Case Studies
Issue 16 • June 2008
By Jean E. Winsor, Allison Hall, and John Butterworth
www.communityinclusion.org
Pushing the Integrated Employment Agenda: 
Case Study Research in Tennessee

Introduction
State intellectual disabilities/developmental disabilities (IDDD) agencies vary widely in their investment in integrated employment as part of their overall day and employment supports. This brief is part of a series of publications highlighting findings from case studies in states that have developed initiatives to expand integrated employment. These products are intended to be a practical resource for other states as they work to help people with disabilities obtain and maintain gainful employment.
In the Spring of 2006, ICI researchers conducted several preliminary telephone interviews with individuals in Tennessee who were involved in their state’s initiatives around integrated employment. With this information as a foundation, a team of researchers visited Tennessee for in-person interviews and focus groups to collect more in-depth information from several stakeholders, including parents, individuals with disabilities and self-advocates, state administrators, and employment support providers. With permission, most interviews were tape recorded and transcribed. State policy documents also contributed to data collection. 

Background
The growing emphasis on integrated employment at the Department of Mental Retardation Services (DMRS) and the development of its Employment First Initiative has been characterized by a remarkable level of partnership and collaboration across a wide range of groups. Early partnership between DMRS and the Department of Rehabilitation Services (DRS) was supported by a Rehabilitation Services Administration systems change grant. Settlement of a series of lawsuits that challenged the quality of DMRS services encouraged the expansion of the community support system. Within the context of these developments stakeholders coalesced and formed the Tennessee Employment Consortium (TEC), whose primary goal is the expansion of integrated employment.
Litigation Filed Against DMRS
DMRS faced its first in a series of three lawsuits in 1989. It was filed by People First of Tennessee and addressed health and safety concerns at the Arlington Developmental Center in West Tennessee. In 1995, a second lawsuit was filed by People First of Tennessee against Clover Bottom and other remaining developmental centers. In 2000, Tennessee Protection & Advocacy, Inc. filed a third lawsuit against DMRS representing approximately 3,000 people on DMRS’s waiting list for services. Settlements were reached in all cases, and a court monitor and court appointed panel (referred to as the Quality Review Panel) currently oversee compliance with the settlement agreement and remedial order. 
Many believe that the DMRS lawsuits and resulting settlement agreements and remedial order helped to prime DMRS for an expansion of integrated employment services. As plans to respond to the lawsuits developed, a major focus that emerged was the need for meaningful day services. Many stakeholders equated a meaningful day with gainful employment, regardless of severity of disability. Additionally, one stakeholder noted that the settlement agreements and the Quality Review Panel encouraged DMRS to place an emphasis on improving the quantity and quality of employment outcomes as one strategy to provide better day service options.  
The Impact of Vocational Rehabilitation Systems Change Grants 
Just prior to the initial litigation filed against DMRS, DRS began allocating funds for providers who were interested in pursuing supported employment. From 1987-1990, DRS began to provide some supported employment services for people with intellectual disabilities, with DMRS providing follow along dollars. The University of Tennessee’s Center on Disability and Employment (CDE), in conjunction with DRS, developed a database to track the employment outcomes of DRS vendors. In 1990 DRS was awarded a three-year state systems change grant from the Rehabilitation Services Administration (RSA). The grant was administered in conjunction with CDE and was cross-disability. 
An important outcome of the RSA grant was that it provided an opportunity for DRS and DMRS to work together to support integrated employment. The collaboration between the two groups during the systems change grant provided a foundational relationship between DMRS and DRS and has been an important part of Tennessee’s efforts to increase integrated employment outcomes.  

The Development of the Tennessee Employment Consortium 
In 2000, the Tennessee Council on Developmental Disabilities reviewed two different data sources regarding the number of people in integrated employment served by DMRS. One was a Community Services tracking report that put the rate of integrated employment for people served by DMRS at 7%. The other was an internal phone survey of day providers conducted by DMRS staff that put the number at 4%. Based on this data, the Council began discussions with DMRS on strategies to improve integrated employment outcomes. The Council and DMRS agreed that a challenge grant of $150,000 to stimulate the state’s integrated employment system would be the most flexible strategy to allow DMRS and providers to develop creative ideas and strategies to increase integrated employment. The Tennessee Employment Consortium (TEC) was developed through these initial grant funds and officially began operating in July 2001. One TEC member noted that without the Council’s initial challenge grant and ongoing support, it was unlikely that TEC would have been developed or had a lasting presence in the state. The Council was the sole funder of TEC for the first three years, but since 2004 TEC has been jointly funded by the Council, DMRS, and DRS. DMRS and DRS funding for TEC does not come from federal funds.
