and provide training to upgrade the skills and value of their employees if they are to attract and maintain a suitable infrastructure workforce. Providing greater flexibility in work schedules and hourly work arrangements would attract a greater diversity of workers. Employers need to offer incentives to older workers to keep them on the job longer. Professional and business associations should promote this effort with their memberships.

Recommendation 8:

Many of the disability infrastructure occupations with strong future demand characteristics have credentialing requirements. Because these requirements ensure a high level of service quality, they must not be weakened or compromised. However, developing new ways to achieve the necessary competencies and credentials would turn transferable opportunities into viable solutions to worker shortages. Workers who have already demonstrated successful tenure in related occupations should not be discouraged from pursuing opportunities in other infrastructure occupations.

Facilitating career advancement for people in lower tier jobs will require creative approaches to overcoming credentialing barriers where they exist. Employers, credentialing agencies, and education and training programs should develop creative alternative credentialing opportunities. Gaining credentials for higher level jobs through education and training while on the job is one approach to developing these opportunities. Distance learning opportunities, coupled with on-the-job training, need to be tapped to create new credentialing avenues. Overcoming credentialing barriers that prohibit movement of skilled workers across infrastructure occupations should become a high priority. The Department of Education should partner with State and professional credentialing bodies to create smoother pathways to enter and advance in disability infrastructure careers.

Recommendation 9:

Programs that serve people with disabilities, including the State/federal vocational rehabilitation system, as well as Work Force Investment programs intended to assist the general population, need to work more closely with one another and partner more with infrastructure employers to ensure that an adequate flow of job candidates, with and without disabilities, is channeled to fill job openings. These programs need to be fully accessible, including facility and services accessibility. They also need to use new Internet technologies to support service delivery. Infrastructure employers need to see these programs as valued recruiting resources for the workers they need. The programs need to include performance measures that show their success at placing candidates into infrastructure jobs. Such indicators will be useful to achieve a better workforce supply and demand balance. Leadership for this effort should rest with the Departments of Labor and Education, as well as the VA and the Social Security Administration.

Recommendation 10:

An ongoing, coordinated effort is required to systematically monitor how well the disability services infrastructure is responding to people's needs. A consortium of federal agencies—each with responsibility for some aspect of quality of life for people with disabilities—should design a system to collect and share data. The agencies would include the Census Bureau, the Departments of Labor and Education, and the Centers for Medicare and Medicaid Services.

Recommendation 11:

Research must be funded to develop a strong evidence base for the services offered by employment, health care, and education support programs. Improved practice is needed to serve job candidates as well as employers, to ensure that properly trained workers are successfully hired, retained, and provided with career opportunities in infrastructure occupations. The Departments of Education and Labor and the National Institutes of Health have important roles to play in implementing this recommendation.

People with disabilities from all walks of life and all backgrounds are a vital component of our society. It is time to implement these recommendations and commit resources to pursue opportunities for their full participation in all aspects of our society and economy.

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Letter of Transmittal

National Council on Disability Members and Staff

Members

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Section 1. Introduction and Background

Recommendation 1:

Recommendation 2:

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Recommendation 6:

Recommendation 7:

Recommendation 8:

Recommendation 9:

Recommendation 10:

Recommendation 11:

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