DEPARTMENT OF EDUCATION CFRPART:National Institute on Disability and Rehabilitation Research; Notice of Proposed Long-Range Plan for Fiscal Years 1999-2004 SUMMARY: The Secretary proposes a Long-Range Plan (LRP) for the National Institute on Disability and Rehabilitation Research (NIDRR) for fiscal years (FY) 1999-2004. As required by the Rehabilitation Act of 1973, as amended, the Secretary takes this action to outline priorities for rehabilitation research, demonstration projects, training, and related activities, and to explain the basis for these priorities. DATES: Comments must be received on or before November 25, 1998. ADDRESSES: All comments concerning this proposed LRP should be addressed to Donna Nangle, U.S. Department of Education, 600 Maryland Avenue, S.W., room 3418, Switzer Building, Washington, D.C. 20202-2645. Comments may also be sent through the Internet: comments@ed.gov. You must include the term "Long- Range Plan" in the subject line of your electronic message. FOR FURTHER INFORMATION CONTACT: Donna Nangle. Telephone: (202) 205-5880. Individuals who use a telecommunications device for the deaf (TDD) may call the TDD number at (202) 205-2742. Internet: Donna_Nangle@ed.gov Individuals with disabilities may obtain this document in an alternate format (e.g., Braille, large print, audiotape, or computer diskette) on request to the contact person listed in the preceding paragraph. Invitation to Comment: Interested persons are invited to submit comments and recommendations regarding these proposed priorities. All comments submitted in response to this notice will be available for public inspection, during and after the comment period, in Room 3424, Switzer Building, 330 C Street S.W., Washington, D.C., between the hours of 9:00 a.m. and 4:30 p.m., Monday through Friday of each week except Federal holidays. SUPPLEMENTARY INFORMATION: This proposed LRP presents a five-year agenda anchored in consumer goals and scientific initiatives. The proposed LRP has several distinct purposes: (1) To set broad general directions that will guide NIDRR's policies and use of resources as the field of disability enters the 21st century; (2) To establish objectives for research and dissemination that will improve the lives of individuals with disabilities and from which annual research priorities can be formulated; (3) To describe a system for operationalizing the Plan in terms of annual priorities, evaluation of the implementation of the Plan, and updates of the Plan as necessary; and (4) To direct new emphasis to the management and administration of the research endeavor. This proposed LRP was developed with the guidance of a distinguished group of NIDRR constituents--individuals with disabilities and their family members and advocates, service providers, researchers, educators, administrators, and policymakers, including the Commissioner of the Rehabilitation Services Administration, members of the National Council on Disability, and representatives from DHHS. The authority for the Secretary to establish a LRP is contained in sections 202(h) of the Rehabilitation Act of 1973, as amended (29 U.S.C. 762(h). Electronic Access to This Document Anyone may view this document, as well as all other Department of Education documents published in the Federal Register, in text or portable document format (pdf) on the World Wide Web at either of the following sites: http://ocfo.ed.gov/fedreg.htm http://www.ed.gov/news.html To use the pdf you must have the Adobe Acrobat Reader Program with Search, which is available free at either of the preceding sites. If you have questions about using the pdf, call the U.S. Government Printing Office at (202) 512-1530 or, toll free at 1-888-293-6498. Anyone may also view these documents in text copy only on an electronic bulletin board of the Department. Telephone: (202) 219-1511 or, toll free, 1- 800-222-4922. The documents are located under Option G--Files/Announcements, Bulletins and Press Releases. Note: The official version of this document is the document published in the Federal Register. Applicable Program Regulations: 34 CFR Parts 350 and 353. Program Authority: 29 U.S.C. 760-764. Dated: October 19, 1998. Long Range Plan Table of Contents Section One: Background Chapter 1: Introduction and Background Chapter 2: Dimensions of Disability Section Two: NIDRR Research Agenda Chapter 3: Employment Outcomes Chapter 4: Health and Function Chapter 5: Technology for Access and Function Chapter 6: Independent Living and Community Integration Chapter 7: Associated Disability Research Areas Section Three: Priorities for Related Activities Chapter 8: Knowledge Dissemination and Utilization Chapter 9: Capacity Building for Rehabilitation Research and Training References Section One Chapter 1: Introduction and Background "Research has the potential to reinvent the future for millions of people with disabilities and their families" (Richard W. Riley, U.S. Secretary of Education). Two developments have converged to enhance the significance of disability research. First, breakthroughs in biomedical and technological sciences have changed the nature of work and community life. As these breakthroughs provide the potential for longer and more fulfilling lives for individuals with disabilities, they reinforce the second major development--successful independent living and civil rights advocacy by disabled persons. This intersection of scientific progress and empowerment of disabled persons has generated momentum for disability research. These developments highlight the importance of more fully integrating disability research into the mainstream of U.S. science and technology policy, and into the Nation's economic and health care policies. An estimated 43 million Americans are significantly limited in their capacity to participate fully in work, education, family, or community life because they have a physical, cognitive, or emotional condition that requires societal accommodation. Public Law 101-336, the Americans with Disabilities Act (ADA) of 1990, declares that individuals with disabilities have fundamental rights of equal access to public accommodations, employment, transportation, and telecommunications. The recognition of these rights, and of society's obligation to facilitate their attainment, provides the opportunity for major improvements in the daily lives of individuals with disabilities. It is the mission of the National Institute on Disability and Rehabilitation Research (NIDRR) to generate, disseminate, and promote the full use of new knowledge that will improve substantially the options for disabled individuals to perform regular activities in the community, and the capacity of society to provide full opportunities and appropriate supports for its disabled citizens. NIDRR's Statutory Purpose The inception of a Federal rehabilitation research program was part of the legacy of the late Mary E. Switzer, pioneering director of the Federal-State vocational rehabilitation program. By establishing NIDRR 1 in 1978, through Amendments to the Rehabilitation Act of 1973 (Public Law 93-112), Congress realized Switzer's vision and created a research institute in the public interest. As such, NIDRR must generate scientifically based knowledge that furthers the values and goals of the disability community, the knowledge needs of service providers, and the creation of rational public policy. Note 1 Established as the National Institute of Handicapped Research, the Institute's name was changed to NIDRR by the 1986 Amendments to the Rehabilitation Act. In founding NIDRR, Congress recognized both the opportunities for technological and scientific advances to improve the lives of individuals with disabilities and the need for a comprehensive and coordinated approach to research, development, demonstration, information dissemination, and training. The Rehabilitation Act of 1973, as amended, (with significant changes in 1992), charged this Institute with the responsibility to provide a comprehensive and coordinated program of research and related activities to maximize the full inclusion and social integration, employment, and independent living of individuals of all ages with disabilities, with particular emphasis on improving the coordination and effectiveness of services authorized under the Act. Related activities were mandated to include the widespread dissemination of research-generated knowledge and practical information to rehabilitation professionals, individuals with disabilities, researchers, and others; the promotion of the transfer of rehabilitation technology; and an increase in opportunities for researchers who are individuals with disabilities or members of minority groups. NIDRR is ideally positioned to facilitate the transfer of new knowledge into practice given its administrative co-location with two major service programs--the Rehabilitation Services Administration (RSA) and the Office of Special Education Programs (OSEP)--in the Office of Special Education and Rehabilitative Services (OSERS). NIDRR's linkage to the greater science community through its leadership of the Interagency Committee on Disability Research (ICDR) affords an opportunity to facilitate the transfer of advances in basic research into the agenda for applied research and knowledge diffusion. To further advance work in the field of applied research, the legislation requires a Long-Range Plan,2 updated every five years, describing NIDRR's future research agenda. This Long-Range Plan presents a five-year agenda anchored in consumer goals and scientific initiatives. The plan has several distinct purposes: Note 2 As a component of the Department of Education within OSERS, NIDRR is guided by the Department's Strategic Plan, the OSER's Strategic Plan, and NIDRR's own strategic goals and objectives as laid out in its performance plan for the Government Performance and Results Act (GPRA). The Rehabilitation Act, however, calls for a plan from NIDRR--one that identifies research needs and sets forth priorities. This Long-Range Plan describes the issues related to the content and management of NIDRR's research and other activities that will constitute the substantive portion of NIDRR's strategies to achieve its GPRA performance objectives. (1) To set broad general directions that will guide NIDRR's policies and use of resources as the field of disability enters the 21st century; (2) To establish objectives for research and dissemination that will improve the lives of individuals with disabilities and from which annual research priorities can be formulated; (3) To describe a system for operationalizing the Plan in terms of annual priorities, evaluation of the implementation of the Plan, and updates of the Plan as necessary; and (4) To direct new emphasis to the management and administration of the research endeavor. This Long-Range Plan was developed with the guidance of a distinguished group of NIDRR constituents--individuals with disabilities and their family members and advocates, service providers, researchers, educators, administrators, and policymakers, including the Commissioner of the Rehabilitation Services Administration, members of the National Council on Disability, and representatives from DHHS. It draws upon public hearings and planning activities conducted under the prior NIDRR administration (William H. Graves, Director) and on papers prepared for the Plan by more than a dozen authors. The Plan addresses a range of diverse objectives, including: (1) The needs of individuals with disabilities for knowledge and information that will enable them to achieve their aspirations for self- direction, independence, inclusion, and functional competence; (2) The needs of rehabilitation service providers for information on new techniques and technologies that will enable them to assist in the rehabilitation of individuals with disabilities; (3) The needs of researchers to advance the capabilities of science as well as the body of scientific knowledge; (4) The needs of society, and its leadership, for strategies that will enable it to facilitate the potential contributions of all citizens; and (5) The need to transfer findings from basic to applied research. Accomplishments of the Past In creating NIDRR, Congress recognized that research has contributed substantially to improvements in the lives of individuals with disabilities and their families. Individuals with disabilities live longer, have a better quality of life, enjoy better health, and look forward to more opportunities than they did 30 years ago, and more advances occur every day. Today it is commonplace to find people in wheelchairs traveling in airplanes and private vehicles, people who are blind using computers, and people who are deaf attending the theater, while individuals who have significant disabilities are being recognized as world leaders in the arts and sciences. These developments owe much to research advances at both the individual and societal levels. Advances at the Individual Level Research, and its use to improve practice, inform policy, and raise awareness, has changed the lives and the outlook for individuals with disabilities and their families. For example, the life expectancy of individuals with paralysis from spinal cord injury has risen continuously in the past 25 years (DeVivo & Stover, 1995). The concerted efforts of U.S. researchers, most of whom received NIDRR support, have succeeded in greatly reducing the number of severe urinary tract infections and other urinary tract complications in this population, thereby reducing renal failure as a cause of death for these individuals from 1st to 12th place over the past two decades. Decubitus ulcers also have been a serious problem for persons with spinal cord injury, as well as for those with stroke, multiple sclerosis, and other immobilizing conditions. Decubitus ulcers are destructive and costly to treat, resulting in lost work days, high medical expenses, hospitalizations, and further secondary complications. Through the efforts of medical researchers and rehabilitation engineers, preventive measures have been developed including seating, cushioning, and positioning devices; behavioral protocols; and improved treatment methods. These efforts have greatly reduced the length of time needed for medical treatment of decubiti, and the cost of this treatment. Rehabilitation engineering research has been responsible for the development of new materials for wheelchairs and orthotic and prosthetic devices that render these technologies comfortable and serviceable, and allow their users to accomplish many important personal goals. For example, wheelchair racers using the newest sports wheelchairs can complete races longer than 800 meters at speeds faster than those of Olympic runners. In the Paralympics, runners using prosthetic legs repeatedly have demonstrated impressive speeds. In everyday life, people who use wheelchairs have benefited from lightweight, transportable chairs as well as powered chairs that greatly increase the independence of some users. Advances at the Environmental-Societal Level In the last two decades, NIDRR has participated in an unprecedented expansion of opportunities and possibilities for persons with disabilities. During this period, technology has greatly enhanced the accommodation of disability, self-awareness has raised the expectation of and for persons with disabilities, and