Providing Mental Health Services to TANF Recipients

Chapter II
Designing a Mental Health Service System
for TANF Recipients

Main Page of Report | Contents of Report

Contents

1. Types of Services
   1. Screening and Assessment
   2. Linking Clients to Existing Community Mental Health Treatment Services
   3. Targeted Short-Term Mental Health Counseling Services
   4. Expansion of Existing Mental Health Services
   5. Training/Consulting for Employment Case Managers
   6. Intensive Case Management
   7. Assistance in Applying for SSI (Supplemental Security Income)
2. The Population Targeted for Services
   1. Adults on TANF
   2. Adults Transitioning off TANF
   3. Children in TANF Households
   4. Low-Income Families
3. Defining the Range of Needs to be addressed
   1. Primary Focus on Mental Health
   2. Primary Focus on Mental Health and Substance Abuse
   3. Broad Focus on a Variety of Personal and Family Challenges
4. Identifying Clients in Need of Assistance
   1. Broad Screening for Mental Health Needs and Informing Clients about Services
   2. Referrals by Employment Case Managers
   3. Automatic Referrals to Mental Services
   4. Community Outreach

Each of the study states has a distinctive approach to addressing the mental health needs of welfare recipients. In Oregon and Utah, mental health services were implemented in the early 1990s, before welfare reform, as a part of a range of services to address barriers to employment faced by welfare recipients. Since the passage of welfare reform, Florida and Tennessee have developed statewide systems for addressing the mental health needs of TANF recipients. More specifically, all four states vary with respect to the decisions they have made regarding four key program elements: (1) the types of services provided, (2) the population targeted for services, (3) the range of personal and family challenges addressed, and (4) strategies for identifying clients in need of assistance. In this chapter, we explore these decisions states have made in each of these areas.

TYPES OF SERVICES

There is great variation in the types of mental health services provided by the study states to TANF recipients (see Table II.1). In Oregon, mental health specialists primarily screen and assess TANF clients for mental health conditions and link them to a mental health treatment provider in the community. In Tennessee, family services counselors conduct in-depth assessments and provide crisis intervention and short-term mental health treatment. Individuals with more severe mental health treatment needs are linked with Medicaid-funded treatment providers. In Florida, outreach workers identify and screen clients who appear to need mental health services and link them to Medicaid-funded providers or to contracted mental health treatment providers that are paid through TANF funds. In Utah, clinical social workers stationed in the local welfare offices conduct clinical assessments and make diagnoses and recommendations for mental health treatment. They also provide some crisis intervention and short-term, employment-focused mental health treatment.

The choice of which mental health services to offer is often based on the needs of clients and the resources available in the local communities. This section explores the types of mental health services provided through the local welfare office and describes some of the ways that these types of services are delivered. Most programs include one or more of the following services: (1) screening and assessment, (2) linking clients to existing treatment, (3) targeted short-term mental health counseling, (4) expansion of existing mental health services, (5) resource or consultation for employment case managers, (6) intensive case management, and (7) assistance in applying for Supplemental Security Income (SSI).

1. Screening and Assessment

All of the programs use some variation of screening and assessment to identify clients and link them to mental health services. In general, this process occurs in two stages. In the first stage, TANF clients are screened to detect individuals more likely to face mental health conditions. This may be a broad screening during TANF orientation or an individual screening by employment or mental health staff. In the second stage, clients are assessed through a more in-depth examination of the nature and extent of the mental health condition. Assessments may also include a recommendation about the number of hours and types of activities to include in the client's employment plan. The box on the next page more fully describes the screening and assessment tools and the techniques used to identify TANF recipients in need of mental health services.

The study states approach screening and assessment in several ways. Florida is the only state that has hired outreach staff to identify and screen welfare recipients and other low-income families to determine those who may need mental health services.⁽⁶⁾ These outreach staff are not licensed mental health professionals; they use a standardized screening instrument and are expected to make referrals to treatment providers in the community based on the results of the screen. Further assessment and treatment planning is provided by licensed mental health professionals after the referral is made. Oregon, Tennessee, and Utah have hired primarily licensed mental health staff, who are highly skilled in conducting mental health assessments, to carry out a screening and assessment before a treatment referral is made. The screening and assessment process in these three states is designed to identify persons in need of mental health treatment, determine the most appropriate treatment provider, assess the client's ability to participate in work activities, and develop a plan for addressing the client's mental health and employment needs. In Utah, staff also use standardized assessment inventories to diagnose specific mental health disorders.

