Providing Mental Health Services to TANF Recipients

Appendix A
Profile of the Study Sites

Main Page of Report | Contents of Report

Contents

• Florida's TANF Substance Abuse/Mental Health Program
• Oregon's Mental Health Services
• Tennessee's Family Services Counseling Program
• Utah's Mental Health Services

Florida's TANF Substance Abuse/Mental Health Program

Program origins. In 1998, the Florida legislature allocated $20 million from the TANF block grant for mental health and substance abuse services. By the end of 1999, most of the local welfare offices around the state had fully implemented the TANF Substance Abuse/Mental Health (SAMH) Program for participants in the state welfare program, known as WAGES. Eligibility for the TANF SAMH Program was expanded in 2000 to target families at risk of becoming WAGES participants. Non-WAGES participants are distinguished from WAGES participants administratively, but there is no distinction in the amount or types of services they can receive. In 2001, funding for the TANF SAMH Program was increased to $45 million. The TANF SAMH Program served over 24,000 people in 2000 and the state estimates that 25,000 people will be served during 2001.

Scope of barriers targeted. The TANF SAMH program targets individuals with substance abuse or mental health conditions.

Eligibility for mental health services. Individuals eligible for the TANF SAMH Program are WAGES recipients and their family members and also non-WAGES families with incomes less than 200 percent the Federal Poverty Level. Services can be provided to noncustodial parents as long as both custodial and noncustodial parents are below the income requirement and are permanent residents of Florida. Also eligible for services are individuals who have left WAGES within the past 12 months, child-only cases⁽¹⁷⁾, families receiving services in the Family Safety system (the child welfare agency) and individuals receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).

Strategies for identifying participants with mental health conditions. There is wide variation among the local one-stop welfare offices for informing and identifying participants of the TANF SAMH program. The primary approaches used by the outreach workers are described below.

• Referrals by WAGES Staff. Statewide, TANF SAMH outreach workers are co-located in most of the one-stop centers at least part time. Being co-located within the office appears to help develop relationships between the outreach workers and WAGES staff, which tends to increase the number of referrals.
• Presentations during WAGES Orientation and Job Club Workshops. Presentations during orientation and job club workshops are one way outreach workers inform WAGES participants about the TANF SAMH Program. The frequency of these presentations varies by local office. At the Caleb One-Stop Center in Miami, participants learn about the TANF SAMH Program during the employment services provider's job club.
• Community Outreach. In areas where the outreach worker is not co-located within the one-stop center, there is an emphasis on developing community outreach activities to inform low-income families about the TANF SAMH Program and to encourage participation in screening and treatment. In some areas, outreach workers make home visits and work with other agencies, such as community health clinics, day-care centers, and food stamp offices, to gain access to TANF participants and low-income families. Additionally, some contracted service providers have negotiated with community agencies to co-locate outreach staff within their agencies.

Types of mental health services provided. The TANF SAMH program provides screening, assessment, and treatment for participants with mental health and substance abuse conditions.

• Screening. TANF SAMH outreach workers use a standard 32-item survey to conduct screenings. The screening tool includes CAGE questions to detect drug and alcohol abuse and a mental health screening tool. A scoring system for the screening tools allows outreach workers to determine whether a client should be referred to treatment. There are also two emergency referral questions and seven automatic referral questions. The state requires use of the uniform TANF SAMH Program Survey, but additional questions can be added to the screening. Discretion for how broadly to screen participants is left to the local one-stop administrator. Some centers screen all WAGES participants during orientation. Others screen only participants referred by the WAGES case managers, other community agencies, or those self-referred.
• In-Depth Psychosocial Assessments.The outreach workers schedule intake appointments for in-depth psychosocial assessments with licensed mental health or substance abuse counselors typically within 10 days of the initial screening. The psychosocial assessments vary by treatment provider, but counselors usually speak with participants about their health status, employment and economic circumstances, drug and alcohol use, legal status, family history, and family/social relationships. In most cases, outreach workers refer participants to their own agencies. However, when the participant requires treatment that an outreach worker's agency does not provide or if there is a wait for treatment, the participant is referred to other mental health and substance abuse treatment providers within the area. Referring participants to other agencies occurs primarily in urban areas where there is more than one treatment provider.
• Mental Health Treatment.In general, there are few restrictions on the types of services provided under the TANF SAMH contracts. Treatment plans are negotiated with the participant and contracted mental health/substance abuse treatment provider and approved by the TANF SAMH specialist. Some agencies offer a wide variety of mental health and substance abuse services, while other agencies contract to provide a very narrowly defined service. For example, one Miami treatment provider offers outpatient mental health treatment for adults only. A second, larger, treatment provider in Miami offers an extensive range of mental health and substance abuse services for children and adults including outpatient, in-home/on-site, outreach, residential treatment, and case management for addressing substance abuse and mental health needs.

