State vocational rehabilitation services and employment in multiple sclerosis

Abstract

Background:

Obtaining and maintaining suitable employment can be a significant challenge for people with multiple sclerosis (MS).

Objective:

The objective of this article is to identify what vocational rehabilitation (VR) services helped MS clients obtain and maintain employment, after controlling for the effect of demographic covariates and disability-related government benefits.

Methods:

We retrieved data from the Rehabilitation Services Administration (RSA) 911 database in the fiscal year (FY) 2009, and used VR services as predictors to predict employment outcomes of people with MS by hierarchical logistic regression.

Results:

A total of 924 out of 1920 MS clients (48.1%) were successfully employed after receiving VR services. Logistic regression analysis results indicated that cash benefits (OR =0.51, p < 0.001) and public medical benefits (OR =0.76, p < 0.01) were negatively associated with employment outcomes, whereas counseling and guidance (OR = 1.68, p < 0.001), job placement assistance (OR = 2.43, p < 0.001), on-the-job supports (OR = 1.62, p < 0.01), maintenance services (OR = 1.59, p < 0.01), and assistive technology services (OR =2.09, p < 0.001) were significant predictors of positive employment outcomes.

Conclusion:

VR services were found to be associated with employment status. MS patients experiencing problems obtaining or maintaining employment should be encouraged to pursue services from state VR agencies.

Keywords

Multiple sclerosis vocational rehabilitation vocational services service delivery employment logistic regression

Introduction

Employment is an important aspect of well-being and quality of life, providing access to economic security, increased opportunities for social participation, and access to health insurance and health care. Work also contributes to personal identity and promotes physical and psychosocial health.^1–3 The fact that adults with multiple sclerosis (MS) consistently experience significantly higher levels of unemployment and underemployment than the general population is a critical concern. More than 90% of individuals with MS in the United States (US) have employment histories, and approximately 60% of people with MS were working at the time of diagnosis;⁴ however, only a minority retains employment after diagnosis.⁵ The diagnosis of MS is typically made among adults in the early stages of their careers,⁶ and according to data from the North American Research Committee on Multiple Sclerosis (NARCOMS) Patient Registry data, the unemployment rate of people with MS was estimated to be 56%–58%.⁷

The impact of MS on employment is not the result of any single factor, but represents a complex interaction of personal, functional, financial, and psychosocial variables.⁸ For example, increased age, lower levels of education, higher levels of cognitive impairment and physical disability, and longer duration since diagnosis have consistently been associated with lower rates of employment.^4,5,7,9–16 Other demographic and employment-related variables, such as socioeconomic status, job type and working conditions, reactions of co-workers and employers, workplace discrimination, and disability beneﬁts have also been identified as contributing factors.¹⁷ It has also been established that the majority of working-age people with MS who are unemployed would prefer to be working. Among people with MS who are unemployed, 80% believe that they retain the ability to work,¹⁸ and 75% say that they would like to re-enter the workforce.¹⁹

These data highlight the importance of identifying effective vocational interventions that increase job retention and promote employment outcomes. Unfortunately, this area of research has received relatively less attention than identifying the barriers to employment, and as a consequence the most effective vocational interventions are not well understood. Researchers have previously explored the overall impact and specific services of vocational rehabilitation (VR) programs, yet these studies have frequently been based on relatively small samples, often from a single vocational program, and are frequently based on self-reported or qualitative data.^20–22 In the present study we utilized a large national data set to explore the effectiveness of vocational interventions in promoting employment outcomes for people with MS who receive services from the US state-federal VR program.

The state-federal VR program spends more than $2.5 billion per year to provide vocational services for individuals with disabilities. These services range from assessment and diagnosis to job training and placement and form the basis of the present study.²³ A complete description of these VR services is presented in Table 1.

Table 1.

Description of services provided by state vocational rehabilitation (VR) agencies.

