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Even with a strong program design and a well-developed administrative structure, implementing programs to address the mental health needs of welfare recipients presents ongoing challenges. In this chapter, we examine some of these key implementation challenges and present the innovative strategies used by the study sites to meet these challenges. The chapter covers (1) strategies to encourage employment case managers to refer clients to mental health services, (2) strategies to encourage clients to participate in mental health services, (3) ways to integrate mental health services into work activities, (4) options for creating a support network for mental health staff, and (5) approaches to monitoring and tracking client participation in mental health services. We conclude with a discussion of implementation issues that are specific to rural areas.
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Addressing the mental health needs of welfare recipients represents a dramatic shift in the focus of welfare programs. Before welfare reform, there was little emphasis on encouraging welfare recipients to find employment and even less on helping individuals resolve personal and family challenges that may form obstacles to work. While some welfare staff have adapted easily to the new emphasis on work and mental health, using all of the resources at their disposal, others not yet comfortable delving into recipients' personal lives may not see the value of programs designed to address the mental health needs of their clients. In addition, some staff may be overwhelmed by their broad range of responsibilities unrelated to client mental health needs, while still others with high caseloads may be able to accomplish only tasks that require immediate attention.
Given that the system is still in flux, the study sites, acknowledging that referrals from welfare staff are critical to the success of their programs, make a concerted effort to educate welfare staff about the availability and usefulness of mental health services. The most common strategies for encouraging referrals include the following:
Training workers to identify a mental health condition. For employment case managers to refer clients to mental health services, they must be able to identify clients who may have mental health conditions that prevent or restrict employability. Mental health staff frequently work with employment case managers individually and in groups to teach them how to recognize some of the behaviors or characteristics that may signal the need for mental health services.
Developing a simple referral process or a "clear pathway" for linking clients to mental health services. Most of the study sites have developed a simple and quick process for referring clients to mental health services. Typically, employment case managers submit a short form to the mental health counselor to refer clients to treatment. Some mental health staff have used flow charts to illustrate for employment case managers the process for referring clients to mental health services.
Keeping caseloads manageable. The size of an employment case manager's caseload often influences the relationship between the case manager and client, which may affect the number of referrals to mental health services. According to some case managers, clients are more likely to disclose mental health conditions once they have developed trust in the case manager, which is more likely to happen when a caseload is small and the manager has more time for each client. A manageable caseload also allows the employment case manager to follow up with clients who are referred to mental health services.
Stationing mental health and welfare staff closer together. In general, the more accessible mental health staff and service providers are to welfare staff, the greater the likelihood of referrals. According to program staff at all levels, co-locating mental health staff in welfare offices and employment centers (one-stop centers) is the most efficient way to make mental health workers accessible to welfare staff. The physical proximity encourages more contact, more communication, and, hence, more trust on the part of welfare staff in mental health staff. Because of this trust, welfare staff feel more comfortable about, and are therefore more inclined to, refer their clients to mental health services. Mental health staff members who are not co-located in the welfare office may find other ways to develop relationships with the employment case managers. In St. George, Utah, where the social worker is not co-located in the employment center that serves welfare recipients, the social worker regularly attends staff meetings, participates in agency functions, and finds ways to interact with agency staff on an individual and ongoing basis.
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Even the most well-designed mental health services are successful only insofar as clients participate in them — initally and on an ongoing basis. For program staff, the challenge is therefore to encourage participation. In most of the study sites, participation in mental health services is voluntary, but it becomes mandatory if the client includes it as an activity in his/her employment plan. Family services counselors in Tennessee estimate that the initial no-show rate for clients referred to their agency is about 50 percent but that more clients participate over time. Statewide, two-thirds of clients who have been referred to the program have completed the initial assessment. Other states reported similar participation rates. Client participation rates in mental health services vary by local office and often are influenced by such factors as how quickly clients are linked to services, the accessibility of services, stigma associated with participation in mental health treatment, and the relationships between clients and employment and mental health staff. The following are some of the strategies that successfully increased client participation in mental health services in the study sites:
Addressing the stigma associated with mental health treatment. The stigma associated with mental illness and treatment may deter some employment case managers from talking with clients about mental health services and referring them to the program. The stigma may also make clients less willing to participate in mental health services. To address the stigma and thus encourage greater participation in mental health services, the study sites sought ways to educate clients and case managers about mental health conditions and services.