The relationship between mental health services and work requirements. Florida requires participation in at least 30 hours a week of work activities, which includes job search, vocational training, work experience, adult basic education and up to five hours per week of mental health and substance abuse treatment. Participants also are assigned to one of two time limit tracks. Participants who are work-ready can receive cash assistance for 24 out of 48 months; those with more serious barriers to employment are allowed cash assistance 36 out of 72 months. Additional months may be added to a participant's time limit to compensate for months that they are actively involved in mental health or substance abuse treatment. The lifetime limit for all participants is 48 months.

Participants also may obtain an exemption from the time limit. Hardship exemptions are granted when a client has been participating diligently in work activities but still has a barrier to employment or is enrolled and participating in a program that extends beyond the time limit. Participants awaiting SSI approval also are exempt from the time limits. However, most participants are granted a deferral rather than an exemption. A deferment lasts up to 90 days and allows the client to be temporarily relieved from the work requirement. Deferments are granted when there are serious barriers that limit the client's ability to work. Typically, the client must obtain a written statement from a doctor to receive a deferral. Participants who are deferred from the work requirements are still subject to the time limit.

Administrative structure. The TANF SAHM Program is housed within the Department of Children and Families⁽¹⁸⁾ (DCF) and operates under both the Mental Health and the Substance Abuse Program Offices but works in collaboration on policy issues with the Office of Economic Self-Sufficiency.⁽¹⁹⁾ A program director and three staff members in the state office administer the TANF SAMH Program. Within each of the DCF districts or regions, there is at least one TANF SAMH specialist to oversee program activities within the local offices. All of the TANF SAMH employees are hired as OPS (Other Personnel Services) employees. These are temporary positions, renewed every six months, without employment benefits (such as health insurance, sick leave, and retirement).

The DCF district or region administrator selects and contracts with mental health and substance abuse treatment providers within each of the local communities. These contracts are negotiated with the TANF Specialists and local district administrators. In some communities there is one primary contractor, and in others there are multiple providers. Contracted service providers include a range of agencies, including substance abuse and community mental health centers, residential treatment providers, faith-based organizations, and hospitals. The contracted service providers hire the outreach workers, conduct clinical assessments and provide mental health and substance abuse treatment.

Funding mental health services. The Florida legislature allocated $45 million to the TANF SAMH Program for 2001. TANF SAMH dollars are used to pay for the administration and most nonmedical services provided through the TANF SAMH Program. Medicaid covers the cost of medical services, such as medications and psychiatric assessments. Approximately 4 percent of the TANF funds are for administrative overhead and the rest is for direct services. Funding is distributed to each of the 13 DCF districts and 1 regional office using a formula based on the welfare population within the district or region. Funds from the DCF district or regional offices flow down to the local service providers, with whom contract amounts and types of services are negotiated. Monetary reimbursements may vary among the different service providers. Overall, local offices are given broad flexibility in how the funds are spent.

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Oregon's Mental Health Services

Program origins. Oregon began to create a welfare program with a strong emphasis on work and supportive services in the mid-1980s. Beginning in 1992, Oregon started expanding the services provided to welfare recipients to include mental health and substance abuse services. The expansion of services was the result of a statewide analysis of client needs. There was special concern for those clients who were leaving and returning to welfare. Based on clients' needs analyses, the state found many clients could benefit from mental health and substance abuse services. The state purposely implemented a broad policy that gave local and district offices the flexibility to design mental health and substance abuse services based on the needs and resources of the local communities.

Scope of barriers targeted. Local welfare offices provide services to address mental health and substance abuse issues.

Eligibility for mental health services. All clients applying for cash assistance are eligible for mental health services. There is a 45-day assessment period where clients are required to look for employment prior to certification for TANF benefits. Clients in the assessment phase and those receiving cash assistance may be screened to assess their need for mental health services.

Strategies for identifying clients with mental health conditions. Local offices vary in how they identify clients to participate in mental health services. In most offices, clients are informed about services from multiple sources. The primary ways clients are identified for services are described below.