2. Linking Clients to Existing Community Mental Health Treatment Services

In Florida and Oregon, the primary purpose of mental health services is to identify clients with mental health conditions through an assessment and link them to mental health treatment providers within the community. In Utah and Tennessee, mental health counselors provide short-term therapy to some clients and link others to mental health treatment agencies. However, mental health counselors who have high caseloads or are working with clients with extensive mental health needs typically link clients to other treatment providers. The complexity of the process for linking clients to mental health services depends on the availability and structure of mental health services in the local community; the process is often streamlined when the mental health counselor is an employee of the agency to which the client is referred.

One of the primary challenges faced by mental health counselors in linking clients to services is obtaining access to treatment in a timely manner. The wait time for treatment is particularly problematic under managed care arrangements. In some sites, clients are required to wait up to a month before they see a mental health counselor, and sometimes even longer to see a psychiatrist. The ability to access treatment in a timely manner appears to be worse in the urban than in the rural areas. According to mental health professionals, as the wait for treatment increases, so does the likelihood that the client will no longer participate in treatment. Mental health counselors often provide short-term mental health treatment until a mental health treatment provider can see the client.

Overall, there are two primary advantages to having mental health counselors link clients to services: clients have someone to guide them through the process of accessing mental health treatment, and according to some workers, counselors can actually help clients access treatment more quickly, especially when it is provided through Medicaid providers. One of the challenges for mental health counselors is that their role requires them to be aware of different treatment options in the community.

3. Targeted Short-Term Mental Health Counseling Services

The study states provide two types of short-term mental health counseling services to TANF recipients through the welfare system —  crisis intervention and short-term employment-focused counseling. Crisis intervention services are typically and more easily provided when a mental health clinician is co-located, and therefore readily available, in local welfare and employment service offices. Crisis intervention services are offered in the welfare office in all of the study states except Florida. These services are provided when a client is extremely emotional (e.g., crying, angry, etc.) or when a client has told mental health or employment staff of a plan to harm themselves or others. The goal of crisis intervention is to stabilize a client and link him or her to appropriate services (such as hospitalization or a crisis unit at a local mental health agency).

Utah and Tennessee hire or contract with licensed mental health professionals to provide short-term mental health therapy to welfare recipients. On average, short-term therapy consists of 6 to 10 sessions and may be provided individually or in groups. In general, the therapy is employment-focused and is designed around addressing barriers to employment. Those with long-term mental health needs are referred to a Medicaid provider.

4. Expansion of Existing Mental Health Services

Two of the study states, Florida and Utah, have used TANF funds to expand community mental services. Florida contracts with a wide variety of community providers to provide the full range of mental health services to TANF recipients, including individual and group counseling, marital therapy, intensive case management, substance abuse treatment, and numerous other nonmedical treatment options. These services are also available to those at risk for TANF involvement. Florida is the only state that provides funding to existing providers to provide long-term therapy for TANF clients. Utah uses a more targeted approach to expanding the services available to TANF recipients. Generally, clients who need extensive mental health treatment are referred to Medicaid-funded providers. However, if the wait for services at a Medicaid provider is longer than two weeks, or if the services needed are not available, the client can be referred to a mental health professional who is not funded through Medicaid. Contracting out mental health treatment also allows the program administrator to determine the treatment model or approach used by the contractor, which they cannot do with a Medicaid-funded service provider.

5. Training/Consulting for Employment Case Managers

Except in Florida, mental health counselors in the study states provide consultation and training for employment case managers in how to identify and manage clients with mental health conditions. The types of consultation vary by local office, but mainly include the following:

• In-Service Training. Mental health counselors in some offices provide in-service training to new and experienced workers in how to identify clients with mental health conditions and in how to handle difficult behaviors.
• Case Staffings. Mental health counselors are often included in case staffings for clients who are about to be sanctioned or who are nearing the end of their time limit. Employment case managers with whom we talked indicated that they often rely on the expertise of the mental health counselors to make recommendations for how to handle cases and to identify resources in the community to which a client may be referred.
• Recommendations for Employment Plans. Mental health counselors frequently provide initial and ongoing recommendations to employment case managers about the types and volume of activities to include in clients' employment plans. Recommendations are based on client assessments completed by mental health counselors.
• Individual Consultation with Employment Case Managers on Difficult Cases. Employment case managers often consult with a mental health counselor when faced with a difficult case, such as a client with a personality disorder. Mental health counselors tell case managers about certain behaviors they can expect to see with certain conditions and about ways to handle these behaviors.

