A place for work in the lives of your patients New resources and techniques for supporting patients with disabilities a

1. A place for work in the lives of your patients New resources and techniques for supporting patients with disabilities and chronic illness to work Phil Barry, PhD

2. Disclosures Phil Barry, PhD Grant and Research support (Medical Professional Associates of Arizona) (Arizona Health Care Cost Containment System) Name Identification of specialties/credentials/affiliations Reasons interest in conducting the peer to peer training initiative Disclosures: Receives grant and research support from MedPro (Barry) Consultant for AHCCCS (Barry and Dubiel) Name Identification of specialties/credentials/affiliations Reasons interest in conducting the peer to peer training initiative Disclosures: Receives grant and research support from MedPro (Barry) Consultant for AHCCCS (Barry and Dubiel)

3. Disclosures Training provided by the Arizona Employment and Disability Partnership, a Medicaid Infrastructure Grant Solely funded by the Centers for Medicare and Medicaid Services of the U.S. Department of Health and Human Services Administered by the Arizona Health Care Cost Containment System Advisory Committee Dara Johnson, Project Director No disclosures AHCCCS Alan Schafer, ALTCS Manager No disclosures AHCCCS Amina “Donna” Kruck, Member No disclosures Arizona Bridge to Independent Living Michael Steinbring, Member No disclosures Rehabilitation Services Administration Paige Finley, Member No disclosures Arizona Department of Health Services, Behavioral Health Services Susan Webb, Member No disclosures Arizona Bridge to Independent Living Training provided by the Arizona Employment and Disability Partnership Medicaid Infrastructure Grant Funded by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services Managed by the Arizona Health Care Cost Containment System Initiated January 2007 and renewable annually through December 2010 ($500,000 per year) More details about the Medicaid Infrastructure Grants will be noted in future slides Disclosures of Advisory Committee Members The list of Advisory Committee Members is not exhaustive. The individuals identified are those who have participated in the planning and will participate in the monitoring of the training implementation. Training provided by the Arizona Employment and Disability Partnership Medicaid Infrastructure Grant Funded by the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services Managed by the Arizona Health Care Cost Containment System Initiated January 2007 and renewable annually through December 2010 ($500,000 per year) More details about the Medicaid Infrastructure Grants will be noted in future slides Disclosures of Advisory Committee Members The list of Advisory Committee Members is not exhaustive. The individuals identified are those who have participated in the planning and will participate in the monitoring of the training implementation.

4. Acknowledgements Arizona Department of Health Services Regional Behavioral Health Authorities Arizona Department of Health Services Encouraged prescribing clinicians to attend the training Regional Behavioral Health Authorities Training Specialists assisted in the training coordinationArizona Department of Health Services Encouraged prescribing clinicians to attend the training Regional Behavioral Health Authorities Training Specialists assisted in the training coordination

5. ACCME/AMA PRA Accreditation Statement This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the Joint sponsorship of The University of Arizona College of Medicine at the Arizona Health Sciences Center and the Arizona Health and Disability Partnership. The University of Arizona College of Medicine at the Arizona Health Sciences Center is accredited by the ACCME to provide continuing medical education for physicians. The University of Arizona College of Medicine at the Arizona Health Sciences Center designates this educational activity for a maximum of two AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

6. Disclosures CONTINUING MEDICAL EDUCATION COMMITTEE A requirement of the CME accreditation is to state the noted disclosures of the Continuing Medical Education Committee Members.A requirement of the CME accreditation is to state the noted disclosures of the Continuing Medical Education Committee Members.

7. Project Author Ms. Susan Webb Employment Services & Business Development Director Arizona Bridge to Independent Living

8. Medicaid Infrastructure Grant (MIG) “Supporting the development of new relationships between the primary asset development programs and providers and the disability community.” National Consortium for Health Systems Development. (2007, July). Asset development for people with disabilities: a conceptual framework. Davis, Tobey & Malloy, JoAnne. The term “asset development” is used for the purposes of this presentation in the most general sense of the word. (i.e. programs that support individuals with disabilities to make the transition from unemployment, employment to economic self-sufficiency). The MIGs are used as a catalyst, under the Ticket to Work and Work Incentives Improvement Act, to enhance and/or develop the systems infrastructure to support increased competitive employment opportunities for individuals with disabilities (i.e. lessening their dependence on public cash benefits). Individual level changes. The Arizona MIG noted that individual level barriers needed to be addressed prior to systems level barriers. This training is addressing the educational need for practitioners (new resources and support techniques) while a marketing campaign is geared toward encouraging individuals to consider employment and be informed of resources available to support their transition to employment. Systems level changes. Discussions have already been initiated to focus on changing the Social Security system including the Ticket to Work and Work Incentives Improvement Act. This training is an opportunity for health care practitioners to provide input on systems level barriers and improvements. The term “asset development” is used for the purposes of this presentation in the most general sense of the word. (i.e. programs that support individuals with disabilities to make the transition from unemployment, employment to economic self-sufficiency). The MIGs are used as a catalyst, under the Ticket to Work and Work Incentives Improvement Act, to enhance and/or develop the systems infrastructure to support increased competitive employment opportunities for individuals with disabilities (i.e. lessening their dependence on public cash benefits). Individual level changes. The Arizona MIG noted that individual level barriers needed to be addressed prior to systems level barriers. This training is addressing the educational need for practitioners (new resources and support techniques) while a marketing campaign is geared toward encouraging individuals to consider employment and be informed of resources available to support their transition to employment. Systems level changes. Discussions have already been initiated to focus on changing the Social Security system including the Ticket to Work and Work Incentives Improvement Act. This training is an opportunity for health care practitioners to provide input on systems level barriers and improvements.