• Intake. Some local offices have their most experienced case managers conducting intake and asking clients questions regarding the circumstances that brought them to the welfare office. The intake worker screens for eligibility, informs clients of services, including mental health and substance abuse services, and may refer clients to mental health services.
• Orientation. Mental health specialists may screen clients for mental health and substance abuse issues during the welfare orientation. The orientation screening procedures vary across local offices. For example, in the St. John and Albina welfare offices, clients receive separate group screenings for substance abuse and mental health during their initial orientations. In Astoria, there is one mental health/substance specialist who administers a brief group screening for both mental health and substance abuse during orientation
• Welfare Case Manager. Clients are most commonly referred to the mental health specialist through the welfare case manager. Typically, either the client will disclose mental health issues or the case manager will identify mental health needs after the client fails to participate in program activities or has trouble keeping a job.
• Specialized Case Manager/Worker. In some local offices there are case managers who handle a caseload of clients with severe barriers to employment. These specialized case managers conduct more thorough assessments of clients' mental health and they work closely with mental health specialists.
• Self-Referral. Clients may refer themselves to the mental health specialist directly after being informed about mental health services during orientation or by their case managers.
• Clients in Sanction Status. Clients who are in sanction status and have indicators of mental health conditions are referred to mental health services and encouraged to participate in an assessment.

Types of mental health services provided. Once clients are identified, mental health specialists provide a wide range of services to both clients and welfare case managers. They are described below.

• Screening and Assessment. Mental health screenings and assessments are the primary service provided by mental health specialists. Most of the mental health specialists do not use a formal assessment tool, but instead rely on their professional experience to guide the types of questions that they ask. Assessments typically consist of open-ended questions aimed at uncovering current problems. Information usually is gathered on the clients' mental health history, physical health, family history, and drug and alcohol use.
• Connecting Clients with Mental Health Services. Mental health specialists link clients to treatment. The mental health specialists may refer clients to their own agencies (if they are employees of a contracted service provider), or other agencies within the community.
• Short-Term Crisis Intervention. Mental health specialists handle crisis situations and work to stabilize clients before referring them to mental health treatment.
• Training and Consultation for Welfare Case Managers. Mental health specialists provide in-service training for welfare staff and consult with case managers on a case-by-case basis, giving them guidance on ways to handle difficult behaviors and attitudes among clients.

The relationship between mental health services and work requirements. Oregon operates under a federal waiver that allows for flexibility in time limits for receiving cash assistance and work requirements. Most clients involved with mental health services have an individualized case plan developed by the case manager, mental health specialist, and client. The activities included in the individualized case plans are based on the severity of the client's mental health condition and may require fewer hours than a case plan without mental health services. Often, the focus of the work plan is to start the client out slowly with moderate activities, and gradually move into work activities. In most cases, even with mental health services, clients are required to do some work activities, such as a life-skills training workshop. Clients that are participating in an individualized work plan are not subject to the time limits.⁽²⁰⁾

Administrative structure. The administrative structure of Oregon's mental health services is comprised of one state program analyst and local mental health and substance abuse specialists. The program analyst oversees the policy guidelines and training for mental health and substance abuse services. The program analyst also coordinates with the mental health contracted treatment providers and addresses contractual questions if they arise. In the local offices there is wide variation in the organization of mental health services. In two counties, there are local program coordinators who administer, monitor, and supervise the mental health and substance abuse services in their counties. Most counties have specialists in mental health and substance abuse who have extensive experience and strong clinical training. Some offices use separate specialists for mental health and substance abuse, while other offices have hired a specialist with expertise in both areas.

Most of the staffing for mental health services are handled by using contractors and, in general, are arranged in one of two ways. Contracting may be handled either by the AFS⁽²¹⁾ (Adult and Family Services) district office or through the prime employment and training service contractor. For example, in Astoria, the AFS district office contracts directly with Clatsop Behavioral Healthcare for a part-time (20 hours a week) licensed counselor to provide mental health and substance abuse services to welfare recipients. This licensed counselor is co-located in the Astoria welfare office. In Multnomah County, the employment and training service providers, Mount Hood and Portland Community Colleges, hire the mental health specialists and subcontract with local mental health treatment providers for outstationed workers in the area.

Mental health treatment is provided by Medicaid providers. In general, the agencies provide a range of outpatient mental health treatment services, including assessment, case management, and individual and group therapy. In-patient treatment is limited to the urban areas, and throughout the state there is limited treatment for co-occurring mental health and substance abuse conditions.