TEC’s members include representatives from the DMRS, DRS, the Tennessee Council on Developmental Disabilities, the Arc of Tennessee, and the CDE; community services providers; family members; members of the Quality Review Panel; members of advocacy groups and other stakeholders. The group has focused on identifying barriers to integrated employment and strategies to increase the number of people served by DMRS who are working in the community. TEC has been described as a “positive change promoter.”
TEC functions as a conduit through which money for training and development for integrated employment flows. While the organization functions on both a statewide and regional level, TEC’s operational costs are covered by the in kind support of members. All of TEC’s financial resources are used to support training and development initiatives. 

Findings
Several themes emerged through the research that spoke to both the successes and challenges that Tennessee’s integrated employment system has experienced. These are: 
Formal policies in place help to convey integrated employment as a priority.
Relationships and interagency collaboration have been a boon for growth in integrated employment.
Funding systems that reward providers for integrated employment outcomes can contribute to growth in employment.
Competing priorities can undermine efforts around integrated employment.
Full implementation can occur through accountable systems.
Theme 1: Formal policies in place help to convey integrated employment as a priority
TEC and the Arc of Tennessee, as well as other advocates in the state, collaborated to encourage DMRS to institute a series of policies to communicate Tennessee’s commitment to employment. These include a policy identifying employment as the preferred day service outcome, mandatory job coach training for DMRS providers, and situational work assessments. The DMRS central office representative to TEC and other administrators at DMRS helped to champion these policies at the statewide level.   
Employment First
DMRS implemented the Employment First Initiative on January 30, 2003, with the goal of making integrated employment the first day service option for adults receiving supports from DMRS. 
Several assumptions underlie Employment First: 
Employment should be considered for anyone who wants a job.
Respect for an individual’s employment goals should drive efforts to assist people to identify, obtain, and maintain employment. 
As people’s interests and skills change, their desire to seek new employment opportunities must be valued and supported. 
Both formal and natural job supports should be available on an ongoing basis to meet individual needs. 
After a person obtains a job, his or her satisfaction with the position should be assessed. 
A skill or career plan should be developed and implemented to identify opportunities for professional development and career advancement.
(Day Services Resource Handbook, 2005).
The language of the policy assumes a high level of collaboration between state agencies (DMRS and DRS specifically, but also between DMRS and other agencies). References throughout the policy relate the importance of shared planning and service delivery. The policy also addresses the importance of working with integrated employment provider agencies. For example, the policy states: 
As a part of the Employment First Initiative, DMRS will support providers who have goals for employment and are moving toward expanded integrated employment opportunities for people. This support includes identifying ways to maximize existing available resources within and beyond DMRS and identifying barriers and the implications for needed policy revisions within and beyond DMRS (“Employment First Initiative”, 2003).
Mandatory job coach training for integrated employment providers 
Tennessee requires that any individual who provides integrated employment support complete an established job coach training curriculum. The Winners at Work Job Coach Training and Apprenticeship Program was developed by a TEC subcommittee and an outside consultant with project oversight and final curriculum approval provided by TEC. Vital input into the development of the curriculum came from the CDE as well as other TEC stakeholders. The first year the training was piloted across the state by designated TEC members.  Based upon feedback, the training was revised into two modules. The first module is an introductory training for job coaches and the second module is designed to teach advanced skills. After the first year of implementation and revision of the job coach training, TEC decided to contract out the training. The CDE was the successful bidder for the contract and continues to implement and manage the training across the state.  
The job coach training uses a train-the-trainer strategy. To ensure that providers are using the curriculum to train new integrated employment staff, DMRS requires that each contracted provider of integrated employment services identify and qualify provider staff to train new job coaches. 
Topics covered in the Winners at Work Job Coach Training and Apprenticeship Program include a comparison of the readiness model and the supported employment model; the role of the job coach; supported employment strategies; and the role of DRS, DMRS, and provider employment staff in developing and maintaining supported employment. 
Mandatory situational assessments
A notable characteristic of Employment First is its requirement of a periodic community-based work assessment. Independent Support Coordinators (see text box) ensure that individuals who are not in integrated employment participate in a community-based work assessment at least every three years. 