9. Services to Individuals with Disabilities Development must be driven by values articulated by the disability community: Equality of Access Environmental Redesign Full Community Participation

10. Agenda Presentation Information about techniques and resources Open Discussion Discussion of case scenarios and systemic barriers It is intended to have open discussion throughout the presentation specifically the identification and discussion of systemic barriers. Presentation Length (1 hour and ½) Open discussion length (1/2 hour-if held at the end of the presentation) It is intended to have open discussion throughout the presentation specifically the identification and discussion of systemic barriers. Presentation Length (1 hour and ½) Open discussion length (1/2 hour-if held at the end of the presentation)

11. Educational Need Literature New techniques and protocol New support services and resources The training content has been identified as an unmet educational need for health care practitioners for, but not limited to, the following reasons: Literature confirms the need for practitioners to acknowledge, facilitate and play a role in assessing and supporting a patient’s desired employment outcomes; New support services and resources are now available for individuals with disabilities desiring to work and New techniques and protocol have been identified to support employed patients to continue working after the onset of a injury/illness. The training content has been identified as an unmet educational need for health care practitioners for, but not limited to, the following reasons: Literature confirms the need for practitioners to acknowledge, facilitate and play a role in assessing and supporting a patient’s desired employment outcomes; New support services and resources are now available for individuals with disabilities desiring to work and New techniques and protocol have been identified to support employed patients to continue working after the onset of a injury/illness.

12. Purpose To provide resources and techniques that may be used in serving patients with disabilities who are interested in: Starting to work Staying at work Returning to work

13. Objective #1 You will learn about techniques you can use to make effective employability decisions & support patients to stay at or return to work after the onset of either an occupational or non-occupational injury/illness The order of the objectives identifies the order of the presentation contentThe order of the objectives identifies the order of the presentation content

14. Objective #2 You will be informed of programs and services available for your patients with disabilities who are currently accessing public cash benefits

15. Objective #3 You will help us identify systemic barriers that may impede your ability to make effective employability decisions and/or support patients to start, stay at or return to work

16. Role of the Practitioner Legal decisions have reinforced treating physicians as a definitive source of information on a patient’s fitness to work Physicians board-certified in rehabilitation and occupational specialties represent less than 2% of all US physicians Legal decisions have reinforced treating physicians as a definitive source of information on a patients fitness to workPhysicians board-certified in rehabilitation and occupational specialties represent less than 2% of all US physicians Legal decisions have reinforced treating physicians as a definitive source of information on a patients fitness to work

17. Role of the Practitioner Is Certifying Disability in the Best Interests of the Patient? The attending physician is part of the team including the injured/ill employee, the employer, insurers, etc. The attending physician is part of the team including the injured/ill employee, the employer, insurers, etc.

19. Medical Evaluation3 Basic SAW/RTW Questions 1. Current work capacity, medical restrictions & functional limitations? 2. Functional demands of the intended job? 3. If the worker’s functional capacity matches the functional demands, what is required for actual return to work?

20. Annual Cost Disability Benefits Paid Under Various Federal Programs > 100 Billion The estimated annual cost of disability benefits paid under the following systems/laws is greater than $100 Billion. -Sick leave -Worker’s compensation -Short-term disability -Long-term disability -Social Security Disability Insurance -Family Medical Leave Act -Americans with Disabilities ActThe estimated annual cost of disability benefits paid under the following systems/laws is greater than $100 Billion. -Sick leave -Worker’s compensation -Short-term disability -Long-term disability -Social Security Disability Insurance -Family Medical Leave Act -Americans with Disabilities Act

21. Annual Savings 1% reduction = $1 billion estimated savings “…a 1% reduction in cases with prolonged disability should generate a substantially larger reduction in overall system cost (100 Billion).” “…a 1% reduction in cases with prolonged disability should generate a substantially larger reduction in overall system cost (100 Billion).”

