Ancillary Services to Support Welfare to Work. Substance Abuse

06/22/1998

INTRODUCTION

 

Most states need, but do not yet have, a clear course of action for helping welfare recipients for whom substance abuse is a barrier to employment. Estimates of the population facing this barrier vary but suggest that it is significant. The rationale for a clear, aggressive approach to providing treatment for people with substance abuse problems is clear. First, substance abuse directly impairs a person's ability to secure and retain a job, and ignoring the problem will result in fewer successful exits from welfare. Second, children of adult substance abusers are affected, and welfare agencies that ignore this intergenerational impact will contribute to the need for additional social services in both the short and the long term. Finally, ample research evidence shows that not only is treatment effective, it is cost-effective, since it reduces the need for social services in a range of other areas. Welfare-to-work programs will have to deal with issues of client screening and assessment, treatment options, and coordination of services, but the needs are clear and the payoffs indisputable.

This section provides information on and addresses the following questions related to substance abuse among welfare recipients:

NEED FOR SERVICES:

How is substance abuse defined?

What percentage of the welfare population faces this barrier to employment?

  • What relationship does substance abuse have to welfare dependency and employment?

Definition

As a barrier to a successful transition from welfare to work, substance abuse, often referred to as AOD (alcohol and other drug) abuse, has a wide range of definitions, which vary according to the role of the definer. People who treat AOD abuse define it based on their interest in determining the need for treatment; welfare agency staff and employers are more likely to define it by some measure of client or employee performance; and researchers often use a broader definition based on the number of people who need assistance, whether they receive it or not.

From the perspective of those who treat AOD abuse, substance "dependence" is different from substance "abuse." Dependence entails three or more exhibited behaviors from a set of seven, including the level of tolerance, difficulty of withdrawal, extent of use, and various other behavioral responses. Abuse is defined by the extent to which recurrent substance use has impaired performance at work or school, caused legal or personal problems, or endangered another's life (American Psychiatric Association 1994). This differentiation has important implications for coverage of treatment: under managed care, treatment for substance dependence is generally covered, but treatment for substance abuse often is not.

Welfare agencies and employers define substance abusers as those who fail an employer's drug test, those for whom AOD abuse interferes with a welfare agency's program participation requirements, or those who face legal problems as a result of their habit. A client may be defined as having a substance abuse problem because a caseworker documented repeated incidents of intoxication at the welfare office.

From the research perspective, abuse is often defined by the amount of substance consumed: the number of drinks consumed or the frequency of using illicit drugs. Researchers at DHHS have, in turn, assigned amounts of use to increasingly severe "levels of impairment," from none, to little, to some, to significant. Significant impairment, for example, applies to people who use an illicit drug at least monthly, used heroin at least once in the past year, or are intoxicated weekly or more (Young 1996).

Percentage of Welfare Population Facing This Issue

National estimates: 5 to 27 percent
State/local estimates: 9 to 60 percent

Tables 18 and 19 in Appendix A provide national and state and local estimates of the prevalence of substance abuse among welfare recipients. The wide ranges in these estimates--particularly at the state and local levels--presented in the box above are due to the following factors:

  • Barrier Definition. Estimates based on a narrow definition of substance abuse, as discussed earlier, will tend to be much lower than estimates from a very broad definition. A broad definition, such as "possible alcoholic and/or drug user" will naturally produce higher estimates than will the narrower definitions of either alcoholic or drug user alone (Sisco and Pearson 1994).
  • Time Period. Variation in state and local estimates is increasingly a function of an area's experience with welfare reform. Those state and local agencies that have a longer history with reform measures, such as time limits, may have already successfully moved many of the least needy clients into employment. As a result, their caseloads may contain a higher proportion of the "hardest-to-serve" clients and hence a higher percentage with barriers like substance abuse.
  • Demographic Characteristics. Characteristics of the population under analysis can affect the estimates of those with a substance abuse barrier. Those with less than a high school diploma are almost twice as likely to report use of illicit drugs as are college graduates (although the opposite is true for rates of alcohol use). Likewise, those who are younger and those who are unemployed have higher rates of reported substance abuse than do their counterparts (Olson and Pavetti 1996). Geographic location can also affect the estimates. Those living in small metropolitan areas are more likely to report drug use (13.5 percent) than those living in either larger cities (9.5 percent) or rural areas (9.4 percent) (U.S. Department of Health and Human Services 1994c).

Relationship to Welfare Receipt

  • Most studies find substance abuse more common among welfare recipients than among nonrecipients. The 1991 National Household Survey on Drug Abuse found that, while 5.2 percent of all women reported any illicit drug use in the past month, the comparable figure for welfare recipients was 10.8 percent. Likewise, 3.8 percent of all women reported heavy drinking in the past month, while the comparable figure for welfare recipients was 8.2 percent (U.S. Department of Health and Human Services 1994d).(1)
  • Evidence suggests that substance-abusing welfare recipients place greater demands on other areas within social services. It is estimated that 78 percent of children entering foster care are from families in which substance abuse is a significant factor in placement (General Accounting Office 1994a). In Sacramento County, California, an average of 490 substance-exposed infants were referred to Children's Protective Services each year between 1989 and 1992 . In Oregon, the costs per case rose 28 percent during 1997, a result of the increased expense in services--from drug treatment to wage subsidies--needed by clients who faced serious barriers to self-sufficiency.(2)