Theme 2: Relationships and interagency collaboration have been a boon for growth in integrated employment  
Most striking in Tennessee was the collaboration between multiple agencies and individual stakeholders to promote integrated employment. This was highly visible through the work of the Tennessee Employment Consortium (TEC). DMRS and DRS have a strong commitment to collaborating and reaching new integrated employment goals.
Ongoing communication and a sustained focus on employment through TEC
The collaboration among key stakeholders in the state through TEC has been a strong catalyst for integrated employment. Several stakeholders stressed the importance of highlighting the collaboration that exists between TEC members. They described TEC as “a catalyst for change” and a tool to help the stakeholders work together to increase integrated employment outcomes.
Ongoing communication around integrated employment is an ever-present reminder of the group’s focus. Because it is a consortium of members and does not reside solely in DMRS, a respondent said that one strength was TEC’s capacity to weather changes in leadership and priorities at DMRS. TEC members consistently meet even though different leaders may at times shift priority away from integrated employment. 
One of TEC’s most important functions is the regular opportunity it provides at the state and regional level for employment stakeholders to develop and implement plans to increase outcomes. Recommendations from TEC reach DMRS through the Director of Day Services, who is an active participant in TEC. 
The Consortium is also a vehicle for communication in the provider community about both TEC activities (such as the incentive grants that are described below) and DMRS policies and procedures. One TEC member reflected on the relationships within TEC and how they contribute to better service delivery:
TEC functions as a good conduit of information. We are not a contractor with DMRS but we work closely with a lot of these folks who are and this meeting provides opportunities…for the service providers to receive a lot of information from DMRS and the DMRS regional administrator is very involved and supportive and so he’s also receiving information from the service providers that can get fed back to DMRS so that you have a lot of information flowing back and forth, which is not always the case sometimes with contractual arrangements between state agencies and local agencies…I think that facilitates more effective working relationships there and maybe some smoother transitions for the providers and the individuals that they’re working with.
Three regional TEC groups operate in the state, one each in the east, middle, and west regions. TEC is viewed as a valuable tool for communication among its regional members, and between the regional groups and state level leadership. Regional TEC membership provides a network of support at the grassroots level. Information flows to the regional groups from the statewide TEC about integrated employment opportunities and challenges and information flows back to the statewide TEC from the regional groups regarding recommendations for changes in state policy and practice. One example of their advocacy efforts have been the 2005 changes in the payment rates for integrated employment (described in Theme 3). 
Not only is there good communication between the regional and statewide TEC members, but the regional groups share information and support one another as well. One participant in the east described the benefit of being part of two regional groups: 
By my participation in the Consortium in the east region, I have a chance to go back and share the information that I hear here with the Consortium in Chattanooga…and hopefully that’s both ways; some of the things that I may bring here from Chattanooga can be used by some of the providers in the east region. 
The importance that stakeholders place on their membership in TEC is also apparent by the number of people who consistently attend monthly TEC meetings. Approximately 30 to 35 people attend the statewide monthly meeting on a regular basis, while many more who cannot attend the statewide meeting in Nashville participate regularly at the regional meetings. 
Collaboration between DMRS and DRS 
As individuals transitioned out of the DMRS-run state developmental centers, DMRS was encouraged by the Quality Review Panel to support an even greater number of people in integrated employment. DMRS recognized that if they were going to serve more individuals in integrated employment they would need to collaborate closely with DRS. As the system of integrated employment in Tennessee has developed, the organizations have worked together to pool resources and ideas to improve integrated employment outcomes. 
While all states must abide by the federal directive that in order to access Medicaid waiver-funded employment services, individuals must first be referred to their state’s rehabilitation agency, Tennessee is somewhat unique in its strict adherence to this policy. This commitment is evidenced both in policy, in DMRS’s Day Services Resource Handbook, as well as in practice. 
Tennessee’s “Day Services Resource Handbook” states: 
Any available DRS services must be accessed prior to provision of DMRS-funded day services. DMRS-funded day services are available only to people who do not qualify for and have been denied access to DRS services, and/or who have exhausted DRS services and continue to require support (p.32). 
Respondents spoke of a strong connection between DMRS and DRS staff members at the state level and between vocational specialists and DMRS regional staff. One DRS administrator who was an active TEC member was named as key in ensuring that each DRS region had a designated supported employment lead. These counselors are trained in the DMRS system and integrated employment issues for people with significant disabilities. They also work directly in the state’s developmental centers with lawsuit class members. These DRS-supported employment leads have gone through many of the same trainings as DMRS staff members and attend regional TEC meetings. 