23. Early Intervention A worker’s odds of ever returning to work drop 50% by the 3rd month of absence “Research confirms that people who never lose time from work have better outcomes that people who lose some time from work” “…the odds of a worker ever returning to work drop 50% by just the 12th week.” “Studies have show that the odds for return to full employment drop to 50/50 after 6 months of absence.”“Research confirms that people who never lose time from work have better outcomes that people who lose some time from work” “…the odds of a worker ever returning to work drop 50% by just the 12th week.” “Studies have show that the odds for return to full employment drop to 50/50 after 6 months of absence.”

24. ACOEM Guidelines Adopt a disability prevention model Address behavioral and circumstantial realities that create and prolong work disability Acknowledge the powerful contribution that motivation makes to outcomes and make changes that improve incentive alignment Invest in system and infrastructure improvements The 16 specific guidelines are broken down into the 4 respective general categories Created by a group of 21 physicians for stakeholders in the worker’s compensation and non-work related disability benefits systems. The physicians represented 7 medical specialties including emergency medicine, family practice, internal medicine, occupational medicine, orthopedics, physiatry and psychiatry. Adopt a disability prevention model Absence from work is rarely medically required -Utilize criteria to determine whether or not absence from work is medically required, discretionary, or unnecessary Encourage a patient’s return to work as quickly as possible after injury/illness provided work is not an endanger to the patient -An patients return to work enhances recovery, reduces disability and minimizes social and economic disruption Address behavioral and circumstantial realities that create and prolong work disability Acknowledge and deal with normal human reactions -Point out the functional aspects of the medical condition, options, and length of treatment Investigate and address social and workplace realities -Exert significant effort to investigate and screen workplace and social issues that may be lending to an individual desiring absence from work that is not medically necessary Find ways to effectively address psychiatric conditions -Recognize the interaction between psychiatric and physical problems and develop effective means to treat psychiatric co-morbidities Acknowledge the contribution of motivation on outcomes and make changes to improve incentive alignment Pay physicians for disability prevention work to increase their professional commitment Increase “real-time” availability of on-the-job recovery, transition work programs, and permanent job modifications -Encourage or require employers to use transitional work programs; adopt clearly written policies and procedures that instruct and direct people in carrying our their responsibilities; consult with unions to design on-the-job recovery programs Invest in system and infrastructure improvements Simplify/standardized information exchange methods between employer/payers and medical offices Improve/standardize methods and tools that provide data for SAW/RTW decision-making -Help physicians participate more effectively in the SAW/RTW process by standardizing key information and processes; persuade employers to prepare accurate, up-to-date functional job The 16 specific guidelines are broken down into the 4 respective general categories Created by a group of 21 physicians for stakeholders in the worker’s compensation and non-work related disability benefits systems. The physicians represented 7 medical specialties including emergency medicine, family practice, internal medicine, occupational medicine, orthopedics, physiatry and psychiatry. Adopt a disability prevention model Absence from work is rarely medically required -Utilize criteria to determine whether or not absence from work is medically required, discretionary, or unnecessary Encourage a patient’s return to work as quickly as possible after injury/illness provided work is not an endanger to the patient -An patients return to work enhances recovery, reduces disability and minimizes social and economic disruption Address behavioral and circumstantial realities that create and prolong work disability Acknowledge and deal with normal human reactions -Point out the functional aspects of the medical condition, options, and length of treatment Investigate and address social and workplace realities -Exert significant effort to investigate and screen workplace and social issues that may be lending to an individual desiring absence from work that is not medically necessary Find ways to effectively address psychiatric conditions -Recognize the interaction between psychiatric and physical problems and develop effective means to treat psychiatric co-morbidities Acknowledge the contribution of motivation on outcomes and make changes to improve incentive alignment Pay physicians for disability prevention work to increase their professional commitment Increase “real-time” availability of on-the-job recovery, transition work programs, and permanent job modifications -Encourage or require employers to use transitional work programs; adopt clearly written policies and procedures that instruct and direct people in carrying our their responsibilities; consult with unions to design on-the-job recovery programs Invest in system and infrastructure improvements Simplify/standardized information exchange methods between employer/payers and medical offices Improve/standardize methods and tools that provide data for SAW/RTW decision-making -Help physicians participate more effectively in the SAW/RTW process by standardizing key information and processes; persuade employers to prepare accurate, up-to-date functional job

25. Mental Illness & Employment 1990: Depression was 4th leading cause of disability 2005: Depression 2nd only to musculoskeletal conditions

26. Mental Illness & Employment 26% of the general population have at least one psychiatric diagnosis 9.2% of workers report depression &/or anxiety Individuals are working who have mental illnessIndividuals are working who have mental illness

27. Oops…Sorry. That’s a figment of MY imagination

28. Psychiatric Symptoms Do not necessarily = Inability to work Can contribute significantly to permanent disability

29. Psychiatric Disorders In order to maintain functional work status, intervention should involve: Intensive early Tx of new episodes Long-term, low level Tx to prevent recurrence

30. Medical Illness May precipitate a psychiatric episode In over 50% of all serious illness More among people with a major psychiatric disorder

31. Mental Illness & Disability

32. Effective Intervention Medication + Counseling Encourage early return to work

33. Standard of Care for Significant Mental Illness Psychiatric evaluation/med management every 4-6 weeks Individual counseling at least every 2 weeks Additional treatment if no improvement Day Treatment Partial hospitalization ECT

34. Poverty & Disability Rate for people with at least one disability is 2x the rate of individuals without disabilities The content now shifts from the focus of the ill/injured worker to individuals who are receiving public cash benefits.The content now shifts from the focus of the ill/injured worker to individuals who are receiving public cash benefits.

