IV. Experiences of TTW Participants: the Participation Process
This chapter presents new information on the program-related experiences of TTW participants, as reported by participants themselves, in the 2004 NBS. The most surprising finding is that most respondents who, according to administrative data, were participants at the time of the survey did not know they were participants—even after they were asked several probing questions. Based on the NBS, we estimate that only 31 percent of TTW participants at the time of the survey knew they were participating in the program.1
It is not clear why TTW participants are not aware of their status in the program. One possibility is that TTW is primarily a payment system for service providers. Participants may pay more attention to the provider and relatively little, if any, to how the provider is paid—especially if they approached the provider without knowledge of TTW. This explanation seems especially plausible for two types of participants: “pipeline” cases at SVRAs (i.e., participants who started to receive services from SVRAs before they received their Ticket) and new participants whose Tickets were assigned to SVRAs under a simplified procedure that does not require beneficiaries to sign the Ticket assignment form.2 A multivariate analysis of the likelihood that an individual was aware of participating in the program did show that those who assigned their Tickets to SVRAs were less likely to be aware that they had assigned their Ticket, holding other characteristics constant (Appendix Table B.24). Another finding from that analysis suggests that communication issues might reduce awareness, as those with sensory impairments were less likely to be aware of their participation, holding other characteristics constant. No other characteristics were identified as being associated with awareness.
The remainder of this chapter focuses on the experiences of those who were aware that they were participants (“self-identified” participants). The NBS asked all such respondents about both their interactions with providers and their satisfaction with services. Of those who first assigned their Tickets in 2003 (the “2003 cohort”), the NBS asked more detailed questions about how they assigned their Tickets and about the number of providers they contacted in the process.3 When interpreting the findings on these questions and the rest of the material presented in this chapter, readers should recognize that the results might not be representative of the experiences of all participants.4 It is also important to recognize that the findings reflect only the early program experiences in the Phase 1 states, so it is likely that both participants and providers were still learning about and adjusting to the program when the NBS was conducted. In future reports, we will be able to assess the degree to which participants' experiences improve, deteriorate, or remain the same.
Despite these caveats, the experiences of self-identified participants early in the program rollout offer an important perspective on various aspects of the TTW environment, including the availability of adequate information, participants' knowledge of program rules, choice of service providers, problems and their solutions, progress toward employment goals, and satisfaction with the program.
The key findings for self-identified participants are as follows:
Most of those who assigned their Ticket in 2003 reported that it was very or somewhat easy to get the program information they wanted, but a substantial share (over one-fourth) had some trouble getting information.
Most of those who assigned their Ticket in 2003 and received information about the TTW service providers in their area found the information to be useful, but many (about one-third) did not.
Most of those who assigned their Ticket in 2003 did not know certain basic facts about the program at the time of the interview.
A large majority of those who assigned their Ticket in 2003 contacted just one provider; only a small percentage tried unsuccessfully to assign their Ticket to any given provider before finding the provider that eventually accepted it.
Most had positive experiences with their providers, but nontrivial minorities reported negative experiences related to, for example, the availability and usefulness of services.
About half reported that they reached their work goal.
Nearly two-thirds expressed satisfaction with TTW overall, but one-third said they were not satisfied.
A. Information Sources and Program Knowledge
Most self-identified participants in the 2003 cohort (those who first assigned their Ticket in 2003) recalled knowing relatively little about TTW before they started participating. Virtually half, in fact, said they knew nothing, compared with about 14 percent who said they knew a lot (Exhibit IV.1). This suggests that most of these participants entered TTW without information on its rules, opportunities, and choices.
Exhibit IV.1. Extent of Participants' Self-Reported Knowledge About TTW Before They Started to Participate, 2003 Cohort
Source: 2004 NBS, question H11.
Note: Sample size = 199. Includes only those who self-identified as TTW participants and first assigned their Ticket in 2003. Excludes respondents who required another person to respond on their behalf. Percentages do not sum to 100 because of rounding; an additional 0.1 percent (not shown) refused to answer or answered, “Don't know.”