Funding mental health services. Local offices determine how much of their TANF funds are allocated to mental health services. TANF funds cover the cost of the local mental health specialists and the district coordinators. Medicaid covers the cost of all mental health treatment.

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Tennessee's Family Services Counseling Program

Program origins. In 1999, the director of Families First Services⁽²²⁾ initiated an assessment of the types and prevalence of work barriers among TANF recipients. Based on local welfare administrators' reports, Tennessee's Department of Human Services (DHS) determined that a portion of families on cash assistance needed more intensive clinical case management and counseling services. This prompted the creation of a statewide program, Family Services Counseling (FSC), to assist families with barriers to move from welfare to work. DHS contracted with the College of Social Work at the University of Tennessee (UT) for the administration of the FSC program. In January 2000, UT hired a director to design and implement the FSC program. Family services counselors began receiving referrals in February 2000.

Scope of barriers targeted. The FSC program targets TANF customers and family members with mental health conditions, learning disabilities, or substance abuse, domestic violence, or child behavioral problems, but will also provide services to families with other types of challenges, such as parenting difficulties and homelessness.

Eligibility for mental health services. Services are available to all family members on the TANF case. Families may receive FSC services while on cash assistance and up to 12 months after case closure.

Strategies for identifying customers with mental health conditions. Tennessee uses a multifaceted approach to identify and connect customers to the FSC program.

• Orientation. TANF clients first are made aware of the FSC program at their group orientations. During orientation, a family services counselor explains the FSC program and provides an outline of the types of services offered and how to access these services.
• Case Managers. TANF clients are commonly referred to the FSC program by DHS case workers. During the development of a customer's personal responsibility plan, the case worker may recommend FSC services. The DHS case workers are educated about the FSC program, and they are trained to identify substance abuse problems, mental health conditions, and domestic violence.
• Referrals by Employment Service Providers or Community Agencies. The local contracted employment and education agencies are informed about FSC services. They may refer customers to the program through the DHS case worker or directly to a family services counselor.
• Mandatory Referrals. DHS case workers are mandated to offer referrals to sanctioned clients. Sanctioned clients who chose FSC as an activity to remedy a sanction are required to meet with family services counselors during the two-week compliance period before they can begin receiving cash assistance again.
• Community Outreach. The FSC program has a widespread social marketing effort. Presentation and training sessions for DHS staff and other community partners help educate workers statewide about the FSC program mission, goals, and success. Some areas have outlocated family services counselors to inform clients about the FSC program. In Chattanooga, for example, there is a family services counselor located at the Harriet Tubman Housing project.

Types of mental health services provided. There is a range of mental health services available to customers in the FSC program. They are described below.

• Standardized Assessment. All customers receive a statewide standardized assessment with a family services counselor to determine the appropriate treatment for the client.
• Solution-Focused Therapy. Family services counselors provide solution-focused therapy to their clients. Family services counselors receive extensive training on using a solution-focused brief therapy approach, which identifies and uses client strengths and resources to identify and solve problems.
• Linkage with Local Mental Health Providers. Customers that require intensive long-term treatment or medication management are referred to mental health centers accepting TennCare.⁽²³⁾ Family services counselors also refer customers with learning disabilities or domestic violence, substance abuse, and child behavioral problems to other agencies for assessment and treatment.
• Intensive Case Management. The family services counselors provide customers with individualized assistance to address barriers to self sufficiency. Family services counselors may assist customers with supportive services such as housing and transportation.
• Consultation with DHS Case Workers. The family services counselors make recommendations to DHS case workers for modified work plans based on their work with clients. Because family services counselors are co-located in the local welfare offices, DHS case workers frequently consult with them about difficult cases and most family services counselors provide training for DHS staff to identify barriers to work among clients.
• Assistance with Applying for SSI. The family services counselors help to coordinate psychological evaluations and walk customers through the Supplemental Security Income application process.

The relationship between mental health services and work requirements. While the Families First program emphasizes employment, it allows customers to participate in other activities such as mental health treatment, education, or training before going to work. Customers referred to the FSC program are not required to participate in self-sufficiency activities until a family services counselor has assessed them. The month of the client's assessment does not count against their time limit for receiving cash assistance, and a family services counselor may request a time limit interruption for clients with severe mental health conditions. There is a broad range of activities that may be included in the client's self-sufficiency plan, including mental health treatment. Most customers participating in the FSC program blend work activities, such as life skills workshops, with mental health treatment. The goal is to gradually move customers into work, but work is not required as a first activity.