35. AZ Adults with Disabilities (21-64) 22.8% work full-time +14.4% work part-time =37.2% Employed People with disabilities are working. This sets the premise for requesting them to identify three of their patients who are not working. Two to refer for Work Incentive Counseling or Vocational Rehabilitation and One to support utilizing the techniques identified to make effective employability decisions/support a patient in staying at or returning to work after injury or illness (occupational or non-occupational). -2.4% of working individuals with a disability are receiving SSI -4.9% of working individuals with a disability are receiving SSDI Houtenville, A. J., Erickson, W. A., Lee, C. G. (2007, March 16). Disability Statistics from the American Community Survey (ACS). Ithaca, NY: Cornell University Rehabilitation Research and Training Center on Disability Demographics and Statistics (StatsRRTC). Retrieved December 28, 2007 from www.disabilitystatistics.org People with disabilities are working. This sets the premise for requesting them to identify three of their patients who are not working. Two to refer for Work Incentive Counseling or Vocational Rehabilitation and One to support utilizing the techniques identified to make effective employability decisions/support a patient in staying at or returning to work after injury or illness (occupational or non-occupational). -2.4% of working individuals with a disability are receiving SSI -4.9% of working individuals with a disability are receiving SSDI Houtenville, A. J., Erickson, W. A., Lee, C. G. (2007, March 16). Disability Statistics from the American Community Survey (ACS). Ithaca, NY: Cornell University Rehabilitation Research and Training Center on Disability Demographics and Statistics (StatsRRTC). Retrieved December 28, 2007 from www.disabilitystatistics.org

36. Public Cash Benefits Only 1/2 of 1% of SSI/SSDI program participants leave the rolls and return to work Kennedy, J., & Olney, M.F. (2006) Factors associated with workforce participation among SSDI beneficiaries. Journal of Rehabilitation, 72(4), 24-30. The majority of individuals with disabilities who leave the SSDI benefit rolls did so because they are transferred to retirement benefits or deceased Honeycutt, Todd C. (2004). Program and benefit paths to the Social Security Disability Insurance Program. Journal of Vocational Rehabilitation, 21, 83-94. A total of 85% individuals were disenrolled in 2002 because their either transferred into receiving retirement benefits or were deceased. Only 6% were disenrolled for earning too high of an income (representing about one-half of one-percent of all disabled worker SSI/SSDI program participants) Honeycutt, Todd C. (2004). Program and benefit paths to the Social Security Disability Insurance Program. Journal of Vocational Rehabilitation, 21, 83-94. Doubling the number of SSDI beneficiaries who return to work (.5% to 1%) would return billions to the Social Security trust fund. Kennedy, J., & Olney, M.F. (2006) Factors associated with workforce participation among SSDI beneficiaries. Journal of Rehabilitation, 72(4), 24-30. A total of 85% individuals were disenrolled in 2002 because their either transferred into receiving retirement benefits or were deceased. Only 6% were disenrolled for earning too high of an income (representing about one-half of one-percent of all disabled worker SSI/SSDI program participants) Honeycutt, Todd C. (2004). Program and benefit paths to the Social Security Disability Insurance Program. Journal of Vocational Rehabilitation, 21, 83-94. Doubling the number of SSDI beneficiaries who return to work (.5% to 1%) would return billions to the Social Security trust fund. Kennedy, J., & Olney, M.F. (2006) Factors associated with workforce participation among SSDI beneficiaries. Journal of Rehabilitation, 72(4), 24-30.

37. Does Work Mean Loss of Disability Benefits? Loss of health care coverage? Loss of personal assistance care services? Loss of cash benefits and future reinstatement?

38. No Evidence of Negative Side Effects! Research consistently finds no evidence: Competitive work is not too stressful Does not increase risk of relapse or hospitalization

39. Employment Among People with Mental Illness Decrease in symptoms Increase in self esteem More financial satisfaction

41. Today Workers with Disabilities: Can maintain their Medicaid health care coverage Have access to Social Security work incentives that are more flexible than ever Work incentives and health care coverage options Today workers with disabilities: Can work and keep their Medicaid health care coverage (including personal assistant services) Have access to Social Security work incentives that are more flexible than ever that, including other options, allowing for trial work periods and easy reinstatement of benefitsWork incentives and health care coverage options Today workers with disabilities: Can work and keep their Medicaid health care coverage (including personal assistant services) Have access to Social Security work incentives that are more flexible than ever that, including other options, allowing for trial work periods and easy reinstatement of benefits