Type of services	Description of services
Assessment	Services provided and activities performed to determine an individual’s eligibility for VR services, to assign an individual to a priority category of a state VR agency that operates under an order of selection, and/or to determine the nature and scope of VR services to be included in the Individual Plan for Employment (IPE); included in this category are trial work experiences and extended evaluation.
Diagnosis and treatment of impairments	Surgery, prosthetics and orthotics, nursing services, dentistry, occupational therapy, physical therapy, speech therapy, and drugs and supplies; this category includes diagnosis and treatment of mental and emotional disorders.
VR counseling and guidance	Discrete therapeutic counseling and guidance services necessary for an individual to achieve an employment outcome, including personal adjustment counseling; counseling that addresses medical, family, or social issues; vocational counseling; and any other form of counseling and guidance necessary for an individual with a disability to achieve an employment outcome; this service is distinct from the general counseling and guidance relationship that exists between the counselor and the individual during the entire rehabilitation process.
College or university training	Full-time or part-time academic training above the high school level that leads to a degree (associate, baccalaureate, graduate, or professional), a certificate, or other recognized educational credential; such training may be provided by a four-year college or university, community college, junior college, or technical college.
Occupational/vocational training	Occupational, vocational, or job skill training provided by a community college and/or a business, vocational/trade, or technical school to prepare students for gainful employment in a recognized occupation; this training does not lead to an academic degree or certification.
On-the-job training	Training in specific job skills by a prospective employer; generally the individual is paid during this training and will remain in the same or a similar job upon successful completion; this category also includes apprenticeship training programs conducted or sponsored by an employer, a group of employers, or a joint apprenticeship committee representing employers and a union.
Basic academic remedial or literacy training	Literacy training or training provided to remediate basic academic skills needed to function on the job in the competitive labor market.
Job readiness training	Training to prepare an individual for the world of work (e.g. appropriate work behaviors, methods for getting to work on time, appropriate dress and grooming, methods for increasing productivity).
Disability-related, augmentative skills training	Service includes, but is not limited to, orientation and mobility, rehabilitation teaching, training in the use of low vision aids, Braille, speech reading, sign language, and cognitive training/retraining.
Miscellaneous training	Any training not recorded in one of the other categories listed, including GED or high school training leading to a diploma.
Job search assistance	Job search activities that support and assist a consumer in searching for an appropriate job; may include help in preparing resumes, identifying appropriate job opportunities, and developing interview skills, and may include making contacts with companies on behalf of the consumer.
Job placement assistance	A referral to a specific job resulting in an interview, whether or not the individual obtained the job.
On-the-job supports	Support services provided to an individual who has been placed in employment in order to stabilize the placement and enhance job retention; such services include job coaching, follow-up and follow-along, and job retention services.
Transportation services	Travel and related expenses necessary to enable an applicant or eligible individual to participate in a VR service; includes adequate training in the use of public transportation vehicles and systems.
Maintenance services	Maintenance means monetary support provided for those expenses such as food, shelter, and clothing that are in excess of the normal expenses of the individual, and that are necessitated by the individual’s participation in an assessment for determining eligibility and VR needs or while receiving services under an individualized plan for employment (IPE).
Rehabilitation technology	The systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of, and address the barriers confronted by, individuals with disabilities in areas that include education, rehabilitation, employment, transportation, independent living, and recreation; includes rehabilitation engineering services, assistive technology devices, and assistive technology services.
Reader services	Services for individuals who cannot read print because of blindness or other disability; includes reading aloud and transcribing printed information into Braille or sound recordings if requested by the individual; generally are offered to individuals who are blind or deaf-blind but may also be offered to individuals unable to read because of serious neurological disorders, specific learning disabilities, or other physical or mental impairments.
Interpreter services	Sign language or oral interpretation services performed by specially trained persons for individuals who are deaf or hard of hearing, and tactile interpretation services for individuals who are deaf-blind; includes real-time captioning services; does not include language interpretation.
Personal attendant services	Those personal services that an attendant performs for an individual with a disability such as bathing, feeding, dressing, providing mobility and transportation, and so on.
Technical assistance services	Technical assistance and other consultation services provided to conduct market analyses, to develop business plans, and to provide resources to individuals in the pursuit of self-employment, telecommuting, and small business operation outcomes.
Information and referral services	Services provided to individuals who need assistance from other agencies (through cooperative agreements) not available through the VR program.
Other services	All other VR services that cannot be recorded elsewhere; included here are occupational licenses, tools and equipment, initial stocks and supplies, and medical care for acute conditions arising during rehabilitation and constituting a barrier to the achievement of an employment outcome.

GED: General Educational Development.

