Pathways to Work Project Abstract

The Wisconsin Department of Health and Family Services (DHFS) requests $1,994,265 from the Health Care Financing Administration over a period of four years, as a fully eligible state, to establish the Pathways to Work project. This project is the result of significant evaluation and consumer input regarding Wisconsin’s current health and long-term care systems for people with disabilities who want to work. Over the last four years, DHFS has invited hundreds of consumers, service providers and advocates to provide information in two primary areas: 1) What are the difficulties in the current health and long-term care system? and 2)  What prevents many individuals with disabilities from becoming employed or maintaining employment?

With the responses to these questions in mind, the overall goal of the Pathways to Work project is to increase the extent to which existing programs and policies work together to create a stronger, consumer-centered safety net in support of an individual’s employment goals.

The objective of the Pathways to Work project is to achieve the following:

• Improve Implementation of the Medicaid Purchase Plan by increasing the efficiency of the Medicaid eligibility process and evaluating the disability determination process.

• Create a Coordinated, Comprehensive Return-to-Work Approach to 1) develop programs and policies that work in concert with one another and 2) improve the understanding of all programs that may affect the employment successes of the consumer.

• Develop and Study a Personal Assistance Service Model to explore innovative means of providing attendant services by partnering with employers and others to support the competitive employment of people with disabilities.

• Build State-to-State Coalitions to enhance our own effectiveness through participation in a multi-state group that brings state policy makers together to share innovation, best practices and common issues.
  
  Thank you for your consideration of the enclosed proposal designed to support the competitive employment of people with significant disabilities.

Introduction
Wisconsin, like much of the country, is currently experiencing a robust economy and a subsequent shortage of  qualified workers. With an average unemployment rate of less than 3%, the question remains: Why are only 19.8% of people with disabilities who were receiving Supplemental Security Income (SSI) in March 2000  engaged in employment?  This pool of untapped workers—people with disabilities—often want to work, but face significant barriers to employment.

The most commonly cited barriers to employment include the fear of losing health and long-term care coverage,  fragmentation in the system, and the likelihood of a negative net income or losing more in supports than s/he  will be able to achieve through employment. These barriers keep many skilled workers from pursuing their  employment goals and experiencing the satisfaction of participating in the workforce.

Wisconsin has made progress in developing programs designed to address these barriers to employment through innovative programs such as Wisconsin Pathways to Independence and the Medicaid Purchase Plan. (The  details of these programs will be discussed in subsequent sections.) In addition to these programs, Wisconsin also maintains a commitment to the continued improvement of the health and long-term care systems for people with disabilities.

To pursue continued improvement, the Pathways to Work project proposes to affect the existing health and long-term care systems infrastructure by meeting four primary objectives: 1) increasing the effectiveness of the Medicaid  Purchase Plan, Wisconsin’s Medicaid buy-in program, 2) strengthening the coordination of employment-related health and long-term care services, 3) developing a personal assistance service demonstration model, and 4) building state-to-state technical assistance consortiums.

The remainder of this narrative will describe how Wisconsin intends to achieve these objectives over the next four years, thereby continuing to work toward a health and long-term care system that works for people with disabilities interested in employment.

A. Current Infrastructure, Level of Competitive Employment
Wisconsin has approximately 120,000 working-age people with disabilities receiving SSI and/or SSDI. The table  below provides an overview of available data on the employment levels of individuals receiving SSI and/or SSDI. Unfortunately, the data does not describe levels of "competitive employment" using the definition outlined in the  request for proposal. Specifically, level of earnings is not a reliable measure of competitive employment in an integrated setting, in that many individuals with disabilities work part-time.

Table 1. Summary of Employment for Individuals Receiving SSI or SSDI in Wisconsin

1. SSI Quarterly Report, March 2000.
2. Numbers do not indicate level of employment.
3. Employment data is not available for individuals receiving SSDI.

Description of Services Provided through State and Federal Funds

1. Vocational Services
Wisconsin provides a significant level of vocational services to individuals with disabilities  beyond those available through the traditional vocational rehabilitation service system (Division of Vocational Rehabilitation). One such program providing a comprehensive vocational model is Wisconsin Pathways to Independence. "Pathways" is a five-year research and demonstration project designed to evaluate employment outcomes when a person-centered vocational approach is coupled with ongoing benefits counseling and alternative federal benefits (waivers from the Social Security Administration). Wisconsin currently serves consumers in 17 provider sites located around the state, and estimates 1200 to 1800 people will receive Pathways’ services over the life of the demonstration.

