- Policy Context
- Rationale for Providing Mental Health Services to Welfare Recipients
- Overview of the Study Sites
- Key Choices in Designing and Providing Mental Health Services
- Key Implementation Issues
- General Conclusions
The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) shifted the emphasis of the welfare system from providing ongoing cash assistance to needy individuals to moving them into jobs. This shift created new expectations and opportunities for nearly all poor families seeking government assistance, including those facing multiple and significant barriers to employment. In the past, these hard-to-employ individuals were rarely required to meet work requirements, either by working or participating in an approved work activity. As a result, few states had specialized services to address barriers to employment. With the new emphasis on work, however, programs targeted to hard-to-employ welfare recipients have recently emerged in an effort to help these individuals find and keep a job.
In this report, we profile the efforts of four states (Florida, Oregon, Tennessee, and Utah) to address the mental health conditions of welfare recipients, one of the many barriers that they may face. This report is based on the findings from a study that Mathematica Policy Research (MPR) conducted for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. This study was designed with three purposes in mind: (1) to identify and provide detailed information about the design and structure of mental health services developed by state and local welfare offices to address the mental health needs of welfare recipients, (2) to highlight options for delivering these services, and (3) to discuss the key implementation challenges involved in and the lessons learned from providing mental health services to welfare recipients.
The flexibility built into the federal welfare reform legislation allows states to use TANF funds to provide nonmedical mental health treatment services for welfare recipients and other low-income families at-risk for TANF involvement. Although most welfare recipients qualify for Medicaid, which allows them access to mental health treatment through a Medicaid-funded treatment provider, TANF recipients may not be aware they have a mental health condition that may be affecting their employability, or they may not know how to access Medicaid-funded mental health services. To address the mental health needs of these individuals, states have used TANF funds primarily in three ways: (1) to identify clients with mental health conditions and refer them to Medicaid-funded providers, (2) to provide specialized short-term counseling services, and (3) to augment existing Medicaid-funded mental health treatment.
The rationale for providing mental health services to welfare recipients is based on research showing that welfare recipients and other low-income populations are at-risk for mental health conditions that may affect their ability to obtain and/or maintain employment. Although the reported rates of mental health conditions among welfare recipients vary widely, they are always substantially higher than rates in the general population. Estimates differ depending on how mental health conditions are defined and measured and by the population studied. In the National Survey of America's Families, 35 percent of low-income families reported having poor mental health using scales measuring anxiety, depression, loss of emotional control, and psychological well-being (Zedlewski 1999). Danziger et al. (1999) found similar rates of mental health conditions among welfare recipients (36 percent). In a look at the prevalence of mental health, substance abuse, and domestic violence issues among California's CalWORKs participants, Chandler and Meisel (2000) found that more than one-third of these individuals had at least one diagnosable mental disorder in the previous 12 months, and about 20 percent had two or more. Of those with a mental health disorder, more than one-fourth indicated that their disorder created "a lot" of interference with life or daily activities. The high incidence of spouse/partner violence, childhood abuse, crime, and rape among poor women, in particular, puts them at greater risk for mental disorders such as depression, post-traumatic stress disorder, and generalized anxiety disorder.
Overall, there is a strong relationship between mental health and employment. For instance, mental health conditions often result in fatigue, an inability to concentrate, and poor interpersonal skills, all of which can adversely affect employment. Furthermore, those with mental health conditions are more likely to have poor and sporadic work histories, to be unemployed, and to be receiving cash assistance.
The exploratory study documented in this report is based on in-depth site visits to eight communities, a rural and an urban location in each of four study states Florida, Oregon, Tennessee, and Utah. In each visit, we conducted semi-structured interviews with a variety of program administrators and staff and with mental health treatment providers to gather information on services that address the mental health needs of welfare recipients. We also reviewed psychological assessment tools, reporting forms, service delivery pathways, confidentiality forms, and other information related to mental health services programs. When selecting programs for this analysis, we sought to represent the diversity of approaches to addressing the mental health needs of welfare recipients. We also looked for programs that had enough implementation experience to provide lessons to other administrators interested in implementing similar programs. The criteria used to select programs included the following:
- Provision of mental health services statewide or countywide
- Mix of programs developed pre- and post-PRWORA
- Experience serving a substantial number of clients
- Variation in administrative and service delivery structures
- Mix of rural and urban sites
The study sites represent a range of programs designed to address the mental health needs of welfare recipients. Two of the states, Oregon and Utah, have been providing mental health services to welfare recipients for many years before welfare reform. Utah is the only state in which state employees, rather than contracted mental health agencies, provide mental health services, and Florida is the only state to administer the program through an agency outside of the TANF system.
