Specialized Screening Approaches Can Substantially Increase the Identification of Substance Abuse Problems Among Welfare Recipients
By Jon Morgenstern1, Annette Riordan2, Dominick Dephilippis3, Thomas W. Irwin1, Kimberly A. Blanchard1, Barbara S. McCrady4, Katharine H. McVeigh4
1Mount Sinai School of Medicine2New Jersey Department of Human Services3National Council on Alcohol and Drug Dependence New Jersey, 4Rutgers University
As welfare caseloads decline, states increasingly are faced with the challenge of addressing the needs of hard-to-serve families who experience a variety of barriers to employability. Substance abuse is one of the major problems affecting hard-to-serve families. Since welfare reform was adopted, estimates suggest that 15% to 35% of welfare recipients have a substance abuse problem. Although substance abuse among welfare recipients is thought to be a prevalent and serious problem, it is widely recognized that individuals with substance use disorders often fail to acknowledge that they have a problem or seek treatment. Therefore, developing effective screening, identification, and referral strategies are necessary components of any state plan to address substance abuse among welfare recipients.
The purpose of this report is to describe results of two approaches to screening for substance abuse among TANF recipients in New Jersey (NJ). Results of this report suggest that a generic approach to screening in welfare settings one that relies primarily on caseworkers administering paper and pencil measures as part of benefit eligibility determination is useful, but that specialized screening programs can substantially increase case identification rates. This study employed a program evaluation rather than an experimental design. Specifically, the first approach was implemented and outcomes were monitored. Based on an evaluation of these findings, a second approach was designed and implemented in an attempt to boost case identification rates. The first approach was implemented statewide in NJ beginning in 1998. In this approach, welfare caseworkers administered a brief paper and pencil measure to screen for alcohol and other drug use problems to all individuals being interviewed for initial or redetermination of TANF benefits. Those screening positive were then referred to a specially trained addiction counselor for further assessment. This approach is similar to that used by most states (e.g., California, Kansas, New York) attempting to implement innovative programs to address substance abuse among welfare recipients. The key features of this typical approach are: front-line caseworkers conduct the screening, screening occurs for all recipients at the point of benefit determination, and there is a reliance on paper and pencil screening measures. We label this approach "generic screening."
The generic screening approach has yielded disappointing results. Only about 1% of the welfare caseload in NJ received a referral for substance abuse assessment during the first six months of program operation. Referral rates increased to 4.4% in the succeeding 12 months, but these rates are much lower than estimates of 20%-30% prevalence rates for substance abuse reported in a study of NJ welfare recipients (Klein et al., 1998). Other states using the generic approach have reported similarly low rates of identification (Health Systems Research, 1999; Nakashian & Moore, 2000).
The second approach is "specialized screening." Specialized screening is designed to augment, but not replace generic screening. There are three key features of specialized screening: high-risk populations (those among welfare recipients who are most likely to have a substance abuse problem) receive more intensive screening, screening is conducted by specially trained staff, and interview methods are used to establish rapport and facilitate self-disclosure.
Two specialized screening programs were implemented. In one program, all sanctioned clients in one NJ county were required to be assessed by an addictions counselor as part of the process of restoring benefit eligibility. Results indicated that 49% or about half of sanctioned clients who were interviewed met criteria for a substance use disorder. A second specialized screening program was implemented in the NJ county with the largest caseload. Two welfare caseworkers with a special interest in helping substance abusers were assigned to conduct specialized screening interviews. These caseworkers interviewed high-risk clients such as those requesting emergency assistance or clients responding positively to items on a paper and pencil screening measure. Results suggest that this specialized screening program was effective. The rate of referrals for substance abuse assessments in this county was 10.3% versus 4.4% for other NJ counties during the same time period. Thus, specialized screening appeared to more than double the rate of referral for assessment.
Overall, results of this report suggest that a generic approach to screening in welfare settings one that relies primarily on caseworkers administering paper and pencil measures as part of benefit eligibility determination is useful, but that specialized screening programs can substantially increase case identification rates. The finding that 49% of sanctioned clients interviewed met criteria for a substance use disorder is notable because it suggests that the prevalence of substance abuse among clients failing at work activities may be especially high. This study did not employ an experimental design. Thus, although findings are promising, causal inferences about the effectiveness of specialized screening approaches have not been established. Further details of the study are provided below.
