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A key challenge faced by program administrators is to create an administrative infrastructure through which appropriate mental health services are cost-effectively delivered to those in need. Such an infrastructure must draw on the strengths of the mental health resources in the local community and successfully integrate mental health services with employment services for welfare recipients. However, because TANF program administrators are not experts in the design and delivery of mental health services, it is usually necessary for them to rely on other agencies, organizations, or specialized staff for these functions. Cross-agency coordination is therefore critical to program success. In this section, we examine the key decisions made by the study states in their efforts to create a service delivery structure to address the mental health needs of TANF recipients. These decisions fall into four areas: (1) developing an administrative structure for the program, (2) defining staffing needs, (3) determining where services will be provided, and (4) allocating program funds.
Each study state developed a very different administrative structure for delivering mental health services to TANF recipients. In three of the study states — Oregon, Tennessee, and Utah — the TANF agency maintains primary oversight for the program, although the extent to which the TANF agency is actively involved in the delivery of services varies considerably. In Florida, the responsibility for program oversight was transferred to the agencies that deliver and/or monitor mental health and substance abuse services. These differences in administrative structure reflect differences in the structure through which employment services are provided to TANF recipients as well as differences in the scope of mental health services provided.
Utah is the only study state in which mental health services for TANF recipients are provided primarily in-house through the TANF administrative agency. For over 10 years, licensed clinical social workers hired as welfare staff have been providing mental health treatment to welfare recipients in the welfare office. In 1996, Utah consolidated the six agencies that handled employment, job training, and welfare functions into the Department of Workforce Services (DWS). In 1998, a social work unit was formed within DWS to provide mental health services, and a uniform statewide set of policies, procedures, and reporting forms was developed. All mental health staff that serve welfare clients are DWS state employees. A state program manager administers and monitors the mental health services and acts as a liaison with welfare administrators to coordinate mental health services. Although most mental health services are provided by DWS staff, the state contracts with other mental health professionals to provide more extensive services when a Medicaid provider is not available to provide them in a timely manner.
The benefit of an in-house service delivery system is that program staff can be easily integrated into the agency's employment program, which may improve the communication between employment case managers and mental health staff and increase the number of referrals to mental health services. One of the drawbacks is that social workers can become professionally isolated within the local offices, making it difficult for them to obtain professional consultation from other mental health counselors. In Utah, the mental health program administrator in Salt Lake City provides supervision for all of the mental health workers. Social workers in rural areas communicate by E-mail and telephone when they need clinical consultation and support.
Oregon has a state-administered TANF system, but local (district) offices have considerable flexibility to decide how to structure and provide employment-related services to TANF recipients. A program analyst in the state TANF agency acts as the statewide coordinator for mental health services. 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. In the local offices, there is wide variation in the organization of mental health services. In two counties we visited, local program coordinators administer, monitor, and supervise the mental health and substance abuse services in their counties. Most counties have specialists in mental health and substance abuse treatment who have extensive experience and strong clinical training. Some offices have separate specialists for mental health and substance abuse treatment, while other offices have a specialist with expertise in both areas.
Most mental health services are staffed by contractors, and, in general, contracting arrangements are handled either by the Adult and Family Services (AFS)(9) 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 and Clatsop Behavioral Healthcare. In Multnomah County, the employment and training service providers, Mount Hood and Portland Community colleges, hire mental health specialists directly. Through a subcontract with local mental health treatment providers, these specialists work within the local welfare offices. Mental health treatment is provided by Medicaid providers. In general, the Medicaid-funded mental health agencies provide a range of outpatient mental health services, including assessment, case management, and individual and group therapy. In-patient treatment is limited to the urban areas, and treatment for co-occurring mental health and substance abuse conditions is limited throughout the state.
The advantage of this model is that local communities can develop an administrative structure that works best for them. In addition, it provides district offices with an opportunity to fully integrate their mental health services into their welfare employment services program.
Tennessee's Family Services Counseling (FSC) program is under the purview of the TANF agency. However, the TANF agency has a contract with the College of Social Work at the University of Tennessee (UT) to administer 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. FSC program staff are hired through both UT and local contracted service providers. The FSC program director and district coordinators are university employees. Within each district, the TANF agency contracts with local not-for-profit agencies to provide family services counselors and clinical supervision. In some of the communities, the local agencies had formed collaborative relationships prior to the FSC program. These relationships were instrumental in implementing the 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 FCS has been administering programs such as life skills training, parenting classes, employee assistance programs, and outpatient mental health treatment for over 120 years.