2. Personal Assistance Services
Wisconsin provides personal assistance services of sufficient scope and capacity to meet the Fully Eligible standard for this proposal. This criterion is met through the combination of services  offered under the Medicaid State Plan, Wisconsin’s four approved 1915(c) waivers, one state-funded long-term care program, and two long-term care demonstrations. Wisconsin is able to serve  individuals statewide in a competitive employment setting. The specific information regarding  each program is outlined below.

a. Medicaid State Plan
The personal assistance services defined in the Medicaid State Plan cover all individuals  receiving Medicaid in Wisconsin. Individuals who receive over 50 hours of services per month must receive prior authorization for these services. The level of service provided is based on individual need. Services are available in the individual’s place of residence, as well as outside the home for purposes of attending medical appointments. The personal care worker may also assist with activities of daily living (e.g. grocery shopping, house cleaning, and meal preparation). According to January 2000 data, the Medicaid State Plan provides personal assistance services to approximately 2,900 working age Medicaid recipients (ages 18-65) and spends an average of $2.2 million per month, or $758 per person per month. The Medicaid State Plan is a combination of federal Medicaid and state match dollars.

b. Medicaid Statewide Home and Community Based Waivers 1915(c)
Wisconsin has four Home- and Community-Based 1915(c) Waivers that provide personal assistance services sufficient in scope and capacity to support competitive employment for people with disabilities. All waiver programs require the development of a comprehensive  individual service plan that addresses the participant’s physical, mental and emotional needs. The programs summarized below were developed based on a foundation of consumer choice,  preference and flexibility as intrinsic values. See Appendix A for additional waiver program specifics.

1. Community Integration Program (CIP I)
   The CIP I program, available statewide, provides services for individuals with developmental disabilities who have been relocated from institutional settings. Among the services waiver participants may utilize are supported employment services (such as job coaching) which may be provided in the setting of the individual’s choice.
2. Community Options Program (COPW) & Community Integration Program II (CIP II)
   The COP-W and CIP II programs, available statewide, serve individuals with physical disabilities who meet the institutional level of care. Program services offered include supportive home care*, thereby allowing for personal care services both in the individual’s place of residence and/or place of employment (provided that this level of need is described in the individual’s care plan).
   
   *Supportive Home Care, for the purposes of the Wisconsin waiver programs, applies to any kind of hands-on or other care needed by the individual, including care given outside the home, on the job or in a variety of other settings. There are no limits on the type of service offered; supportive home care is offered based on available funding through the county budget.
3. Community Supported Living Arrangement (CSLA)
   The CSLA program provides supported living services for adults with developmental disabilities living in their own homes. These individuals do not necessarily meet institutional level of care. As with the other Home- and Community-Based Waiver programs, CSLA services are coordinated with a high degree of consumer direction and an emphasis on person-centered planning. Services offered include supportive home care, thereby allowing for personal care services both in the individual’s place of residence and/or place of employment (provided that this level of need is described in the individual’s care plan). The CSLA program is limited by funding and therefore not available statewide.
4. Brain Injury Waiver
   The BIW, available statewide, provides home- and community-based services for people with brain injuries who require significant supports. The services offered include supportive home care, thereby allowing for personal care services both in the individual’s place of residence and/or place of employment (provided that this level of need is described in the individual’s care plan).

Other Programs Providing Personal Assistance Service Supports
In addition to the Medicaid Home- and Community-Based Waivers, Wisconsin has several other state-funded and demonstration programs providing personal assistance services summarized in this section. See Appendix A for additional program specifics.

Community Options Program (COP-R)
The Community Options Program began in 1981 and is a 100% state-funded program for individuals who meet the institutional level of care. COP is an extremely flexible benefit in which participants can receive personal assistance services in any setting (including an employment setting) provided this service is outlined in the individual’s care plan. The Community Options Program is available statewide and serves approximately 1,671 individuals with disabilities. Individuals participating in a Home and Community-based Waiver may also receive Community Options Program services to supplement those services not covered by the waiver.