Independent Support Coordination
Independent Support Coordination plays an important role in the delivery of DMRS services. This model began in Tennessee in 1997, and is required for everyone served by DMRS who is funded through a Medicaid waiver. Individuals who are not funded through Medicaid waivers are not required to receive this service. 
Independent Support Coordinators (ISCs) are state-contracted, independent service providers. This model was initiated as a safeguard for the individual by reducing conflict of interest that occurs when one agency does both case management and day/residential service provision. The ISC is an objective third party who assists individuals in service delivery decisions and helps individuals and their families to plan, locate, choose, and coordinate services and supports. They typically carry a caseload of 15 to 30 individuals and are required to meet monthly with individuals. 
While many ISCs do an excellent job of providing services, stakeholders noted some weaknesses within the system. Coordinators lack resources and training on how to enact the DMRS Employment First policy. Moreover, ISCs and DRS counselors have clashed when working to support individuals in integrated employment. DRS and ISC counselors appear to be challenged by the lack of clear guidelines as to which group is responsible for implementing integrated employment plans and goals. This may stem from the competing priorities of ISCs; many have noted that health and safety issues take precedence over integrated employment, which can be “at the end of the list.” 

Theme 3: Funding systems that reward providers for integrated employment outcomes can contribute to growth in employment
Acting on feedback from employment providers and other stakeholders, DMRS worked to develop a funding structure that adequately funded integrated employment services. TEC offered DMRS several recommendations to guide the creation of the funding structure. TEC suggested:
a higher rate of payment for integrated employment than for all facility-based services and community- based non-work services, and 
the development of a funding structure that facilitated the appropriate fading of job coaches without financially penalizing provider agencies. 
The development of a new employment rate structure
In 2005 DMRS implemented a new rate structure for funding day and employment services. The new rate structure not only pays more for individual jobs ($75 to $105 per day) than group jobs ($44 per day); but pays more for any integrated employment outcome than for facility-based work, facility-based non-work, or community based non-work (“Day Services Resource Handbook,” 2005). 
Under the new rate structure, DMRS changed from paying providers an hourly rate to a daily rate. Under the hourly payment plan, if an individual lost a job, the provider could not bill for job development services to assist the individual to obtain a new job unless this service was listed in the individual’s cost plan. The rigidity in the funding stream resulted in the providers fearing that supporting individuals with significant barriers in integrated employment would lead to a loss in billable hours. The transition to a daily rate allows individuals to move fluidly between various day and employment services without the need to amend an individual’s cost plan. 
The move to a daily rate has also helped providers to develop supports that allow people to succeed at work without the constant presence of a job coach. If a person works at least two hours per day, the provider may claim the integrated employment rate for the entire day rather than having to adhere to the rule that billing must reflect the way in which time was spent for the majority of the six hours of DMRS-funded day services. If an individual works two or more hours per day the job coach is only required to make three contacts per week for the provider to bill for the full integrated employment rate. One in-person contact is required; other contacts may be over the phone with the individual and the employer.
Providers have responded favorably to the new daily rate structure. The new rate structure has encouraged some providers to begin offering integrated employment services, while other providers have increased the number of individuals they support in integrated employment. It was also noted that the new rate structure allows providers to increase the pay scale of and to offer financial bonuses to job coaches. 
Cash stipends for providers 
TEC has also had some success in using incentive grants to improve integrated employment outcomes. Initially a request for proposal was issued to providers, offering mini-grants for innovation in integrated employment. While the grants produced integrated employment outcomes, they did not lead to sustained change at the provider level. In FY 2005 TEC began offering $1,000 to providers and individuals in the community who assisted an individual served by DMRS to obtain and maintain a job in the community. In FY 2005 TEC set aside $100,000 for these stipends. TEC has tied conditions to the reciept of the stipends. To encourage use of both DRS and DMRS funds, eligible candidates must have a signed letter of understanding for employment funding with DRS. 
Some stakeholders are critical of the TEC stipends and feel that the providers who are receiving the grants are already inclined to engage in integrated employment, while there is little pressure to change for providers who are not in compliance with Employment First policy. For example, at the end of 2005, 50% of day and employment service providers in Tennessee were not supporting people in jobs in the community (Division of Mental Retardation Services Employment Status Report, 2005). In response to the criticism, in FY 2006 the stipends were targeted to providers that support less than 15% of their total base in integrated employment. These stipends are paired with technical assistance from CDE. 
