195

Journal of Vocational Rehabilitation 42 (2015) 195200

DOI:10.3233/JVR-150739
IOS Press

Working with ODEP to create systems

change: The story of two protege states
SueAnn Morrowa, , Amy Gonzalezb , Tyler Hamptonc and Ashlea Lantzd
a University

of Iowa, Mount Pleasant, IA, USA

Department of Intellectual and Developmental Disabilities, Nashville, TN, USA
c SRVS, Memphis, TN, USA
d Candeo, Inc., Johnston, IA, USA
b Tennessee

Revised/Accepted February 2015

Abstract.
BACKGROUND: The United States Department of Labors (DOL) Office of Disability Employment Policy (ODEP) initiated
the Employment First State Leadership Mentoring Project (EFSLMP) to assist states to align policies, regulations and funding
priorities to encourage integrated employment as the primary outcome for individuals with significant disabilities.
OBJECTIVE: This paper describes the activities undertaken by two states designated as Protege States of the Employment First
State Leadership Mentoring Project of the United States Department of Labors (DOL) Office of Disability Employment Policy
(ODEP).
CONCLUSION: Protege states received mentoring from the identified mentor state as well as training and technical assistance
by Subject Matter Experts (SMEs). While five aspects of system change were shared by the states, the efforts undertaken to effect
change were individual to each state. Lessons learned are also noted.
Keywords: Employment First State Leadership Mentoring Project (EFSLMP), Department of Labors (DOL), Office of Disability
Employment Policy (ODEP), systems change

1. Introduction
For decades the employment status of individuals with disabilities has been regarded as dismal. In
an effort to change this long-standing dilemma there
has been a resurgence of effort to increase integrated
employment outcomes for all individuals with disabilities regardless of the severity of the disability. Recent
Department of Justice settlements i.e., Rhode Island
(Samuels, 2014) and Oregon (Lane v. Kitzhaber, 2012)
and the recognition that the Americans with Disabilities
Act, thus the Olmstead Decision, relates to employment
settings and services in addition to residential settings
and services (Lane v. Kitzhaber, 2012) has brought
Address for correspondence: SueAnn Morrow, Ph.D., University
of Iowa, Money Follows the Person Program, 2927 Old Highway 218,
Mount Pleasant, IA 52641, USA. Tel.: +1 319 430 8710; Fax: +1 319
385 1365; E-mail: Sue-morrow@uiowa.edu.

attention to current employment practices. Continued

national efforts such as the State Employment Leadership Network (www.selnmembers.org); changes in
the Center for Medicare and Medicaid Services (CMS)
definition of relevant services (CMS, 2011, 2014a&b);
and the growing evidence that individuals once thought
to be unemployable are, in fact, quite capable of working in integrated settings when given the appropriate
supports (Disability Rights Iowa, 2014; Gravelle, 2014;
Tennessee Department of Intellectual and Developmental Disabilities, 2014) have fueled the growing demand
for systems that support opportunities for individuals
to secure employment in the community. This effort
has become collectively known as Employment First
and is now operating at some level in over 46 states
(www.apse.org). Given the grim employment rates for
individuals with disabilities, the continued national
efforts and the recent DOJ findings, integrated employ-

1052-2263/15/$35.00 2015 IOS Press and the authors. All rights reserved

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S.A. Morrow et al. / Working with ODEP to create systems change: The story of two protege states

ment is becoming a priority not only for the federal

government, but for state governments as well.
However, sometimes states wanting to change their
employment systems to better support the Employment
First agenda often find themselves with the will, but
without the way. In 2012 the United States Department
of Labors (DOL) Office of Disability Employment
Policy (ODEP) initiated the Employment First State
Leadership Mentoring Project (EFSLMP) to help meet
that need. It was designed to help states align policies, regulations and funding priorities to encourage
integrated employment as the primary outcome for individuals with significant disabilities (www.dol.odep).
Three states (Iowa, Tennessee, and Oregon) were identified as protege states and one state (Washington) as
the mentor state.
This article tells the story of two of the three protege
states as we attempted to align our practices, policies, regulations and funding to incentivize integrated
employment.
The basic premise of the EFSLMP was straightforward. Each state would receive mentoring from the
mentor state as well as assistance from multiple Subject
Matter Experts (SMEs) that best fit the needs of their
state. In addition there would be Community of Practice
Calls and Work Groups determined by similar interests
for more in-depth technical assistance. As the Project
continued other Tiers of Assistance (Lowe, 2013)
were added.
The first Tier included the intensive technical assistance and training provided to the three protege states.
Each state selected SMEs from a list developed by
ODEP based on the needs of their state to provide
in-person and virtual training and or technical
assistance. Additionally, the protege states received
individualized peer-to-peer mentoring from the mentor
state, Washington.
The second Tier added the Employment First Vision
Quest Series. A topic or issue was identified by each
state most germane to them. SMEs were identified
and calls were held monthly for in-depth discussions around that topic or issue. SMEs also gave
us feedback regarding our employment policies and
practices.
Tier 3, the Community of Practice calls, represents
still another method of training and technical assistance
provided through the Project. Topical monthly Community of Practice calls were held and open to any state, not
just the protege states, interested in learning more about
that particular topic. ODEP also published informational bulletins, developed a collaborative workspace on