Mental health staff in some sites talk candidly with clients and employment case managers about mental health conditions. For instance, mental health counselors in the St. John's and Albina welfare offices in Portland, Oregon, talk with clients for typically 90 minutes during orientation about the signs of a mental health condition, how mental health problems may affect their behavior, and ways to treat mental health conditions (such as exercise, medication, mental health therapy, etc.). Social workers in Utah provide in-service training to case managers and discuss mental health treatment with individual managers to make them more knowledgeable about and comfortable with mental health services. Partly to "de-mystify" the treatment process, mental health staff in Florida replaced words such as "treatment" with "life-management help."
Offering flexibility in service location. Tennessee and some welfare offices in Utah are flexible in where they conduct client assessments and provide short-term mental health treatment. Services are provided at the welfare office, in the client's home, at a community-based agency, or at any other location convenient to the client. According to mental health staff in these states, providing services in the welfare office or at locations other than the local mental health agency makes clients less apprehensive about participating and improves access to treatment, especially in rural areas.
Providing supportive services such as transportation and child care while delivering mental health treatment. All of the study states provide child care and transportation assistance for clients participating in mental health services when those services are included as an activity in employment plans. Without supportive services, some clients may not be able to take advantage of the mental health services available to them.
Modifying existing policies or creating new ones to ensure that they support clients participating in mental health services. Flexibility in TANF work requirements (volume and types of activities) appears to encourage both employment counselors to include mental health treatment in an employment plan and clients to participate in mental health services. In Florida, where no more than five hours of mental health services per week can count toward the work requirement, few employment case managers include mental health services in employment plans. The other study states (Oregon, Tennessee, and Utah) do not restrict the number of hours or types of mental health services that count toward the work requirement. Instead, this decision is left to the employment case manager or mental health counselor. These mental health counselors suggested that the modified employment plan encourages clients to participate in mental health services.
Another policy that may influence participation in mental health treatment is extending or temporarily suspending time limits for families in treatment. Utah extends the time limit for families facing severe personal and family challenges who are participating in mental health treatment. In Tennessee, the month of assessment does not count toward the time limit, and families with severe mental health conditions may request an "interruption," or a temporary stop in the "clock" ticking toward the time limit. Currently, about half of the clients participating in mental health treatment have been granted such interruptions.
In most states, clients who include mental health services in their employment plan are subject to grant sanctions if they do not participate in mental health program activities. However, sanctions are not used to force clients to participate in mental health treatment against their will. In general, participation in mental health services is voluntary, and clients may also choose to include treatment in their employment plan.
Providing services that consider and address cultural differences. An ongoing challenge for program managers and mental health staff is to provide mental health services that are sensitive to cultural and language differences. Mental health staff in the study states identified three primary ways in which cultural and language differences may influence mental health service delivery. First, if ethnic and racial differences are not considered by counselors, they may act as a wedge in the relationship between the client and mental health counselor, eroding the trust that is central to this relationship. In the absence of this trust, the effectiveness of mental health services may be reduced. Second, bilingual children are sometimes expected to serve as translators between the mental health counselor and a parent or parents. Children cast in this role are exposed to life stressors and personal details of the parents' lives otherwise "reserved for" adults. The result, according to mental health staff, may be an emotionally unhealthy environment for the children. Third, cultural differences in how mental illness and mental health treatment are perceived can influence the level of comfort in participating in mental health services and therefore the decision to participate at all.