advocacy has resulted in recognition of the rights of persons with disabilities to societal access and reasonable accommodations. Today's research on the application of the principles of universal design to the built environment, information technology and telecommunications, transportation, and consumer products is based on the concept of an environment that is usable by persons with a very broad range of function. For example, after years of research, all television sets are now equipped with decoders that allow people with hearing loss to access most programs. In addition, ergonomic research undergirds the development of workplace designs and the standards for building codes, consumer products, and the telecommunications infrastructure. These advances have been instrumental in leading to a change in the disability paradigm, expanding the focus of disability to include environmental factors, as well as individual factors. NIDRR's research activities also have led to the development of small businesses in hearing aids, prosthetics, communication devices, and instructional software. NIDRR research provides an important stimulus in a field of orphan products with small markets. Expectations for the Future: A New Paradigm of Disability The identification of trends in the distribution of disabilities, the emergence of new disabilities, and the prevalence of disability in the nation's aging population further challenge the disability research field. Additionally, the research field must develop ways to measure and address the impact of environmental factors on the phenomenon of disability. NIDRR has provided leadership in research leading to a new conceptual foundation for organizing and interpreting the phenomenon of disability--a "New Paradigm" of disability. This paradigm is a construction of the disability and scientific communities alike and provides a mechanism for the application of scientific research to the goals and concerns of individuals with disabilities. The new paradigm of disability is neither entirely new nor entirely static. Thomas Kuhn defines paradigm as "universal achievements that for a time provide model problems and solutions to a community of practitioners" (Kuhn, 1962). The term paradigm is used here in the quasi- popular sense it has acquired over the last 40 years to indicate a basic consensus among investigators of a phenomenon that defines the legitimate problems and methods of a research field. NIDRR posits that the paradigm in this case applies not to a single field, but to a single phenomenon-- "disability"--as it is investigated by multiple disciplinary fields. The disability paradigm that undergirds NIDRR's research strategy for the future maintains that disability is a product of an interaction between characteristics (e.g., conditions or impairments, functional status, or personal and social qualities) of the individual and characteristics of the natural, built, cultural, and social environments. The construct of disability is located on a continuum from enablement to disablement. Personal characteristics, as well as environmental ones, may be enabling or disabling, and the relative degree fluctuates, depending on condition, time, and setting. Disability is a contextual variable, dynamic over time and circumstance. Environments may be physically (in)accessible, culturally (ex) (in)clusive, (un)accommodating and (un)supportive. For example, on a societal level, institutions and the built environment were designed for a limited segment of the population. Researchers should explore new ways of measuring and assessing disability in context, taking into account the effect of physical, policy, and social environments, and the dynamic nature of disability over the lifespan and across environments. Perhaps the new paradigm can be understood best in contrast to the paradigm it replaces and through a clarification of the importance the paradigm has for all aspects of research and policy (see Table 1). The "old" paradigm, which was reductive to medical condition, and is reflected in many aspects of the Nation's policy and service delivery arenas, has presented disability as the result of a deficit in an individual that prevented the individual from performing certain functions or activities. This underlying assumption about disability affected many aspects of research, rehabilitation, and services. The new paradigm of disability is integrative and holistic, and focuses on the whole person functioning in an environmental context. This new paradigm of disability is reflected in the ADA and sets a goals framework for research, policy, and delivery of services and supports relative to disability. The new paradigm with its recognition of the contextual aspect of disability--the dynamic interaction between individual and environment over the lifespan that constitutes disability--has significant consequences for NIDRR's research agenda over the next decade. These consequences include: changes in the ways disability is defined and conceptualized; new approaches for measuring and counting disability; a focus on new research issues; and changes in the way research is managed and conducted. Definitional Issues One of the fundamental consequences of the new paradigm is the need for the reformulation of definitions. The definition of disability is critical to building a conceptual model that identifies relevant components of disablement and their relationships to each other, and the dynamic mechanisms by which they change. Typically, definitions of disability have varied depending on their intended use. Table 1.--Contrast of Paradigms "Old" Paradigm "New" Paradigmq Definition of Disability An individual is limited An individual requires by his/her impairment an accommodation to or condition perform functions required to carry out life activities. Strategy to Address Fix the individual, Remove barriers, create Disability correct the deficit access through accommodation and universal design, restore function, maintain wellness and health. Method to Address Provision of medical, Provision of supports, Disability vocational, or e.g., assistive psychological technology, personal rehabilitation services assistance services, job coach. Source of Intervention Professionals, Peers, mainstream clinicians, and other service providers, rehabilitation service consumer information providers services. Entitlements Eligibility for benefits Eligibility for based on severity of accommodations seen as impairment a civil right. Role of Disabled Object of intervention, Consumer or customer, Individual patient, beneficiary, empowered peer, research subject research participant. Domain of Disability A medical "problem" A socio-environmental issue involving accessibility, accommodations, and equity. Note: Adapted from materials prepared for this Long-Range Plan by Gerben DeJong and Bonnie O'Day. From a research perspective, definitions used for counting and describing disabled people have been important, while definitions establishing eligibility for benefits and services have been critical from the policy perspective. The majority of Federal definitions of disability, including those in the Rehabilitation Act, the ADA, and the National Health Interview Survey (NHIS), derive from the old paradigm. These definitions all attribute the cause of limitations in daily activities or social roles to characteristics of the individual, that is, "conditions" or "impairments." Even the ADA, which promotes accessibility and accommodations, locates the disability with the individual. This is understandable not only because of the time involved in changing a paradigm, but because of the lack of a system to define, classify, and measure the environmental components of disability and the absence of a model to describe and quantify the interaction of environmental and individual variables. This need for a change in definitions must be addressed by activities such as the attempt to revise the International Classification of Impairments, Disabilities, and Handicaps (ICIDH) (1980), to better define and measure the factors external to the individual that contribute to disability.3 Note 3 The ICIDH is a manual issued by the World Health Organization (WHO) in 1980 as a tool for the classification of the consequences of disease, injury, and disorder, and for analysis of health-related issues. Measurement Issues Sources of data, including demographic studies and national surveys, should be adjusted to reflect new definitions or concepts, and to take into account contextual variables in survey sampling techniques. Survey questions must reflect environmental factors as well as individual factors such as socioeconomic characteristics or impairments. Under the new paradigm, questions about employment status, for example, should focus on the need for accommodations as well as on the existence of an impairment. Measures must enable researchers to predict and understand changes in the prevalence and distribution of disabilities--the emerging universe of disability--which illustrates the link between underlying social and environmental conditions such as poverty, race, culture, isolation, the age continuum, and the emergence of new causes of disability, new disability syndromes, and the differential distribution of disability among various population groups in our society. Concern increasingly is focused on vulnerable populations as researchers find more evidence that disability, and risk thereof, are disproportionately concentrated in populations in poverty, populations that lack access to state-of-the-art preventions or interventions, and populations that are exposed to additional external or lifestyle risk factors. There are new impairments, exacerbated impairments, or new etiologies that are associated with socioeconomic status, education levels, access to health care, nutrition, living conditions, and personal safety. Individuals from racial, linguistic, or cultural minority backgrounds are more likely to live in poverty and to lack adequate nutrition, pre-natal and other health care, access to preventive care, and health information. These individuals also have more exposure to interpersonal violence and intentional injury. The new paradigm's recognition of environmental factors leads to a focus on underserved minority populations--part of the emerging universe of disability discussed in Chapter Two. New Focus of Research Inquiries The new paradigm adds, or increases the relative emphases on, certain areas of inquiry. Research must develop new methods to focus on the interface between person and society. It is not enough simply to shift the focus of concern from the individual to the environment. What is needed are studies of the dynamic interplay between person and environment; of the adapting process, by the society as well as by the individual; and of the adaptive changes that occur during a person's lifespan. The aging of the disabled population in conjunction with quality of life issues dictates a particular focus on prevention and alleviation of secondary disabilities and co-existing conditions and on health maintenance over the lifespan. Research must focus on the development and evaluation of environmental options in the built environment and the communications environment, including such approaches as universal design, modular design, and assistive technology that enable individuals with disabilities and society to select the most appropriate means to accommodate or alleviate limitations. Research must lead to a better understanding of the context and trends in our society that affect the total environment in which people with disabilities will live and in which disability will be manifested. These include: economy and labor market trends; social, cultural, and attitudinal developments; and new technological developments. Research must develop ways to enable individuals with disabilities to compete in the global economy, including education and training methods, job accommodations, and assistive technology. Research must develop an understanding of the public policy context in which disability is addressed, ignored, or exacerbated. General fiscal and economic policies, as well as more specific policies on employment, delivery and financing of health care, income support, transportation, social services, telecommunications, institutionalization, education, and long-term care are critical factors influencing disability and disabled persons. Their frequent inconsistencies, contradictions, and oversights can inhibit the attainment of personal and social goals for persons with disabilities. Research Management The new paradigm requires new models for the management of the research enterprise that include stakeholder participation, interdisciplinary and collaborative efforts, more large-scale and longitudinal research, and new research methodologies to conduct meaningful studies in the emerging policy environments. Training in disability and rehabilitation research must be expanded to include disciplines such as architecture and business. There will be new venues for the conduct of research, and a need for validated methodologies to conduct research on dynamic person-environment interactions and under constricted circumstances. Through training programs, the disability and rehabilitation research field also should work to increase the number of disabled and minority researchers. The role of disabled consumers in research under the new paradigm, as well as in policy and services, is proactive and participative. Consumers have a role in shaping their environments and in managing the supports and services they require. Research must be more inclusive and participatory, involving not only consumers but also other stakeholders in understanding and interpreting research, in disseminating and applying research findings, and in planning, conducting, and evaluating research. Consumer satisfaction with research as well as services will be subject to assessment. Moreover, interdisciplinary and collaborative research are important for explicating the multidimensional qualities of disability. It is only through research coordination and collaboration that the findings of basic research can be translated into the knowledge base of disability research. Regardless of its auspices, research is a cumulative and integrative process; new knowledge comes from many sources, often in response to concerted pursuit, but also sometimes serendipitously. Research is often slow-moving and always painstaking; one of the ironies of the research effort is that a disproved hypothesis may constitute a successful project, particularly if it diverts the time and resources of others from an unfruitful direction. As one participant in the planning process put it, "sometimes the new questions you stimulate are more important than the ones you answer in your research project." NIDRR is pleased to have collaborated with many other Federal and private agencies that sponsor various aspects of disability and rehabilitation research, and is committed to making research an inclusive, collaborative, and coordinated undertaking. Organization of the Plan This introductory chapter has set the framework for understanding NIDRR's mission and approach. After the next chapter, "Dimensions of Disability," the Plan will discuss, in Section Two, an agenda for research that provides opportunities