6. Intensive Case Management

Mental health counselors or other mental health staff may also provide more intensive case management that includes working with clients to develop basic life skills such as managing their time, setting goals, and budgeting their money. It may also include linking clients to other types of services in the community (e.g., substance abuse treatment, domestic violence service, homeless shelters, food pantries, etc.). In Clarksville, Tennessee, and St. George, Utah, master's level mental health clinicians are paired with bachelor's level workers to provide intensive case management and mental health services. In these arrangements, the bachelor's level workers primarily provide the intensive case management, leaving the clinicians more time to conduct assessments and provide short-term treatment. Western Palm Beach County Mental Health Clinic, a contracted mental health service provider in Belle Glade, Florida, hired one intensive case manager exclusively for welfare recipients.

7. Assistance in Applying for SSI (Supplemental Security Income)

Mental health staff may also provide assistance in applying for SSI (Supplemental Security Income) to clients with a diagnosed mental health condition that prevents them from working. In Utah, social workers coordinate psychological evaluations and walk clients through the often long and difficult application process. Assistance in applying for SSI is also extended to TANF recipients in Tennessee and parts of Oregon. Providing this kind of service requires mental health staff to act as advocates for clients and to be informed about the policies and procedures for accessing SSI. In general, mental health counselors estimate that 5 to 10 percent of the clients who are referred to mental health services may be eligible for SSI.

[ Go to Contents ]

THE POPULATION TARGETED FOR SERVICES

The population targeted for TANF-funded mental health services differs by state, reflecting, for the most part, whether program administrators chose to provide services only to TANF recipients, to those considered "at risk" for TANF involvement, and/or to those who once received TANF services. Program administrators also considered whether to serve only adults on TANF or to extend mental health services to children. These decisions about the target population influence not only who might be eligible for mental health services, but also how many individuals might be eligible.

1. Adults on TANF

All of the study states provide mental health services to adult TANF recipients. However, Oregon was the only state to provide mental health services only to adults receiving TANF. The other states expanded eligibility by continuing mental health services for some period after the TANF case closed by providing services to children in the household or by defining eligibility using income criteria rather than TANF receipt. The decision to restrict eligibility to adults on TANF reflects primarily resource constraints, but it also reflects the goals of the program. In Oregon, the primary goal is to identify clients in need of services and link them with resources in the community. The hope is that by the time clients leave assistance, they will be solidly connected with mental health providers who can provide ongoing services that are not tied to their TANF eligibility. In addition, providing mental health services to the head-of-household on TANF reflects Oregon's belief in the importance of helping the primary breadwinner become employed. In Multnomah County (which includes Portland), mental health staff already carried high caseloads. Families outside of TANF could only have been served at the expense of TANF recipients or by allocating additional funds to the program.

2. Adults Transitioning off TANF

The transition from welfare to work creates a new set of challenges for nearly all families. For adults with a mental health condition, the transition can be even more challenging. To provide parents with extra support if they need it, Tennessee and Utah extend eligibility for mental health services to TANF recipients for a year after their TANF case closes. Because Tennessee and Utah also provide short-term mental health counseling services directly to TANF recipients, it is possible that many of these individuals would not be receiving services from other mental heath providers, making it especially important to continue to deliver services through the TANF program to clients leaving TANF. Providing support to families during the transition to work could help to improve job retention.

3. Children in TANF Households

According to the U.S. Department of Health and Human Services (2000a), at least one in five children and adolescents age 9 through 17 has a diagnosable mental health disorder in a given year. Mental disorders among children can lead to failure in school, alcohol or drug use, violence, and suicide. Furthermore, the responsibilities and emotional stress associated with managing a child with a mental health condition can limit a parent's employability.