42. AHCCCS Freedom to Work A Medicaid health insurance program for individuals with disabilities who are employed Coverage for acute and long term care services Individuals may earn up to $51,072 per year Monthly premiums range from $0 to $35 No resource limit

43. Social Security Programs Supplemental Security Income (SSI) Individuals who are elderly or disabled, who have limited assets and low incomes automatically receive Medicaid health coverage Social Security Disability Insurance (SSDI) Individuals who are disabled and have worked and paid money into the Social Security trust fund get Medicare health insurance after a two-year waiting period

44. SSI Work Incentives Impairment Related Work Expenses Attendant Care Job Coaching Transportation Vehicle Modifications DME (Also applies to SSDI recipients) Impairment Related Work Expenses (IRWE) Excludes money that an individual pays for work related support items/services from countable earnings (i.e. attendant care, job coaching, transportation, vehicle modifications, durable medical equipment, etc.)Impairment Related Work Expenses (IRWE) Excludes money that an individual pays for work related support items/services from countable earnings (i.e. attendant care, job coaching, transportation, vehicle modifications, durable medical equipment, etc.)

45. SSI Work Incentives Earned and Unearned Income Exclusion The first $65.00 of earned income and one-half of the remainder is ignored The first $20.00 of unearned income is excluded

46. SSI Work Incentives Student Earned Income Exclusion $6, 240 per year or $1, 550 monthly Excluded when calculating monthly benefits For recipients under 22, regularly attending school Student Earned Income Exclusion A certain amount of your earned income ($6,240 per year or $1,550 monthly) is excluded when calculating monthly benefits and is determined by a formula to account for the cost of education. The recipient must regularly attend school, under the age of 22 and single. Student Earned Income Exclusion A certain amount of your earned income ($6,240 per year or $1,550 monthly) is excluded when calculating monthly benefits and is determined by a formula to account for the cost of education. The recipient must regularly attend school, under the age of 22 and single.

47. SSI Work Incentives Expedited Reinstatement Apply anytime within 5 years of ineligibility for SSI or SSDI benefits due to employment Quick SSA review Cash & medical benefits up to 6 months during eligibility determination (Not subject to reimbursement if ineligible) Expedited Reinstatement Within five years of ineligibility for SSI or SSDI benefits due to employment, an individual may re-apply for benefits.  The application will be reviewed quickly and the individual will receive both cash and medical benefits for up to a period of six months throughout the duration of the eligibility determination.  If the individual is not deemed eligible, the cash benefit is not required to be reimbursed. Expedited Reinstatement Within five years of ineligibility for SSI or SSDI benefits due to employment, an individual may re-apply for benefits.  The application will be reviewed quickly and the individual will receive both cash and medical benefits for up to a period of six months throughout the duration of the eligibility determination.  If the individual is not deemed eligible, the cash benefit is not required to be reimbursed.

48. SSI Work Incentives Other Blind Work Expenses Plan for Achieving Self Support (PASS) Blind Work Expenses Items necessary for work (not necessarily related to the individual’s blindness) be deducted from countable earned income. Plan for Achieving Self-Support (PASS) Lets an individual save some income in a special account and utilize the money to provide services/supports to achieve employment goals (i.e. school, vocational training, etc.). The money is excluded when SSI calculates monthly benefits. Plan must be pre-approved by Social Security. (This is a similar concept to pre-taxed 401k investment account). Blind Work Expenses Items necessary for work (not necessarily related to the individual’s blindness) be deducted from countable earned income. Plan for Achieving Self-Support (PASS) Lets an individual save some income in a special account and utilize the money to provide services/supports to achieve employment goals (i.e. school, vocational training, etc.). The money is excluded when SSI calculates monthly benefits. Plan must be pre-approved by Social Security. (This is a similar concept to pre-taxed 401k investment account).

49. SSDI Work Incentives Trial Work Period Work for 9 months & receive full benefit check 9 months do not have to be consecutive Trial Work Period Recipients may work for nine months and receive a full benefit check no matter how high the earnings. The nine months do not have to be consecutive. Triggered by gross monthly earned income of $670.Trial Work Period Recipients may work for nine months and receive a full benefit check no matter how high the earnings. The nine months do not have to be consecutive. Triggered by gross monthly earned income of $670.

50. SSDI Work Incentives Extended Eligibility 3 years SSDI eligibility upon completion of Trial Work Period If earnings < $940 (Substantial Gainful Activity) recipient receives full monthly benefit check 3 month grace period if earnings > SGA Extended Period of Eligibility Provides three years of SSDI eligibility following the completion of the Trial Work Period. Recipients receive the full benefit check with the exception of the months that earnings are reported over SGA (Substantial Gainful Activity) which is $940.00. For the visually impaired, the SGA is $1,570. Extended Period of Eligibility Provides three years of SSDI eligibility following the completion of the Trial Work Period. Recipients receive the full benefit check with the exception of the months that earnings are reported over SGA (Substantial Gainful Activity) which is $940.00. For the visually impaired, the SGA is $1,570.