Florida. In Florida, TANF funds have been used to purchase mental health treatment for welfare recipients and those at risk for TANF involvement. These funds also pay for outreach staff, who link individuals to mental health services. The services themselves are administered and coordinated by the Mental Health and Substance Abuse Program Offices, which operate outside the welfare office and workforce development system. The development of an administrative structure outside of the TANF eligibility and TANF employment services system has made integration difficult.
Oregon. In Oregon, the focus is on assessing clients and linking them to Medicaid-funded mental health treatment providers. Oregon has integrated mental health services into the welfare agency by co-locating mental health staff in most local welfare offices and by allowing each district office to develop an administrative structure that takes into account the resources available in the local community.
Tennessee. The Family Services Counseling (FSC) program in Tennessee provides assessment and short-term, solution-focused mental health treatment for welfare recipients. Using a program model that is uniform statewide, Tennessee strives for maximum integration of mental health services into the welfare office by co-locating program administrators in the state welfare office, and family services counselors and district coordinators in local welfare offices. Individuals with more intensive mental health needs are linked to a Medicaid-funded mental health treatment provider.
Utah. Social workers in Utah conduct clinical assessments and some short-term therapy. They also link clients to Medicaid-funded mental health treatment and to some contracted mental health treatment providers. Hiring mental health staff members as employees of the welfare agency has created a high level of integration of mental health services into employment services.
Although each study state has developed a different approach to addressing the mental health needs of TANF recipients, they have all had to make decisions regarding seven key program design elements: (1) the types of services provided, (2) the population targeted for services, (3) the range of personal and family challenges addressed, (4) strategies for identifying clients in need of assistance, (5) integration of mental health and employment services, (6) administrative and service delivery structure, and (7) funding.
Types of mental health services provided. The TANF-funded mental health services provided in the study states include (1) screening and assessment, (2) linking clients to existing mental health treatment, (3) short-term, solution-focused mental health counseling, (4) expansion of existing mental health services, (5) resource/consultation for employment case managers, (6) intensive case management, and (7) assistance in applying for SSI. The states vary substantially in the emphasis given to each service. For example, mental health specialists in Oregon primarily screen and assess 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 conditions are linked with Medicaid-funded treatment providers. In Florida, outreach workers identify and screen clients for whom services may be appropriate and link them to Medicaid-funded providers or to contracted mental health treatment providers who are paid through TANF funds. Clinical social workers in Utah, who are stationed in the local welfare offices, conduct clinical assessments and make diagnoses and recommendations for mental health treatment. They also provide some crisis intervention services and short-term, employment-focused mental health treatment.
Eligibility for mental health services. Eligibility is defined in a variety of ways and may or may not be contingent upon TANF participation. All of the states offer mental health services to all adults on TANF; Tennessee and Florida extend services to children and other family members within the TANF household. Tennessee and Utah made mental health services available to individuals transitioning from welfare to work. Florida has extended eligibility to non-custodial parents and other low-income families with an income up to 200 percent of the poverty line.
Range of service needs addressed. According to several researchers, a substantial proportion of welfare recipients have multiple barriers to employment, and the presence of multiple barriers decreases the probability that these families will find and retain a job (Danziger et al. 1999, Zedlewski 1999, Olson and Pavetti 1996). Thus, when designing a system to address the mental health needs of welfare recipients, program administrators must decide whether mental health needs should be addressed separately or in combination with other personal and family challenges. Addressing needs in combination means designing services not only for mental health conditions, but also for a host of other issues that may be preventing clients from finding employment. However, it is likely to be difficult to find staff who are expert in assessing and treating multiple types of conditions or issues. Utah is the only study state to focus its program only on mental health needs. Florida and Oregon focus on mental health and substance abuse issues, and Tennessee focuses on mental health, substance abuse, domestic violence, learning disabilities, and children's behavioral issues.
Strategies for identifying clients with mental health conditions. A variety of strategies are used to identify clients with a mental health condition. In all of the study sites, clients may self-refer after listening to a formal presentation describing mental health services, or they may be identified during a broad group screening conducted by an outreach worker or a licensed mental health professional. In three of the study sites Oregon, Tennessee, and Utah the primary way clients are linked to mental health services is by referrals from employment case managers. In Utah, licensed social workers participate in review hearings for clients in sanction status or for those reaching the end of their time limit. Florida and Tennessee have developed extensive community outreach campaigns to inform partnering agencies and clients who receive services outside of the welfare office about mental health services.
Integration of mental health and employment services. Most of the study states allow flexibility in the number and types of work activities that can be included in a client's employment plan. For example, a mental health counselor may request that mental health services be included in the plan or may recommend that the number of required hours in work activities be modified to accommodate a client's mental health issues and needs. Florida is the only state that restricts the number of hours, to five per week, that a client can participate in mental health services as part of an employment plan.