Some of the study sites have attempted to address these cultural and language differences. For example, in Belle Glade, Florida, paraprofessionals from the community are paired with licensed mental health counselors to facilitate the relationship between the client and mental health counselor. For instance, bilingual paraprofessionals may translate in counseling sessions, build relationships with clients in the community, and link clients to mental health services. In Miami, program administrators at contracting agencies have hired mental health outreach workers and counselors who are racially and ethnically similar to communities in which they work.
Protecting client confidentiality. According to mental health staff, protecting the confidentiality of clients creates a trusting relationship, which encourages client to participate in mental health services. Mental health counselors take several precautions to protect the confidentiality of clients. In general, mental health counselors begin the process of working with clients by clearly explaining the steps they take to protect the confidentiality of clients' information. Counselors then ask clients to sign release-of-information forms allowing the exchange of information between mental health counselors and other agencies. In some areas, mental health counselors store all client records in a locked filing cabinet.
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One of the distinguishing features about programs designed to address the mental health needs of welfare recipients is the strong emphasis on employment. In all of the study sites, mental health program workers reiterated that the goal of mental health services is to help the client move from welfare to work. Some of the ways states integrate work into mental health services include the following.
Counting participation in mental health services toward the TANF work requirement. All of the study states allow mental health services to be counted as a work activity in the client's employment plan. This policy not only creates an incentive for clients to participate in treatment but also encourages employment and mental health staff to work together in helping the client progress toward self-sufficiency.
States vary in who can modify employment plans. In Tennessee, the mental health counselor is the only person who can modify the client's employment plan, whereas in Utah and Oregon, mental health counselors make recommendations about the types and amount of activities, but the employment case manager makes the final decision. In most cases, the employment case manager accepts the recommendations of the mental health staff. When mental health is written into the employment plan, the employment case manager is also responsible for ensuring that the client participates in treatment.
Educating treatment providers about work and participation requirements. At many of the study sites, mental health staff help mental health treatment providers understand the TANF requirements for receiving cash assistance, such as work requirements, time limits, sanctions, etc. In Multnomah County, Oregon, mental health counselors specifically said that educating treatment providers about TANF requirements is one of their job responsibilities. This educational experience not only strengthens the relationship between mental health and employment staff but also brings dual-system support to the effort to move welfare recipients into jobs by building the treatment providers' understanding of the circumstances of welfare recipients and the demands placed on them to become employed.
Allowing Mental Health Activities in Client Employment PlansPRWORA requires states to meet increasingly higher work participation rates and specifies which work-related and mental health activities can count toward that requirement. However, because of substantial caseload declines, states actually have considerable flexibility in defining the types of mental health activities that can count toward the work requirement. In fiscal year 1999, states were required to have 35 percent of all families participating in work activities, less any caseload reduction credit. On the basis of caseload declines, 23 states were not required to have families participating in work activities, and only 2 states were required to have 20 percent or more of their TANF caseload participating in work activities (U.S. Department of Health and Human Services 2000). This loosening of the work requirement has allowed states to approve participation in activities such as mental health counseling or to temporarily defer clients from participation in work activities while they address issues that may be interfering with their ability to find or maintain employment. The biggest challenge states are likely to face in permitting mental health activities to be included in employment plans is overcoming the belief by policymakers that participation in mental health counseling or other similar activities may weaken the emphasis on work. This need not be the case if these activities are provided with an eye toward helping clients find and maintain employment. Oregon and Utah are two states that have broadly defined the activities that can be included in a client’s self-sufficiency plan, and neither their participation rates nor their program emphasis has been negatively affected. |
Using a short-term, employment-focused and/or solution-focused mental health treatment model. Some states, such as Tennessee and Utah, have encouraged mental health counselors and treatment providers to use a short-term, employment-focused mental health treatment model for working with TANF clients. In fact, family services counselors in Tennessee have been trained to use a short-term, solution-focused mental health treatment approach. District coordinators in the state review case files at random to ensure that mental health counselors use this approach. Similarly, mental health counselors in Utah work closely with contracted mental health treatment providers to ensure that treatment is short-term and employment-focused. Mental health counselors in Tennessee and Utah indicated, however, that some clients require a different approach However, in general, mental health staff believe that the short-term, solution-focused method is effective for welfare recipients with less severe mental health conditions.