These services are designed to provide employment-related assistance for people whose impairments/disabilities have impeded their ability to obtain or maintain gainful employment.²⁴ The state-federal VR program has consistently been shown to be effective in achieving its mission, with the overall employment rate for people with disabilities after receiving VR services at around 60%.^25,26

For the purpose of the present research we analyzed data retrieved from the US Department of Education, Rehabilitation Services Administration’s (RSA) Case Service Report (RSA-911) database, which contains personal history, types of vocational-related services, and employment outcome information on all individuals who received services from state VR agencies to evaluate the extent to which demographic variables and specific VR services affect the employment outcome of people with MS. The following research questions were addressed:

How do demographic variables and the provision of cash or medical benefits affect the employment outcomes of individuals with MS after receiving VR services?

Which VR services are directly related to employment outcomes of individuals with MS who received state VR services?

Methods

Participants

Data for this study were extracted from the US Department of Education RSA-911 database. This large archival database is provided annually to RSA by state VR agencies across the country. The fiscal year 2009 RSA-911 data, the most current dataset released by RSA at the time of this study, were used for the analyses. There were data for 1920 individuals with MS whose cases were closed as either successfully rehabilitated (i.e. placed in competitive employment) or unsuccessfully rehabilitated (i.e. not placed in competitive employment) after receiving VR services. The demographic characteristics of the sample are presented in Table 2.

Table 2.

Demographic characteristics.

Variable	n (%)	Mean (SD)
Age		42.69 (10.99)
16–34	443 (23.1%)
35–54	1221 (63.6%)
55–64	256 (13.3%)
Gender
Men	599 (31.2%)
Women	1321 (68.8%)
Race
European American	1420 (74.0%)
African American	376 (19.6%)
Native American	23 (1.2%)
Asian American	16 (0.8%)
Hispanic American	85 (4.4%)
Education
Less than high school	105 (5.5%)
Completed high school	574 (29.9%)
Post-secondary/associate	733 (38.2%)
College degree or higher	508 (26.5%)
Significant disabilities
Yes	1894 (98.6%)
No	26 (1.4%)
Co-occurring psychiatric disabilities
Yes	230 (12.0%)
No	1690 (88.0%)
Receiving benefits
Yes	1105 (57.6%)
No	815 (42.4%)
Case service variables		Mean (SD)
Time to become eligible for service		1.14 Months (1.73)
Time in service		29.28 Months (26.97)
Time to closure		30.42 Months (27.29)
No. of services		4.21 (2.22)
Case expenditures		US $5917.55 (11,216.69)

Study design and method

The dependent variable was competitive employment. Competitive employment is defined in the RSA-911 manual as employment in an integrated setting, self-employment, or employment in a state-managed Business Enterprise Program (BEP, which refers to vending facilities and small businesses operated by individuals with significant disabilities as well as home industries that fall under the management of the state VR agency) that is performed on a full-time or part-time basis for which an individual is compensated at or above the minimum wage. Unsuccessful outcome refers to clients who were not so employed after completing their planned VR program.

Two sets of predictor variables were used for this study. The first set of predictor variables included gender (male or female), age at intake (16–34, 35–54, 55–64), education (less than high school, high school graduate, associate degree, and college degree or higher), race/ethnicity (African American, American Indian, Asian American, European American, Hispanic/Latino), co-occurring psychiatric disability (i.e. depression), and receipt of government, medical, or cash benefits, that is, the number of government benefits (Supplemental Security Income (SSI), Social Security Disability Insurance (SSDI), Temporary Assistance for Needy Families (TANF), general assistance, workers’ compensation, and Medicare/Medicaid, etc.). The second set of predictor variables included each of the types of VR services.

Data analysis

Data extracted from the RSA-911 data were analyzed using SPSS 19.0. Hierarchical logistic regression analysis was used to examine the effect of demographic covariates, work disincentives, and VR services on employment outcomes of MS clients.

Results

Descriptive statistics

The sample of 1920 participants included 599 men (31.2%) and 1321 women (68.8%). After receiving VR services, a total of 924 clients (48.1%) were employed. There was no gender difference between the employed and unemployed groups. Mean age of the clients was 42.69 years (SD = 10.99). Clients reported secondary conditions, including in some cases multiple conditions, including physical impairments (e.g. mobility, orthopedic/neurological impairments) (1655; 86.2%); sensory impairments (e.g. visual impairments/blindness) (171; 8.9%); and mental impairments (e.g. cognitive, psychosocial impairments) (94; 4.9%). In addition, 12% of the clients were reported to have comorbid major depression. Racial and ethnic backgrounds were dominated primarily by European Americans (74%) followed by 19.6% African Americans and other races. There was a significant difference between race/ethnicity and employment outcomes (χ² = 12.50, p < 0.05), with African American clients having lower employment rates compared to White. In terms of education, 5.5% had less than high school education, 29.9% completed high school, 38.2% completed community college, and 26.5% had a college education. More clients in the employed group had higher educational attainment than their counterparts (χ² = 40.46, p < 0.000). Significantly more unemployed clients at closure were receiving disability-related medical or cash benefits (χ² = 70.38, p < 0.000).