Family Care
The Family Care program established a managed care environment with flexible benefits for enrollees using a combination of Medicaid and state-funds to provide long-term care services. The program is currently being piloted in four counties and has enrolled approximately 500 people with disabilities.  The Family Care program is rooted in a team-decision-making model, and relies solely on consumer- centered planning and services. Among the services offered is the option of personal assistance services outside of the home, information and assistance, long-term care options counseling, benefits counseling, emergency response, and prevention/early intervention. In each demonstration county, the Family Care model has established 1) a comprehensive Resource Center providing a one-stop center for referrals and information, and 2) the operation of a care management organization.

Wisconsin Partnership Program
The Wisconsin Partnership Program, an 1115-222 Medicaid/Medicare demonstration project,  is a comprehensive program of services for people who are disabled or elderly in Wisconsin.  The program integrates health and long-term support services, and includes home and community-based services, physician services, and all other medical care. Services are delivered  in the participant’s home or a setting of his/her choice. A key element of the program is team-based care management, in which the participant, his or her physician, and a team of nurses and social workers develop a care plan together. The team coordinates all service delivery. The Partnership Program currently enrolls approximately 400 people with disabilities through contracts with four community-based organizations.

Table 2. Summary of Wisconsin’s Personal Assistance Services

*Data not available at the time of grant submission.

3. Health and Long-Term Care Services
In addition to the Medicaid State Plan and waiver programs, Wisconsin implemented the Medicaid Purchase Plan (MAPP) on March 15, 2000. This additional Medicaid eligibility category, authorized under the Balanced Budget Act of 1997, offers people with disabilities who are working or interested in working, the opportunity to purchase health care services by paying a monthly premium (based on income). Wisconsin currently has enrolled approximately 150 individuals, of whom 28% are required to pay a monthly premium. Included in the Pathways to Work proposal are two initiatives designed to strengthen the infrastructure of the Medicaid  Purchase Plan by increasing the efficiency of the application process and evaluating the impact of the disability determination process on MAPP consumers.

Overall Assessment of the State’s Capacity to Offer Personal Assistance Services Strengths
Wisconsin has a number of programs providing statewide, flexible and person-centered health and long-term care services. As seen through efforts established nearly two decades ago, such as the Community Options Program, services for individuals with disabilities have been of great concern  and interest to consumers, advocates, legislators and policymakers alike. In combination with the  current program and service provisions, Wisconsin maintains a commitment toward improving the entire employment picture—through implementing programs to increase informed consumer choice through intensive benefits counseling; and Resource Centers to offer individuals "one-stop shopping" for health, long-term care and employment goals. Wisconsin has also recently passed legislation to increase the availability of personal assistance services by raising the hourly wage for personal care attendants by $3.25 from $12.25 to $15.50 per hour.

Weaknesses
Although Wisconsin is pleased to have had some success in offering comprehensive services to people with disabilities, we still face several issues. For example, a robust economy—although offering additional opportunities for people with disabilities to achieve employment—does not guarantee adequate availability of personal assistance services to meet the needs associated with this growth of the labor market. One attempt to lessen the impact of this shortage was to pass legislation increasing the hourly wage for personal care attendants, as described above. However, there is also a strong desire to address these issues from additional avenues, including the integration and coordination of existing programs. We believe the starting point for additional and comprehensive service provision is through an evaluation of these  programs—specifically critiquing the level of coordination among and between these systems regarding employment-related services—and through testing the feasibility of alternative personal assistance service models.

B. Use of Grant Funds
Wisconsin is looking toward a long-range effort to continue removing barriers and increasing employment options for people with disabilities. This proposal addresses two significant health and long-term care systems issues: improving the effectiveness of our Medicaid buy-in operations, and addressing the need for integrated employment-related services.

As noted, our understanding of these needs has developed from intensive consumer involvement and input, including several consumer surveys over the past seven years. The most recent of these surveys was completed as part of the extensive research agenda of the Wisconsin Pathways to Independence project. The results of this survey are described in this section. Also, see Appendix B for letters of support from consumers.

Survey Results: Major Barriers to Employment
As part of Wisconsin’s efforts to remove barriers to employment for people with disabilities, the Wisconsin Pathways to Independence project surveyed 209 people with significant disabilities. The Employment Barriers survey is one source of data being used in the evaluation of the Pathways program’s capacity to reduce barriers to employment. The respondents were individuals with physical disabilities, severe and persistent mental illness, HIV/AIDS and developmental disabilities. The information reflects baseline information of individuals who had enrolled in the Pathways project from July 1999 to April 2000. The responses reflect the individual’s opinion about his/her own barriers to employment.