Theme 4: Competing priorities can undermine efforts around integrated employment
Despite Tennessee’s efforts, factors within the system have thwarted more significant progress. As noted earlier, DMRS is under settlement agreements related to a series of lawsuits, a situation which poses many challenges. In addition the state has an ever growing waiting list for day and employment services, and has struggled with how to ensure self-determination in integrated employment.
Litigation: a double edged sword
Several respondents described the three lawsuits filed against DMRS since the 1990s as both blessings and barriers to integrated employment. While the lawsuits encouraged the state to increase their focus on employment outcomes, they have also limited DMRS’s ability to make widespread changes to day and employment services. Although there are no specific barriers to integrated employment within the agreements, efforts of DMRS and providers to respond to monitoring visits and compliance issues limits the attention paid to integrated employment outcomes. One stakeholder described the lawsuit settlements as “[putting] DMRS in the position of putting out fires and placing patches on problems instead of overhauling the whole system.” Others felt that the lawsuits had had little positive impact on services and noted that after many years under the settlement agreements “support coordination, support planning, work, school-day, relationships, independence, mental health, and communication are still areas of weakness within the system.” Despite the challenges faced by DMRS in the implementation of the settlement agreements, most stakeholders agree that the litigation has been helpful in keeping a focus on consistent efforts to improve the lives of people served by DMRS, including improving access to integrated employment.
Waiting list for services
Tennessee’s efforts to increase integrated employment outcomes have also been hampered by their waiting list for day and employment services. For several years Tennessee was under a moratorium from the Centers for Medicare and Medicaid Services (CMS) and was not allowed to fund new services recipients with CMS dollars. The moratorium lead to significant growth of the DMRS wait list. In 2000 a lawsuit was filed by Tennessee Protection & Advocacy, Inc. (currently the Disability Law & Advocacy Center of Tennessee) representing approximately 3,000 people on DMRS’s waiting list for services. 
While the settlement of the lawsuit has had the impact of moving people off of the waiting list, it still continues to grow as students transition to adult services, and caregivers age and are no longer able to provide supports at home. New additions to the waiting list are largely served after class members and those who are deemed to be “in crisis.” As of July 2007 there were 5,924 people on the waiting list, with 1,056 people on the list described as “in crisis” (Lafferty, 2007). One self-advocate expressed that many individuals perceive the wait list as a major hurdle to their active participation in the community, and that being labeled as “in crisis” did not significantly decrease the waiting time for services. 
DMRS’s waiting list impacts the ability of the vocational rehabilitation system to support people with significant disabilities to transition into long term integrated employment. Individuals on the DMRS wait list who obtain a job through DRS and need long-term follow along are ineligible for DMRS integrated employment supports unless they are classified as “in crisis.” This has resulted in people on the wait list losing their DRS-obtained jobs after their case has been successfully closed.  
The movement of people off of the waiting list and into DMRS services has also impacted Tennessee’s ability to meet its integrated employment goals. DMRS has not reached its goal to increase the percentage of people served in integrated employment each year, because while the number of people served each year in integrated employment increases it does not increase enough to offset new service recipients who do not choose integrated employment services. For example, between December 2005 and December 2006 the total number of people served by DMRS increased by 586 people, but within that same period of time there was only an increase of 154 people in integrated employment; the overall percentage of people in integrated employment remained constant (“Division of Mental Retardation Services Employment Status Report,” 2005; “Division of Mental Retardation Services Employment Status Report,” 2006). 
DMRS has worked to make integrated employment a more desirable service for people who are transitioning off the waiting list. The state recently introduced a self-determination waiver for individuals who are members of the waiting list lawsuit that includes the option for individuals to hire their own integrated employment supports. However because of the newness of the waiver there is little information available about the impact the option to directly hire supports is having on choosing integrated employment over other services.  
The importance of informed choice 
While Tennessee is promoting integrated employment, DMRS has struggled to balance this with self-determination for individuals that they serve. Although DMRS has instituted promising practices such as the requirement of a situational work assessment and the requirement that yearly service planning meetings address the possibility of community employment, some individuals can and do choose not to participate. Refusal of educational and experiential opportunities to learn about and participate in integrated employment services challenges the intent of DMRS’s efforts to support self-determined behavior. One ISC recalled helping an individual balance his right to make his own decisions with the DMRS requirement of considering integrated employment first. “I have a consumer who chooses to sleep all day, but also I know it’s not healthy for him to sleep all day long. How do you honor the person’s choice but still motivate him to go out in the community?”