The average time between submitting an application and becoming eligible for VR services was 1.14 months, with a median of 0.77 months. The average time in VR services was 30.42 months, with a median of 21.29 months. For MS clients receiving university training as a vocational service, the average time in VR service (M = 57.78 months) was significantly higher than MS clients who did not receive university training (M = 24.21); t ₍₁₉₁₈₎ = 21.816, p < 0.001. The average number of services received was 4.21 and the average case expenditure was $5917.55, with a median of $2189.50. The successfully employed group waited for a shorter time (M = 1.03 months, SD = 1.34) to be determined eligible than the unemployed group (M = 1.24, SD = 2.03); t₍₁₉₁₈₎ = −2.70, p < 0.01. The successfully employed group was found to spend significantly less time in services (M = 23.31 months, SD = 22.72) than the unsuccessful group (M = 34.82 months, SD = 29.32); t_{(1918 )}= −9.65, p < 0.000. However, the successfully employed group was found to receive significantly more services (M = 4.52, SD = 2.13) than the unsuccessful group (M = 3.92, SD = 2.27; t₍₁₉₁₈₎=5.91, p < 0.000). Also, average case expenditures (U.S. dollars) for the successful group (M = 7443.13, median = 3222.50, SD = 12,146.02) was higher than the unsuccessful group (M = 4502.24, median = 1484.50, SD = 10,081.35).

In terms of the use of public support and medical insurance, SSDI, Medicare, and Medicaid were the top three benefits received by clients. Sixty-six percent of clients aged 55–64 received cash benefits, compared to 58% for clients aged 35–54, and 51% for clients 16–34 (χ² = 14.23, p < 0.001). Among public support and medical insurance used by more than 10% of clients, there were significant relationships between the employment outcomes and SSI, SSDI, Medicaid, and Medicare. More unemployed clients reported receiving these disability-related benefits than employed clients (Table 3).

Table 3.

Receipt of public support and medical insurance coverage of employed and unemployed applicants at the time of closure.

Support insurance		All (n = 1920)		Employed (n = 924)		Unemployed (n = 996)		X ² _(df)	p
Support insurance		n	(%)	n	(%)	n	(%)	X ² _(df)	p
SSI	Yes	230	(12.1)	61	(6.6)	169	(17.2)	49.66	0.000
	No	1675	(87.9)	895	(93.4)	816	(82.8)
TANF	Yes	20	(1.1)	5	(.5)	15	(1.5)	4.40	0.036
	No	1884	(98.9)	915	(99.5)	969	(98.5)
GA	Yes	19	(1.0)	4	(.4)	15	(1.5)	5.71	0.017
	No	1885	(99.0)	916	(99.6)	969	(98.5)
SSDI	Yes	888	(46.6)	348	(37.8)	540	(54.8)	54.89	0.000
	No	1018	(53.4)	572	(62.2)	446	(45.2)
VA	Yes	7	(.6)	2	(.2)	5	(.5)	1.10	0.295
	No	1897	(99.4)	918	(99.8)	979	(99.5)
WC	Yes	1	(.1)	0	(0)	1	(.1)	NA	NA
	No	1902	(99.9)	919	(100)	983	(99.9)
OPA	Yes	78	(4.1)	26	(2.8)	52	(5.3)	7.31	0.007
	No	1826	(95.9)	894	(97.2)	932	(94.7)
CAID	Yes	460	(24.3)	167	(18.2)	293	(30.1)	36.78	0.000
	No	1431	(75.7)	752	(81.8)	679	(69.9)
CARE	Yes	589	(31.1)	245	(26.7)	344	(35.4)	16.79	0.000
	No	1302	(68.9)	674	(73.3)	628	(64.6)
PINSURE	Yes	40	(2.1)	20	(2.2)	20	(2.1)	0.03	0.855
	No	1852	(97.9)	899	(97.8)	953	(97.9)
EMPINS	Yes	315	(16.7)	286	(31.1)	29	(3.0)	268.46	0.000
	No	1573	(83.3)	633	(68.9)	940	(97.0)
OTHRINS	Yes	386	(20.4)	204	(23.1)	182	(18.7)	3.51	0.061
	No	1505	(79.6)	715	(76.9)	790	(81.3)