The most commonly reported barrier to employment was the limitation due to the disability itself. The next two most frequently mentioned barriers include the loss of Social Security benefits and health and long-term care coverage. See Appendix C for additional information regarding the survey results.

In addition to the barriers reported above, the survey results also highlight the fact that many respondents were not sure what barriers to employment they will face. The strongest area of uncertainty reported was whether earnings will affect Medicaid or Medicare eligibility, and whether individuals will be eligible for private insurance through an employer. A more detailed description of these results can be found in Appendix C.

Given the existence of multiple employment barriers and a limited general understanding of the issues present, initiatives to increase competitive employment must be comprehensive and informative in nature. Initiatives must consider not only health and long-term care coverage, but also develop greater integration of income supports and vocational services. The Pathways to Work project proposes to begin this development of a more comprehensive health and long-term care system that supports integration while building the necessary infrastructure to increase overall program effectiveness.

C. Pathways to Work Proposal
Wisconsin proposes four major objectives, described in this section, through the Pathways to Work proposal.

1.) The federal determination as currently exists for SSI and SSDI recipients, and
2.) The Buy-In determination, which is based on federal requirements that imply that the performance of Substantial Gainful Activity (SGA) should not preclude a finding of disability.

Because participants in the Medicaid Buy-Ins must be both working and disabled in order to be eligible, there remains confusion as to the interpretation of work activity in the disability determination. For example, it is unclear as to whether excluding the performance of SGA also means that an individual cannot be denied because of the activities associated with work—such as relating well to co-workers or showing up for employment on time each day— that are considered at nearly every step in the disability determination process.

The Wisconsin Disability Determination Bureau adjudicates nearly 60,000 claims for SSI, SSDI and Medicaid annually, and is expected to adjudicate 600 cases in the next year under the Medicaid Buy-In. We propose to design and implement an evaluation that includes the systematic assessment of the outcomes (allowance/denial) of case adjudication for the two different types of disability determinations. For example, one focal point of this evaluation may be eligibility for the Buy-Ins—because it requires work activity in order to participate—is the disability claim denied more often than other Medicaid claims? If so, at what point in adjudication is the claim denied? What evidence was used to support the unfavorable determination? Furthermore, what role did the functional activities of work play in the determination?

Analysis of these data may serve as the basis for policy recommendations for adapting the disability determination process for Buy-In claims if the decisional outcomes reached do not in follow the federal intent of the Buy-In authority.

The model will also calculate the financial status of individuals with disabilities and his/ her family at various levels of employment. This comprehensive tool, in addition to modeling current program benefits, will permit the user to test the effects of program policy changes. For example, the tool could be used to simulate and evaluate the impact of various Medicaid policy changes.

The general structure of the HEAT model will be similar to the Wisconsin FIRST model. This model is an income and resource simulation tool for Wisconsin’s Temporary Aid to Needy Families (TANF) recipients. See Appendix D for additional information about the Wisconsin FIRST model.

The level of integration possible between programs through the use of an electronic assistance tool has not previously been available through this type of user-friendly format. The software could potentially improve significantly the coordination of health and income supports, for the purpose of enhancing competitive employment opportunities among people with disabilities.

Data analyzed will include expenditure reporting in addition to consumer, employer and provider surveys.

As many individuals with disabilities are in communication with the Disability Determination Bureau at some point, a key time to make this connection to information and referral is when the disability is established or determined to continue. Therefore, Pathways to Work proposes utilizing the Wisconsin Disability Determination Bureau (DDB) as an additional resource center for consumers. As noted earlier, the DDB completes nearly 60,000 determinations annually and is thereby well situated to serve as an information and referral source for people with disabilities interested in work. By including this component in the Pathways to Work proposal, Wisconsin can capitalize on a naturally existing linkage between the DDB and consumers to increase information about available community resources.

Specifically, this demonstration will explore ways to address the lack of personal assistance services available at the work site by collaborating with employers to "share the costs" of personal assistance to the employed consumer. Personal care attendants will be paid to do meaningful work for the consumer, experience reduced travel time to provide services and develop new job experiences working for the employer—thus increasing employment opportunities for people with disabilities.