The lack of information at program entry did not seem to be a serious issue for many of the self-identified participants because most of them reported that they were able to get the information they wanted about TTW without much difficulty (Exhibit IV.2). Over two-thirds got information very or somewhat easily, and almost three-quarters said there was no information they needed but could not get when they were choosing an EN.5 Most participants who obtained information on ENs before assigning their Ticket (60 percent) found the information to be useful (Exhibit IV.3).
Exhibit IV.2. Participants' Perspectives on Ease of Getting TTW Information, 2003 Cohort
Source: 2004 NBS, question H8.
Note: Includes only those who self-identified as TTW participants and first assigned their Ticket in 2003. Sample size = 216. Percentages do not sum to 100 because of rounding.
Nevertheless, there appears to be some reason for concern about the availability of information in the TTW market because over 19 percent of the self-identified participants said that getting information was not very easy, and almost 9 percent said it was not at all easy (Exhibit IV.2). Furthermore, approximately 40 percent of participants who received some information on ENs before assigning their Ticket rated it either not very useful or not at all useful (Exhibit IV.3).
Exhibit IV.3. Usefulness of Information About Available ENs As Reported by Participants Who Obtained Any Such Information
Source: 2004 NBS, question H20.
Note: Sample size = 74. Includes only those who self-identified as TTW participants, first assigned their Ticket in 2003, and obtained information about TTW. Percentages do not sum to 100 because of rounding.
We found that the likelihood of having trouble obtaining information was not strongly related to any specific characteristics of the participant. We used logit analysis to assess the relationship between the likelihood of having trouble and the characteristics of participants (Appendix Exhibit B.25). Few characteristics had statistically significant coefficients in this analysis. We did find that (1) those reporting mental illness or sensory limitations and those reporting above-average physical or mental health (but not both) were significantly more likely to have trouble obtaining information, and that (2) those with a family income over 300 percent of FPL, those who had been on the disability rolls for less than one year, and those reporting above-average physical and mental health were significantly less likely to report difficulties.6
Before or after assigning their Ticket, many of the self-identified participants in the 2003 cohort were proactive about getting information about TTW from a variety of sources (Exhibit IV.4). The most common source was an SVRA, followed by SSA the Program Manager. In addition, 35 percent of the 2003 participant cohort received information (without necessarily seeking it out) from some organization or individuals trying to tell them about ENs serving their area—most often through the mail. In addition, a relatively small share (15 percent) of participants who got information about ENs before assigning their Ticket in 2003 learned about ENs on a website.7
|Agency or Individual||Percentage|
|Benefits specialist or caseworker||26.6|
|Friend or family member||8.7|
|Another agency or organization||7.3|
|Independent living center||6.8|
|Benefits planning and assistance organization||4.6|
Source:2004 NBS, question H7.
Note: Sample size = 216. Includes only those who self-identified as TTW participants and first assigned their Ticket in 2003. Percentages do not sum to 100 because respondents could identify more than one individual or agency. Also, categories are not mutually exclusive; for example, a center for independent living may also be an EN.
To judge whether the preceding efforts and interactions made participants well-informed about TTW, the NBS interviewers read four basic, factual statements about participation in TTW to members of the 2003 cohort and asked them whether they were aware of each before hearing it in the interview. The results were mixed (Exhibit IV.5). A large majority (88 percent) knew that participation was voluntary and not a requirement for keeping their disability benefits. But the fact that more than one in 10 did not know this fact raises concern about whether some beneficiaries started to participate under the false impression that they had to do so in order to keep their benefits. Nearly one-third of participants did not know that they could unassign their Ticket and reassign it to another provider. Similarly, almost one-third did not know they could keep their medical benefits while working. Two-thirds were unaware of the rules about making timely progress.
|Fact||Knew||Did Not Know|
|Participation in the Ticket to Work program is voluntary and you do not have to participate to keep your disability benefits||88.3||11.7|
|You can, during any month, take back your Ticket and give it to another EN or participating provider||66.2||32.1|
|To remain in the program you must participate in the activities described in your individual work plan during the first few years, and work for 3 to 6 months each year during the later years of your participation||31.8||68.2|
|While you are working, you can keep your Medicaid and/or Medicare benefits||68.1||31.9|
Source: 2004 NBS, question H10.