Two of the study states, Tennessee and Florida, extend eligibility for mental health services to children living in a TANF household regardless of whether the household head is receiving mental health services. The decision to provide mental health services more broadly to children of TANF families requires program administrators to think differently about the types of services offered. For instance, the mental health needs of children differ from those of adults, so an entirely different set of treatment options must be offered. This approach may be more costly than restricting services to adults on TANF, but it addresses the needs of the entire family.

Another advantage of extending mental health services to children is that it may actually encourage parents who need treatment to participate in treatment. Mental health counselors indicated that parents may feel more comfortable accessing treatment for their children than for themselves and that being exposed to and involved in treatment through their children frequently decreases parents' anxiety about their own participation in mental health treatment.

4. Low-Income Families

Florida has taken full advantage of the flexibility to use TANF funds to serve families who may not be receiving cash assistance. For instance, TANF recipients and their children, former TANF recipients, households with a child-only TANF case, and non-TANF families that meet income and eligibility guidelines are eligible to receive TANF-funded mental health services. Non-TANF families include (1) a parent, caretaker, relative, or child in a family with an income less than 200 percent of the federal poverty level, (2) families receiving services in the Family Safety system (Florida's child welfare agency), (3) noncustodial parents where there is a court-ordered child support requirement and both custodial and non-custodial parents earn less than 200 percent of the federal poverty level and live in Florida, and (4) individuals receiving SSI or Social Security Disability Insurance (SSDI). Because many families move on and off of TANF, this "preventive" approach may reduce the number of families who receive cash assistance by helping parents stay employed. In addition, providing mental health services more broadly improves access to mental health services for sanctioned families, those who have reached their time limit, and families at-risk for TANF involvement.

[ Go to Contents ]

DEFINING THE RANGE OF NEEDS TO BE ADDRESSED

Several researchers have found that a substantial proportion of welfare recipients have multiple barriers to employment and that the presence of multiple barriers decreases the probability of finding and keeping a job (Danziger et al. 1999, Zedlewski 1999, Olson and Pavetti 1996). Thus, an important decision in designing a system to address the mental health needs of welfare recipients is whether to address mental health issues separately or in combination with other personal and family challenges. The advantage of the latter approach is that it could address other issues that may be preventing clients from finding employment. However, it is likely to be difficult to find staff who are expert in assessment and treatment in multiple areas.

Decisions about how broadly to address service needs influence the kind of staff hired, how clients are identified for services, and the types of services provided. Among the study states, there are three different models, or approaches, to defining the range of needs to be addressed: (1) primary focus on mental health conditions, (2) primary focus on mental health and substance abuse issues, and (3) broad focus on a variety of personal and family challenges. This section describes each model and its associated strengths and weaknesses.

1. Primary Focus on Mental Health

Programs designed to address mental health needs exclusively tend to provide intensive, comprehensive mental health services through experienced clinical staff. Utah's program focuses primarily on identifying mental health conditions and providing the services to address those conditions. Mental health staff may address other conditions (e.g., substance abuse, domestic violence, and child behavioral problems) as they arise, but staff mostly refer clients to agencies in the community to deal with other types of service needs. The advantage of this approach is that employment and mental health staff can focus exclusively on identifying and treating mental health conditions. In addition, staff in these programs typically have extensive experience in providing mental health treatment. They have a solid understanding of the mental health system and ways to access mental health treatment. The downside of this approach is that mental health staff may be so specialized that other conditions that may affect work go undetected and untreated.

2. Primary Focus on Mental Health and Substance Abuse

In general, there are high rates of co-occurrence between substance abuse and mental health conditions. A study conducted by Reis (1995) estimates that more than half of those with a mental health disorder also have problems with substance abuse. Individuals with co-occurring conditions often have treatment needs that addresses both substance abuse and mental health issues. Unfortunately, there is a shortage in most communities of treatment that addresses both conditions (U.S. Department of Health and Human Services 1999).

Oregon and Florida focus on both mental health and substance abuse needs. In Oregon, the staffing is structured in one of two ways. In some areas, one worker handles both substance abuse and mental health conditions. For example, in Astoria, the specialist has a Ph.D. in clinical psychology and is a certified substance abuse treatment provider. In other areas of the state, specialists in either function work as a team. In Multnomah County, for instance, individuals hired as either mental health or substance abuse specialists meet weekly to staff cases and coordinate the mental health and substance abuse treatment of clients.⁽⁷⁾

Given the prevalence of co-occurring substance abuse and mental health conditions, the service model addressing both may be especially effective. The primary challenge in implementing this model is to find staff who are clinically proficient in both areas. Typically, it is easier to find individuals with training in one area or the other. In most communities, hiring staff who perform separate functions is easier than hiring staff with combined expertise. However, in some areas, particularly in rural locations, there are not enough clients to justify the need for two specialists. For instance, the Florida state Mental Health and Substance Abuse Program Offices contract with mental health and substance abuse agencies to provide services, relying on outreach workers to link clients to these services.