The role an individual’s family takes in service planning was also thought to impact an individual’s ability to be self-determined. One stakeholder felt that at times the parent, and not the individual, refuses integrated employment; after the parent declines employment, the individual may not always get the opportunity to make his or her preferences known. Others noted that parents may prefer sheltered employment over integrated work. 
Efforts to educate individuals and their families about integrated employment have been put in place with the intent of ensuring real choice in day and employment services. In July 2005 the Tennessee Microboards Association, Inc., with funding from TEC, began conducting training for individuals and their families about integrated employment. Project Income is a series of trainings, written and presented by individuals with intellectual disabilities and developmental disabilities and their family members. The trainings use peer-to-peer education to disseminate the economic and social benefits of integrated employment for people served by DMRS. In July 2006, responsibility for providing the training was taken on by the Arc of Tennessee. Despite multiple attempts to inform individuals and their families about the trainings, few individuals or families attended the meetings. In 2007 Project Income was discontinued by TEC, and the funding for the project was redirected towards other initiatives to increase integrated employment outcomes.  
Some respondents suggested that individuals served by DMRS were also limited in their choices of integrated employment by local providers. A participant said: “Vocational assessment is usually done by the providers and whether or not an assessment gets done can be based upon if there is staff available. Providers seem to be able to make their own in house policy.” Another issue impacting the implementation of the situational work assessments was that some providers will only complete an assessment if the individual is in a sheltered workshop and expresses an interest in integrated employment. Another issue is that providers often assume that if an individual is not a productive employee in the sheltered workshop, he or she will not be successful working in the community. One ISC noted the challenge she faced in trying to get a provider to complete a situational work assessment.
I know one woman who spent most of her life in a sheltered workshop. Even when there was work to do she spent most of her days with her head on a desk sleeping. I talked to her about the possibility of integrated employment. The woman decided she would like to try working in the community, but the sheltered workshop was hesitant, noting that this woman slept most of the day. I said, well, you know, let’s try it, let’s just try it, she can always come back to the workshop if it doesn’t work out. The woman has been employed in the community now for 6 years and she has done great; she has just blossomed, it just changed her entire life.
DMRS has targeted provider agencies to ensure that they can support individuals to acquire knowledge and skills that will allow them to make self-determined choices about integrated employment through the situational work assessment. Beginning in December 2005, training was made available to providers on how to conduct situational job assessments and why it is important to provide the assessment opportunity. As reluctant providers have learned more about the importance of situational work assessments, many have begun to adopt the attitude that all people are capable of working in the community. Further, the increase in the number of providers who provide situational work assessments has lead to greater opportunities for individuals to make an informed choice about integrated employment.
Theme 5: Full implementation can only occur through more accountable systems
Tennessee has made significant efforts to increase its integrated employment outcomes, but the state continues to face many challenges to the full implementation of Employment First. A consistent investment and message is needed in order for real change and progress to take place. There is some evidence that not all stakeholders have fully bought into the initiative at this point. Clarity of the intended goal of expansion of integrated employment is critical. 
The greatest challenge seems to stem from where the Employment First Initiative is based. As noted earlier, a respondent reported the positive aspects of TEC being based outside of DMRS because it was able to maintain some autonomy from shifting priorities within DMRS. However, there are some negative aspects of this autonomy. While there are many strong advocates for integrated employment within DMRS, DMRS as a whole agency has not taken full ownership of integrated employment outcomes. While DMRS has implemented many initiatives to expand integrated employment, including rate restructuring and enforcing the mandatory situational assessment, state policy and practice initiatives have also emerged from TEC as opposed to within the DMRS administration. Some respondents felt that DMRS policies do not always consistently reflect integrated employment as the first priority. For example, the design of the Quality Assurance Process was felt to be disconnected from this goal. If a person does not have a job, a designation of “N/A” is applied. If a person has a job, the quality of that job is rated. Thus, the perceived message is “no job is better than a less-than-ideal job.” 
DMRS has developed the goal of increasing the percentage of people in integrated employment, and relies on TEC to analyze its data. The data analysis has occurred for several years and targets information on the regional, provider, and individual level. Prior to the TEC analysis, DMRS did not have an accurate count of the number of people they served. Data is also specifically broken down for lawsuit class members. There is concern about the accuracy of the data, especially for class members, but it is the best data that is available for the state. 