SSI: Supplemental Security income; TANF: Temporary Assistance for Needy Families; GA: general assistance; SSDI: Social Security Disability Insurance; VA: Veterans’ Disability Benefits; WC: workers’ compensation; OPA: other public support; CAID: Medicaid; CARE: Medicare; PINSURE: public insurance from other sources; EMPINS: private insurance through own employment; OTHRINS: private insurance through other means.

The most frequently received VR services were comprehensive assessment and counseling and guidance, followed by diagnosis and treatment of impairments and job placement assistance. Among the services received by more than 10% of clients, there were significant relationships between employment outcome and diagnosis and treatment of impairments, counseling and guidance, college or university training, job search assistance, job placement assistance, maintenance services, and assistive technology. These services, except for college or university training, were more likely to be provided to the employed group than the unemployed group. In addition, 41 clients (2%) received only assessment services; of these clients, nine (22.0%) achieved employment outcome without further services, and the remainder of these clients were closed for the reasons of unable to locate or contact (n = 10, 24.4%), disability too significant to benefit from VR services (n = 1, 2.4%), refused services (n = 11, 26.8%), failure to cooperate (n = 3, 7.3%), and other reasons (n = 7, 17.1%). Twenty-one of these clients (51.2%) were also SSI/SSDI recipients (Table 4).

Table 4.

The use of vocational rehabilitation services.

Type of service	Use condition	All (n = 1920)		Employed (n = 924)		Unemployed (n = 996)		X² _(df)	p
Type of service	Use condition	n	%	n	%	n	%	X² _(df)	p
Assessment	Yes	1328	(69.2)	646	(69.9)	682	(68.5 )	0.47	0.495
	No	592	(30.8)	278	(30.1)	314	(31.5)
Diagnosis and treatment of impairments	Yes	670	(34.9)	355	(38.4)	315	(31.6)	9.74	0.002
	No	1250	(65.1)	569	(61.6)	681	(68.4)
Vocational rehabilitation counseling and guidance	Yes	1316	(68.5)	693	(75.0)	623	(62.6)	34.46	0.000
	No	604	(31.5)	231	(25.0)	373	(37.4)
College or university training	Yes	290	(15.1)	124	(13.4)	166	(16.7)	3.94	0.047
	No	1630	(84.9)	800	(86.6)	830	(83.3)
Occupational/vocational training	Yes	220	(11.5)	93	(10.1)	127	(12.8)	3.41	0.065
	No	1700	(88.5)	831	(89.9)	869	(87.2)
On-the-job training	Yes	47	(2.4)	34	(3.7)	13	(1.3)	11.32	0.001
	No	1873	(97.6)	890	(96.3)	983	(98.7)
Basic academic remedial or literacy training	Yes	15	(0.8)	7	(0.8)	8	(0.8)	0.01	0.910
	No	1905	(99.2)	917	(99.2)	988	(99.2)
Job readiness training	Yes	181	(9.4)	81	(8.8)	100	(10.0)	0.91	0.340
	No	1739	(90.6)	843	(91.2)	896	(90.0)
Disability-related, augmentative skills training	Yes	89	(4.6)	38	(4.1)	51	(5.1)	1.10	0.294
	No	1831	(95.4)	886	(95.6)	945	(94.9)
Miscellaneous training	Yes	247	(12.9)	120	(13.0)	127	(12.8)	0.02	0.877
	No	1673	(87.1)	804	(87.0)	869	(87.2)
Job search assistance	Yes	435	(22.7)	229	(24.8)	206	(20.7)	4.60	0.032
	No	1485	(77.3)	695	(75.2)	790	(79.3)
Job placement assistance	Yes	614	(32.0)	366	(39.6)	248	(24.9)	47.69	0.000
	No	1306	(68.0)	558	(60.4)	748	(75.1)
On-the-job supports	Yes	191	(9.9)	111	(12.0)	80	(8.0)	8.48	0.004
	No	1729	(90.1)	813	(88.0)	916	(92.0)
Transportation services	Yes	553	(28.8)	249	(26.9)	304	(30.5)	2.99	0.084
	No	1367	(71.2)	675	(73.1)	692	(69.5)
Maintenance services	Yes	247	(12.9)	141	(15.3)	106	(10.6)	9.12	0.003
	No	1673	(87.1)	783	(84.7)	890	(89.4)
Rehabilitation technology	Yes	523	(27.2)	314	(34.0)	209	(21.0)	40.86	0.000
	No	1397	(72.8)	610	(66.0)	787	(79.0)
Reader services	Yes	2	(0.1)	0	(0)	2	(0.2)	1.86	0.173
	No	1918	(99.9)	924	(100)	994	(99.8)
Interpreter services	Yes	2	(0.1)	2	(0.2)	0	(0)	NA	NA
	No	1918	(99.9)	922	(99.8)	996	(100)
Personal attendant services	Yes	22	(1.1)	10	(1.1)	12	(1.2)	0.06	0.801
	No	1898	(98.9)	914	(98.9)	984	(98.8)
Technical assistance services	Yes	78	(4.1)	43	(4.7)	35	(3.5)	1.60	0.206
	No	1842	(95.9)	881	(95.3)	961	(96.5)
Information and referral services	Yes	417	(21.7)	218	(23.6)	199	(20.0)	3.68	0.055
	No	1503	(78.3)	706	(76.4)	797	(80.0)
Other services	Yes	593	(30.9)	300	(32.5)	293	(29.4)	2.09	0.148
	No	1327	(69.1)	624	(67.5)	703	(70.6)