51. SSDI “RTW” Timeline

52. Ticket to Work All SSI recipients and SSDI receive a “ticket.” Increases beneficiary choice in obtaining rehabilitation & vocational services Protection against Continuing Disability Reviews for up to 5 years with “timely progress” Ticket to Work SSI recipients and SSDI who want to be employed and work their way off of cash benefits Options for obtaining free vocational and employment support services Protection against Continuing Disability Reviews Employment Networks provide the vocational and employment support services Private company or government agency that is contracted by the Social Security Administration Vocational Rehabilitation is an Employment Network Individuals (in consultation with the Employment Network) will develop and Individualized Plan for Employment (identify occupation, goals and services) Individuals may choose the Employment Network of choice (assign their ticket) and there is no charge for the services Employment Network does not have to agree to support the individual Vocational Rehabilitation must serve the individual Individuals may change the assigned Employment Network, but can only have their ticket assigned to one at a time Continuing Disability Reviews Individuals will not have a CDR while they are actively using the Ticket and making progress on IPE goals CDR protection may last up to (as long as progress is being made on IPE goals) five years or until the individual turns 65 years of ageTicket to Work SSI recipients and SSDI who want to be employed and work their way off of cash benefits Options for obtaining free vocational and employment support services Protection against Continuing Disability Reviews Employment Networks provide the vocational and employment support services Private company or government agency that is contracted by the Social Security Administration Vocational Rehabilitation is an Employment Network Individuals (in consultation with the Employment Network) will develop and Individualized Plan for Employment (identify occupation, goals and services) Individuals may choose the Employment Network of choice (assign their ticket) and there is no charge for the services Employment Network does not have to agree to support the individual Vocational Rehabilitation must serve the individual Individuals may change the assigned Employment Network, but can only have their ticket assigned to one at a time Continuing Disability Reviews Individuals will not have a CDR while they are actively using the Ticket and making progress on IPE goals CDR protection may last up to (as long as progress is being made on IPE goals) five years or until the individual turns 65 years of age

53. Work Incentive Coordination Eligibility Between the ages of 16 and 64 SSI recipient and/or SSDI beneficiary Interested in working either full or part time Services Benefits Planning and Counseling Work Incentive Seminars Information and Referral Individualized work incentive counseling and coordination Eligibility requirements Between the ages of 16 and 64 SSI recipient and/or SSDI beneficiary Interested in working either full or part time Services If the individual is in the process of securing employment in the immediate future, the work incentive counseling and coordination process will be initiated by the beneficiary contacting the Community Work Incentive Coordinator. If the individual is simply interested in learning more about health care and work incentive options, they will be asked to attend either a SSI or SSDI specific seminar to learn about the options until they are actively engaged or ready to engage in the job development process If the individual receiving work incentive counseling identifies areas of support outside of the scope of the work incentive counseling (i.e. housing assistance, peer advocacy, etc.) the Work Incentive Coordinator will provide information and referral assistance servicesIndividualized work incentive counseling and coordination Eligibility requirements Between the ages of 16 and 64 SSI recipient and/or SSDI beneficiary Interested in working either full or part time Services If the individual is in the process of securing employment in the immediate future, the work incentive counseling and coordination process will be initiated by the beneficiary contacting the Community Work Incentive Coordinator. If the individual is simply interested in learning more about health care and work incentive options, they will be asked to attend either a SSI or SSDI specific seminar to learn about the options until they are actively engaged or ready to engage in the job development process If the individual receiving work incentive counseling identifies areas of support outside of the scope of the work incentive counseling (i.e. housing assistance, peer advocacy, etc.) the Work Incentive Coordinator will provide information and referral assistance services

54. Arizona Freedom to Work

55. Vocational Rehabilitation Eligibility Individual desires economic independence through work Disability impacts the individual’s ability to obtain or maintain a job Services are available to support an individual to obtain or maintain a job Services Vocational counseling, evaluation and planning Assistive aides and modifications Job search and placement Training related costs including tuition Eligibility -Economic independence through work -Disability is serious enough to make it hard for them to get or keep a job -Available services can help them to get or keep a job Services -Individuals will always receive personal attention, program information, evaluation of abilities and needs and vocational counseling -VR may also pay for, or provide, other services including assistive aids, modifications necessary for work and help in finding a job -When re-training or education is the only or best way they will be able to go to work or keep a job, VR may be able to help you with tuition payments and other training related costs NOTE: VR will help when other services or goods which are not purchased or provided through the VR program* are needed to help the individual get or keep a job. VR will help decide what services/goods are needed and how to get them. *The Vocational Rehabilitation Program is not a medical program; does not pay for goods or services that are provided by other programs; does not provide goods or services that are not related to getting or keeping a job. has regulations which do not permit payment of daily living costs. + VR purchase of some services may depend on an individual's I income level.   Eligibility -Economic independence through work -Disability is serious enough to make it hard for them to get or keep a job -Available services can help them to get or keep a job Services -Individuals will always receive personal attention, program information, evaluation of abilities and needs and vocational counseling -VR may also pay for, or provide, other services including assistive aids, modifications necessary for work and help in finding a job -When re-training or education is the only or best way they will be able to go to work or keep a job, VR may be able to help you with tuition payments and other training related costs NOTE: VR will help when other services or goods which are not purchased or provided through the VR program* are needed to help the individual get or keep a job. VR will help decide what services/goods are needed and how to get them. *The Vocational Rehabilitation Program is not a medical program; does not pay for goods or services that are provided by other programs; does not provide goods or services that are not related to getting or keeping a job. has regulations which do not permit payment of daily living costs. + VR purchase of some services may depend on an individual's I income level.  