The TEC reports are shared among members of TEC, and representatives from DMRS and DRS transmit the analysis back to their respective agencies, but there is little evidence the data is used outside of the TEC members or that the data is used by DMRS to amend policies and practices that impact the Employment First Initiative. For example, the data indicates that many providers are not in compliance with the policy, but there is little evidence that the data has been used as a basis for responding to providers who do not support DMRS policy. During 2006 DMRS began to discuss the potential for performance requirements in provider contracts, and regional DMRS coordinators are now expected to address providers’ integrated employment outcomes each time they meet. 
Perhaps most important is how the implementation of the Employment First policy looks “on the ground.” The perspectives of self-advocates who were interviewed as part of this research reflects a lack of connection between the policies and discussions held at the leadership level, and the experiences of some individuals who actually receive integrated employment services. One self-advocate said, “I think there’s a big disconnect between the big people that make the money and the people that they’re providing their services to.” For instance, while the majority of our data suggested a very strong relationship between DRS and DMRS and a focus on the transition from initial job development and stabilization to long-term supports, it is important to note that a few self-advocates interviewed held differing views. One person spoke of the lack of collaboration between DRS and DMRS as, “the left hand not knowing what the right hand is doing.” Regarding a focus on integrated employment, one self-advocate acknowledged an emphasis on individuals finding jobs, but noted that little time was spent on ensuring full choice in the matter. She said of Circle of Support team meetings, “they’re not really taking the time to find out what people like to do…And if I’m going to get a job, it should be where I want to work.” Another participant echoed a perceived lack of choice in finding a new job, saying, “Well if somebody gets tired working a certain job, and you’re a person with a disability, they say, ‘Well what’s wrong? We [got you] a job, and you’ve kept it for three years. Now we’re not going to get you another job,’ you know.”
While these comments reflect the opinions of a few self-advocates who were interviewed as part of this project, perspectives such as these suggest that some stakeholders may be confused about intent, commitment, and implementation of the goal of greater employment outcomes for all individuals served. 
Conclusion
Tennessee has taken many important steps in its development and implementation of a policy that values work as the first option in day supports. Collaboration between DMRS and DRS, as well as the goals, priorities, and activities of TEC have done much to generate support and momentum around integrated employment in the state. However, full actualization of the Employment First policy remains a goal for the future. Inconsistent implementation of such policies as the mandatory work assessment, a quality assurance process that penalizes providers who may attempt employment and ignores those do not, and the lack of good outcome data can lead to ambiguity about the system’s goals. 
The policies, practices, and funding mechanisms that Tennessee put in place set the stage for dramatic systems change, and there is widespread commitment to this goal.  Data reported by DMRS indicates that the number of individuals supported in integrated employment nearly doubled from 735 in FY1999 to 1457 in FY2004.  Implementation barriers identified by respondents were perceived as surmountable and participants remained hopeful about the progress already achieved and that which can be attained in the future.   
References
Day Services Resource Handbook. (2005). Tennessee Division of Mental Retardation Services. 
Division of Mental Retardation Services Employment Status Report. (2005). Tennessee Employment Consortium.
Division of Mental Retardation Services Employment Status Report. (2006). Tennessee Employment Consortium.
Employment First! Initiative. (2003). Division of Mental Retardation Services Statement of Support. 
Lafferty, M.M. (2007). Federal district court hears motion on Waiting List case. Retrieved September 26, 2007 from www.dlactn.org/content.asp?ContentId=60 
Supported Employment Resource Handbook. (2004). Tennessee Division of Mental Retardation Services.
Winners at Work Employment Training. (2006). Center on Disability Employment Policy. University of Tennessee. 

If you have comments or questions on this publication, or need additional information, please contact:
Jean Winsor 
Institute for Community Inclusion 
UMass Boston 
100 Morrissey Blvd. 
Boston, Massachusetts 02125
jean.winsor@umb.edu
The authors wish to thank the participants in Tennessee who generously shared their time and insight with us, and who also provided feedback on earlier drafts of this report. 
This document was supported in part by cooperative agreement #90ND0126 from the Administration on Developmental Disabilities, Administration for Children and Families, U.S. Department of Health and Human Services. Points of view and opinions do not necessarily represent official Administration on Developmental Disability policy.

This publication will be made available in alternate formats upon request.

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