When clients need services, they are referred to the TennCare mental health providers in addition to FSC counselors. The types of providers vary across the state. For example, urban Hamilton County has a variety of treatment providers, including a residential and an outpatient substance abuse treatment center, while rural Montgomery County has only one mental health center and several not-for-profit agencies that provide primarily group treatment to low-income families.
The advantage of this model is that it allows the welfare office to delegate responsibility for administering and providing mental health services to mental health professionals while maintaining some oversight over the program. Contracting with UT and local providers has made it possible for Tennessee to develop a statewide program model while drawing on community resources to deliver services at the local level. In addition, since the program was developed under the auspices of the TANF agency, it has been well integrated with welfare employment services from the start. The co-location of the mental health program director in the state welfare office and the co-location of district coordinators and mental health counselors in local welfare offices have also helped to integrate services.
Florida is the only study state to transfer full responsibility for the operation of its mental health services program to an agency that has no direct ties to the welfare or the employment services system. The program is housed within the Department of Children and Families (DCF)(10) and operates under both the Mental Health and the Substance Abuse Program offices but collaborates on policy issues with the Office of Economic Self-Sufficiency.(11) A program director and three staff members in the state office administer the program. In each DCF district or region, at least one specialist oversees program activities in the local office. All program employees are hired as "other personnel services" (OPS) employees, which 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 in each local community. The terms of 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 many contractors. Contracted service providers include a range of organizations such as substance abuse and community mental health centers, residential treatment providers, faith-based organizations, and hospitals. The contracted service providers hire outreach workers, conduct clinical assessments, and provide mental health and substance abuse treatment.
The advantage of transferring administrative responsibility to a mental health agency is that the state can bring into play the agency's in-depth understanding of the local mental health system that the TANF agency does not have. The drawback is that it can be much harder to integrate mental health services into existing welfare employment services, and, indeed, Florida's system is the least integrated of the four study states. The integration of services is further complicated by the fact that the employment services system that serves TANF recipients is locally administered, making the employment expectations and service delivery structure different in every local office.
Communication and Collaboration between Agencies and WorkersA recurring theme in each study site is the importance of communication and collaboration among agency administrators and mental health and employment staff. Three strategies or factors appear to foster or improve communication and collaboration.
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The types of staff who provide mental health services are directly related to the types of mental health services provided to welfare recipients. The study states differ not only in the types of staff who provide mental health services but also in the roles and responsibilities of staff with similar job titles. For example, mental health counselors in Oregon primarily assess clients and link them to mental health treatment, whereas mental health counselors in Tennessee assess clients and provide short-term mental health treatment. Staff roles and responsibilities may also vary by local office within the same program. In addition, state regulations sometimes dictate the type of staff who can be hired. For example, only licensed clinical social workers can deliver certain mental health services, such as clinical assessments and mental health treatment. Based on the programs in this study, we have identified four types of staff who provide mental health services: outreach workers, mental health counselors/specialists, interns in a master's of social work (M.S.W.) program, and intensive case managers. Some of their responsibilities and the services they provide are described below.
In Florida, more than 100 outreach workers have been stationed throughout the state to screen TANF recipients and other low-income families and to link them with mental health and substance abuse treatment. Typically, outreach workers are bachelor's level staff with training in psychology, social work, or other social service-related fields. Outreach workers inform clients about the social services available to them and community agencies about social services offered.
The drawback to using outreach workers to screen TANF clients is that this creates an additional step in linking clients to services. In addition, the workers may not be professionally trained to handle intense traumatic experiences that may be disclosed to them by clients (such as having been raped, witnessing a murder, or physical or sexual abuse during adulthood or childhood). Outreach workers indicated that when they heard of these kinds of experiences, they quickly referred the clients to licensed mental health professionals.