Note: Sample size = 199. Includes only those who self-identified as TTW participants and first assigned their Ticket in 2003. Members of this group were asked whether they knew these facts prior to hearing them in the interview. Rows may not sum to 100 because respondents could also refuse to answer or indicate they didn't know how to answer. Excludes respondents who required somebody else to respond on their behalf.
B. Choices Regarding Ticket Assignment
Because beneficiary choice is a key aspect of the TTW program, it is important to understand both the extent to which participants considered the various service providers and the factors that affected their decision to assign their Ticket to one provider rather than another.
More than three-fourths of the 2003 cohort of self-identified participants (77 percent) contacted their SVRA in 2003 to assign their Ticket or to discuss the possibility of getting services from the agency. In other words, 17 percent of self-identified participants did not use their SVRA, contacting only the new providers made available through TTW.8 Of those who contacted an SVRA, the great majority (89 percent) tried to assign their Ticket to the agency, and the SVRA accepted Tickets from virtually all (99 percent) of these individuals. These survey data are consistent with the administrative data showing that the vast majority of Tickets were assigned to SVRAs (see Chapter III).
About 21 percent of participants in the 2003 cohort contacted more than one provider—that is, at least one provider in addition to the one to which they assigned their Ticket (Exhibit IV.6). The number of additional providers contacted ranged from one to 15, with 6.3 percent of participants contacting 5 or more providers.
|Number of Providers Contacted||Percent|
|One (the provider to which the Ticket was assigned)||71.2|
|Two to four||13.7|
|Five or more||6.3|
|Don't know or refused to answer||8.8|
Source: 2004 NBS, questions H21 and H27.
Note: Sample size = 216. Includes only those who self-identified as TTW participants and first assigned their Ticket in 2003. Percentages do not sum to 100 due to rounding.
Ultimately, a variety of factors led participants to choose a given TTW provider (Exhibit IV.7), but the factors cited most often had to do with convenience and practicality: the participant already knew about the SVRA or the EN or got a referral to it, or it was the closest provider or the only one nearby.
|Knew about or were referred to provider||
|Closest/only provider nearby||
|Most willing to provide services beneficiary wanted||
|Staff were most responsive/courteous/knowledgeable||
|Served people with participant's disability/needs||
|Provider offered financial compensation||
|Only provider willing to accept Ticket||
|Wait for services was not too long||
Source: 2004 NBS, question H35.
Note: Sample size = 216. Includes only those who self-identified as TTW participants and first assigned their Ticket in 2003. Question refers to the provider to which the Ticket had been assigned for the longest period at the time of the interview. Percentages do not sum to 100 because respondents could identify more than one reason.
C. Interaction with TTW Providers
Most self-identified participants had positive comments about their interaction with the SVRA or EN to which they assigned their Ticket. Among those in the 2003 cohort, a substantial majority agreed or strongly agreed that they had been able to choose the goals designated in their individualized work plan (IWP) and that the activities in the plan would help them to meet their work goals (Exhibit IV.8).
|Participant Perspective||Agree or Strongly Agree|
|Beneficiary could choose the goals he/she wanted in the IWP||86.7|
|Beneficiary helped develop the IWP||85.2|
|Activities in the IWP are likely to help beneficiary meet his/her work goals||79.9|
|EN told beneficiary that he/she could change the IWP||62.4|
Source: 2004 NBS, question H34.
Note: Sample size = 216. Includes only those who self-identified as TTW participants and first assigned their Ticket in 2003. Question refers to the provider to which the Ticket had been assigned for the longest period at the time of the interview.