the ePolicyWorks website and provided federal policy

updates quarterly.
While we directed our efforts differently, both states
focused on five major features:
a) Increasing Collaboration and Partnerships b)
Developing a Family Coalition c) Business Model
Transformation d) Rate Restructuring and e) Capacity
Building.
2. Iowas story
2.1. Increasing collaboration and partnerships
From the beginning, Iowa developed a team of
stakeholders to lead our efforts of aligning systems
and setting rates to incentivize integrated employment.
Members represented state agencies, advocacy organizations, community employment providers and family
members. Our team also included representatives from
the DOL Disability Employment Initiative (DEI) and
our Administration of Intellectual and Development
Disabilities (AIDD) system change grant.
Like many states attempts at collaborative solutions,
individual agendas, and predetermined solutions initially dampened our collective spirit. However, with
strong leadership from the Administrator of Iowa
Vocational Rehabilitation Services (IVRS), monthly
meetings, jointly funded activities and real progress on
changing Medicaid definitions and rates, collaboration
began to emerge.
For example, EFSLMP initially planned to have three
pilot projects learn about and implement customize
employment and provide data specific to Iowa. The
AIDD grant funds were used to increase that number
to six allowing for more people to be served as well as
more robust and meaningful data.
The DEI has stretched us to work across systems
through the use of Integrated Resource Teams (IRTs).
Serving on an IRT helped strengthen our ability to get
out of our silo and form partnerships at the individual
level.
On the state level the existing Memorandum of
Agreement signed by eight state agencies involved in
employment services for Iowans with disabilities was
revised to better support integrated employment, maximize cooperation and minimum duplication of service.
2.2. Develop a family coalition
Knowing that families and individuals with disabilities themselves are the real change agents, Iowa started

S.A. Morrow et al. / Working with ODEP to create systems change: The story of two protege states

a Parent and Family Coalition, a grassroots effort inclusive to all parents and families who desired employment
for their family member. Both EFSLMP and our
AIDD grant have led these efforts. The goals of the
Coalition include generating legislative priorities; providing leadership; and serving as a liaison for parents
with community groups, policy makers and stakeholders. It also provides another avenue to distribute
relevant information from federal, state, and local
policymakers.
2.3. Business model transformation
For years Iowa has relied heavily on segregated
employment services and spent approximately 80%
of its Medicaid employment service dollars on segregated employment services (Morrow, Amsbaugh,
Moskowitz, Westhoff, & Walker, 2011). To help show
providers a different way of doing business, EFSLMP,
along with the AIDD grant, worked with six agencies
to implement Customized Employment.
The six pilot projects worked with a total of 30
individuals specifically targeted for EFSLMP. The
individuals were to have been previously considered
unemployable. At the end of the Project, 14 of those
individuals were employed, working an average of
13-14 hours a week with an average wage of $7.65
per hour. One individual employed through the Project
noted, This is my first minimum wage job in my entire
wheel-chair life (Idactionia, 2013). And that timespan
had been over 40 years.
Another SME was brought in to provide information
and technical assistance to administrators of agencies
interested in transforming their services. While we
originally targeted the six administrators from the Pilot
Projects, it has grown as administrators from other
agencies are asking to be part of the movement. Multiple on-site training and technical assistance have been
provided either through EFSLMP, Iowa Association of
Community Providers (IACP) or the AIDD grant. With
the new focus on integrated employment, the 14 agencies involved in the transformation activities helped 427
individuals with disabilities secure integrated employment with an average wage of $7.81 per hour and
average number of hours worked at 17 per week.