56. RBHA Rehab Services Skills Training & Development Independent Living Skills Training Cognitive Rehabilitation Prevention education & medication training & support Pre-job training, job development Ongoing support to maintain employment Teaching independent living, social, and communication skills…including self-care, household management, social decorum, friendships, avoidance of exploitation and how to advocate for one’s self, budgeting, recreation, development of social support networks, connecting to community resources…can be provided to an individual, in a group setting, or with the individual’s family. Goals of cognitive rehab include: relearning of targeted mental abilities, strengthening of intact functions, relearning of social interaction skills, substitution of new skills to replace lost functioning, controlling the emotional aspects of one’s functioning…treatment generally includes auditory and visual directed tasks, memory training, training in the use of assistive technology, and anger management…done through exercises or stimulation, cognitive neuropsychology, cognitive psychology and behavioral psychology, or a holistic approach…generally one on one and highly customized. Teaching independent living, social, and communication skills…including self-care, household management, social decorum, friendships, avoidance of exploitation and how to advocate for one’s self, budgeting, recreation, development of social support networks, connecting to community resources…can be provided to an individual, in a group setting, or with the individual’s family. Goals of cognitive rehab include: relearning of targeted mental abilities, strengthening of intact functions, relearning of social interaction skills, substitution of new skills to replace lost functioning, controlling the emotional aspects of one’s functioning…treatment generally includes auditory and visual directed tasks, memory training, training in the use of assistive technology, and anger management…done through exercises or stimulation, cognitive neuropsychology, cognitive psychology and behavioral psychology, or a holistic approach…generally one on one and highly customized.

57. Vocational Rehabilitation: Local Offices Application Processes -Direct Contact with Local RSA OfficesIndividuals are encouraged to call or visit the office nearest them to set up an appointment to attend regularly scheduled orientation  sessions. if you are not able to come to the local office or have scheduling conflicts, an individual appointment can be requested.  -Referral By An Agency Worker From A Program That Has An Existing Relationship With The Vocational Rehabilitation Program:This refers to students with disabilities still in High School, individuals who receive mental health services through Regional Behavioral Health Agencies (RHBAs), individuals who receive services from the Division Developmental Disabilities (DDD), or others who are involved in programs that have coordination and referral relationships with the Arizona Rehabilitation Services Administration VR Program. Long-Term Supported Employment VR does not have enough money to pay for specially supervised work environments, job coaching, or personal care assistance on an ongoing basis to maintain their job after completing a VR program. The VR counselor will help them see who might help pay for this support, such as: -Social Security Work Incentives to help pay for work expenses -The services of employers, friends or family members -The assistance from other agencies or programs to provide or pay for these supports (i.e. RHBA, DDD) When the only option is for RSA to pay the costs of long-term vocational supports, their name will be put on a waiting list for VR services, even if they are otherwise eligible for the Vocational Rehabilitation Program. When VR has moneys to pay for these supports they will be contacted to begin a VR program of services.  Responsibility of the Individual -Bring records from doctors about their disability or sign a release form so that their doctors will send them to VR. If there are no records, or if the records are too old or incomplete, they will be asked to see a doctor at RSA's expense. -Meet with a counselor or other assigned staff to: -talk about plans for work -talk in detail about their education training and experience that they can still use to get or keep a job (including past jobs if you have previously worked) -discuss those things that you feel may get in the way of work and what is needed to get around them -set specific goals and to decide what actions will be necessary to reach those goals -make a commitment to a plan of action for going to work Application Processes -Direct Contact with Local RSA OfficesIndividuals are encouraged to call or visit the office nearest them to set up an appointment to attend regularly scheduled orientation  sessions. if you are not able to come to the local office or have scheduling conflicts, an individual appointment can be requested. -Referral By An Agency Worker From A Program That Has An Existing Relationship With The Vocational Rehabilitation Program:This refers to students with disabilities still in High School, individuals who receive mental health services through Regional Behavioral Health Agencies (RHBAs), individuals who receive services from the Division Developmental Disabilities (DDD), or others who are involved in programs that have coordination and referral relationships with the Arizona Rehabilitation Services Administration VR Program. Long-Term Supported Employment VR does not have enough money to pay for specially supervised work environments, job coaching, or personal care assistance on an ongoing basis to maintain their job after completing a VR program. The VR counselor will help them see who might help pay for this support, such as: -Social Security Work Incentives to help pay for work expenses -The services of employers, friends or family members -The assistance from other agencies or programs to provide or pay for these supports (i.e. RHBA, DDD) When the only option is for RSA to pay the costs of long-term vocational supports, their name will be put on a waiting list for VR services, even if they are otherwise eligible for the Vocational Rehabilitation Program. When VR has moneys to pay for these supports they will be contacted to begin a VR program of services. Responsibility of the Individual -Bring records from doctors about their disability or sign a release form so that their doctors will send them to VR. If there are no records, or if the records are too old or incomplete, they will be asked to see a doctor at RSA's expense. -Meet with a counselor or other assigned staff to: -talk about plans for work -talk in detail about their education training and experience that they can still use to get or keep a job (including past jobs if you have previously worked) -discuss those things that you feel may get in the way of work and what is needed to get around them -set specific goals and to decide what actions will be necessary to reach those goals -make a commitment to a plan of action for going to work