Administrative structure. Staff members for the FSC program are hired through UT and local contracted service providers. The FSC program director and district coordinators are university employees. Within each district, DHS contracts with local not-for-profit agencies to provide family service counselors and clinical supervision. In some of the sites, the local agencies had formed collaborative relationships prior to the FSC program. These relationships were instrumental in implementing the FSC program in these areas. For example, DHS contracted with Family and Children's Services of Greater Chattanooga (FCS) to provide family services counselors for Hamilton County because they have been administering programs such as life skills training, parenting classes, employee assistance programs, and outpatient mental health treatment for over 120 years.

When customers need services, in addition to family services counseling, they are referred to the TennCare mental health providers. The types of agencies providing treatment vary across the state. For example, the urban area of Hamilton County has a variety of treatment providers including a residential and an outpatient substance abuse treatment center, while rural Montgomery County is more limited, with one mental health center and several not-for-profit agencies that provide primarily group treatment to low-income families.

Funding mental health services. The operating budget for the FSC program is approximately $8 million. Most of the money allocated is used to contract with UT for program administration and with local not-for-profit agencies to hire family services counselors. Most TANF families can access mental health treatment through their TennCare assistance. Families who leave cash assistance generally qualify for transitional TennCare benefits, which cover mental health treatment.

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Utah's Mental Health Services

Program origins. Utah began providing mental health services in 1990 when the Office of Family Support (OFS) hired two licensed clinical social workers to help clients with mental health needs access treatment. In 1993, OFS implemented the Single Parent Employment Demonstration (SPED) program⁽²⁴⁾, which allowed a broad range of activities to count as required self-sufficiency activities and gave case managers flexibility in determining the number of hours clients had to participate in self-sufficiency activities. Under SPED, two additional social workers were hired to identify mental health and substance abuse problems, provide brief therapy and work on the conciliation process for families who were noncompliant and being recommended for sanctioning. Eventually, social workers were hired statewide and the types of services social workers provided were determined locally.

In 1996, Utah consolidated the six separate agencies that handled employment, job training and welfare functions into the Department of Workforce Services (DWS). At this time DWS administrators decided to reorganize and centralize social work services. In 1998, the social work unit was formed with a program manager at the state level and a uniform statewide set of policies, procedures, and reporting forms were developed.

Scope of barriers targeted. Social work services focus on mental health conditions. The social workers may address substance abuse and other needs of the client by linking them to service providers in the community.

Eligibility for mental health services. All TANF clients qualify for mental health services and may continue to receive services up to a year after TANF case closure. In general, social work services are geared toward the welfare recipient rather than the entire family receiving cash assistance.

Strategies for identifying clients with mental health conditions. Clients are informed and identified for social work services in a variety of ways and at different points while on cash assistance.

• Orientation Video.During the first meeting with an employment counselor, clients are shown a computerized slide show that gives an overview of the FEP and outlines the services available, including mental health services. This is typically the client's first introduction to mental health services.
• Client Assessments/Case Managers. All employment counselors complete a standardized assessment with each client to gather information about the client's background, including work, family, legal, and medical history. Case managers refer clients to mental health treatment based on the assessment results and if a client demonstrates signs of a mental health condition.
• Automatic Referrals. The CAGE questionnaire is administered during the client assessment to screen for possible substance abuse conditions. If the customer responds "yes" to two or more of the four CAGE questions then the employment counselor is required to make a referral to the social worker. The client may chose not to participate in mental health services.
• Conciliation Process and Time Limit Extension Reviews. If a client is not participating in program activities or is nearing their time limit, a social worker may be included in case staffings and recommend social work services.

Types of mental health services provided. Once clients are identified and referred to mental health services, they are given an appointment with a social worker. The types of services social workers provide are described below.