Agencies administering and providing mental health services. Deciding how to administer and deliver services is an important step in designing mental health program for welfare recipients. The key challenge for program administrators is to create a service system that builds on the strengths of the mental health resources in the local community and successfully integrates mental health services into welfare employment efforts. TANF program administrators are not experts in the design and delivery of mental health services, usually making it necessary for them to rely on other agencies or specialized staff for the design and delivery of mental health services. Interagency coordination is therefore critical to program success.
The study states developed very different administrative structures for delivering mental health services to TANF recipients. In three states Oregon, Tennessee and Utah the TANF agency maintains primary oversight of the program, although the extent to which the TANF agency is actively involved in the delivery of services varies considerably. Utah is the only state to hire staff directly to provide mental health services to TANF clients. In Oregon, each local district decides how to provide services, with most relying on contracted service providers. Tennessee has contracted with the University of Tennessee to administer the program and with local providers to deliver services. In Florida, program responsibility has been transferred to the agencies responsible for delivering and/or monitoring mental health and substance abuse services. These differences in administrative structure reflect differences in the structures for providing employment services to TANF recipients as well as differences in the scope of mental health services provided.
Paying for mental health services. The study states have primarily used their TANF block grant and state Maintenance of Effort (MOE) 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 to provide 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 to low-income families at-risk for TANF involvement. The state welfare agency in Tennessee designated $8 million to provide mental health and other services (e.g., for substance abuse problems, domestic violence issues, and learning disabilities) to welfare recipients. Programs like these, which operate under a designated funding source, appear to have a distinct identity and a centralized program administrator and some uniformity in terms of how they operate. Under the second model, which Oregon uses, funding for mental health service is included in a pool of funds designated for all services designed to help TANF recipients find employment. In Oregon, the decision about how much of this funding is allocated to mental health services is made primarily at the local level. Under this model, mental health services compete with other services for funding.
Our analysis of the study states indicates that there are six key implementation issues involved in providing mental health services. We also discovered interesting approaches and innovative strategies developed by local offices to improve service delivery.
Encouraging employment case managers to refer clients to mental health services. A social worker in Salt Lake City, Utah, trains newly hired employment staff to identify mental health conditions. In Tennessee and most of Oregon, contracted mental health counselors co-located in the welfare office build relationships with employment staff to encourage referrals. The mental health program director in Florida developed a referral pathway chart for employment and mental health staff that outlines the process for referring clients to mental health services.
Encouraging client participation. To increase client participation in mental health services, staff have been flexible about where they provide services. In Tennessee, family services counselors meet with clients in their homes or at a location convenient to the client. To address the cultural and language differences in one site in Florida, paraprofessionals from the community were paired with licensed mental health counselors to translate counseling sessions, build relationships with TANF clients in the community, and link clients to mental health services.
Integrating mental health services into work activities. All of the study states count mental health treatment as a work-related activity in client's employment plans. Mental health and employment staff gradually increase conventional work activities until the client becomes employed. States have developed other strategies for integrating mental health into work activities. In Tennessee, mental health staff use a short-term, solution-focused treatment model. In Multnomah County, Oregon, mental health staff educate treatment providers about work and work-participation requirements.
Creating a professional support network. Mental health staff must be able to handle the wide variety of personal and family challenges facing individuals who participate in mental health services. Mental health staff in most sites have developed a professional support network to help them handle difficult cases and to exchange information about different community resources. In Oregon, mental health staff meet weekly to staff cases. Contracted mental health staff in Tennessee participate in routine case staffings in their agencies.
Maintaining client confidentiality. In general, the confidentiality of information shared by the client is well-maintained. All the study states have developed confidentiality forms to allow the exchange of information between mental health and employment staff, mental health treatment providers, and other community agencies. Social workers in Utah ensure that client case files are secured in a locked filing cabinet. In some sites, mental health counselors co-located in the welfare office have had difficulty finding private office space, an issue that is critical to maintaining client confidentiality.
Monitoring and tracking client participation. Employment case managers and mental health staff typically work together to monitor and track client participation and progress in mental health services. Monitoring and tracking appears to be a difficult task in most of the study states. Tennessee has the most comprehensive process for tracking client participation. In each client's file, mental health staff keep a record of the client's service plan, participation and progress in treatment, and contacts with mental health staff.
The mental health needs of welfare recipients may be addressed in any number of ways, and there is no evidence to suggest that one model for providing mental health services is better than any other. More research is needed to examine the effectiveness of the mental health services that are now provided in improving the employability and general well-being of welfare recipients. But regardless of the questions that may remain, it is clear that mental health services can be a valuable resource for employment case managers in their effort to move hard-to-employ individuals from welfare to work.