197

held throughout the state and attended by over 175

people to respond to the recommendations that the
State Employment Leadership Network (SELN) had
developed for Iowa to have a high quality employment
funding system.
From these meetings, 30 individuals were asked to
serve on a Work Group to make recommendations
regarding service definitions, new rates and staff qualifications. The Work Group met seven times during
the year. Webinars were held to keep other interested
parties well informed of the progress of the Work
Group.
Currently, the recommendations of the Work Group
are waiting for approval from the Administrators of
the Division of Mental Health and Disability Services
(MHDS) and Iowa Medicaid Enterprise (IME). There
have been several advocacy efforts, i.e., a letter writing
campaign, submitting a petition, and phone calls made
to get the process to move forward.
While the discussions with the mental health and disability side of the system have been delayed, the IVRS
side has made changes. They have added Discovery
and Customized Employment as services they will purchase and they have increased their rates for community
employment.
2.5. Capacity building
Staff qualifications, training and credentialing were
all components considered by the Work Group. Iowa
has an ACRE approved curriculum offered by IA-APSE
and personnel also have access to DirectCourse at
no charge. Additionally, because of EFSLMP, we
have been conducting topical Monthly Community of
Practice Calls for anyone wanting to join. We are
working with Washington State to supplement these
current offerings. Our goal is an affordable, accessible, sustainable and high quality system of professional
development.

3. Tennessees story
While Tennessee worked on the same five aspects of
systems change, our approach was slightly different.

2.4. Rate restructuring

3.1. Increasing collaboration and partnerships

One of the biggest obstacles faced by Iowa was a

rate structure that incentivized sheltered employment.
To start the work, five Community Conversations were

In Tennessee, the Department of Intellectual and

Developmental Disabilities (DIDD) took the lead of the
EFSLMP efforts with a greater emphasis on working

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S.A. Morrow et al. / Working with ODEP to create systems change: The story of two protege states

directly with community rehabilitation providers that

delivered employment services. At the same time,
however, we identified methods to partner with our Vocational Rehabilitation (VR) agency incorporating joint
training including Customized Employment, Discovery
and Job Coaching. Through this collaboration, we also
developed a pilot Letter of Agreement (LOA) that was
offered to the three providers that began working with
the EFSLMP Initiative in 2012. The LOA reimburses
providers for using Customized Employment and Discovery to place a person in integrated employment.
Through conducting meetings with CRPs, we
learned that a significant number of persons who were
being supported had not been through the VR system.
The initial recommendation for the providers was to
identify individuals who needed Vocational Rehabilitation services and begin referring them in increments.
It was suggested that the individuals with significant
disabilities and a need for Customized Employment
be referred in the last wave. However, we quickly
realized that we needed to serve these individuals as
soon as possible to demonstrate the need for Customized Employment and gain the support of the
Vocational Rehabilitation leaders for expansion of the
LOA statewide.
On June 19, 2013, Governor Haslam signed Executive Order No. 28 indicating his support for the
Employment First Initiative. The Executive Order
contained specific directives for the DIDD and the TaskForce as a whole. The primary task for the DIDD was
to create an Employment First TaskForce and convene
an initial meeting by August 1, 2013. After that we
created Work Groups that merged with the TennesseeWorks Partnership subgroups. TennesseeWorks is a
collaboration of organizations and agencies committed
to increase integrated employment outcomes for Tennesseans with disabilities. Our Work Groups focused
on Policy, Data, Employer and Provider, and Families.
These Work Groups identified needs and obstacles and
then developed plans to address them.
3.2. Develop a family coalition
We also recognized the importance of involving
family members; however, rather than having a state
wide Family Coalition, we determined that we needed
regional Coalitions. We currently have three pilot Parent
Coalitions operating in Nashville, Memphis, and Chattanooga. The Coalition members identify their needs
and we provide resources to help address those needs.
It might be a speaker or another resource that makes it

easier for a family member to access employment services. All of the respective coalition members have the
vision of their family member employed in the community. Members also learn how to advocate for services
that lead to enhanced employment outcomes.
3.3. Business model transformation
Our state decided early on that we wanted to meet
providers where they are and then work collaboratively to assist them in transforming from facility based
services to integrated services. We also heavily publicized the lawsuits in Oregon and Rhode Island and
shared that some of the concerns noted in these states
mirrored some of the services being provided in Tennessee. We strategically asked three providers in each
of our Regions (East, Middle, and West) to gauge their
interest in participating in the Initiative. The majority of
them said no including SRVS, who eventually agreed
to be involved.
SVRS is one of the oldest, largest nonprofit
providers of services for individuals with disabilities
in Tennessee. It provides a range of services including
residential support, integrated employment services,
adult day services, and a sheltered workshop. While
they initially declined, they looked at actions in Oregon and Rhode Island and realized that at some point
there might be litigation and they would be forced to
close their workshop. They wanted to be pro-active
and make changes in a systematic and planful manner. They anticipated resistance by a number of entities
including the people with disabilities themselves, their
family members, other team members, and likely some
board members. They also realized that lack of funding
would be a potential obstacle.
They addressed these obstacles through meeting with
the different concerned groups as well as conducting
meetings with individuals. They formed a steering committee of board members who wanted to move forward.
They re-worked their employment process to make it a
much more dynamic system with a full time job developer, an on-site rehabilitation counselor and separate
employment consultants.
They did a major marketing campaign to raise awareness of the community including employers. They used
TV spots, billboards, You-Tube, a newsletter, and word
of mouth.
3.4. Rate restructuring
Our rate restructuring work is not complete. Tennessee uses a tier system with the highest reimbursement