A majority of self-identified participants—typically a substantial majority—agreed or strongly agreed with a variety of positive statements about their provider's staff and the services they received (Exhibit IV.9). The two items with which the smallest percentage of respondents agreed or strongly agreed had to do with the availability and usefulness of services for meeting their work goals. But this reaction might be more a reflection of the fact that participants were still trying to reach their goals than of the services themselves. In time, it is possible that some participants would have rated the services as more useful (we will address this point in a subsequent report when the additional waves of NBS data become available).
|Staff and Service Characteristics||Agree or Strongly Agree|
|Staff were courteous||89.5|
|Staff could answer participants' questions||83.8|
|Staff listened to participants' opinions and concerns||81.1|
|Services provided were in participants' IWP||76.1|
|Services provided were available to participants when needed||68.6|
|EN responded to participants' requests for changes to the IWP||61.5|
|EN offered all the services needed to meet participants' work goals||56.7|
|Overall, the services helped participants meet their work goals||52.2|
Source: 2004 NBS, question H36.
Note: Sample size = 480. Includes only those who self-identified as TTW participants. Question is based on provider to which the Ticket had been assigned for the longest period at the time of the interview.
Self-identified participants who worked in 2003 essentially split into two groups with respect to their assessment of services intended to help them find or keep their job (Exhibit IV.10). Half described the services as helping somewhat or a lot, but 44 percent said the services were of no help at all. The latter does not necessarily imply that the services were inappropriate or poorly planned or delivered because some employed participants who gave this response may simply have not needed their EN's help to find or keep their jobs.
Exhibit IV.10. Assessment of Providers' Services in Helping Participants to Find or Keep a Job, for Those Employed in 2003
Source: 2004 NBS, question H40.
Note: Sample size = 280. Includes only those who self-identified as TTW participants. Primary EN is defined as the one with whom the participant had been signed up for the longest period at the time of the interview. Percentages do not sum to 100 because of rounding; an additional 0.4 percent (not shown) refused to answer or answered, “Don't know.”
Participants rarely reported being pressured by their provider to make employment choices they did not want to make. Only 7 percent reported that they had been pressured to take a job they did not want, and only 4 percent said that their EN had pressured them to work more hours than they wanted.
Only 20 percent of all self-identified participants reported having problems with a TTW provider—primary or otherwise—in 2003. Among this subset of participants, 64 percent cited problems with an SVRA, 13 percent cited problems with another EN, and 19 percent cited problems with both types of providers.9 The distribution by provider type reflects the distribution of assignments; the incidence of problems for those who had assigned their Ticket to SVRAs was not significantly different from the incidence for those who had assigned their Ticket to ENs.10
The most common problems involved communication (37 percent) or services (35 percent). Participants cited such communication problems as not being able to reach a provider on the phone, not receiving a call back from staff, and not getting good answers to their questions. Service problems included not getting the type or extent of services they expected and not getting appropriate job leads. The remaining participants cited a variety of other problems such as issues concerning their medications and a lack of basic program knowledge on the part of provider staff.
About three-quarters (74 percent) of the self-identified participants who experienced problems tried, or had someone else try on their behalf, to resolve the problem. The most common approach taken by either person was to contact the caseworker or job coach (Exhibit IV.11). Relatively few (about 8 percent) contacted a Protection and Advocacy (P&A) agency.11 Perhaps participants' problems did not rise to the level at which they felt it was necessary to seek a resolution beyond contacting their provider. Just over half (53 percent) of those who contacted their provider said the problem had been resolved. However, nearly two-thirds (65 percent) said they were not very or not at all satisfied with the provider's response to their problem.
D. Overall Perspectives on Outcomes and Providers
Self-identified participants had mixed views on the degree to which they achieved their employment goals. They divided almost evenly into two groups, with just over half reporting that they were successful and just under half reporting otherwise (Exhibit IV.12). What is noteworthy is the fact that far more participants said they were not at all successful (31 percent) than said they were very successful (18 percent). It seems likely that some who believed they were not successful simply need more time to reach their goals.