for leadership and innovation. NIDRR will implement this research agenda in conjunction with excellent management strategies, a dynamic program of knowledge dissemination, and a vigorous effort to build capacity of the field through training researchers and users of research. Section Three will focus on these activities. NIDRR intends this five-year research Plan to balance the competing demands of consumer relevance and scientific rigor, and to present an agenda for research that is responsive, scientifically sound, and accountable, and which makes a contribution to the refinement of the Nation's science and technology policy. Chapter 2: Dimensions of Disability "Policy issues at the forefront of the disability agenda require accurate data, routinely repeated measures, sophisticated analysis, and broad dissemination" (National Council on Disability, Action Steps for Changes to Federal Disability Data Collection Activities, draft report, Sept. 19, 1997). This chapter of the Plan presents NIDRR's operative definitions of disability, discusses several analytical frameworks for the categorization of disability, and highlights deficits in current definitions and data collection. The chapter then presents data about the prevalence and distribution of disability in the nation and includes selected demographic data related to the major NIDRR goals of independence, inclusion, and employment. Definitions and Concepts of Disability and Disablement The definition of an individual with a disability under which NIDRR operates is contained in the Rehabilitation Act of 1973, (Public Law 93-112) as amended, and is as follows: any person who (i) has a physical or mental impairment which substantially limits one or more of such person's major life activities, (ii) has a record of such an impairment, or (iii) is regarded as having such an impairment (29 U.S.C. 705(20)(B)). This definition is similar to those contained in the ADA and the Technology-Related Assistance for Individuals with Disabilities Act (Tech Act). The impairments that lead to limitations in activities may be related to genetic conditions or to acquired diseases or traumas that may occur throughout the lifespan. The extent of disability, and the conditions associated with disability, are significant to individuals and their families, and to the Nation. Prevailing definitions, based in statute and supporting program authorities, clearly do not reflect new paradigm concepts of disability. Nearly all definitions identify an individual as disabled based on a physical or mental impairment that limits the person's ability to perform an important activity. Note that the complementary possibility--that the individual is limited by a barrier in society or the environment--is never considered. This Plan suggests that it is useful to regard an individual with a disability as a person who requires an accommodation or intervention rather than as a person with a condition or impairment. This new approach derives from the interaction between personal variables and environmental conditions. Because accommodations can address person-centered factors as well as socio- environmental factors, a "need for accommodation" is a more adaptable concept for the new paradigm. The various definitions of disability that have formed the basis for both program eligibility and survey data collection do not have explanatory power for research purposes. The field of disability research lacks a widely accepted conceptual foundation for the measurement of disability as well as consistent definitions for data collection. In recent years, however, a number of efforts to develop conceptual frameworks to organize information about disability have been initiated (see Table 2). Table 2.--Concepts in Models of Disability ICIDH Nagi/1991 IOM NCMRR Disease--Something Active pathology-- Pathophysiology-- abnormal within the Interruption or Interruption or individual; etiology interference of normal interference with gives rise to change in bodily processes or normal physiological structure and structures and developmental functioning of the body processes or structure. Impairment--Any loss or Impairment--Anatomical, Impairment--Loss or abnormality of physiological, mental abnormalities of psychological, or emotional cognitive, emotional, physiological, or abnormalities or loss physiological, or anatomical structure or anatomical structure or function at the organ function, including level losses or abnormalities, not those attributable to the initial pathophysiology. Disability--Any Functional limitation-- Functional limitation-- restriction or lack Restriction or lack of Restriction or lack of (resulting from an ability to perform an ability to perform an impairment) of ability action or activity in action in the manner or to perform an activity the manner or within within the range in the manner or range the range considered consistent with the considered normal for a normal that results parts of an organ or human being from impairment organ system. Handicap--A disadvantage Disability--Inability or Disability--Inability or resulting from an limitation in limitation in impairment or performing socially performing tasks, disability that limits defined activities and activities, and roles or prevents fulfillment roles expected of to levels expected of a normal role individuals within a within the physical and depending on age, sex, social and physical social context. and sociocultural environment factors Societal limitation-- Restrictions attributable to social policy and barriers (structural or attitudinal) which limits fulfillment of roles and denies access opportunities that are associated with full participation in society. Note: Information in column 1 is from International Classification of Impairments, Disabilities, and Handicaps, by the World Health Organization, 1980, Geneva, Switzerland: Author. Information in column 2 is from Disability concepts Revisited: Implications for Prevention, by S.Z. Nagi, 1991, (p. 7) in Disability in America: Toward A National Agenda for Prevention by A.M. Pope and A.R. Tarlov (Eds.), 1991, Washington, DC: National Academy Press. Information in column 3 is from Research Plan for the National Center for Medical Rehabilitation Research, (p. 33), by the National Institute of Child Health and Human Development (1993) (NIH Publication No. 93-3509), Washington, DC: U.S. Government Printing Office. Among these efforts are: (1) The ICIDH, which was developed in 1980 by the WHO. The ICIDH was designed to provide a framework to organize information about the consequences of disease. An ongoing revision process is considering social, behavioral, and environmental factors to refine the concept of "handicap;" (2) The "Nagi model" (Nagi, 1991), which was presented by the Institute of Medicine (IOM) in its 1991 Disability in America report (Pope & Tarlov, 1991). The model was revised in the 1997 report entitled Enabling America (Brandt & Pope, 1997). The IOM (1997) also posits that disability is a function of the interaction of individuals with the social and physical environments. The revised Nagi model describes the environment as including the natural environment, the built environment, culture, the economic system, the political system, and psychological factors. The new model includes a state of "no disabling condition." The state of disability is not included in this model because disability is not viewed as inherent in the person, but rather as a function of the interaction of the individual and the environment; and (3) The schematic, adopted by the National Center for Medical Rehabilitation Research (NCMRR) in its Research Plan (1993, p. 33), which added the concept of societal limitation. Continuum of Enablement-Disablement The most widely used conceptual frameworks applied to disability and rehabilitation research have in common a continuum that progresses from some underlying etiology or disease to limitations in physical or mental function. These functional limitations, when combined with external or environmental conditions, may lead to some deficit in the performance of daily activities or expected social roles. In "Enabling America," the IOM has urged the adoption of a new conceptual framework as a model for the enablement- disablement process (Brandt & Pope, 1997). This model has the advantage of identifying components of person-centered and environment-centered variables. The IOM framework identifies four categories of individual factors (person, biology, behavior, and resources) and nine categories of external environment factors (natural, culture, engineered environments, therapeutic modalities, health care delivery system, social institutions, macro-economy, policy and law, and resources and opportunities). NIDRR research focuses on crucial areas of functional loss, disability, and socio-environmental aspects of the continuum. In keeping with the new paradigm, NIDRR emphasizes the importance of explicating the connection between the person and the environment, an interface that determines the disabling consequences of impairments and conditions. This study of the dynamic interaction among various individual and environmental variables requires NIDRR's continued and increased attention to shaping the structure, management, and capacity for research. Methodologies are needed, often in an interdisciplinary context, that can illuminate multiple facets of disablement and enablement from numerous perspectives. Limitations in Federal Data Sources The various Federal data collection efforts that assess the extent and distribution of disability in society are less than ideal for measuring the population that meets the NIDRR definition of an individual with a disability. These efforts generally can be categorized as either program data, which focus on the recipients of Federal benefit or service programs, or national surveys that focus on perceived limitations in activities caused by health conditions. Both program and survey data focus on the "physical or mental impairment" as the cause of the limitation. This is a reductionist approach that discounts social and environmental factors or assumes that these factors are subsumed within individual attributes. The National Health Interview Survey (NHIS) and the Survey of Income and Program Participation (SIPP), are the two most widely used sources of survey data to describe the population of individuals with disabilities. The data from the Disability Supplement to the NHIS currently is being analyzed by a number of researchers and will yield much-needed information on persons with disabilities. The Disability Supplement is the product of a 1994 to 1996 data collection effort that was the result of years of cooperative development by Federal agencies concerned with disability issues. While the Disability Supplement will have enormous value to its users, the Supplement, like other data sources, lacks any measures of the environmental factors (social or physical) that contribute to disablement, as well as any measures of interaction between person and environment. Federal data collection efforts, including the Census, the NHIS, the SIPP, the Current Population Survey (CPS), and many other program-specific or topical data collections, not only fail to address important new concepts of disability, but also are limited in other respects. Sampling procedures may result in the exclusion of low-incidence disabilities and insufficient information about minority populations; self-reporting leads to underreporting many conditions; and survey formats frequently are inaccessible to persons with cognitive, sensory, or language limitations. Many Federal data collection efforts, as well as most private ones, do not routinely include information about persons with disability in their collection and reporting. Improvements in data quality and availability will be a key goal of NIDRR in this five-year Plan. Particular problems exist in defining and quantifying disability in children. Many service programs rely on diagnostic categories for eligibility, and even those that have attempted a functional approach have had difficulty assessing the effect of context, expectations, transactions with adults, chronicity and duration, in determining the extent of disability among children. The Office of Special Education Programs (OSEP)--administers the Individuals with Disabilities Education Act (IDEA), which mandates that schools have a full range of services necessary to provide a free and appropriate public education for children with disabilities. According to OSEP's 1995-1996 IDEA annual report to Congress, 5.6 million disabled children (ages 3 to 21) received educational services. Approximately, one- half of these children were identified as having specific learning disabilities. Other high incidence disabilities included speech and language impairments, mental retardation, and serious emotional disturbances. Because OSEP and other Department of Education offices focus their research on activities based in the educational system, including the development of curriculum and teaching methods and the training of teachers, NIDRR has directed its research on disabled children to aspects of life outside that arena. These issues include family-child relations; social relationships; community integration; medical technologies for replacing, or substituting for, function; accommodations; and supports to families. NIDRR research also has a role in addressing the critical problems of succeeding in the transitions from school to adult life in the community, and in the work and adult service systems. In a broader context, it is important to note that 5.5 percent of all American families contain one or more children with a disability (LaPlante, Carlson, Kaye, & Wenger, 1996). Children with disabilities are more likely to be found in low-income families and families headed by single mothers. Prevalence of Disability The importance of disability research is underscored by the frequency and widespread dispersion of disabilities in the U.S. population. The following data about disability were selected because of their relevance to NIDRR's specific priorities and to the overall objectives of this plan. The 1994 NHIS estimated that 15 percent of the noninstitutionalized civilian population--some 38 million people--were limited in activity due to chronic conditions (Adams & Marano, 1995). The Institute of Medicine interpolated the NHIS data to indicate that 38 percent of disabilities were associated with mobility limitations, followed by chronic disease (32 percent); sensory limitations (8 percent); intellectual limitations (7 percent); and all other conditions (15 percent) (Pope & Tarlov, 1991). The SIPP identified 48.9 million persons who reported themselves as limited in performing functional activities or in fulfilling a socially defined role or task. Of these, 24.1 million persons were identified as having a "severe disability" (Kraus, Stoddard, & Gilmartin, 1996). Both surveys excluded persons in nursing homes or institutions, who would be expected to have a high rate of disability. Including that population through extrapolation has led to the commonly cited figures of 43 to 48 million Americans with disabilities. Both the NHIS and SIPP focus on limitations in major life activities, due to a physical or mental condition, but also provide data on persons who are limited in or unable to perform activities of daily living (ADLs)--such as eating, bathing, dressing, toileting, or transferring--without assistance or devices, or to perform instrumental activities of daily living (IADLs)--such as basic home care, shopping, meal preparation, telephoning, and managing money. Approximately eight million people reported difficulty with ADLs, and approximately four million with one or more ADLs needed the assistance of another person (McNeil, 1993). The range of these estimates--from approximately 4 million people who need help simply to sustain their lives to the nearly 40 million who report any kind of activity limitation--illustrates the danger in discussing the disabled population or its needs as a homogeneous group. More refined data are needed to assess the needs for medical and health care, vocational rehabilitation and employment assistance, supports for living in the community, and assistive technology. Demographics of Disability: Age, Gender, Race, Education, Income, and Geography Disability is distributed differently in the population according to characteristics of age, gender, race, and ethnicity, and both region and size of locality in which a person resides. Educational level is inversely correlated with the prevalence of disability. Poverty is a key factor both as a contributing cause and a result of disability. Table 3 presents NHIS data on sociodemographic correlates of activity limitations. This table indicates that disability is very likely linked to other social factors and reinforces the need to address disability in a broad context. Emerging Universe of Disability NIDRR has begun to focus on an "emerging universe" of disability, in which either the conditions associated with disability, their distribution in the population, or their causes and consequences, are substantially different from those in the traditional disability population. Table 3.