Mental health counselors are mostly licensed clinical social workers (LCSWs), certified social workers(12) supervised by an LCSW, or other licensed mental health professionals (such as psychologists and marriage and family therapists). The credentials required by the state depend on the types of mental health services provided. For example, in Tennessee, which provides a wide range of services, mental health staff are required to have expertise in at least two of five areas (mental health, substance abuse, domestic violence, child behavior, or learning disabilities). In some areas of Oregon, staff are required to have expertise in both mental health and substance abuse.
In addition to their clinical training, mental health counselors in the study states have extensive experience in providing mental health treatment and a deep understanding of the mental health service delivery system. Both professional credentials and experience are a key consideration in the hiring decisions of program administrators. In most states, licensure is required to conduct in-depth psychosocial assessments and mental health therapy. Certified social workers may provide these services only under the supervision of an LCSW or other licensed mental health professional.
Social workers have a range of responsibilities associated with providing mental health services to welfare recipients. These responsibilities may include performing client assessments, providing or linking clients to mental health treatment, making recommendations for the volume and types of activities to include in an employment plan, consulting with employment case managers, and monitoring and tracking client participation in mental health treatment. Caseload sizes, which vary by site, are influenced by the types of services provided, number of TANF clients served in the local welfare office, and the length of time case managers hold on to a case.
The benefit of hiring licensed mental health professionals is that they are trained to deal with the challenging behaviors and mental health conditions often exhibited by TANF clients. Accessible to employment staff, they can also serve as resources for the client and employment case managers. The drawback is that qualified mental health professionals may be difficult to find and expensive to retain compared with bachelor's level staff.(13)
Utah is the only study state that uses M.S.W. student interns to provide mental health services to TANF recipients under the supervision of an LCSW. Interns are trained by the program manager and perform many of the same functions as the full-time social workers, such as performing clinical assessments, consulting with employment case managers, attending staffings, referring and monitoring treatment, and conducting short-term therapy. The advantage of using interns is that they are a less costly way to expand staff capacity. The challenge, at times, is providing the supervision and mentoring support that interns require.
Intensive case managers, also known as specialized case managers, may be employment case managers with a reduced TANF caseload of hard-to-employ clients or bachelor's level mental health staff who work with LCSWs to link clients to services. Intensive case managers in Utah's welfare-to-work-funded GROW(14) program teach clients basic living and problem-solving skills, link clients to mental health and other services, and monitor and track client participation in mental health services. In Clarksville, Tennessee, a bachelor's-level intensive case manager assists the LCSW by coordinating services, and by monitoring and tracking client participation in mental health and other activities. Western Palm Beach County Mental Health in Belle Glade, Florida, hired an intensive case manager to assist clients receiving mental health services with housing referrals, immigration paperwork, and SSI applications and to teach clients about job search activities and resume-writing skills.
The advantage of intensive case managers is that they can provide some of the linking and monitoring responsibilities performed by the mental health counselor, allowing the mental health counselor to focus on client assessments and mental health treatment. The drawback is that, at times, limited funding restricts the amount of social work staff that can be hired to provide mental health services. Typically, intensive case managers are used to augment, rather than to replace, clinical workers.
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Where mental health services are provided influences how and the extent to which clients are connected with mental health services. We observed several variations among sites with regard to where mental health services are provided. Except for Tennessee, which co-locates all mental health counselors in the welfare office or with contracted employment service providers (e.g., a local housing project), most states vary by local office as to where services are provided. In some of the study sites, mental health workers co-located in the local office that serves welfare recipients provide services in that office. In other study sites, mental health workers are co-located and provide services in other agencies that serve low-income families (e.g., public health centers, Head Start offices, etc.). Contracted mental health counselors often work out of the agency where they are employed.
Most mental health workers, regardless of where they work, indicated that being co-located in the welfare office is the ideal arrangement for providing mental health services. Tennessee and some offices in Utah, Oregon, and Florida co-locate mental health staff in the local welfare office. Providing mental health services in the welfare office by co-locating mental health staff has several advantages:
The primary challenge in providing mental health services in the welfare office is finding enough office space in which mental health counselors can meet privately with clients.
In some local offices, mental health services are provided in the contracting agency's office by a mental health counselor. The screening and assessment services provided by the mental health counselor are paid for with TANF funds, but the treatment may be paid for either by TANF or Medicaid funds. In this arrangement, the employment case manager refers clients with mental health conditions to the contracted mental health service provider. Outreach workers in Florida and some mental health counselors in Oregon provide services out of the agency where they are employed.