3. Broad Focus on a Variety of Personal and Family Challenges

Tennessee is the only state in this study that provides mental health services as one of several services targeted to hard-to-employ welfare recipients. Family services counselors in Tennessee address mental health, substance abuse, domestic violence, learning disabilities, and child behavioral conditions in welfare recipients. According to program administrators, identifying learning disabilities and providing services to address them has been the most difficult challenge for family services counselors.

Program administrators in Tennessee attempt to hire staff with expertise in at least two of the five service areas. In addition, the program director coordinates extensive training in how to identify the various mental health needs and in the types of services available in the community for addressing them. The advantage to this "holistic" approach to service provision may be an increase in the employability of TANF clients to the extent that none of the conditions interfering with employment goes unaddressed. The primary challenge in using this approach is finding staff with expertise in most of the service areas.

[ Go to Contents ]

IDENTIFYING CLIENTS IN NEED OF ASSISTANCE

One of the first steps in providing mental health services is identifying clients who would benefit from the services and who are willing to participate in mental health treatment. Not only do programs vary in how clients are identified for mental health services, local offices within the same program frequently vary in their approach to identifying clients. Overall, there is no evidence to suggest that one approach is better than another for identifying clients in need of mental health services. Using multiple approaches in combination appears to be the most effective strategy and the one used by most local offices. Some of the primary ways that clients are identified for or informed about mental health services are discussed below.

1. Broad Screenings for Mental Health Needs and Informing Clients about Services

Broad screenings during client orientation to employment services and job club workshops are one way in which clients are informed about and identified for mental health services. In some local offices, mental health staff administer screening tools to all welfare recipients during orientation to identify those at risk for mental health conditions. Welfare recipients in Miami, Florida, who receive employment services from the AWI (Agency for Workforce Innovation) Hialeah One-Stop Center, are screened by a bachelor's level outreach worker. A licensed clinical social worker in the St. John's welfare office in Portland, Oregon, talks with new welfare recipients during orientation and administers a depression scale and a general mental health screening.

A local welfare office in Astoria, Oregon, which has a unique approach to screening, identifies clients as candidates for mental health services during the initial intake. For instance, when clients first apply for cash assistance, they meet with the lead staff person, who has more than 20 years of experience as a welfare case manager. This lead staff person screens for TANF eligibility, informs clients about mental health services, and conducts a brief assessment to identify clients who may have a mental health condition. This type of approach may be more realistic in rural areas, where the caseloads are relatively small and staff are familiar with the families who receive cash assistance.

The advantage of broadly screening welfare recipients in the welfare office ensures that clients are identified and linked to services. The drawback of broad screening is that clients who may not need mental health services or who are not willing to participate in treatment are referred to mental health staff, which may overload mental health staff.

Clients also are informed about mental health services during formal presentations given during individual or group orientations, or during other meetings in the welfare office. Clients may then self-refer to mental health services. In Tennessee and Utah, mental health services are described to new and returning clients as part of their standard orientation. Clients receiving employment services in the Caleb One-Stop Center in Miami, Florida, learn about mental health services during the job club workshop. Clients may refer themselves to the program based on the information they obtain during the presentations.

Formal presentations ensure not only that clients are informed about mental health services, but also that they receive the same information about the services. Furthermore, it brings clients and mental health staff together, creating a direct link to services, rather than relying on a referral from employment staff. One challenge is obtaining permission from local welfare administrators to participate in client TANF orientation or during job search workshops to talk about mental health services.

2. Referrals by Employment Case Managers

Most programs rely heavily on employment case managers to identify clients in need of assistance and to refer them to mental health services. Employment case managers may be trained to identify mental health conditions as part of their own orientation when they are hired, during in-service meetings or case staffings, or individually by mental health counselors.