--Degree of Activity Limitation Due to Chronic Conditions, by Demographic Characteristics: 1994 Limited in Unable to amount or Limited, All carry on kind of but not in persons With major major major (in activity activity activity activity Characteristic thousands) limitation (percent) (percent) (percent) All persons 259,634 15 4.6 5.7 4.7 Age: Under 18 years 70,025 6.7 0.7 4.2 1.8 18-44 years 108,178 10.3 3.2 3.9 3.1 45-64 years 50,405 22.6 9.2 7.9 5.5 65-69 years 9,685 36.7 16.7 11.9 7.3 70 years and older 21,340 38.9 8.1 12.6 19.3 Sex: Male 126,494 14.4 4.8 5.3 4.3 Female 133,139 15.7 4.4 6.1 5.2 Race: White 214.496 15.1 4.4 5.8 4.9 African American 33,035 16.3 6.3 6.2 3.8 Family Income: Under $10,000 23,363 28 11.2 9.9 6.9 $10,000-$19,999 37,271 21.1 7.3 7.7 6.2 $20,000-$34,999 54,171 14.8 4.1 6.0 4.7 $35,000 or more 100,302 9.4 1.9 3.9 3.6 Geographic Region: Northwest 50,610 14.3 4.3 5.6 4.3 Midwest 63,238 14.6 3.9 6.0 4.6 South 88,088 16.1 5.3 6.0 4.8 West 57,697 14.7 4.6 5.0 5.0 Place of Residence: Metropolitan statistical area (MSA) 203,079 14.3 4.4 5.5 4.5 Central city 79,510 15.8 5.4 5.9 4.5 Not central city 123,570 13.4 3.8 5.2 4.5 Not MSA 56,554 17.6 5.4 6.6 5.6 Note: From Tables 67-68 in Current Estimates from the National Health Interview Survey, 1994, Series 10, No. 193, by P. F. Adams and M.A. Marano, Hyattsville, MD: National Center for Health Statistics. This emerging universe is identified with new disabling conditions; new causes for impairments; differential distributions within the population; increased frequency of some impairments, including those associated with the aging of the population; and different consequences of disability, particularly as related to social-environmental factors, lifespan issues, and projected demands for services and supports. Researchers have identified a "new morbidity" (Baumeister, Kupstas, & Woodley-Zanthos, 1993) in which the cluster of factors associated with poverty--such as poor education, poor medical care, low birthweight babies, lack of prenatal care, substance abuse, interpersonal violence, isolation, occupational risks, and exposure to environmental hazards--have a high correlation with the existence of impairments, disabilities, and exacerbated consequences of disabilities. For example, the leading cause of mental retardation is no longer RH-factor incompatibility, but may be related to any factor associated with high-risk births, which are more common among low- income mothers. Interpersonal violence accounts for the rising incidence of certain conditions, especially spinal cord injury and traumatic brain injury, among inner-city minority populations. These developments have enormous implications for research problems to be addressed and future demands for various types of services. New illnesses or conditions have emerged in recent years; some, but by no means all, are poverty-related. AIDS, Attention Deficit Hyperactivity Disorder (ADHD), violence-induced neurological damage, repetitive motion syndromes, childhood asthma, drug addiction, and environmental illnesses are all either relatively new conditions or ones of increasing prevalence and severity in society. Additionally, the aging of the population, given the higher rates of many disabilities among older persons, is another demographic factor that will influence issues to be addressed by applied research. As new causes of disabilities emerge, the new paradigm of disability clearly provides a progressive approach to successfully addressing environmental and social barriers for people with disabilities. These new issues have implications not only for disability research and services, but also for public health and prevention activities. Disability, Employment, and Independent Living Because of NIDRR's statutory concern with improving employment outcomes for persons with disabilities, it is valuable to present a brief overview of the employment status of persons with disabilities. LaPlante & Carlson (1996) report that 19 million Americans with an impairment or health problem (ages 18-69) were unable to work or limited in the amount or type of work they could According to the CPS, about 10 percent of the population between 16 and 64 had work limitations (different age ranges reflect changing concepts of "working age") (LaPlante, Kennedy, Kay, & Wenzer, 1996). Back disorders, heart disease, and arthritis were frequently reported as major causes of work disability (LaPlante & Carlson, 1996). However, mental illness is one of the most work-disabling conditions; data showed that among adults with serious mental illness (an estimated 3.3 million persons), 29 percent were reported to be unable to work or limited (18 percent) in their ability to work because of their mental disorder (Barker, Manderscheid, Hendershot, Jack, Schoenborn, & Goldstrom, 1992). While the presence of any disability reduces the likelihood of employment, the effect is closely tied to the severity of the disability. The SIPP estimates that among persons 21 to 64 years old, the employment rate was 81 percent for persons with no disability, 67 percent for persons with a disability that was not severe, and 23 percent for persons with a severe disability (McNeil, 1993). Only 21 percent of persons needing personal assistance with ADLs or IADLs were employed (U.S. Bureau of the Census, 1998). The unemployment rate for persons with disabilities, which counts only those persons in the labor force, was 12.6 percent, more than twice the unemployment rate of nondisabled Americans (Stoddard, Jans, Ripple, & Kraus, 1998). Disabled persons who work full time typically earn less than nondisabled workers with the earnings gap widening with age and severity of disability. Persons with disabilities who do not work may qualify for income support payments under Social Security Disability Insurance (SSDI) (if they have a work history) or Supplemental Security Income (SSI). As of January 1996, 5 million persons received SSDI benefits, including 4.2 million disabled workers, 686,300 disabled adult children, and 173,800 disabled widows and widowers (Social Security Administration, 1996). A 1993 report cited mental disorders as the most frequent cause of disability (35 percent), followed by musculoskeletal, circulatory, and nervous system disorders (Social Security Administration, 1993). At the end of 1993, about 3.8 million persons under age 65 received SSI benefits due to disability and poverty (Kochhar & Scott, 1995). More than one-half of these persons had either mental retardation or mental illness. The Social Security Administration (SSA) has noted a sharp increase in the number of disabled SSI recipients, an increasing proportion with mental illness, and a growing number who enter the rolls as children and remain for long periods (Kochhar & Scott, 1995). Many of these increases in both SSDI and SSI programs can be attributed to program changes (such as different eligibility requirements and outreach), to a shifting from other income support categories, to changes in stability of employment and private health insurance, and to the bundling of health insurance coverage with income supports. Eligibility for public health insurance is generally tied to the receipt of income transfer payments from a public income support program. Data elements about residential status, family composition, and need for personal assistance services illuminate some of the characteristics of the disabled population. Of the estimated 48.9 million persons with disabilities from the SIPP data, 32.5 million own their own homes and 16.4 million rent (McNeil, 1993). An estimated 9.8 million live alone and over 27 million persons with disabilities are married. An estimated 8.3 million individuals with disabilities live in a household with their spouse and children under 18 years of age, while an estimated 1.9 million are single parents with disabilities. An estimated 20.3 million families, or 29.2 percent of all 69.6 million families in the United States have at least one member with a disability (as measured by having an activity limitation). This rate for families is much higher than the rate of individuals having a disability. Further, there appears to be a clustering of people with disabilities in families and households, with a much higher than expected likelihood of both adult partners having disabilities and a greater than average chance that children with disabilities will live with one or more parents with disabilities. Families headed by adults with disabilities are more likely to live in poverty or to be dependent on public income support programs. Conclusion This chapter of the Plan highlighted some important disability statistics that illustrate the scope of disability in the United States. Throughout the Plan, significant data also are interspersed about use of assistive technology, access to health care, labor force participation, and community living. In addition, Chapter Seven addresses the need for future research in disability data collection. Overall, current data on disabilities provide both a picture for concern and a cause for optimism. People with disabilities tend to have lower than average educational levels, low income levels, and high unemployment rates, especially for people with severe disabilities. Moreover, the relationship between disability and poverty tends to be bi-directional, with the conditions of poverty creating a high risk for disability and disability itself leading to poverty. At the same time, it is clear that more individuals with disabilities are completing high school and college educations, and education is closely correlated with employment and independence. Increasingly, individuals with disabilities are living in the community, marrying, and raising families. These individuals may receive increased attention from businesses as they constitute a market for accessible housing and adaptive devices, recreation, adult education, accommodated travel, health care, and other services. It is also true that, while the presence of a disability may have deleterious effects on individuals and families, society increasingly is able to assist persons with disabilities in their need for equity and access through new discoveries in research, improved service methods, and informed policy decisions. Section Two: NIDRR Research Agenda Chapter 3: Employment Outcomes "With the ADA, we began a transformation of the proverbial ladder of success for some Americans into a ramp of opportunity for all Americans. Yet, * * * (so many) Americans with severe disabilities are still unemployed, * * * (making it) clear we still have many steps to take before people with disabilities have full access to the American dream" (Tony Coelho, Chairman, President's Committee on Employment of People with Disabilities, Keynote Address "Employment Post the Americans with Disabilities Act," National Press Club, Washington, DC, November 17, 1997). Overview Unemployment and under-employment among working-age Americans with disabilities are ongoing, and seemingly intractable, problems. Data from the Census Bureau on the labor force status of persons ages 16 to 64 in fiscal year 1996 highlight the magnitude of this problem. While four-fifths of working-age Americans are in the labor force and more than three-fourths are working full time, less than one-third of persons with disabilities are in the labor force, and fewer than one-quarter are working full time. Fully two- thirds of working-age persons with disabilities are not in the labor force; other research suggests that a substantial portion of this staggering figure can be attributed to disincentives inherent in social and health insurance policies, to discouragement, and to lack of physical access to jobs. Finally, among those in the labor force, the unemployment rate for disabled persons is more than double that of persons without disabilities (12.6 percent versus 5.7 percent). Disparities in employment rates and earnings are even greater for disabled individuals from minority backgrounds and those with the most significant disabilities (Stoddard, Jans, Ripple, & Kraus, 1998). Economy and Labor Force Issues Several emerging characteristics of the nation's labor market exacerbate the difficulties experienced by persons with disabilities in their attempts to gain employment and even in their motivation to seek employment. Downsizing, for example, has led to a reduction in the percentage of the labor force with stable, long-term, benefits-carrying jobs; much of business and industry is moving to other configurations that fill their labor needs without requiring a long-term commitment on the part of the employer. The "contingent" workforce takes many forms, including on-call workers and those in temporary help agencies, workers provided by contract firms, and independent contractors paid wages or salaries directly from the company. Many of these jobs lack security and benefits, particularly health insurance, that most persons with disabilities require for participation in the labor force. In addition, while many business spokespersons and educators point to the need for highly educated, highly skilled workers if the nation is to succeed in the increasingly competitive global economy, the reality is more complex. On the one hand, availability of jobs requiring specialized skills combined with rapid advances in technology may improve the employment prospects of persons with disabilities as well as other workers, through such work