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How Ticket to Work helped a county improve employment outcomes

By Maria Walker, employment program planner, Polk County Health Services

To paraphrase a popular book title, it takes a village to reduce the large unemployment rate for persons with mental illness and intellectual or other developmental disabilities. Increasing employment opportunities for these individuals is every service provider’s responsibility, whether they provide community living, employment, behavioral health, or case management services.

Polk County Health Services (PCHS) in the Des Moines, Iowa, area works with a network of service providers in the community to increase employment outcomes. In collaboration with service providers and other stakeholders, PCHS developed a supportive employment service framework that identifies key elements that define a quality service.

The mental health and disability services agency adheres to four core values to accomplish its goal of increasing community employment:

Core value 1: Increasing self-sufficiency through community employment
PCHS defines the purpose of community employment as it is understood by most persons in the rehabilitation field—a means to achieve greater self-sufficiency.

Persuading employers that persons with disabilities are good workers is but one challenge. Persuading persons with disabilities that employment will improve their quality of life can be an immense challenge in itself. To meet both of these challenges and enhance the employability of the persons served, PCHS introduced short-term, competency-based skills training and supported education services.

Core value 2: Maintaining a collaborative partnership with a network of service providers to achieve a common goal. PCHS turned to CARF-accredited community providers and other stakeholders for their expertise in developing a plan to improve employment outcomes in the county.

Each community provider in the PCHS network aligns its services within a quality framework that is evidence based and follows best-practice models identified through the Substance Abuse and Mental Health Services Administration ( SAMHSA), Employment First initiatives, and the CARF standards.

Core value 3: Maintaining accountability of taxpayer service dollars. In collaboration with its stakeholders, PCHS developed an employment scorecard to gather and share information about the services that the agency funds.

Scorecard key indicators include averages for the number and types of disabilities served, barriers for the persons served (such as limited work history, transportation, criminal background, financial disincentives, education level), types of jobs secured, length of time to find employment, retention rate, hourly wages earned, and number of hours worked.

The scorecard also allows employment providers to measure the success of their organization’s services against averages in the network. The scorecard data also help individuals seeking services to make an informed decision about choosing a provider that they believe will best meet their needs.

An independent evaluation process validates the scorecard’s data and helps governmental officials to assess PCHS’ use of public funds.

Core value 4: Using an incentive structure to achieve defined employment outcomes. PCHS believed that an incentive structure tied to outcomes could drive improvement. But the agency faced one huge, seemingly insurmountable problem: It had no funding to use as incentives.

Enter Ticket to Work, or TTW.

PCHS staff members were at first skeptical that TTW could bring the changes needed to adequately support service providers that, in turn, support individuals with significant barriers to achieve self-sufficiency. After consulting with providers to determine the best way to use TTW, PCHS successfully applied for an Employment Network (EN) on behalf of the five providers in its network.

PCHS chose to become the EN—rather than each of the contracted providers becoming an EN—because administrative costs would increase if each of the five providers became an EN on its own.

TTW works for PCHS

Internally, PCHS set up a TTW account for each of the five service providers and a sixth account for development/training. The structure looks like this:

Ticket to Work chart

Each milestone payment received is placed into the respective provider’s account. At the end of the year, the employment scorecard is applied to rate each provider for the following three outcomes:

  1. Number of persons working five or more hours per week. This is called the engagement phase, because people are often trying work for the first time.
  2. Number of persons working twenty or more hours per week.
  3. Average number of barriers of the persons served. This outcome measure encourages providers to serve individuals with a significant number of barriers.

The score is calculated into a percentage, and, at the end of the year, each provider earns that percentage of its total account. The money not awarded is placed in the development/training account, which can be accessed by all five providers to enhance employment outcomes and meet training needs. For example, if a provider has a total of $10,000 in its account and its evaluation score is 85 percent, it is awarded $8,500, and the remaining $1,500 is placed into the development/training account.

Incentive money can be used for the providers’ staff development and training, startup of new services that will enhance employment outcomes, and other projects that are tied directly to increasing self-sufficiency of the persons served.

The future looks bright for TTW

In PCHS’ fifth year of using the employment scorecard, a significant impact is made by being able to provide opportunities for the contracted service providers’ staff members to grow professionally and improve their organizational service delivery.

As the TTW incentives model remains in place and the economy improves, PCHS hopes it will be able to provide more incentives for the service providers in the network, which will in turn produce greater employment and self-sufficiency among persons with significant disabilities.

About Polk County Health Services

PCHS,, is a nonprofit organization that is the local mental health and developmental disabilities authority for Iowa’s most populous county. PCHS does not deliver direct services to consumers. Rather, the agency maintains a provider network system to meet the county management plan for service delivery.

About the author

Maria WalkerAs the employment program planner for PCHS, Maria Walker is responsible for the planning and implementation of the employment and day services delivery system. She is also a program and administrative surveyor for the Employment and Community Services customer service unit of CARF.

More TTW information

For more information on Ticket to Work, visit, a Social Security Administration website.

For information about Polk County’s outcome system and experience as an Employment Network for TTW, write Maria Walker,

MAXIMUS,, is a company that partners with state, federal, and local governments to provide health and human service programs, including TTW.

For information about becoming an Employment Network, write the Technical Assistance and Support Center at Operations Support Manager,

(Historical Newsletter Articles,Employment and Community Services,Performance Management and Improvement)

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