The demonstration will study the feasibility and cost-effectiveness of the model described above in terms of consumer and employer interest in this type alternative. Additionally, the evaluation of this demonstration will attempt to respond to the following questions:

• Are employers willing to look for creative ways to fill positions, such as hiring two people or allowing an employee to telecommute from home?
• Are individuals with significant disabilities willing to participate in this kind of demonstration?
• What kind of assistance or support is required for employers to successfully implement this alternative model?

To design this model, DHFS proposes to take the lead in bringing together a planning committee to develop the framework, implementation and evaluation of a demonstration. At a minimum, the planning committee will include persons with disabilities or representative organizations, the Department of Commerce, the Division of Vocational Rehabilitation, and DHFS. The expertise provided from each of the partners is described in this section:

Table 3. PAS Demonstration Partnerships and Areas of Expertise

Coalition of State Experts
Finally, as part of the Pathways to Work project, Wisconsin proposes to work with the Consortium for Health Systems Development as proposed by the Oregon Health Policy Institute. The purpose of the Consortium is to share and transfer information and provide assistance to one another in terms of the design, costs, and administration of health care initiatives for people with disabilities. The goal of the Consortium is to build supportive, state-tailored health care systems for individuals with significant disabilities who wish to return to work or increase their earnings without fear of loss of health care coverage. Wisconsin will participate as a member and as part of the panel of early implementers of the Medicaid Buy-In available to provide expertise to other states. It is through this Consortium that Wisconsin will meet the requirement outlined by the Request for Proposals to participate in state-to-state technical assistance as a fully-eligible state.

Table 4. Summary of Grant Proposal: Pathways to Work 4-Year Initiatives

Communication/Access Plan
Wisconsin currently provides a great deal of consumer information regarding other employment-related projects, such as the Medicaid Purchase Plan. Communication efforts and outreach in the past have included the design and distribution of consumer guides, fact sheets, brochures, posters and staff presentations across the state to hundreds of consumers, advocates and providers. We will continue to provide comprehensive communications regarding the availability of infrastructure improvements through these methods. In addition, we will implement the following:

• The Disability Determination Bureau Evaluation and Access Specialist. This individual will be responsible for networking with existing community resources and referring consumers to potential community supports. The Evaluation and Access Specialist will also maintain an (800) number for comprehensive access by consumers.
• The Health and Employment Assessment Tool. Upon completion of the software, the Department will make this tool available to a wide audience, including Medicaid case managers, benefits counselors and policymakers.

• The Internet. The Department will continue to maintain and update the DHFS web site, including links to useful information for employers, persons with disabilities and other target audiences regarding infrastructure opportunities.

Partnerships
Building on the foundation set by Wisconsin’s return-to-work initiatives for people with disabilities, the Pathways to Work project will further this effort through the development of significant partnerships to accomplish the objectives of the proposal. Partnerships will include the following:

Persons with Disabilities: Consumers will be involved in the planning, design and evaluation efforts of the Pathways to Work project through a statewide advisory committee. Consumers with disabilities represent at least one-half of the advisory committee membership, and include additional representation from employers, state agencies, service providers and advocacy groups.

In addition, the Pathways to Work project will look to include consumers in the design and implementation of the personal assistance services demonstration.

Employers: The Pathways to Work project intends to establish and maintain collaborative partnerships with employers, specifically through the proposed demonstration for joint funding of personal assistance services.

State Agencies: Wisconsin’s Department of Commerce and Department of Workforce Development are key agencies in ensuring the success of the Pathways to Work project. As noted earlier, both agencies will be invited to participate in the planning and design efforts regarding an alternative personal assistance services model.

Monitoring Plan: Many of the elements outlined in the Pathways to Work proposal have a significant evaluation and monitoring component. The planning and development in the first grant period will include estimating the number of people with disabilities who are currently competitively employed. Wisconsin DHFS has significant research capacity to assess and evaluate the data needed in accordance with reports required from the Health Care Financing Administration. Additionally, the Medicaid Purchase Plan evaluation and the Pathways to Independence research design can assist in establishing a reliable baseline of employment rates by disability group.

Research/Program Development: Pathways to Work Research: The evaluation efforts described earlier as part of the Pathways to Work project complement the two significant research and program development initiatives currently underway in the Center for Delivery Systems Development on return-to-work initiatives.