Providing employment services in mental health treatment facilities. In Florida, where mental health treatment is provided by using TANF funds, some of the mental health treatment facilities have developed employment-focused activities exclusively for welfare recipients referred to them. For example, Western Palm Beach County Mental Health, a contracted treatment provider in Belle Glade, developed a job-seekers club, in which TANF recipients receiving mental health services meet to talk about life skills such as prioritizing, balancing work and family responsibilities, and child rearing.
Developing a plan to transition clients from mental health treatment to work. Mental health staff at most of the sites work closely with employment case managers to monitor client progress in treatment and to recommend ways for gradually increasing work activities. Recommendations may be given during case staffings or during informal conversations between employment case managers and mental health staff.
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In general, mental health counselors working with welfare recipients have a difficult job. The people they see have experienced severe trauma such as childhood abuse, domestic violence, rape, homelessness, and other personal tragedies. The ability to deal with these complex life circumstances requires not only intense clinical and/or problem-solving skills but also a knowledge about the other mental health resources available in the community. Many mental health counselors working with welfare recipients may not have an obvious link to a professional support network, especially in rural locations, where professional support networks may be limited.
Mental health staff in some of the study sites have developed professional support networks to help solve difficult cases and to establish a source of ongoing training and consultation. For example, in Multnomah County, the program coordinator convenes weekly meetings with mental health and substance abuse specialists to discuss agency business and to staff difficult cases. In addition, specialists consult each other or their supervisor when they need professional guidance or support. In Tennessee, the program director holds regular training sessions for mental health counselors and district coordinators. In addition, local contracted mental health agencies provide clinical support to counselors on their staff who are co-located in the welfare office. In Utah, social workers meet every month, alternating each month with statewide and half-state meetings, to staff difficult cases and to talk about ways to improve mental health services. The program director at the state level provides clinical support to the social workers.
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In most of the study sites, the goal of mental health services is to help clients manage mental health conditions that may be limiting their ability to find and retain a job. Typically, mental health services are included in the client's employment plan and count toward the TANF work activity requirement. The purpose of monitoring and tracking client participation in mental health services is to ensure both that clients are participating in mental health services when they are included in the employment plan and that they are progressing toward employment. Contracted mental health treatment providers tend to be more responsive than Medicaid providers in reporting client participation and progress to employment case managers in the welfare office. This may be the case because the contract reporting requirements stipulate that treatment providers provide employment and mental health staff with feedback about clients' involvement in mental health treatment.
Employment case managers and mental health staff typically work together to monitor and track client participation and progress in mental health services. However, in most of the study sites, the employment case manager is ultimately responsible for ensuring that the client is participating in mental health services. In Tennessee, family services counselors submit weekly participation reports to the employment case manager. The employment case manager sanctions clients who do not participate in mental health services if the services are included in an employment plan. In Salt Lake City, social workers provide a monthly report to employment counselors summarizing each client's level of employability, participation in mental health treatment, and recommendations for modifying the employment plan. In the Florida sites, contracted service providers reported directly to the state and to regional TANF substance abuse and mental health program administrators, since few clients included mental health services in their employment plans. In Oregon, responsibility for tracking and monitoring client participation often is left to the employment case manager, with some help from mental health staff.
According to agency staff in most of the study states, monitoring and tracking client participation and progress in mental health treatment has been a difficult challenge for the three reasons explained below.
To protect client confidentiality, mental health treatment providers are cautious about the kinds of information they share with employment case managers. For the most part, mental health treatment providers share information about clients with employment case managers whether or not the client is participating in mental health services. Some employment case managers said they would like more information about the employability of clients than many of the treatment providers give them. According to mental health staff in the welfare office, mental health treatment providers are more comfortable talking with them than with employment case managers about clients.