arrangements as telecommuting, and an expanding market for self-employment or small businesses. On the other hand, the labor market appears to be moving toward increasing bifurcation, with top-tier technocracy jobs for persons with sophisticated work skills, and lower-tier unskilled service and maintenance jobs for the less prepared. Assisting individuals with significant disabilities in moving from dependency on public benefits or family support, or from episodic, poor- paying jobs, into stable jobs that will allow them to become self-supporting, is a complex challenge. This challenge involves a number of economic sectors, and service and support systems, and must include an examination of social policies. Providing appropriate assistance requires an extensive knowledge base encompassing economic trends, education and job training strategies, job development and placement techniques, workplace supports and accommodations, and empirical knowledge of the impact of social and health insurance policies on job-seeking behaviors. State-Federal Vocational Rehabilitation Program For the past 75 years, the primary source of publicly funded employment- related services to improve the employment status of disabled persons, especially those with significant disabilities, has been the State-Federal Vocational Rehabilitation (VR) service program, currently authorized under the Rehabilitation Act of 1973, as amended, most recently in 1998. Funded at $2.2 billion in Fiscal Year 1998 in Federal funds and a 22 percent State match for a total of about $2.7 billion annually, the program is implemented primarily as a case management system at the State and local levels. The rehabilitation counselors negotiate, on behalf of and in consultation with the consumer, the purchase of a package of services, such as medical interventions, and supports (e.g., assistive technology and licensure) that will facilitate achievement of employment outcomes. As noted by OSERS Assistant Secretary Judith Heumann in recent testimony to Congress, "As a group, persons who achieve an employment outcome as a result of vocational rehabilitation services each year show notable gains in their economic status," (Barriers Preventing Social Security Recipients from Returning to Work, 1997). The percentage of persons with disabilities reporting their income as their primary source of support increased from 18 percent, at the time of application to the VR program, to 82 percent at the time of exit from the program (Barriers Preventing Social Security Recipients from Returning to Work, 1997). The percentage with earned income of any kind increased from 22 percent at entry to 92 percent at exit. The percentage working at or above minimum wage rose from 15 to 80 percent. Nevertheless, Federal policymakers, consumers, advocates, and rehabilitation professionals remain concerned that persons with disabilities often are excluded from full participation in the nation's labor force. In the past several years, for example, SSA has experienced a very large increase in the number of persons qualifying for SSI and SSDI, and the public costs of these cash benefits are substantially increased by the addition of public support for associated Medicare/Medicaid programs. Further, neither SSA nor the VR system has experienced notable success in returning beneficiaries to the labor force. The VR system, while accepting SSI/SSDI beneficiaries for services at a proportionally higher rate than nonbeneficiaries, typically has less success with this group, that is, relatively fewer SSI/SSDI beneficiaries than nonbeneficiaries achieve an employment outcome as a result of VR services. One of the major changes in the employment sector over the past three decades is the diversification of the laborforce. Workers with disabilities are among the previously underrepresented groups entering the labor market in increasing numbers with raised expectations and legal protections for equal opportunity in employment. Even within the disability community, there is great diversity in the subgroups who have obtained or desire employment. It is very important that future research and service programs demonstrate, in their design and implementation, appropriate sensitivity to and adequate representation of the range of cultural and disability subgroups. This issue should be examined not merely as a response to the current consciousness about multiculturalism but because the basic, implicit foundations of vocational rehabilitation counseling were developed for a clientele that, in terms of demographic characteristics, work-related experience, and service needs, was quite different from today's rehabilitation customers. Specifically, vocational rehabilitation techniques were originally imported from the earlier established disciplines of secondary vocational education and college counseling psychology. Recipients of services from these disciplines tended to have mainstream acculturation and tolerance for the competitive standards, verbal testing, and guidance common in academic environments. Given the cognitively compromised or socially disadvantaged status of many of today's clients, additional scrutiny of the appropriateness and adequacy of the strategies and tools for vocational rehabilitation assessment, counseling, and training is imperative. Rehabilitation counselors need new marketing strategies to reach out to prospective employers to develop job opportunities for this diverse population of persons with disabilities. Community-Based Employment Services NIDRR's research agenda concerning employment addresses, but is not limited to, the State-Federal VR program administered by NIDRR's sister agency, the Rehabilitation Services Administration (RSA). While the VR program plays an important role, there is a wide range of other Federal, State, and local funding sources for, and providers of, employment programs. These include approximately 7,000 community-based rehabilitation programs (CRPs), which serve about 800,000 persons daily, and are funded by VR and/or such diverse sources as the Job Training Partnership Act (JTPA), Worker's Compensation, or private insurance. Legislation such as the Workforce Investment Act and the Workforce Consolidation Act further diversifies the sources of support. The role of community rehabilitation programs in the overall service delivery system may be enhanced even further if Federal employment programs devolve to States and communities and if the intent to increase consumer choice in the selection of service providers becomes more widely implemented. To respond to these developments, community rehabilitation programs must be prepared to offer a full range of vocational services to an increasingly heterogeneous consumer population. Moreover, as return-to-work programs that base provider payments on successful consumer outcomes are implemented, new relationships between service providers and funding sources may emerge over the next few years. These new relationships will require that community rehabilitation programs adapt their current structure and operations in significant ways. A number of questions about how these changes may potentially influence and impact the service delivery of community rehabilitation programs are yet unanswered. For instance, the efficacy of different models designed to maximize competitive employment outcomes for persons with significant disabilities or with specific types of disabilities is unknown. In addition, the impact of consumer choice on service delivery models is unknown. Finally, whether new funding mechanisms will promote increased competition and innovation in service delivery by community rehabilitation programs is a major question. Gaining knowledge in these important areas will allow validation of the assumptions upon which pending reforms are predicated, and the shaping of the future direction of initiatives to increase the numbers of persons with significant disabilities who obtain and retain meaningful employment. Employer Roles and Workplace Supports Employers play a key role in deciding employment outcomes for disabled persons through establishment of policies for recruitment, screening, hiring, training, promoting, accommodating, and retaining disabled individuals in the workforce. The provisions of Title I of the ADA prohibit discrimination against qualified job applicants with disabilities. Applicants are considered qualified if they can perform the essential functions of a job with or without reasonable accommodations. This statute creates duties for employers by requiring them to make the employment process accessible, provide reasonable accommodations, and focus on essential functions of jobs. These employer responsibilities cover all aspects of the pre-employment and post- employment phases. Through the requirements of Workers' Compensation laws, bargaining unit agreements, and insurance provisions, employers have additional obligations to employees who become disabled. Strategies to assist employers in meeting workplace obligations include disability management and workplace supports. Disability management is a term used to describe an array of support mechanisms and benefits that employers use to maintain employment for disabled workers. Workplace supports are programs or interventions provided in the workplace to enable persons with disabilities to be successful in securing and maintaining employment. Some workplace supports may be provided through formal mechanisms established by vocational rehabilitation programs, such as supported employment, in which a job coach who works with the employee provides on-site assistance. Other supports include accommodations such as job restructuring, worksite adaptations, and improved accessibility. Transition From School To Work NIDRR, along with RSA, OSEP, and the Department of Education as a whole, has a particular interest in the process by which disabled students transition into a world of productive work, as opposed to settling into a lifetime of dependency. This is a critical concern because the transition period presents a distinct opportunity to help students embark on a career, thus enhancing their community integration, independence, and quality of life. The transition into work occurs at many points: prevocational experiences, on-the-job training, secondary vocational education or other secondary education programs, and postsecondary education at technical institutions, community colleges, or universities. These various transition points present opportunities for research on strategies for success in transferring from a learning environment to a work environment. Research is ongoing regarding issues of postsecondary education for persons with disabilities. This research shows that youth with disabilities face tremendous difficulties in accessing postsecondary education and making the transition from school to work. Most of the nation's institutions of higher education offer support services to students with disabilities; however, this is less certain for other types of postsecondary schools. When offered, services vary widely and may include customized academic accommodation, adaptive equipment, case management and coordination, advocacy, and counseling. A number of issues have been raised in relation to delivery of these services. Among these are issues of disclosure, accessibility of a range of services, and extent and type of transition services needed to move from school to work. Directions of Future Employment-Related Research Given the magnitude of changes in the nature and structure of the world of work and possible changes in the characteristics of the disabled population, NIDRR's employment-related research agenda for the next five years must extend beyond prior research efforts to discover mechanisms that will make the labor market more amenable to full employment for persons with disabilities. That research agenda must incorporate economic research, service delivery research, and policy research, and most importantly, must relate to the context in which employment outcomes are determined. Among the key policy issues that will affect the evolution of this agenda are SSA reform; restructured funding and payment mechanisms, including the use of vouchers; the impact of workforce consolidation; radical restructuring of employment training services at State and local levels; employment-related needs of unserved and underserved groups; linkage of health insurance benefits to either jobs or benefit programs; and transition from school to work among youth with disabilities. An important focus for research will be changes in the environment (e.g., in the workplace, information technology, and telecommunications and transportation systems) that will make work more accessible, along with strategies for assisting individuals to achieve both the skill levels and the flexibility required for full labor force participation in the 21st century. Finally, as a departure from NIDRR's historical emphasis on the service system and the quality of services, the agenda calls for examination of economic issues (including benefits and costs of various incentive plans) associated with employment of persons with disabilities, labor force projections and analyses, and an increased understanding of employer roles, perspectives, and motivational systems. The purpose of NIDRR's research in the area of employment is to: (1) Assess the impact of economic policy and labor market trends on the employment outcomes of persons with disabilities; (2) Improve the effectiveness of community-based employment service programs; (3) Improve the effectiveness of State employment service systems; (4) Evaluate the contribution of employer practices and workplace supports to the employment outcomes of persons with disabilities; and (5) Improve school-to-work transition outcomes. Research Priorities for Employment Economic Policy and Labor Market Trends As noted earlier in this chapter, NIDRR recognizes that the impact of macroeconomic trends on employment of persons with disabilities, and public policy responses to these trends is a large and complex topic, one that will require increased policy research attention in the next 5 to 10 years. A coordinated research effort must examine such labor market demand issues as the changing structure of the workforce, skill requirements, and recruitment channels, in addition to issues on the supply side such as job preparation and skills, competencies, demographics, and incentives and disincentives to work. Specific research priorities include: (1) Analysis of the implications for employment outcomes of cross-agency and multiagency developments and initiatives, including welfare reform, workforce consolidation, SSA reform, Medicare/Medicaid changes, The Department of Education-Department of Labor school-to-work program, and Executive Order No. 13078 (1998); (2) Analysis of the dissonance between the ADA concept of "essential elements" of a job and the new employer emphasis on core competencies, flexibility, and work teams and the impact on job acquisition and retention; and (3) Analysis of the impact of labor market changes on employment of persons with disabilities. Community-Based Employment Service Programs Proposed restructuring of the financing of employment-related services for individuals with disabilities posits a major role for new or different service delivery