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Studies suggest a high prevalence of substance abuse among women receiving public assistance, with some studies reporting rates as high as 27-39% (CSAT, 1996; Klein et al., 1997; Sisco & Pearson, 1994). Substance abuse among parenting women has long been identified as a major public health problem (e.g. Reed, 1985). However, as states implement welfare reform attempts to address this problem take on greater urgency. Substance abuse is an important barrier to employability. In a recent national survey, welfare administrators estimated that about 20% of recipients had a substance abuse problem and ranked substance abuse as third in importance out of seven challenges to employability (CASA, 1999).
Although substance abuse among welfare recipients is thought to be a prevalent and serious problem, it is widely recognized that individuals with substance use disorders often fail to acknowledge that they have a problem or seek treatment. For example, less than 3% of welfare recipients sought treatment in New York State in 1994, despite estimated prevalence rates for substance abuse problems of 15%-25% (Cohen, 1997). Similarly, a needs assessment of pregnant low-income women indicated that 39% screened positive for a substance use problem, yet less than 14% of these entered treatment (Klein et al., 1997). Therefore, developing effective screening, identification, and referral strategies are necessary components of any state plan to address substance abuse among welfare recipients.
Models have been developed to identify substance abuse problems in settings where there is a high prevalence of such problems. Screening and case identification methods developed in medical settings have proved successful and serve as models for efforts in other settings. Typically these methods involve administering a very brief screening questionnaire 4 to 10 questions - to patients presenting for medical care. Patients scoring above a predetermined threshold are then referred for a more complete evaluation.
This model of screening and case identification would appear to have good applicability in welfare settings. A number of screening measures have been developed to screen for alcohol and other drug use problems. Paper and pencil measures could be administered to welfare recipients at relatively low cost and those screening positive could be referred for further evaluation. A number of states (e.g., California, Kansas, New Jersey, New York) who are in the forefront of addressing substance abuse among welfare recipients have adopted this model. However, experiences during the last two years across states indicate this approach to identification has not yielded the expected result (e.g., Gardner, Young & Merrill, 1999). Only a small percent of TANF recipients are being identified through such methods or seeking substance abuse treatment on their own.
This report describes the experience in NJ of implementing, evaluating, and attempting to improve screening and identification of substance abuse among TANF recipients. The initial program, labeled "generic screening", is described and identification rates are reported. An evaluation was conducted to determine the factors associated with low referral rates. Evaluation results were used to develop a new approach. This approach, labeled "specialized screening", is described and outcomes are presented.
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As part of its welfare reform efforts, the state of NJ implemented an innovative program to address substance abuse among welfare recipients. One important element of this program was a new strategy to screen and identify substance abuse problems in welfare settings. Welfare caseworkers were required to administer a brief screening measure, the CAGE-AID (Brown, 1992), to all individuals applying for or seeking redetermination of TANF benefits. The CAGE-AID is a nine item measure designed to screen for alcohol and other drug use problems. Individuals responding positively to two or more questions were referred for further evaluation to a trained addictions counselor who was co-located at the local welfare office. Welfare caseworkers received training on measure administration and referral. An earlier well designed study of AFDC recipients in NJ estimated the prevalence rate of substance abuse problems at 20-30%. Thus, state planners anticipated that the screening program would lead to a high rate of identification and treatment referrals. We label the approach used statewide in NJ as "generic screening". Generic screening has three key features: front-line caseworkers with only minimal training conduct the screening; screening occurs for all recipients at the point of benefit determination; and the approach relies on paper and pencil measures, rather than interviews.
An examination of state records indicates that the generic approach did not yield the expected rates of identification and referrals. During the first six months of the program about 1% of TANF recipients received a referral for further evaluation. Figures for the last year (6/99-6/00) indicate that 4.4% of TANF recipients were identified and received a referral for further substance abuse evaluation. Our group conducted a brief evaluation to determine factors that might explain the low referral rates (Morgenstern, 1999). We found substantial differences between the structure of screening in medical settings the setting for which the screening tool was designed and that occurring in welfare settings. We found that using front-line caseworkers to screen might limit effectiveness because workers were not trained and saw the task as complex and demanding. In addition, we found a high level of reluctance on the part of welfare recipients to self-disclose a substance use problem indicating that reliance on paper and pencil measures was inadequate.
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We considered findings on generic screening in developing an alternative approach. We label this approach "specialized screening." There are three key elements of specialized screening. First, an interview format is used establish rapport with the recipient. Discrepancies and inconsistencies in response to interviewer questions are carefully probed. In addition, concerns about privacy and confidentiality are addressed. Second, specially trained staff, although not necessarily addiction professionals, conduct the interviews. Third, because of resource allocation and cost associated with conducting interviews, only high-risk groups, i.e., those recipients who are thought to have a substance abuse problem, are screened. Specialized screening is designed to augment, but not replace, generic screening. We implemented specialized screening programs with these features in two counties in NJ.