Finding Private Office Space to Protect Client ConfidentialityMost mental health staff have years of experience as counselors. They have been oriented to confidentiality issues as part of their professional training and their experience in providing mental health services. Overall, maintaining client confidentiality is handled professionally in all study sites. However, one confidentiality issue that did emerge was the availability of private office space to conduct assessments and therapy, particularly when mental health counselors are co-located in the welfare office. In some sites, mental health counselors have been able to negotiate for their own private office. In other sites, mental health counselors use private conference rooms to meet with clients. Given the sensitive nature of their interactions with clients, mental health counselors indicated that access to private office space is essential to successful, confidential service provision. |
Many of the mental health treatment providers, especially those funded through Medicaid, do not fully understand the work participation requirements associated with welfare receipt. In Utah, for example, mental health staff had difficulty obtaining feedback about clients from the Medicaid mental health treatment provider. After meeting with the Medicaid agency staff to explain TANF work requirements and to discuss ways to improve communication between the agencies, the process and frequency of feedback from the treatment providers improved.
In some areas, mental health treatment providers, especially Medicaid-funded providers, have high staff turnover and a limited number of staff, which makes it more difficult to provide feedback in a timely way. In some parts of Utah and Oregon, the staff turnover at the Medicaid-funded service agency made the monitoring and tracking of client participation more difficult. In recent years, for example, the number of Medicaid-funded mental health clients served by Valley Mental Health in Salt Lake County, Utah, has increased sharply, straining already limited resources. This has increased staff workload, which has contributed to high staff turnover.(16)
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Although urban and rural areas face many of the same challenges in addressing the mental health needs of welfare recipients, some aspects of service provision are easier in rural areas, while others are more difficult. In general, we observed four primary considerations when providing mental health services in rural areas.
Clients in rural areas compared with those in urban areas have less difficulty accessing mental health treatment in a timely manner, but they have more difficulty accessing certain types of treatment. In two of the study states, Oregon and Utah, clients in rural sites find it easier to access mental health treatment in a timely way than do clients in the urban sites. Clients seeking Medicaid-funded mental health treatment in urban areas have had to wait up to a month to see mental health therapists, which is substantially longer than the wait experienced by clients in the rural sites. However, in most of the rural sites, clients had more difficulty accessing certain types of treatment, such as psychiatric evaluations, residential treatment, and treatment for co-occurring mental health and substance abuse conditions.
In Tennessee, the proportion of referrals to mental health services is substantially higher in rural than in urban areas. According to researchers at UT, two-thirds of the referrals to the FSC program come from rural areas even though the number of inndividuals referred account for one-third of the state's welfare population. It is unclear why there is a difference in referrals between rural and urban areas. However, employment case managers in the rural areas suggested that they get to know the clients well and tend to have strong collaborative relationships in their own offices and with other agencies. The other study sites had less data than Tennessee on this issue.
Some mental health staff and clients are required to travel long distances to provide or to access services. Mental health staff in rural areas typically provide services in multiple welfare offices and over a large geographical area compared to staff in urban sites. For example, one social worker in Utah provides services to welfare recipients in five counties, which limits the accessibility of the social worker in each of the offices and reduces the time the social worker can meet with clients. Mental health staff in other rural communities have similar arrangements and face similar challenges. Furthermore, some clients living in remote areas have difficulty accessing mental health services and participating in mental health treatment because of the distances they are required to travel.
According to mental health staff, the stigma associated with mental illness and mental health treatment is particularly strong in rural areas. The stigma of participating in mental health services is frequently discussed among mental health counselors and clients in rural areas, where there is concern that neighbors and friends might "find out" that clients are receiving mental health services. Mental health counselors in rural areas also suggested that, in general, employment case managers and clients themselves are more biased about mental illness and more uncomfortable about participating in mental health treatment.
16. Valley Mental Health is the county's sole Medicaid-funded mental health treatment provider and is paid under a capitated managed care funding arrangement.
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