arrangements. The capacity of the existing provider system, represented in part by the 7,000 community-based rehabilitation programs (CRPs) in the nation, to assume this role requires thorough investigation. Specific research priorities include: (1) Evaluation of provisions for accountability and control and protections for difficult-to-serve individuals; analysis of the cost and benefit of services, and measurement of the quality of employment outcomes for consumers with disabilities; (2) Analysis of the extent to which services that CRPs deliver to VR consumers (about one-third of services received by VR consumers come from CRPs) differ in quality, quantity, costs, or outcomes from those provided to consumers of other financing systems (e.g., Workers' Compensation or private insurance); and (3) Evaluation of the potential of this community-based employment system to assume greater responsibility for service delivery under block grants, in consolidation into umbrella agencies, and in "one-stop shop" service configurations. State Service Systems Amendments to the Rehabilitation Act in 1992 and 1998 called for a number of management and service delivery changes in the State-Federal VR program. These include expanded consumer choice regarding vocational goals, services, and service providers; implementation of performance standards and indicators to ensure accountability and improvement in the system; a greater role for consumer direction through the vehicle of State Rehabilitation Advisory Councils; and changes in the eligibility determination process that include presumptive eligibility and order of selection procedures, among others. Order of selection requires that individuals with the most significant disabilities receive priority for services, significantly altering the characteristics of VR clientele. Specific research priorities include: (1) Analysis of the impact of management and service delivery changes in the State-Federal VR program on the quality and outcomes of VR services; (2) Evaluation of the impact of professionalization of the rehabilitation counselor workforce; (3) Assessment of the efficacy of various methods of case management; (4) Development and evaluation of outcome measures for VR consumers under one-stop configurations; (5) Identification and evaluation of marketing strategies to assist VR counselors in helping persons with disabilities obtain jobs in a variety of employer settings; (6) Assessment of interagency coordination in delivery of services to multiagency consumers; and (7) Assessment of the applicability of traditional VR approaches for minority and new universe populations. Employer and Workplace Issues One area that has received insufficient attention in past research is the workplace, including both the physical environment (as represented by job site accommodations, technological aids, and the like) and the "social environment" comprising roles of co-workers, supervisors, and employers. Specific research priorities include: (1) Investigation of employer hiring and promotion practices; (2) Evaluation of models of collaboration between rehabilitation professionals and employers; (3) Development and evaluation of cost-effective strategies for improving the receptivity of the workplace environment to workers with disabilities; (4) Development and evaluation of strategies for encouraging employers to hire disabled workers (e.g., tax credits, arrangements regarding partial support for medical benefits); (5) Evaluation of the impact of new structures of work, including telecommuting, flexible hours, and self-employment on employment outcomes; (6) Identification and evaluation of disability management practices by which employers can assist workers who acquire, or aggravate disabilities to remain employed, transfer employment, or remain in the workforce and out of public benefit programs; and (7) Analysis of the role and potential of the ADA in increasing job opportunities. School-to-Work Transition Moving into employment from educational institutions is one of the most important transitions that people make during their lifetimes. The academic levels at which transitions to the labor market occur include secondary school, secondary school completion, and completion of some level of post- secondary education. In recent years, the U.S. Departments of Education and Labor have collaborated to support the development of state and local systems whose broad mission is to prepare youth for success in the global marketplace. Specific research priorities include: (1) Determination of the impact of these state and local educational system initiatives on work opportunities for the nation's youth with disabilities; (2) Evaluation of the extent to which school reform initiatives, such as academic-vocational integration, Tech Prep, career academies, work-based learning, and rigorous preparation in terms of critical thinking and communication skills, are accessible to and effective with youth who have disabilities; (3) Identification of systemic and environmental barriers to full labor force participation; (4) Assessment of whether innovations in school-to-work practices are accessible to youth with disabilities, and determination of the impact of these practices on employment outcomes; and (5) Assessment of the efficacy of employment and transition services for youth from diverse backgrounds and new disability groups. Future employment research will provide information to develop new VR approaches for helping disabled individuals become competitive in the changing, global labor market. These new methods will focus on provision of culturally relevant services for clients, attainment of competitive job skills by clients, and the application of accommodation in the workplace. Chapter 4: Health and Function "To be healthy does not mean to be free of disease; it means that you can function, do what you want to do, and become what you want to become" (Rene Jules Dubos, 1901-1982). Overview Maximizing health and function is critical to maintaining independence for persons with disabilities. Health care for persons with disabilities encompasses access to care for routine health problems, participation in health promotion and wellness activities, and access to appropriate specialty care, including medical rehabilitation. Medical rehabilitation is the systematic application of modalities, therapies, and techniques to restore, improve, or replace impaired human functioning. It also encompasses biomedical engineering, that is, the use of engineering principles and techniques and biological knowledge to advance the functional ability of persons with disabilities. Health care and medical rehabilitation services operate largely within the constraints imposed by market forces and government regulations. In recent years, significant changes have occurred in health care delivery and reimbursement. Various forms of managed care have become the predominant mode of organizing and delivering health care in much of the private sector. Medicaid and Medicare also have adopted managed care strategies for providing health care to many recipients. In theory, managed care uses case coordination to contain costs by limiting access to "unnecessary" health care, particularly specialty services and hospitalization. Individuals with disabilities have expressed concern that managed care approaches may limit their access to medical rehabilitation specialists, goods, and services. In addition to a market-driven shift to managed care, other related changes have occurred, including shortened length of stays in inpatient rehabilitation facilities and the development of subacute rehabilitation providers. Considerable consolidation also has occurred within the medical rehabilitation industry and has further affected the availability and delivery of services. There also has been a new emphasis on developing performance measures that incorporate concepts of quality, functional outcomes, and consumer satisfaction. These measures are being used to guide purchasing and accrediting decisions within the health care system. During the next five years, NIDRR plans to fund research in a number of broad areas that link health status and functional outcomes to health care and medical rehabilitation. In addition, NIDRR will support research to continue development of new treatments and delivery mechanisms to meet the rehabilitation, functional restoration, and health maintenance needs of individuals with disabilities. This research will occur at the individual and the delivery system levels. In this section, the discussion of general health care and medical rehabilitation will address issues at both levels. Health Care The goal of health care for individuals with disabilities is attaining and maintaining health and decreasing rates of occurrence of secondary conditions of disability. Individuals with disabilities use more health care services, accumulate more hospital days, and incur higher per capita medical expenditures than do nondisabled persons. Persons with no activity limitations reported approximately four physician contacts per year; this figure was doubled for those who had some activity limitation, was five times as high for those unable to perform major life activities, and was seven times as great for those needing help with instrumental activities of daily living (IADLs) (LaPlante, 1993). Understanding the relationship between disability and health has implications for the public health agenda and the application of primary disease prevention strategies to the health of persons with disabilities. In the past, the health needs of persons with disabilities often have been conflated with medical rehabilitation needs. The recognition that persons with disabilities require routine health care or access to health maintenance and wellness services is relatively new. How best to meet these needs requires substantial new research. At the individual level, persons with disabilities need providers and interventions that focus on their overall health, taking disability and environmental factors into consideration. Concern about the health of the whole person is the focus at this level, in recognition that an individual is more than a disability and deserves access to the health services generally available to the nondisabled population. At the system level, study of the organization and financing of health services must include analysis of impacts on persons with disabilities. Ameliorating the primary condition, preventing secondary conditions and co-morbidities, maximizing independence and community integration, and examining the impact of physical barriers and societal attitudes on access to health and medical rehabilitation services are critical issues at each level of focus. Health Care at the Individual Level Although persons with disabilities have higher health care utilization rates than the general population, having a disability does not mean that a person is ill. People with disabilities increasingly are demanding information about and access to programs and services aimed at promoting their overall health, including access to routine health care, preventive care, and wellness activities. This includes primary care and, for women, access to gynecological care. For children, this means access to appropriate pediatric care. In clinical settings, these demands require development of disability-sensitive protocols for proper nutrition, exercise, health screening, and treatment of nondisability-related illnesses and conditions. NIDRR is committed to supporting research to improve the overall health of persons with disabilities. Health Care at the Systems Level Persons with disabilities must have access to, and satisfaction with, an integrated continuum of health care services, including primary care and health maintenance services, specialty care, medical rehabilitation, long- term care, and health promotion programs. Models for organizing, delivering, and financing these services must accommodate an overall health care system that is undergoing tremendous change. Issues of gatekeeper roles, carve-outs, risk-adjusted rate-setting, and service mix are factors for assessment in a context of managed care approaches that balance care coordination with cost control strategies. At issue for all people is whether cost control strategies result in barriers to needed care; and, for persons with disabilities, whether access to specialty care, particularly medical rehabilitation services, is limited. In the current cost-cutting and restrictive climate, it is important to assure that new service configurations preserve equity for persons with disabilities by providing for their unique needs. Medical Rehabilitation Medical rehabilitation addresses both the primary disability and secondary conditions evolving from the initial impairment or disability. Medical rehabilitation also teaches the individual to overcome the barriers in the environment. Medical rehabilitation includes medical and bioengineering interventions, therapeutic modalities, and community and family interventions. Medical Rehabilitation at the Individual Level NIDRR-funded research has improved medical rehabilitation treatment in areas such as spinal cord injury, traumatic brain injury, stroke, and other leading causes of disability. This research must be expanded to include emerging disabilities. Of special concern are new causes of disability such as violence, which has emerged in recent years as a significant precipitator for new disability conditions. In addition, future medical rehabilitation research must be sensitive to cultural difference and must recognize the impact of an individual's environment on functional outcomes. Another important research focus will be examining how technological improvements enhance the ability of biomedical engineering to help people with disabilities regain, maintain, or replace functional ability. Additionally, an urgent need exists for the development of more effective outcomes measurement tools to test the usefulness of new medical rehabilitation interventions and products. These measurement tools must assess the individual's response to medical rehabilitation interventions and account for technology that enhances mobility, independence, and quality of life. Outcomes must be measured not just for the duration of treatment but also over the long term. Another issue of continued importance to medical rehabilitation is the prevention and treatment of secondary conditions. Secondary conditions result directly from the primary disabling condition and may have significant effects on the health and function of persons with disabilities. Examples of secondary conditions may include depression, bladder and skin problems, respiratory problems, contractures or spasticity, fatigue, joint deterioration, or memory loss. Other health conditions such as cardiac problems, autoimmune diseases, or cancer may not always derive directly from the original disability, but may require special preventive efforts or care interventions because of a preexisting disability. Medical Rehabilitation at the Systems Level Cost containment strategies inherent in managed care may constrain access to medical rehabilitation. Thus, it is more important than ever to demonstrate the cost effectiveness of treatments. Research on medical rehabilitation outcomes is critical to establishing