Social rehabilitation service and recent developments in Estonia

1. Social rehabilitation service and recent developments in Estonia Karin Hanga Managing Director, Estonian Chamber of Disabled People; Doctoral Student, Social Work Institute, Tallinn University 20. Nov 2014, Jurmala

2. Content of the presentation: • Statistics about people with disabilities in Estonia • Social Rehabilitation Service (SRS) - short introduction of the legislation • Main problems of SRS by the view of people with disabilities • Recent developments in policy • social- and vocational rehabilitation as separate services • needs based referral to the rehabilitation service • rehabilitation programs

3. Statistics about people with disabilities in Estonia

4. Rehabilitation Service in Estonia • In Estonia rehabilitation service is one of the social services stipulated in the Social Welfare Act, and one of the core services targeted to persons with disabilities. • The aim of SRS is to improve independent functioning, facilitate social integration, entry into and stay in employment. • The service is financed by the state according to the price list and within the limits established by the Government.

5. The target group of rehab.service: All persons who have a determined disability are entitled to SRS: • all children and adults with a disability • working age persons with psychiatrics needs (no degree of disability) • juveniles, who have committed an offense (by a decision of the juvenile committee).

6. Content of the SRS SRS includes: • rehabilitation needs assessment (compiling a rehabilitation plan), • counselling how to implement the rehabilitation plan, • services by various rehabilitation specialists. SRS-s may be targeted to individual, to groups or to families. The legislation sets limits for utilisation of SRS-s: • financial limits per person for every calendar year (e.g., 483 euros/per adult, 1395 euros/per child, 2325 euros for person with psychiatric needs); • limits of the amount of certain service one person can receive (e.g.,15 hours for compiling a rehabilitation plan, or 6 hours for physiotherapy, 5 nights of accommodation etc) – due to a lack of finances in the state budget.

7. SRS does not cover: • medical interventions (e.g., medical rehabilitation, which is financed by the Health Insurance Fund), • labour market services (e.g., special labour market services for people with disabilities, which are financed by the Unemployment Fund), • other social services (e.g., social transport, support person, personal assistant service - provided and financed by local municipalities; or special care services and technical aids – provided and financed by state).

8. Process of SRS • Person submits an application to Social Insurance Board • Social Insurance Board sends the letter of referral to the person • Person chooses and contacts a suitable rehabilitation service provider and waits until there is available time • Rehabilitation team assesses persons’ needs and designs a rehabilitation plan which is a prerequisite for access to other SRS-s (plan is valid for 3 years for children, and 5 years for adults) • Person recives necessary services • Social Insurance Board reimburses the costs directly to the provider

9. Rehabilitation teams in Estonia • Rehabilitation team must consist at least of 5 different specialists (social worker, occupational therapist, physiotherapist, psychologist, speech therapist, special pedagogue, doctor and nurse) • All rehabilitation specialist must have professional higher education (expect the nurse) • Number of the SRS providers has risen: in 2007 – 63; in 2013 - 115. • The number of specialists working in rehab.teams:1884

10. Some statistics about SRS provisionin 2013 In 2013 the total budget of the SRS was 7.9 million euros: • For children – 4,3 million • For adults - 3,5 million Number of applications to the SRS: 19 398 Number of persons referred to the SRS: 18 896 persons Number of persons who got SRS: 13 080 persons Number of persons waiting in queue: 6 318 persons Average cost of services per person: 376,47 euros 6 most frequently provided services in 2013 Rehabilitation needs assessment and compiling a rehabilitation plan Service of physiotherapist Accommodation Counseling of the implementation of the rehabilitation plan Service of occupational therapist Service of speech therapist

11. Problems • Rehabilitation services are fragmented across the social, health, and labour market sectors, and the help provided does not support the objective of entering the labour force or returning to work (OECD, 2012). • Although rehabilitation services in Estonia are defined as social services, the content of the service is strongly inclined towards medical procedures; one of the main social service rendered was physiotherapy (The National Audit Office, 2008). • Only 16% of working age persons who received rehabilitation services got the help needed to access employment (Ministry of Social Affairs, 2008). • While the statutory target group of social rehabilitation is large (including all registered persons with a disability), only about 10% of the target group receives SRS in a given year; the SRS system is not identifying those persons who most need these services (National Audit Office, 2008).

12. Problems by the view of PwD Rehabilitation services are not sufficiently available in different areas of Estonia, due to: • long queues to get the service (up to 2 years); • limited financing from state budget (more than 7000 persons were in the queue in Jan 2014); • inflexibility in service provision (financial limits per person and limits on the amount of certain service one person can receive) - hard to accomplish the goal of rehabilitation; • superficial attitude of the rehabilitation teams in compiling a rehabilitation plan; • excessive bureaucracy and lack of understandable information; • insufficient availability of other necessary services to support the rehabilitation (e.g., medical rehabilitation, social services form local municipality).

13. Recent developments in policy In 2012, the Estonian government launched its biggest social reform in 15 years connected with determining working capacity. Key priorities of the reform: • moving from disability assessment to work-capacity assessment; • a stronger focus on individual responsibilities; • improved cooperation across agencies to deliver effective employment support; • responsibilities for employers. Major changes will be implemented in since 2016

14. 1. Social- and vocational rehabilitation services The reform includes providing different services that individuals need to gain employment. In order to provide necessary services from one state agency: • The Unemployment Office will start to provide technical aids and vocational rehabilitation services to those persons who are in working age and have work capacity; • Social Insurance Board will provide technical aids and social rehabilitation services to children and elderly persons with disabilities and for those working age persons with disabilities, who are not active and do not have working capacity.

15. 2. Needs-based referral to the rehabilitation service Referral to the social- or vocational rehabilitation service will be based on the decision of the initial rehabilitation needs assessment, aim of which is: • to understand the life situation of the person (to guarantee that person is directed to the services that best meet their needs, either social rehabilitation or vocational rehabilitation or other services). • to improve the targeting of social rehabilitation services; • to increase efficiency of resource use. • The pilot study to develop and test the assessment instrument took place in 2010-2013, when almost 450 persons’ rehabilitation needs were assessed. • Assessment instrument is based to the World Health Organisation Disability Assessment Schedule (WHODAS 2.0) and the initial assessment is supporting both – the referral to the SRS and person’s further rehabilitation process.

16. 3. Rehabilitation programs • Although rehabilitation services include various types of counselling from single rehabilitation specialist, there is lack of purposeful, complex (i.e., integrated) interventions that would bring positive change in a person's life. • To improve the situation, Astangu Vocational Rehabilitation Center implemented pilot project in 2010-2013 funded by European Social Fund, to support SRS providers in creating and piloting integrated and complex rehabilitation programs. All programs were aimed to help people with disabilities back to work. • Work continues to develop different rehabilitation programs, aimed to support participation in every day life, to learn specific disability related skills, to adapt with the disability etc.

17. For conclusion: • Big changes in legislation, both in determine working capacity, and providing rehabilitation services will take place in 2016 (currently new laws are in the Parliament). • In order to full fill the goals of rehabilitation and to support people with disabilities participating in society, obtaining and maintaining employment, Estonia needs person-centred rehabilitation assessment, service planning, and budgeting mechanisms as well as flexibility in service provision, and the availability of needs-based rehabilitation and other services (including medical rehabilitation and lifelong learning opportunities).

18. Thank you! Karin.Hanga@gmail.com