Logistic regression analysis

The omnibus test for the logistic regression model was found to be statistically significant, χ² _{(28, n = 1920)} = 287.039, p < 0.001. The Nagelkerke R² was computed to be 0.19, indicating a moderate effect size. The Hosmer and Lemeshow goodness-of-fit test was not significant, χ² (8, n = 1920) = 5.644 (p = 0.69), indicating that the model fits the data reasonably well. Demographic covariates were entered in step one, which included gender (with female as the reference category), age (with age 16–34 as the reference category), education (with less than high school as the reference category), race/ethnicity (with European American as the reference category), co-occurring psychiatric disabilities, and cash and medical benefits. Gender was not a significant predictor. The odds of MS clients who had a college or higher degree finding employment were 1.86 times greater than the odds of those with less than a high school degree. People who received Medicare/Medicaid at application had a 25% reduction in odds of obtaining employment. People who received cash benefits at application had a 42% reduction in odds of obtaining employment. In addition, individuals receiving only medical benefits at the time of application for vocational services (i.e., Medicare, Medicaid or Consolidated Omnibus Budget Reconciliation Act (COBRA)) had a successful employment rate of 51% compared to the 59% success rate for clients who did not receive any benefits (odds ratio (OR) = 0.72; 95% confidence interval (CI): 0.53–0.99); individuals who received SSI/SSDI but not medical benefits had a successful employment rate of 46% compared to the 60% success rate for clients who did not receive any disability benefits (OR = 0.57; 95% CI: 0.43–0.75); and people who received both medical and cash benefits had the lowest employment rate of 38% compared to the 60% success rate for clients who did not have any disability benefits (OR = 0.42; 95% CI: 0.34–0.51). Individuals with MS who received both medical and cash benefits at the time of application for vocational services had the greatest reduction in odds of obtaining employment after receiving VR services.

For individuals receiving medical and/or cash benefits at the time of application who became competitively employed at closure, only 9% left the Social Security rolls entirely. The reduction in SSI/SDDI payment was relatively small but statistically significant, from $1011.82 (SD = 423.07) to $938.08 (SD = 499.37) (t ₍₃₈₅₎₌3.81, p < 0.001). Individuals who continued to receive Social Security benefits worked on average 21.01 hours per week (SD = 10.41), which was significantly lower than the 33.15 hours per week (SD = 9.45) for individuals who were not on the Social Security rolls (t ₍₉₂₂₎=18.51, p < 0.001); these individuals also earned less per week (M = $243.45, SD = 220.79) compared to people who were not on the Social Security rolls (M = 549.90, SD = 427.76) (t ₍₉₂₂₎=18.51, p < 0.001).