58. Conclusion Adopt a disability prevention model Encourage a patient’s return to work as quickly as possible. Address behavioral & circumstantial realities to avoid prolonged LOA Recognize the interaction between psychiatric & physical problems

59. Question and Answer Session Systemic barriers Evaluation form 3 Patients Question and Answer Session Systemic barriers (questions from the trainers) “What are some systemic barriers that may impede your ability to make effective employability decisions and/or support patients with disabilities to start, stay at or return to work?” Case staffing scenarios (questions from the trainees) Evaluation Form All Attendees need to acknowledge attendance on the sign in sheet, complete a “credit request form” (if requesting CMEs) and complete an evaluation form. All Attendees should pick up the pre-printed certificates. Follow Up Identify at least 3 patients with disabilities who have expressed a desire to start, stay at or return to work Refer at least 2 patients for work incentive coordination/counseling services or to Vocational Rehabilitation Apply at least one technique identified in the training aimed at making effective employability decisions and supporting a recently injured/ill worker to stay at or return to work Question and Answer Session Systemic barriers (questions from the trainers) “What are some systemic barriers that may impede your ability to make effective employability decisions and/or support patients with disabilities to start, stay at or return to work?” Case staffing scenarios (questions from the trainees) Evaluation Form All Attendees need to acknowledge attendance on the sign in sheet, complete a “credit request form” (if requesting CMEs) and complete an evaluation form. All Attendees should pick up the pre-printed certificates. Follow Up Identify at least 3 patients with disabilities who have expressed a desire to start, stay at or return to work Refer at least 2 patients for work incentive coordination/counseling services or to Vocational Rehabilitation Apply at least one technique identified in the training aimed at making effective employability decisions and supporting a recently injured/ill worker to stay at or return to work

60. Follow Up Survey An online post-training survey will be appearing in your email in-box in about 3-months AHCCCS has contracted with Partners in Brainstorms to conduct the survey -In 3 months time, an email alert will be sent by AHCCCS informing you that an email invitation will be sent by Partners in Brainstorms, Inc. to participate in a confidential online survey. -The online survey has been designed to elicit your opinions about the relevancy, effectiveness, and long-term potential of this training to influence and impact the lives of patients with disabilities, chronic illness, or occupational/non-occupational injuries. ****REMIND INDIVIDUALS TO INCLUDE THEIR EMAIL ON THE SIGN IN SHEET.**** -In 3 months time, an email alert will be sent by AHCCCS informing you that an email invitation will be sent by Partners in Brainstorms, Inc. to participate in a confidential online survey. -The online survey has been designed to elicit your opinions about the relevancy, effectiveness, and long-term potential of this training to influence and impact the lives of patients with disabilities, chronic illness, or occupational/non-occupational injuries. ****REMIND INDIVIDUALS TO INCLUDE THEIR EMAIL ON THE SIGN IN SHEET.****

61. Online Resources Work Incentive Coordination http://www.abil.org/Programs/work_incentives.htm Vocational Rehabilitation https://www.azdes.gov/rsa/vr.asp ACOEM http://www.acoem.org/ Webility http://www.webility.md/

62. Contact Information Phil Barry, PhD Medical Professionals Associates of Arizona Desert Vista Behavioral Health Center 560 W. Brown Rd., Suite 4007 Mesa, AZ 85201 (602) 470-5520, ext 2031 philip_barry@medprodoctors.com Dara Johnson Arizona Employment and Disability Partnership AHCCCS 701 E. Jefferson St., MD 6100 Phoenix, AZ 85034 (602) 417-4362 Dara.Johnson@azahcccs.gov