One specialized screening program was implemented in a county with a relatively small TANF caseload of 469 recipients. Welfare regulations in NJ allow caseworkers to mandate a substance abuse assessment for any recipient who has failed a work activity. The county welfare office decided that all sanctioned clients would be required to undergo a substance abuse assessment prior to lifting the sanction. Letters were sent to sanctioned clients indicating that the sanction process could be stopped and benefits restored if the recipient came in for an interview. The type of interview was not specified and the tone of the letter was inviting and not punitive.
Clients responding to the letter were interviewed by an addiction counselor who was co-located at the welfare office. As part of the interview, counselors administered several standardized measures, including one that assessed substance use disorder diagnoses. As part of the interview, counselors also assessed for barriers to employability related to medical, mental health, employment, family, or legal problems. Reports were prepared and provided to caseworkers based on these assessments. Overall, 352 letters were sent to sanctioned clients and 86 clients (24%) responded to the letter and were interviewed between February and October 2000. Of these 42 (49% of those interviewed) met criteria for a substance use disorder. In addition to the identification of substance abuse among sanctioned clients, the county also benefited from reports that detailed findings of other barriers to employability among sanctioned clients.
A second specialized screening program was implemented in a county with the largest caseload in NJ, 16,401 recipients. The large caseload made it impractical to conduct in-depth interviews on all sanctioned clients. Instead, two welfare caseworkers with an interest in helping substance abusers were identified. These caseworkers had extensive experience in implementing special programs in welfare settings, but had minimal training in substance abuse assessment or treatment techniques. These caseworkers interviewed high-risk clients. These groups included: clients reporting a lost electronic benefit card, those applying for emergency assistance, clients who another caseworker suspected of having a substance abuse problem, and clients who responded positively to one or more items on the CAGE-AID.
In order to evaluate the effectiveness of this program we examined two sets of data. Available data for the period of March through September 2000 indicated that 853 special screening interviews were conducted. Overall, 36.5% (n=312) resulted in a referral for further evaluation. Almost all those referred for an assessment are determined to have a substance abuse problem. Thus, specialized screening appeared to be an efficient method of identifying substance abuse problems. In addition, we compared the referral rates in the county where the special screening program was implemented to those of other NJ counties. Overall, the rate of referrals for substance abuse assessments in this county was 10.3% versus 4.4% for other NJ counties during the same 12-month period. Thus, specialized screening appeared to more than double the rate of referral for assessment. It should be noted that this method of evaluation has limitations since it is possible that other characteristics of the counties might explain differences in referral rates. Nevertheless, there are no obvious factors (e.g., differences in prevalence rate of substance use across counties) that could account for the size of the difference.
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Overall, results of this report suggest that a generic approach to screening in welfare settings one that relies primarily on caseworkers administering paper and pencil measures as part of benefit eligibility determination is useful in identifying a small percent of substance abusers. Similar results have been reported in other states (Nakashian & Moore, 2000). At the same time, findings suggest that specialized screening programs can substantially increase identification rates. The key elements of this approach are the use of trained staff to conduct interviews on groups who are at high-risk for having a substance abuse problem. Interviews focused on establishing rapport as well encouraging self-disclosure through careful questioning. In addition, it is important to address issues of privacy and confidentiality. Findings also indicate that high-risk groups may have a high prevalence of substance abuse problems: about one-third to one-half of recipients in the specialized screening programs appeared to have a problem. Findings that 49% of sanctioned clients interviewed met criteria for a substance use disorder is notable because it suggests that the prevalence of substance abuse among clients failing at work activities may be especially high.
It is also important to note study limitations. This study did not employ an experimental design. Thus, although findings are promising, causal inferences about the effectiveness of specialized screening approaches have not been established. In addition, findings that 49% of sanctioned clients met criteria for a substance use disorder were based on those clients (24% of those sanctioned) who attempted to cure their sanction. Rates of substance abuse among those not responding to the sanction letter may be higher or lower. In addition, many factors contribute to the low rates of identification of substance abuse among welfare recipients. It is beyond the scope of this report to discuss these factors or other promising solutions. However, a broader analysis of this problem is presented in an excellent report published by the Center for Substance Abuse Treatment (Nakashian & Moore, 2000).
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Correspondence to:Jon Morgenstern, Ph.D. Associate Professor of Psychiatry and Health Policy Mount Sinai School of Medicine One Gustave L. Levy Place, Box 1230 New York, NY 10029-6574 Tel (212) 659-8722 firstname.lastname@example.org