the need for, and assuring access to, medical rehabilitation within the health care delivery system. Previously, NIDRR has initiated research activities to develop methods for measuring function and assessing rehabilitation outcomes, and for measuring the cost and effectiveness of various rehabilitation modalities and delivery mechanisms. These areas will continue to be important foci of NIDRR's future medical research program. Research must continue to assess the impact of changes at the system level on the rehabilitation outcomes of individuals. In addition, providing care in nonacute settings requires development of additional capacity that includes training practitioners for more independent work in the community. NIDRR research must contribute to building this new capacity. The purpose of NIDRR's research in the area of health care and medical rehabilitation is to: (1) Identify and evaluate effective models of health care for persons with disabilities; (2) Develop models to promote health and wellness for persons with disabilities; (3) Examine the impact of changes in the health care delivery system on access to care; (4) Evaluate medical rehabilitation interventions that maximize physical function for individuals with disabilities, taking into account aging, environment, emerging disabilities, and changes in the health services delivery system; (5) Identify and evaluate medical rehabilitation interventions that will help disabled individuals maintain health, through prevention and amelioration of secondary conditions and co-morbidities, and through education; (6) Improve delivery of medical rehabilitation services to persons with disabilities; and (7) Evaluate the health and medical rehabilitation needs of persons whose impairments are attributed to newly recognized causes or whose conditions are newly recognized as disabilities, for example, disability relating to acts of violence or to conditions of children with chronic diseases like asthma. Future Research Priorities for Health Care and Medical Rehabilitation Research on Effective Methods of Providing a Continuum of Care, Including Primary Care and Long-Term Care, to Persons With Disabilities In recent years, a number of different models of providing routine health care for persons with disabilities have emerged. For example, there are medical rehabilitation programs that have developed primary care clinics; and there are other programs where primary care providers have added medical rehabilitation consultants to advise them on care of persons with disabilities. The efficacy of these models is not yet known, especially their impact on the overall well-being of their consumers. There has been some research on long-term care models, especially those that provide community- based services, including personal assistance; however, research questions remain regarding optimal models of long-term care. Specific priorities include: (1) Identification of effective models of primary and long-term care across disability populations including emerging disability groups; (2) Evaluation of the impact of primary and long-term care service delivery models on independence, community integration, and overall health outcomes, including occurrence of secondary conditions and co-morbidities; and (3) Collection and analysis of longitudinal data on health care utilization by persons with disabilities, to identify trends, outcomes, and consumer satisfaction. Research on Application of Wellness and Health Promotion Strategies NIDRR will support research to develop wellness and health promotion strategies, incorporating all disability types and all age groups. Specific research priorities include: (1) Identification and evaluation of models to promote health and wellness for persons with disabilities in mainstream settings where possible. These will include nutrition, exercise, disease prevention, and other health promotion strategies. A particular focus will be placed on prevention and treatment of secondary conditions and on the needs of emerging disability populations, including persons aging with a disability; (2) Evaluation of the impact of health status on independence, community integration, quality of life, and health care expenditures; and (3) Development of guidelines that establish protocols for reaching or maintaining appropriate levels of fitness for persons with varying functional abilities. Research on the Impact of the Evolving Health Service Delivery System on Access to Health and Medical Rehabilitation Services NIDRR anticipates that the health service delivery system will continue to evolve as the marketplace responds to rising costs and as policymakers respond to public concerns about access to care. Specific research priorities include: (1) Evaluation of the impact of changes at the health system level, for example, financing and regulatory changes, on access to the continuum of health care services, including medical rehabilitation; and (2) Evaluation of the impact of triage and case management strategies on health status and rehabilitation outcomes. Research on Trauma Rehabilitation Research to improve the restoration and successful community living of individuals with burns and neurotrauma such as spinal cord injury, brain injury, and stroke, has long been an important component of NIDRR's program. Specific research priorities include: (1) Identification of methods to minimize neurological damage, improve behavioral outcomes, and enhance cognitive abilities; and (2) Identification of effective collaborative research opportunities, using data generated by the model systems. Research on Progressive and Degenerative Disease Rehabilitation Research to maintain and restore function and independent lifestyles for individuals with multiple sclerosis, arthritis, and neuromuscular diseases is a key element of medical rehabilitation research. Specific research priorities include: (1) Identification and evaluation of methods to maintain function for persons with these conditions; (2) Identification of effective health promotion strategies; (3) Evaluation of strategies to minimize the impact of secondary conditions; and (4) Development and evaluation of health care and rehabilitation medicine supports to facilitate community integration and independent living outcomes. Research on Birth Anomalies and Sequelae of Diseases and Injuries Medical and technological interventions to maintain and restore function in persons with cerebral palsy, spina bifida, post-polio syndrome, and other long-standing conditions are an important part of rehabilitation. Specific research priorities include: (1) Development and evaluation of physical therapy techniques, respiratory management techniques, exercise regimens, and other rehabilitative interventions aimed at maximizing functional independence; (2) Development and evaluation of supports to facilitate community integration and independent living outcomes, and; (3) Investigation of factors that lead to disability and loss of full participation in society following disease or injury. Research on Secondary Conditions Prevention and treatment of secondary conditions are critical to preserving health and containing health care costs of persons with disabilities. Specific research priorities include: (1) Development of clinical guidelines to identify at-risk individuals and to involve consumers in regimens to prevent secondary conditions; (2) Identification and evaluation of methods of preventing and treating secondary conditions across impairment categories; and (3) Investigation of the interaction among secondary conditions, impairments, and aging. Research on Emergent Disabilities Explorations of the impact of disabilities resulting from new causes or expanding disability definitions will be of increasing significance to rehabilitation medicine. Emergent conditions may include such things as environmental illnesses, repetitive motion syndromes, autoimmune deficiencies, and psychosocial and behavioral conditions related to poverty and violence. Specific research priorities include: (1) Identification and evaluation of the need for health and medical rehabilitation services to address emerging disability conditions; (2) Identification and evaluation of effective models by which health and medical rehabilitation providers can meet the needs of persons with emerging disabilities; and (3) Development of models to predict future emerging disability populations. Research on Aging With a Disability Advances in acute medical care for persons with disabilities means that, as the population ages, many disabled persons will live longer and may develop the serious, chronic conditions common to many aging populations. Examples of these chronic conditions include heart disease, diabetes, cancer, pulmonary diseases, arthritis, and sensory losses. Specific research priorities include: (1) Determination of the implications of aging with a disability on access to routine health care, medical rehabilitation services, and services that support community integration; (2) Investigation of the impact of aging on disabilities and the impact of various disabilities on the aging process; (3) Investigation of the relationship between age-related disability and employment; and (4) Analysis of the effect of longer lifespan on the durability and effectiveness of previously demonstrated interventions and technologies. Research on Rehabilitation Outcomes NIDRR's prior research efforts have developed new rehabilitation techniques for a number of disability groupings and also have developed and tested comprehensive model systems, home and community-based services, and peer services to improve rehabilitation outcomes. With the renewed emphasis on performance and outcomes and with increasing economic constraints generated by changes in the health services delivery system, rehabilitation medicine needs to document the impact of its services. Specific research priorities include: (1) Expansion of outcomes evaluation approaches, beyond short-term rehabilitation studies, to include outpatient and long-term follow-up information; (2) Development of outcomes measures that include measures of environmental barriers; (3) Evaluation of methods that translate outcomes findings into quality improvement strategies; and (4) Analysis of barriers and incentives to consistent use of health and medical rehabilitation outcomes measures in payer and consumer choice models. Research on Changes in the Medical Rehabilitation Industry The medical rehabilitation industry is undergoing an unprecedented level of consolidation, with unknown consequences for access and flexibility. The industry has undergone significant changes in service sites with the move from inpatient to post-acute, outpatient, and community-based services. Outcomes measurement and quality assurance initiatives are increasingly used in evaluating medical rehabilitation services. Specific research priorities include: (1) Investigation of the impact of financing and other market forces on the medical rehabilitation industry, including service delivery patterns and treatment modalities; and (2) Identification and evaluation of the impact of changes at the medical rehabilitation industry level on access and outcomes for persons with disabilities. A major research challenge will be to integrate research on the efficacy of interventions to improve outcomes with research on the impact of changes in the health care delivery system. A second overarching objective will be to relate medical rehabilitation and health care research to other changes, including the new paradigm of disability, the emerging universe of disability, and participatory research by persons with disabilities. Chapter 5: Technology for Access and Function "For Americans without disabilities, technology makes things easier. For Americans with disabilities, technology makes things possible" (Mary Pat Radabaugh, 1988). Overview Technology has been defined as the system by which a society provides its members with developments from science that have practical use in everyday life. Today, technology plays a vital role in the lives of millions of disabled and older Americans. Each day, people with significant disabilities use the products of two generations of research in rehabilitation and biomedical engineering to achieve and maintain maximum physical function, to live in their own homes, to study and learn, to attain gainful employment, and to participate in and contribute to society in meaningful and resourceful ways. It is more than coincidence that these remarkable advances have occurred during the period in which Federal funds have supported research, development, and training in rehabilitation and biomedical engineering. In planning the future of rehabilitation engineering research, NIDRR and its constituents in the consumer, service, research, and business communities will continue to identify flexible strategies to address emerging issues and technologies, to promote widespread use of research findings, and to maximize the impact of NIDRR programs on the lives of persons with disabilities. NIDRR is particularly well positioned to continue its leadership in rehabilitation engineering research, since NIDRR locates rehabilitation engineering research on a continuum that includes related medical, clinical, and public policy research; vocational rehabilitation and independent living research; research training programs; service delivery infrastructure projects; and extensive consumer participation. The Institute supports engineering research on technology for individuals and on systems technology. For example, NIDRR has supported hearing aid and wheelchair research on the individual level, and telecommunications, transportation, and built environment research at the systems or public technology level. NIDRR also supports research on ergonomics and other interface problems related to the compatibility of various technologies, such as hearing aids and cellular telephones. Technological innovations benefit the individual at the individual level and at the systems level. At the individual level, assistive technology enhances function and at the systems, or public technology level, technology provides access that enhances community integration and equal opportunity. Much of the assistive technology for disabled individuals falls into the category of "orphan" technology because of limited markets; frequently this technology is developed, produced, and distributed by small businesses. Often, technology on the systems level involves large markets and large businesses. Access to technology can be increased by incorporating principles of universal design into the built environment, information technology and telecommunications, consumer products, and transportation. Assistive Technology for Individuals In 1990, more than 13.1 million Americans, about 5 percent of the population, were using assistive technology devices to accommodate physical impairments, and 7.1 million persons, nearly 3 percent of the population, were living in homes specially adapted to accommodate impairments. While the majority of persons who use assistive technology are elderly, children and young adults use a significant proportion of the devices, such as foot braces, artificial arms or hands, adapted typewriters or computers, and leg braces (LaPlante, Hendershot, & Moss, 1992). Assistive technology