In the second step, 15 VR services were entered as predictors of the employment status at closure. (Services used by less than 5% of clients that included on-the-job training; basic academic remedial or literacy training; disability-related, augmentative skills training; reader services; interpreter services; personal attendant services; and technical assistance services were not entered as predictors in the logistic regression analysis.) Gender became a significant predictor. Educational attainment was found to be a non-significant predictor. The OR for cash benefits was computed to be 0.51 and 0.76 for medical benefits, indicating that clients receiving disability-related benefits had significantly less chance of finding employment. After controlling for the effect of the demographic covariates, five VR services were found to significantly increase the chance of successful employment outcomes: counseling and guidance, job placement assistance, on-the-job supports, maintenance services, and assistive technology services (Table 5).

Table 5.

The odds ratios of vocational services and employment.

Independent variable	Step one		Step two
	OR (95% CI)	p	OR (95% CI)	p
Gender ^a
Male	0.828 (.676–1.014)	0.068	0.808 (0.653–1.000)	0.050
Age
16–34	1 (Reference)
35–54	1.093 (0.868–1.377)	0.450	0.953 (0.742–1.224)	0.705
55–64	1.216 (0.873–1.694)	0.248	1.129 (0.790–1.641)	0.506
Education
Less than high school	1 (Reference)
Completed high school	1.054 (0.681–1.632)	0.813	0.882 (0.560–1.390)	0.588
Post-secondary/associate	1.139 (0.741–1.751)	0.553	0.990 (0.633–1.549)	0.965
College degree or higher	1.859 (1.188–2.909)	0.007	1.506 (0.945–2.401)	0.085
Race
European American	1 (Reference)
African American	0.843 (0.662–1.074)	0.166	0.833 (0.645–1.077)	0.163
Native American	1.836 (0.773–4.362)	0.169	1.906 (0.769–4.720)	0.163
Asian American	0.411 (0.136–1.236)	0.113	0.416 (0.136–1.273)	0.124
Hispanic American	0.917 (0.580–1.448)	0.709	0.973 (0.600–1.579)	0.912
Co-morbid mental illness ^b	0.868 (0.651–1.157)	0.334	0.835 (0.617–1.131)	0.245
Medical benefits ^b	0.748 (0.628–0.892)	0.001	0.755 (0.626–0.910)	0.003
Cash benefits ^b	0.575 (0.460–0.720)	0.000	0.514 (0.406–0.651)	0.000
Assessment ^b			1.007 (0.810–1.252)	0.949
Diagnosis and treatment ^b			1.203 (0.976–1.483)	0.083
Counseling and guidance ^b			1.680 (1.339–2.108)	0.000
University training ^b			0.866 (0.648–1.158)	0.331
Vocational training ^b			0.830 (0.603–1.143)	0.254
Job readiness training ^b			0.706 (0.496–1.004)	0.053
Miscellaneous training ^b			0.809 (0.600–1.090)	0.164
Job search assistance ^b			0.912 (0.700–1.187)	0.491
Job placement assistance ^b			2.427 (1.942–3.016)	0.000
On-the-job supports ^b			1.618 (1.163–2.252)	0.004
Transportation services ^b			0.812 (0.642–1.027)	0.082
Maintenance ^b			1.589 (1.171–2.156)	0.003
Rehabilitation technology ^b			2.090 (1.659–2.634)	0.000
Information and referral ^b			1.046 (0.815–1.341)	0.726
Other services ^b			1.035 (0.830–1.289)	0.762

OR: odds ratio; CI: confidence interval. ^aFemale is the reference group. ^bDichotomous variables with Yes/No response; No is the reference group.

Discussion

In the current study, the employment success rate of the MS participants was 48% after receiving VR services, similar to the employment success rate of 49% for people with traumatic brain injuries, but appreciably lower than the 62% overall employment success rate for VR clients, the 75% rate for people with sensory/communicative disabilities, and the 56% rate for people with physical disabilities.^27,28

The current study found that after controlling for the effect of demographic covariates, VR services significantly enhanced the employment outcome of clients with MS. The average time in vocational rehabilitation was 30 months for MS clients in the current study and was slightly longer than 22 months for the average VR clients;²⁹ 25-month duration for people with sensory/communicative impairments, 28 months for people with physical impairments, and 24 months for people with mental impairments.²⁷ Time in VR is relatively long for VR clients because not only can they receive psychosocial and medical interventions, many clients can also receive postsecondary education and other vocational training services as well as job seeking skills training and job placement assistance. In addition, VR clients must be on the job for 90 days before they can be closed as successful closures.