Overall, a large majority of all self-identified participants felt positive about their overall TTW experience (Exhibit IV.13). Two-thirds reported being very or somewhat satisfied with the program. Even so, the level of dissatisfaction may be considered high. About one-third of the self-identified participants were generally dissatisfied with TTW, including nearly one in five (18 percent) who were not at all satisfied. Although it is possible that the satisfaction level will rise over time, particularly as more participants meet their work goals, there is no firm basis for such a prediction; indeed, the level of satisfaction could drop. Thus, there is at least some cause for concern about how well the program is serving, and being perceived by, individuals who have actually participated in it.
The next chapter reports on services received by all participants, including those who were not aware of their participation at the time of the interview.
|Contacted a caseworker or job coach||31.1|
|Contacted provider by phone||26.3|
|Contacted another state or local agency||15.3|
|Contacted local protection and advocacy agency||7.7|
|Referred to documents or other information about the provider||5.9|
|Contacted provider in writing||5.3|
|Contacted SSA by phone||0.8|
|Contacted the Program Manager by phone||0.8|
|Contacted SSA in writing||0.5|
|Contacted Program Manager in writing||0.2|
Source: 2004 NBS, question H50.
Note: Sample size = 53. Includes only those who self-identified as TTW participants and reported problems. Respondents could list more than one approach.
Exhibit IV.12. Participants' Perspectives on How Successful They Have Been in Reaching Their Work Goals Since Participating in TTW
Source: 2004 NBS, question H43.
Note: Sample size = 480. Includes only those who self-identified as TTW participants. Percentages do not sum to 100 because of rounding; an additional 0.9 percent (not shown) refused to answer or answered, “Don't Know.”
Exhibit IV.13. Participants' Overall Satisfaction with the Ticket To Work Program
Source: 2004 NBS, question H45.
Note: This item was not addressed to proxy respondents. Unweighted number of respondents = 451. Percentages do not sum to 100 because of rounding; also, an additional 0.2 percent (not shown) refused to answer or answered, “Don't Know.”
1 The 2004 NBS asked beneficiaries about their participation experience in TTW under only two conditions. First, administrative data had to show that the beneficiary's Ticket had been assigned by June 2003 and that it was still assigned in December 2003. Second, when asked about TTW, beneficiaries had to report that they had participated. For the analyses in this chapter we excluded a small number of respondents who reported that they had participated in TTW during 2003, but whose participation in 2003 was not confirmed in the administrative data. (back)
2 For new clients (those who were not already receiving services from the SVRA when they became TTW eligible), SVRAs are permitted to submit a signed Individual Plan for Employment (IPE) in lieu of a signed Form 1365 ( the State Agency Ticket Assignment Form) to assign a beneficiaries Ticket under TTW. (back)
3 These questions were not asked of those who first assigned their Ticket in 2002 because of concern about low recall. (back)
4 The sample sizes reported in the notes to each exhibit provide a sense of how limited these data are by the fact that only 31 percent of respondents knew that they were Ticket participants. (back)
5 Data not shown in table or figure; source is NBS, question H32. (back)
6 Mental and physical health are based on SF-8 scores. (back)
7 Data not shown in table or figure; source is NBS, questions H12-H19. (back)
8 The remaining approximately five percent either refused to answer this question or did not know whether they had contacted the SVRA. (back)
9 The remaining approximately 4 percent either refused to answer this question or did not know with which type of provider they had encountered problems. (back)
10 Percentages based on analysis of NBS respondents who self-identified as participants. We estimate that 82 percent of the participants represented in this sample had assigned their Tickets to SVRAs. (back)
11 P&As are agencies funded by SSA to protect the legal rights of and assist with problems that Social Security beneficiaries might encounter in dealing with employment service providers, employers, or others in attempting to return to work. (back)