includes devices that are technologically complex, involving sophisticated materials and requiring precise operations--often referred to as "high tech"--and those that are simple, inexpensive, and made from easily available materials--commonly referred to as "low tech." Scientific research in both high tech and low tech areas will serve the consumer need for practical items that are readily available and easily used. Low-tech devices, for example, are widely used by older persons with disabilities to compensate for age-related functional losses. The importance of the development of both types of assistive technologies is found in the words of one engineer who stated, "it is not high tech or low tech that is the issue; it is the right tech." NIDRR research must be able to identify the most appropriate technological approach for a given application, and continue to develop low tech as well as high tech solutions. Given the current trend toward more restrictive utilization of health care funds in both public and private sectors, rehabilitation engineering research must justify consumer or third party costs in relation to the benefits generated for consumers. These benefits may be in the form of long-term cost savings and consumer satisfaction. Equally important, rehabilitation engineers must develop products that are, in addition to being safe and durable, marketable and affordable. End-product affordability is important not only in meeting consumer needs but also in creating the market demand that will encourage manufacturers to enter production. Systems Technology: Universal Design and Accessibility As disabled persons enter the mainstream of society, the range of engineering research has broadened to encompass medical technology, technology for increased function, technology that interfaces between the individual and mainstream technology, and finally, public and systems technology. Key concepts of universal design are interchangeability, compatibility of components, modularity, simplification, and accommodations of a broad range of human performance capabilities. Universal design principles can be applied to the built environment, information technology and telecommunications, transportation, and consumer products. These technological systems are basic to community integration, education, employment, health, and economic development. The application of universal design principles during the research and development stage would incorporate the widest range of human performance into technological systems. Universal design applications may result in the avoidance of costly retrofitting of systems in use and possible reduction in need for orphan products. Technology Transfer The Institute's emphasis on applied research challenges NIDRR and its researchers to find effective ways of ensuring technology transfer--transfer of ideas, designs, prototypes, or products, from the basic to the applied research environment, to the market, and to other research endeavors. Market size, the potential for manufacturability, intellectual property rights, patents, and regulatory approval are considerations in the conceptualization and design phase of research efforts. NIDRR-funded Rehabilitation Engineering Research Centers (RERCs) consider potential industry partners in selecting research projects that will result in marketable products. Issues of orphan technology are key to the process of technology transfer, with small markets that have limited capital occasioning the need for subsidies, guaranteed financing for purchases, or other incentives for producers. Future technology transfer efforts at NIDRR will explore better linkages to the Small Business Innovative Research (SBIR) program, a government-wide program intended to support small business innovative research that results in commercial products or services that benefit the public. Innovativeness and probability of commercial success are both important factors in SBIR funding decisions. Building a Research Agenda Future rehabilitation engineering research agendas must incorporate several cross-cutting issues, including small markets, and outcomes measures. In addition, research must continue to result in improvements in the functional capacities of individuals with sensory, mobility, and manipulation impairments. Telecommunications and computer access offer significant potential to improve participation of persons with disabilities in all facets of life. Continuous innovations in these areas require that the needs of persons with various disabilities be recognized and accommodated. Finally, access to the built-environment remains a critical need for persons with disabilities, and thus requires ongoing research. The purpose of NIDRR's research in the area of technology is to: (1) Develop assistive technology that supports persons with disabilities to function and live independently; (2) Develop biomedical engineering innovations to improve function of persons with disabilities; (3) Promote the concept and application of universal design; (4) Ensure access of disabled persons to telecommunications and information technology, including through the application of universal design principles; (5) Ensure the transfer of technological developments to other research sectors, to production, and to the marketplace; (6) Identify business incentives for manufacturers and distributors; (7) Remove barriers and improve access in the built environment; (8) Identify the best methods of making technology accessible to persons with disabilities; (9) Develop rehabilitation engineering science, including a theoretical framework to advance empirical research; and (10) Raise the visibility of engineering and technological research for persons with disabilities as a consideration in national science and technology policy. Future Research Priorities for Technology NIDRR's research priorities in engineering and technology will help improve functional outcomes and access to systems technology in the areas of sensory function, mobility, manipulation, information communication, and the built environment, and promote business involvement and collaboration. Research to Improve or Substitute for Sensory Functioning. Sensory research is directed toward the problems faced by individuals who have significant visual, hearing, or communication impairments. These major conditions have been the focus of a long tradition of engineering research emphasizing both expressive communication and the receipt of information. Research priorities in the area of sensory functioning will focus on enhancing hearing, addressing visual impairments, and accommodating communication disorders. In the area of hearing impairments, specific research priorities include: (1) Development and evaluation of hearing aids that exploit the potential of digital technology, use advanced signal processing techniques to enhance speech intelligibility, attain a better fit, and insure compatibility with telecommunications systems and information technology; (2) Evaluation of the application of digital processing techniques to assistive listening systems; (3) Evaluation of modern methods of sound recognition in alerting devices; and (4) Development of interfaces for assessment of automatic speech recognition systems. In the area of vision impairments, specific research priorities include: (1) Identification and evaluation of methods to enhance accessibility of visual displays; (2) Development and evaluation of graphical user interface technologies for various document and graphic processing systems; and (3) Improvement of signage in public facilities. In the area of communication impairments, specific research priorities include: (1) Identification and evaluation of technologies to enhance the communication abilities of persons who are deaf-blind; and (2) Assessment of the capacity of research in cognitive science, artificial intelligence, biomechanics, and human/computer interaction to improve the rate, fluency, and use of communication aids. Research To Enhance Mobility Mobility research is directed toward the problems associated with moving from place to place. Mobility can be enhanced by accessible public transportation; modified privately owned vehicles; wheeled mobility devices such as wheelchairs; orthoses, and prostheses; and barrier removal. In the area of enhancing mobility, specific research priorities include: (1) Development, evaluation, and commercialization of wheelchair designs that reduce user stress, repetitive motion injury, and other secondary disabilities, while improving safety, ease of maintenance, and affordability; (2) Revision and dissemination of wheelchair standards; (3) Development and evaluation of techniques to assist consumers and providers in selecting and fitting wheelchairs and wheelchair seating systems; (4) Identification of a theoretical framework of gait and other aspects of ambulation; (5) Development and evaluation of advanced prosthetic and orthotic devices, as well as footwear and other ambulation devices; (6) Development and evaluation of methods to improve person-device interfaces, post-surgical management and fitting, and materials used in bio- engineering applications; and (7) Development of devices to assist with ADLs for persons with disabilities and their caregivers. Research to Improve Manipulation Ability The manipulation area includes research directed toward restoring functional independence for persons with limited or no use of their hands. This encompasses upper extremity prosthetic and orthotic devices, and novel methods of upper extremity rehabilitation. Issues of weight, durability, and reliability remain challenges in this field. Repetitive motion injury is emerging as one of the most serious problems among workers. While there have been a number of ergonomic devices introduced to address this problem, the incidence of this condition continues to increase. In the area of improvement of manipulation, specific research priorities include: (1) Identification of methods to improve the design of and achieve multi- functional control for hand/arm prosthetic technology; (2) Development and evaluation of surgical approaches that increase functionality; and (3) Development and evaluation of devices and techniques to minimize the onset of repetitive motion injuries and to rehabilitate those with the condition. Research to Improve Accessibility of Telecommunications and Information Technology Computerized information kiosks, public web sites, electronic building directories, transportation fare machines, ATMs, and electronic stores are just some current examples of rapidly proliferating systems that face people living in the modern world. Research priorities will include development and evaluation of techniques to make such computerized information systems accessible to persons with a range of disabilities. The information technology and telecommunications industry trend away from standardized operating systems and monolithic applications and toward net- based systems, applets, and object-oriented structures has significant implications for accessibility for some persons with disabilities. Maintaining accessibility to the Internet and World Wide Web is also a formidable challenge facing individuals with disability. Another concern in telecommunications is electromagnetic interference from the rapidly proliferating wireless communication systems (e.g., beepers, cellular telephones) and other electronic devices using digital circuitry (e.g., computers, fluorescent light controllers). This interference is complicating the use of assistive listening devices. Moreover, interference caused by over-use of spectrum is presenting problems in the use of FM Assistive Listening systems. During the past decade, virtual reality techniques, originally developed by NASA and the military for simulation activities, have been applied in a number of other fields, including architecture and health. Applications can be found in telerobotic systems, sign language recognition devices, intelligent home systems, and aids for persons with visual impairments. There has been some beginning research on the use of virtual reality as an evaluation and therapy tool. Telecommunications also emerges in other important areas of the lives of persons with disabilities. In a managed care approach to health care, individuals are discharged from acute rehabilitation hospitals earlier than in the past. Because of the decreased length of stay, there is less time for consumers to learn how to manage their conditions. One promising option for ameliorating these effects is telemedicine or "telerehabilitation." Telerehabilitation may allow for distance monitoring of chronic conditions and for monitoring consumer compliance and progress. In the area of telecommunications and information technology, specific research priorities include: (1) Development and evaluation of fine motor skill manipulation interfaces, telecommunication interfaces, and analog to digital communication technologies; (2) Identification of methods to address issues of accessibility through Internet communications; (3) Development and evaluation of methods for reducing emerging forms of interference that affect hearing aids, telephones, and other communication devices; (4) Determination of the efficacy of virtual reality techniques in both rehabilitation medicine and in applications that affect the daily lives of persons with disabilities; and (5) Identification of appropriate telecommunications strategies for use in distance follow-up to rehabilitation treatment. Research To Improve Access to the Built Environment The built environment includes public and private buildings, tools and objects of daily use, and roads and vehicles, any of which can be accessible or disabling. Architects, industrial designers, planners, builders, and engineers are among the professionals that create this environment. In the area of access to the built environment, specific research priorities include: (1) Analysis of human factors; (2) Development and evaluation of modular design; (3) Determination of best methods of disseminating information on universal design; (4) Development and evaluation of compatible interfaces; and (5) Development and promulgation of design standards. Future engineering research also must recognize the changing roles of consumers, whose participation in research is vital, and the role of assistive technology industries, whose technical capabilities and needs for product development and research are changing. Small businesses, the engine of the orphan technology industry, often cannot support sophisticated research and development efforts necessary to bring quality products to market. NIDRR's research can identify public policy issues, such as orphan technology and tax credits, to foster small business investment in assistive technology innovation. Similarly, NIDRR research can identify public policy and business issues related to mainstream systems and public technology. NIDRR will maintain a research capacity that provides a continuing stream of new ideas, and evidence to validate those ideas, to stimulate the industry. Chapter 6: Independent Living and Community Integration "Whether we have disabilities or not, we will never fully achieve our goals until we establish a culture that focuses the full force of science and democracy on the systematic empowerment of