One advantage of providing mental health services out of the contracted service provider's offices is that clients "look like" other nonwelfare individuals receiving mental health services, removing the stigma of being identified as welfare recipients and thereby making it more likely that they will stay in treatment. The drawback is that, unless clients are directly and quickly linked to mental health staff, they may not participate in mental health services, or they may miss appointments because of the inconvenience of traveling to a location apart from the welfare office, especially if they are ambivalent about participating in mental health services to begin with.
Mental health services are also provided at locations other than the welfare office or contracted service provider agency. In Florida, outreach workers co-located in community health clinics and local Head Start offices identify families that may benefit from mental health services. In St. George, Utah, where private office space is limited in the local employment center, mental health counselors provide services in a DWS administrative office three blocks from the local employment center welfare office. Services are typically provided at these other locations when it is not possible to co-locate mental health counselors in the welfare office.
One advantage to this approach is that it allows mental health staff to network with staff at other agencies. It also helps to identify clients who are at risk for welfare involvement who may otherwise be overlooked. For the social worker in the St. George welfare office, the advantage to being co-located at the administrative office is that she has access to private office space. The drawback to providing mental health services in other locations is that it may make it more difficult to link the employment case manager's clients to mental health services staff.
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The study states primarily used their TANF block grant and state MOE (Maintenance-of-Effort) funds to pay for mental health services. These funds are distributed in two ways. Under the first model, the state welfare agency or state legislative body allocates TANF or MOE funds specifically for the purpose of providing mental health services. In Florida, the state legislature allocated $45 million in TANF/MOE funds to provide mental health and substance abuse treatment to welfare recipients and low-income families at risk for TANF involvement. The state welfare office in Tennessee designated $8 million for mental health and other services for welfare recipients. Programs for which funds have been earmarked in this way appear to have a distinct program identity with a centralized program administrator and some uniformity in how the program operates.
Under the second model for funding mental health services, which is used in Oregon, the money is part of a pool of funds designated for services designed to help TANF recipients find employment. In Oregon, the decision about the amount of funds to allocate to mental health services is made primarily at the local level.
Both approaches to funding have strengths and limitations. The first model guarantees that a certain amount of resources will be used to provide mental health services. It also requires strong centralized leadership at the state level to develop a service delivery structure and process. This model can be limited insofar as it makes it more difficult to integrate mental health and employment services. So while a program with an independent funding arrangement has more autonomy, it also requires more effort to integrate mental health and welfare policies and service delivery. Under the second funding model, integration of mental health and employment services becomes easier, as mental health services exist as one of a range of options to help welfare recipients become employed. The drawback is that mental health services compete with other services for funding, making the availability of funds more tenuous.
In addition to TANF and MOE funds, states may use funds from the Welfare-to-Work grants program to provide mental health services.(15) Washington County (St. George), Utah, is 1 of 11 counties participating in a competitive Welfare-to-Work grant. Part of the funding for this grant has been used to hire additional social workers and intensive case managers to expand social work services in the southern area of the state. The advantage of Welfare-to-Work funds is that they offer program administrators another way to pay for mental health services. These funds can be used to pay for client assessments and mental health treatment, and for supportive services while clients receive treatment. The drawback is that the narrow eligibility criteria for welfare-to-work programs restrict the types of clients who may participate in mental health services paid for with these funds.
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9. AFS operates Oregon's welfare programs, which have a strong emphasis on employment and work supports.
10. DCF is responsible for the state's economic and self-sufficiency services, family safety system services, mental health and substance abuse services, and adult and developmental services.
11. The Office of Economic Self-Sufficiency is responsible for determining eligibility for TANF and other public assistance programs for low-income families.
12. Certified social workers have completed a master's degree in social work but do not have clinical licensure.
13. Salaries range from $30,000 to $35,000 per year for a licensed mental health counselor compared to between $18,000 and $23,000 for bachelor's level staff.
14. GROW stands for Gain immediate employment, Reach needed training, Opportunities for improved wages, and Work toward career goals.
15. Welfare-to-Work funds were authorized by the Department of Labor in 1998. Competitive and state formula Welfare-to-Work grants are no longer available.
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