S.A. Morrow et al. / Working with ODEP to create systems change: The story of two protege states

rate occurring for more hours and more pay for the
individual. We are collaborating with TennCare, our
Medicaid agency, to study rates to best determine
the most appropriate way to move forward. We have
released a concept paper and held community and stakeholder forums to receive input and feedback needed to
develop rates. We are researching other states funding
structures and we have also worked with SMEs for specific guidance on how to successfully restructure rates to
fully incentivize community integrated employment.
3.5. Capacity building
Requiring trained staff is a critical component for
Tennessee to continue to build a system that promotes
integrated employment. To that end, we have held
topical monthly webinars, much like Iowa, featuring
different SMEs. We also provided training around Customized Employment and Discovery through webinars
and in-person sessions.
We also expressed a desire to grow the capacity of
our providers. We have worked with them to become
Employment Networks and to increase the use of the
Ticket to Work program through the Social Security
Administration. Training has also been offered on Plans
to Achieve Self Sufficiency (PASS) and other work
incentives through Social Securitys PASS Cadre.
4. Reections
Our experiences with the EFSLMP demonstrate the
value of technical assistance and support being provided
by a federal agency such as ODEP. Through this assistance both states were able to make progress toward
the adoption of Employment First policies and practice.
While our efforts were similar, the unique environments
of our individual states dictated our specific activities. In
Iowa, stakeholder involvement was particularly needed.
Lisa Mills, the SME who worked closely with us in Iowa
regarding the rate restructuring, noted: The benefits of
stakeholder engagement was clearly evident in the Iowa
process of revising Medicaid service definitions and
developing new rates to incentivize integrated, competitive employment outcomes. Rather than limiting stakeholder engagement to community conversations reviewing SME recommendations, or seeking input from
stakeholders on final change proposals, Iowas state
agencies engaged a Work Group of key stakeholders and
undertook the often arduous work of redesigning service
definitions, provider qualifications, and reimbursement
rates and methodologies in partnership with the Work

199

Group members. While it might be assumed that such

a Work Group would find it impossible to reach consensus, and would lead to funders and providers being
at odds over how change should be accomplished, the
Iowa experience confirmed that stakeholders with varying perspectives can come together to create a plan for
change if sufficient time is given and if an atmosphere
is created which conveys to all participants that the
recommendations of the Work Group will be taken forward. Through first-hand experience, it was clear that
a certain level of trust and respect developed between
Work Group participants that ultimately led to a truly
collaborative process (personal communication, 2015).
Tennessee conducted similar yet different activities. The
progress of the state was noted by Assistant Secretary
Martinez when she wrote:
We (at the U.S. Office of Disability Employment
Policy) have been pleased to see the progress Tennessee
has made in just the past three years investing strategically in building provider capacity and aligning public
policies to help individuals with significant disabilities
obtain and maintain jobs in typical community settings and community wages (Employment First Task
Force, 2014).
5. Conclusion
Changing systems is a long, arduous, and messy process. No agency, group or person comes out unscathed.
Through our experiences, Iowa and Tennessee conclude
the following lessons learned: No one state agency or
advocacy group can make change happen alone. Each
agency or advocacy group has individual barriers to
change and it is necessary to be respectful of them.
True collaboration is difficult. Teams are fragile and
sometimes break down. Begin with the end in mind,
but do not think you have the answer before starting;
there is not a predetermined solution. Celebrate small
changes. More is accomplished through teamwork than
in departmental silos. Changes in one silo affect
another. The work is worth it when change happens and
improves the system, thus improving the employment
outcomes for individuals with disabilities.
Acknowledgments
This work was funded through the Office of Disability Employment Policy (ODEP), U.S. Department of
Labor as part of the free technical assistance provided
through ODEPs Employment First State Leadership

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S.A. Morrow et al. / Working with ODEP to create systems change: The story of two protege states

Mentoring Program (EFSLMP) by Federal Contractor Economic Systems, Inc. (under Blanket Purchase
Agreement DOLQ089427777). Under the first year
of EFSLMP (DOLU119432412; Contract #GS-10F0042M), the states of Iowa and Tennessee were two of
four original states that received funding and technical
support. The lead state government agencies involved
in the receipt of support from EFSLMP on behalf of
these two states were the Iowa Vocational Rehabilitation Services Division and the Tennessee Department
of Intellectual and Disabilities Services, respectively.
The opinions expressed herein are those of the authors
and not necessarily those of U.S. Department of Labor
or the Office of Disability Employment Policy.
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