• Clinical Assessments. A primary function of the social worker is to provide clinical assessments. Most social workers use mental health inventories in their clinical assessments, but they vary in the types of inventories they chose to use. The inventories selected typically detect mental health conditions, such as clinical depression, generalized anxiety, personality disorders, and suicide risk. Assessments are performed at the DWS office, in clients' homes, or at other locations convenient to clients. Summaries of the assessments are distributed to the employment counselors to assist them in negotiating realistic and effective employment plans with their clients. The more detailed clinical assessments are shared with the Medicaid or contracted treatment provider.
• Link Clients to Mental Health Treatment. Social workers have two different options for linking clients with mental health treatment. First, social workers may refer clients to the local Medicaid provider. The Medicaid mental health provider is used for all clients needing long-term treatment or medication management. The social workers facilitate the process of accessing treatment through the Medicaid provider. On average, clients may wait up to one month to see a therapist from the Medicaid provider. Social workers can typically get a client into treatment with the Medicaid provider in less time. In cases where TANF recipients would be required to wait longer than 10 days for treatment or where clients would benefit from a particular treatment⁽²⁵⁾, social workers may refer clients to a contracted treatment provider in the area. The contracted service providers offer outpatient individual and group treatment as well as psychological assessments. Therapy is short-term and focused on helping the client meet employment goals.
• Crisis Intervention. Social workers deal with immediate crises among clients. Social workers help to stabilize clients and link them with inpatient or crisis intervention treatment.
• Short-Term Therapy. In some offices social workers will conduct short-term therapy with clients who have less severe mental health treatment needs. Typically, treatment lasts 6 to 10 sessions and is focused on helping clients become more employable.
• Consultant/Resource for Employment Case Managers. Based on the assessment, social workers makes treatment recommendations and general recommendations regarding other barriers or issues identified during the clinical evaluation process. Employment case managers report that they often rely on the clinical expertise of the social workers in making decisions about the types of activities and amount of hours they should include in clients' self-sufficiency plan. Social workers may also provide guidance to employment counselors for strategies in interacting with the customer and may provide in-house training. Social workers in all the employment centers frequently participate in case staffings.

The relationship between mental health services and work requirements. DWS administrators allow case managers flexibility in deciding the types of activities and participation hours required of clients. In the client's self-sufficiency plan, the employment counselors can include any activity, including mental health, that will help the customer become employed. The 36-month time clock does not stop for clients participating in mental health treatment, but clients may receive an extension for a mental health or physical health condition, a substance abuse problem, or other severe barriers to work. Extensions are determined at 32 months during a mandatory extension review with the client, employment counselor, supervisor, and social worker. Extensions are conditional on clients participating in program activities. Extensions are reviewed monthly.

Administrative structure. All social work services staff are DWS state employees. There is a state social work program manager who implements, administers, and monitors the social work services and acts as a liaison to coordinate social work services among employment center administrators. The program manager also negotiates and monitors the social work treatment provided by the mental health treatment contractors. The social workers are typically licensed clinical social workers (LCSWs) with extensive experience in providing clinical treatment. Social workers may also be experienced bachelor's level staff members, certified social workers with a master's of social work degree or interns⁽²⁶⁾ that are supervised by an LCSW.

Funding mental health services. Federal TANF and state maintenance of effort funds pay for mental health services administrative staff, DWS social workers and contracted mental health treatment services. Statewide, approximately, $1.2 million is allocated for social work services staff and $456,000 for contracted mental health treatment. The majority of nonmedical mental health treatment is paid for with Medicaid funds. All medical-related services are covered through Medicaid.

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Endnotes

17.  For the child or anyone in the household that meets the income eligibility requirements.

18.  DCF is responsible for the state's economic and self-sufficiency, family safety system, mental health and substance abuse services and adult and developmental services.

19.  The Office of Economic Self-Sufficiency is responsible for determining eligibility for TANF and other public assistance programs for low-income families.

20.  In Oregon, a client not participating in an individualized work plan can not receive cash assistance for more than 24 months out of 84 months. The time limit applies only to nonparticipating clients.

21.  AFS operates Oregon's welfare programs, which has a strong emphasis on employment and work supports.

22. Tennessee developed the Families First program in 1995. The program emphasizes education and training for families on cash assistance to move them toward self-sufficiency. Since the implementation of Families First, there has been a 38 percent reduction in the number of families receiving cash assistance, from 91,499 in 1996 to 56,690 in 2000.

23.  TennCare is Tennessee's Medicaid program.

24.  In 1996, the SPED program was expanded statewide and renamed the Family Employment Program (FEP).

25.  For example, clients with PTSD are frequently referred to the Trauma Awareness and Treatment Center, an agency that specializes in treatment for survivors of physical and sexual abuse.

26.  There are 20 social workers and 6 interns across the state for 2001. DWS has an arrangement with the Graduate School of Social Work at the University of Utah to provide clinical internships to master's of social work students in local employment centers.