Counseling and guidance, job placement, workplace support, assistive technology/job accommodation, and maintenance services appear to be the most helpful vocational services for VR clients with MS (i.e. managing work performance by accommodating work environment and demands, and managing expectations through a counselor who can help their employers understand their current work functioning). This study supports that job placement has emerged in other VR services research as a strongly positive service for successful employment.^7,30 Prescribing appropriate assistive technology and job accommodation proved to be an effective employment strategy. For people with MS who might experience unexpected health or other life crises and barriers during the course of rehabilitation, helping clients with maintenance services (e.g. food, shelter, clothing, transportation) could provide them the needed resources to deal with life crises while trying to complete their VR program. In addition, being female and not receiving cash or medical benefits at application also significantly increased the chance of being employed at closure. When disability-related benefit variables were entered into the logistic regression model, the effect of race/ethnicity on employment dissipated, suggesting the race/ethnicity effect can be mediated by poverty.

The current study underscored the importance of early referral of people with MS to state VR agencies for services, given research has indicated that as soon as a worker with disability progresses from using short-term disability benefits to long-term disability benefits and ultimately to SSDI, the possibility of returning to work independently is reduced dramatically.³¹ This is also true for MS clients in our study. We also found that older adults had the highest percentage of receiving Social Security benefits, suggesting the likelihood of a chronic progressive disease course. Older adults also tend to receive cash benefits first and have to wait one to two years to receive Medicare, and this delay in receiving health insurance benefits may have detrimental effects on the health status of older adults with MS, affecting their ability to go to work. It is important for VR professionals to develop competencies in benefits counseling in order to help their clients apply for appropriate benefits and also to help them understand the work incentives associated with federal benefits. For example, during the trial work period, clients may retain their disability benefits for an extended period, and can resume their disability benefits if their employment ends.

Higher education at application did not improve the odds of being employed after controlling for the effect of other demographic variables and VR services in the current study. Also, college education as a VR service is negatively associated with employment outcomes for people with MS. The negative association between college education and employment success is counter-intuitive to expectations. However, transitioning to college can be stressful for MS patients. Loneliness, isolation, and problems adjusting to college can elevate the level of stress, making them vulnerable to depression and other secondary health conditions. Without appropriate psychosocial and healthcare support addressing their adjustment and accommodation needs in college, chances are they will fail. It is unclear how many of these clients actually completed their educational training and how many had dropped out of their college education. Discussion with rehabilitation counselors in the field indicated that providing financial support for people with MS to attend college without arranging appropriate healthcare and psychosocial support and close contact with them over a long period of time can be a plausible explanation for the negative relationship between college education and employment outcomes. Therefore, we conducted additional analyses using time-in-service as a proxy for the dropout variable and found a time-in service and college education service interaction effect indicating that clients who received college education service but did not complete their education (shorter time in VR) had poorer outcomes than clients who received and completed their education (longer time in VR). Therefore, in addition to the risk for academic performance and retention problems, rehabilitation counselors may need to better address psychosocial difficulties associated with the transitional adjustment process to college life when investing in college education as a vocational service for MS clients.

Limitations

Because this study used archival data and employs an ex post facto design, causality cannot be inferred. The RSA-911 data define people with significant disabilities as individuals with physical or mental impairment that seriously limits one or more functional capacities (e.g. mobility, work tolerance, work skills) who are expected to need multiple VR services over an extended period of time. However, no functional assessment data were available in the database. There is no information on the severity of MS symptoms (e.g. cognitive impairments) and dysfunction. It does not provide case expenditure information for each vocational service and no information on specific types of assistive technology and job accommodations. Such information would provide more in-depth understanding of the relationships explored in the present study and may also provide an opportunity to improve the rate of successful closure in VR services.

Conclusion

Vocational services provided by state vocational rehabilitation agencies represent a viable resource to help individuals with MS seek employment.

Footnotes

Conflict of interest

The authors declare that there are no conflicts of interest.

Funding

The contents of this article were developed with support through the Rehabilitation Research and Training Center on Disability Statistics and Demographics (StatsRRTC) located at Hunter College, The City University of New York, under a grant from the Department of Education, National Institute on Disability and Rehabilitation Research (NIDRR) grant number PR# H133B080012, and through the Rehabilitation Research and Training Center on Effective Vocational Rehabilitation Service Delivery Practices at the University of Wisconsin-Madison and the University of Wisconsin-Stout (NIDRR grant number PR# H133B100034). However, the contents do not necessarily represent the policy of the Department of Education, and endorsement by the federal government should not be assumed.

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