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Employment First! Making Integrated Employment the Preferred Outcome in Tennessee


Originally published: 1/2007

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The Tennessee Division of Mental Retardation Services (DMRS) implemented the Employment First! initiative in 2002. The goal of Employment First was to make employment the first day service option for adults receiving supports funded by DMRS, Medicaid, or the state. Employment First set the standard that employment was the preferred service option for adults with mental retardation and developmental disabilities (MR/DD).


Prior to the Employment First initiative, Tennessee did not have a specific focus on integrated employment. However, the DMRS vision statement provided a strong foundation to support the Employment First policy. This statement addressed the importance of supporting choice in residence, employment, recreation, and other community activities. Additionally, data from a late-1990s survey of DMRS consumers indicated that Tennesseans with MR/DD wanted the opportunity to work. The vision statement and consumer survey data were important factors that set the stage for DMRS to focus on integrated employment.

The Employment First policy was a collaborative initiative that grew out of the work of several advocacy groups, including the Tennessee Council on Developmental Disabilities (DD Council) and the Arc of Tennessee as well as stakeholders in the state's settlement of several federal lawsuits. Individually, each of these groups began to discuss the importance of expanding integrated employment in Tennessee. The Arc and DD Council developed and submitted separate position papers to DMRS to make employment the preferred day service option. Additionally, the DD Council offered a grant to DMRS challenging the agency to increase integrated employment outcomes across the state. The challenge grant, data on consumer desires, and advocacy by stakeholder groups were all factors that led DMRS to implement Employment First.

An important feature of the initiative was defining the desired outcome clearly. Employment First defined "employment" as a job in an integrated community setting that provided the opportunity to earn competitive wages and benefits equal to the job's responsibilities, and that encouraged a person to work to their maximum potential. The initiative assumed that both formal job supports (employment provider staff, technology, etc.) and natural supports (co-workers, friends, family, etc.) should be available on an ongoing basis to meet individual support needs, and that all jobs should be developed as part of a larger career plan.

An additional notable characteristic of Employment First was its requirement of a periodic community-based work assessment. In Tennessee, Independent Support Coordinators managed services for people with MR/DD. Under the initiative, a piece of this role's responsibilities was to ensure that individuals who were not in integrated employment participated in a community-based work assessment at least every three years. This requirement aimed to provide an opportunity for individuals who might be hesitant to pursue community employment to experiment without fear of failure. Tennessee struggled with balancing the right of the individual to refuse the assessment and the state's desire to see more people choose integrated employment.

To support Employment First, DMRS reevaluated the rate paid to providers for day services. One important change was to pay a daily rate for all day services. Prior to 2005, the state had paid an hourly rate. The hourly rate was found to discourage providers from expanding integrated employment services because it was not structured to allow people to easily transition between sheltered and integrated employment, or between short- and long-term employment supports. Additionally, to encourage community rehabilitation providers to expand integrated employment activities, DMRS established a higher rate of payment for integrated employment than for other day services.


The Employment First initiative was a pioneering act in Tennessee not only because it made integrated employment the preferred service outcome but because it was developed and implemented in cooperation with multiple stakeholders. This broad coalition of support led to an ongoing commitment across the state to expand integrated employment.

As part of the initiative, the state developed benchmark goals to track state progress in increasing integrated employment placements. Providers were asked to report specific data on the number of people in integrated employment, hours worked, wages earned per hour, and job title. Since 2002, the number of adults in day services employed in competitive jobs in the community has increased by nearly forty percent.

Suggestions for Replication

For More Information, Contact:

Julie Huber
State Director of Day Services
Tennessee Division of Mental Retardation Services

Jean Winsor
Research Fellow
Institute for Community Inclusion/UMass Boston

ICI: promoting inclusion for people with disabilities