According to employment case managers, clients vary in how and when they disclose a mental health condition, but whether they even do so depends on the level of trust between the case manager and the client. This principle of trust is also critical to getting a client into treatment insofar as it also operates in the relationship between the employment case manager and the mental health counselor. Case managers report that they are more likely to make a referral if they trust the mental health counselors and believe the services they provide will benefit the client. In some local offices, a few case managers referred a large proportion of clients to mental health services. In other offices, the number of referrals was more evenly represented across case managers.

To find out more about how clients needing assistance are identified, we asked employment case managers about which behaviors or characteristics acted as a red flag for a mental health condition. Employment case managers cited extreme displays of emotion (such as anger or crying), no emotion at all (flat demeanor), lack of concentration or focus, unkempt appearance, children with behavioral problems, lack of participation or reluctance to participate in program activities, recent eviction from public housing, and making decisions not based on current conditions or with an eye toward the future. In general, most of the employment case managers we interviewed were able to describe some client behaviors and characteristics that signaled a mental health condition.

The advantage of relying on employment case managers to make the referral is that they have the most contact with clients and can therefore more accurately identify those who may have mental health needs. The drawback is that some employment case managers may be uncomfortable talking about mental health issues with clients and so may not refer clients to mental health services. For this reason, it is important to use a variety of approaches to link clients to mental health services.

3. Automatic Referrals to Mental Health Services

In some states, certain subgroups of the TANF population are automatically referred to mental health services. These subgroups include families who have been sanctioned for noncompliance in work activities, families nearing the end of their time limit on cash assistance, and clients with a potential drug or alcohol addiction. In Tennessee, sanctioned families are referred to the Family Services Counseling program. In Utah, licensed clinical social workers participate in extension hearings for families nearing their time limit. In addition, welfare recipients in Utah who respond "yes" to two or more questions on the four-question CAGE⁽⁸⁾ substance abuse screening questionnaire are automatically referred to mental health services by the employment case manager.

The advantage of automatic referrals to mental health services is that clients most in need of these services are likely to get them. That is, the automatic referrals apply to people who are sanctioned or who are reaching their time limit but have not found employment, and we would assume that these clients are in this position because they face more severe barriers to employment, one of which could be a mental health condition. The challenge for the system is getting these clients to participate in mental health services. Some of the same barriers that prevented them from working or from participating in their employment plan may also be obstacles to participating in mental health treatment.

4. Community Outreach

The welfare/employment services local offices are not the only avenue through which clients are informed about mental health services. Some programs use extensive community outreach campaigns as well. Fliers, pamphlets, and formal and informal presentations are part of this "social marketing" effort. Florida and Tennessee's outreach efforts are noteworthy.

In Florida, outreach workers are the link between welfare clients and the mental health service delivery system. These individuals, who have at least a bachelor's degree, are employed by the contracted mental health and substance abuse treatment providers who screen clients and link them to services within their agency or with another contracted service provider. Outreach workers regularly visit community service providers (such as health clinics, day-care centers, food stamp offices, homeless shelters, and other agencies), leaving brochures about the program and talking with staff at these organizations. Outreach workers may be co-located in the welfare office or in other agencies, such as the local Head Start program and the health clinic.

In Tennessee, the program director, district coordinators, and welfare administrators have developed an intense and widespread social marketing effort. Tennessee's social marketing effort mostly consists of presentations and training sessions for welfare staff and other community partners, such as vocational rehabilitation, and education and training providers. The purpose of these efforts is to educate employment case managers and other agency workers who serve TANF recipients about the mission, goals, and successes of the Family Services Counseling program. According to the program director, the intense social marketing campaign not only informs people about the services, but also creates a sense of pride and enthusiasm among program staff members about providing these services.

The advantages of community outreach are that it informs service providers outside of the welfare office about mental health services and helps to cultivate collaborative relationships between agencies. For states that base eligibility for mental health services on income as well as TANF receipt, community outreach helps to identify low-income families who are at risk for TANF involvement. The drawback to this approach is that it is time-consuming and resource-intensive.

Endnotes

6.  How broadly clients are screened varies by local office.

7.  One specialist has combined mental health and substance abuse responsibilities.

8.  The name of the CAGE test comes from an acronym of first letters from questions used in the instrument. For example, the first letter "C" comes from the question, "have you ever felt the need to Cut down on your using/doing?"