Medicaid Purchase Plan Evaluation: A comprehensive evaluation has been contracted to an independent agency to conduct a three-year evaluation of the Medicaid Purchase Plan. This evaluation effort is expected to run from June 2000 through June 2003. The results of the evaluation will be used in ongoing development and implementation of the program. In addition to providing ongoing demographics about individuals participating in the Medicaid Purchase Plan, the analysis includes a multi-pronged evaluation strategy including the following:

1. Impact Evaluation: To examine the effects of the Medicaid Purchase Plan on participants’ earnings and employment, health care choices and savings patterns.
2. Fiscal Evaluation: To evaluate the effects of the Medicaid Purchase Plan on federal, state, and local funding.
3. Process Evaluation: To determine whether the Medicaid Purchase Plan has been implemented efficiently and effectively across the state.  

This evaluation will utilize a combination of administrative and survey data.

Pathways to Independence Evaluation: In addition to the Medicaid Purchase Plan evaluation, there is also a research effort designed to assess the success of the Pathways to Independence demonstration. This ongoing effort is housed within DHFS and led by Research Director, Shawn Barry. As described earlier, the Pathways effort is a five-year research and demonstration project with an expected 1200 to 1800 participants throughout the course of the demonstration. The key measurement of interest is the degree to which increases in both earnings and the duration of employment can be achieved and maintained over time for persons with significant disabilities. The analysis will also assess the relationship between participation in Pathways and changes to individual perceptions, earnings, employment outcomes, public program participation and secondary medical conditions.

D. Products and Timeline
The following work plan offers a summary of the phases of the Pathways to Work project planning and implementation.

Table 5. Grant Deliverables: Phases I, II and III

E. Organization and Staffing
The lead agency for this project will be the Center for Delivery Systems Development. The Center is located in the Office of Strategic Finance, reporting directly to the Secretary’s office of the Department of Health and Family Services. Created in 1997, the Center was established to the focal point for long-term care delivery systems and return-to-work initiatives for people with disabilities. See Appendix E for organization charts.

For this project, the Principal Investigator is Judith Frye. Ms. Frye, Director of the Center, has had significant experience with systems- and research-level change in the role of directing the state’s efforts to evaluate the state-funded long-term care program. As Director, Ms. Frye maintains responsibility for designing, implementing, evaluating and collaborating with staff both inside and outside of the Department.

Evaluation efforts for the Pathways to Work project will be directed by Shawn Barry. Mr. Barry has significant experience in evaluating return-to-work efforts for persons with disabilities. He has in the past worked as an evaluator for a state Medicaid program and is exceptionally qualified by the range and scope of evaluation efforts this project proposes to undertake.

The Pathways to Work project will be implemented by the Center for Delivery Systems Development; however, we will work in close collaboration with the Division of Health Care Financing—specifically the Disability Determination Bureau—in the implementation of this project. Ongoing monthly meetings will be held to coordinate grant activities.

Additional staff for which project funding is requested includes the following:

1. Grant Coordinator, to manage all grant activities including assurance of deliverables and fiscal responsibilities;
2. Disability Determination Evaluation and Access Specialist, to evaluate the disability determination process for Medicaid Buy-in applicants and to improve coordination between state and local resources;
3. Health Systems Research Analyst, to focus on the evaluation of health and long-term care service utilization related to employment in existing programs and assist in design of personal assistance services feasibility model;
4. Health Systems Policy Analyst, to provide policy development and analysis expertise on health and long-term care programs and coordinate the development and implementation of the Health and Employment Assessment Tool.

All positions, except for the Disability Determination Evaluation and Access Specialist (EAS), will be housed in the Center for Delivery Systems Development. The EAS will be co-located with adjudicators in the Disability Determination Bureau for efficient access to information. DHFS has had significant success in recruiting exceptional applicants for its return-to-work and health systems efforts.

See Appendix F for the qualifications of key Pathways to Work project staff.

F. Endorsements and Support
Employment for people with disabilities and a commitment to improving the health and long-term care system enjoys support from the highest levels of state and local government and from people with disabilities. As part of Governor Thompson’s recent biennial budget, the legislature passed the Medicaid Purchase Plan and appropriated nearly $1 million to expand the efforts of Wisconsin’s return-to work initiative, Pathways to Independence.

G. Conclusion
The Pathways to Work project will be implemented thoughtfully in order to develop the necessary infrastructure to build on existing Wisconsin projects and services. By maintaining a focus on increasing the effectiveness, coordination and integration of the current health and long-term care system, Wisconsin will continue to provide important supports and services vital to the efforts to increase opportunities for competitive employment for individuals with disabilities.