Relationship to Employment Status

  • Those who are unemployed have substantially higher rates of substance abuse than those who are employed. Among welfare recipients, a 1994 DHHS study found that nearly 16 percent of unemployed females reported past-month drug use and nearly 30 percent reported past-year use, compared to 8.9 percent and 17.8 percent respectively for females who were employed full-time (U.S. Department of Health and Human Services 1994d, cited in Olson and Pavetti 1996).
  • Much of the challenge for substance abusers is job retention. Although the 1991 National Longitudinal Survey of Youth (NLSY) showed that 63 percent of current welfare recipients who were substance abusers were working in the present or previous year (compared to 58 percent of those who were not), 15 percent of the substance abusers were employed for a full year, compared to 22 percent of those who were not substance abusers (Olson and Pavetti 1996).
  • Research that looks at the effect of past abuse, rather than current abuse, shows that past abusers continue to have low self-esteem. Low self-esteem, in turn, hampers employment and weakens the ability to make a successful transition from welfare to work (Renwick and Krywonis 1992, cited in Olson and Pavetti 1996).

Welfare Agency Approaches

  • What can welfare agencies do to assist clients whose substance abuse is a barrier to employment?
  • What does the evidence suggest about effective ways to address this barrier?
  • What do we know about program costs?
  • What do we know about program implementation?

The two critical program features of an agency's approach to addressing substance abuse as a barrier to employment are (1) identifying which clients are appropriate for a targeted program, and (2) determining the type of program to provide.

Client Identification

Accurate identification of clients with substance abuse barriers to employment--and reliable determination of the severity of the barrier--is the first step to agencies' success in helping welfare recipients move from welfare to work. Three steps in this process are widely recognized: client screening, assessment, and drug testing.

Screening refers to determining the probability that a problem exists.

Assessment refers to collecting information to determine which aspects of a client's life are affected by substance abuse.

Drug testing refers to a process for detecting drug (not alcohol) use, most commonly from urine but also from hair, blood, and sweat (Young and Gardner 1997).

A number of instruments are used either to screen or to assess a client's level of substance abuse. The choice of instrument depends both upon its purpose--whether to do an initial screen or to assess the nature and severity of the substance abuse problem--and upon who will administer it. Two instruments are commonly used for an initial client screening: the CAGE and the Substance Abuse Subtle Screening Inventory (SASSI). Caseworkers in a number of sites have been trained to use one or the other. After an initial screening, a comprehensive assessment is performed with a different instrument, generally by a clinically trained professional in the treatment agency or, less commonly, by a professional who is co-located in the welfare office.

Program Strategies

As awareness grows of the extent to which substance abuse poses a barrier to employment for welfare recipients, state and local agencies are launching new and varied programs in response. Our review of programs suggests that there are at least five broad program strategies agencies currently use to address barriers to employment posed by substance abuse. This review is chiefly concerned with examining what welfare agencies can realistically hope to do in response to client needs and does not extend to potential responses that would go well beyond the welfare agency, for example, to address issues of infrastructure or changes in Medicaid policy. We categorize these strategies below. The distinctions drawn are not intended to suggest that agencies design programs around a single strategy or that these strategies are necessarily mutually exclusive. They are provided instead to foster thinking about the range of programmatic objectives possible, to help agencies define their own service needs, and to classify the programs described at the end of this section for agencies interested in pursuing further information. The five broad program strategies are categorized as follows:

Client Identification. Programs with this strategy are principally about improved accuracy in identification of clients who need further assessment and are likely to need treatment for substance abuse. These include programs that employ clinically trained staff in partnership with caseworkers to identify and refer clients to treatment, as well as programs that invest in developing caseworkers' own identification and referral skills.

Enhanced Case Management. Programs with this strategy approach substance abuse barriers to employment through the provision of some type of enhanced case management, for example, the addition of periodic home visits, development of a detailed and closely monitored self-sufficiency plan, reduced caseloads, volunteer mentors, or special program participation incentives. Enhanced case management is often provided in conjunction with treatment by an external agency.

Service Coordination. Programs with this strategy aim to institute improved coordination systems or procedures between welfare agencies (and possibly other social service agencies) and substance abuse treatment providers. Coordination itself can take any number of forms, including computer-based information systems, designated liaisons to communicate information, formal cross-agency advisory groups, and cross-agency training.

Increased Service Capacity. Programs with this strategy aim to increase the availability of substance abuse treatment. A limited supply of treatment providers poses a significant obstacle to addressing clients' needs. Programs designed to address the lack of supply include those that train caseworkers and others to provide short-term, interim counseling support for clients, as well as those that attempt to monitor available treatment slots through a coordinated information system.

Employment Integration. Programs with this strategy are more explicitly tied to employment, for example, through some level of employer cooperation or participation, through employer-provided incentives, or through the coupling (co-location and simultaneous provision) of substance abuse treatment and employment training.

Program Outcomes

Although there is a wealth of information on the effectiveness of substance abuse treatment in general, very little is specific to the welfare population. In addition, there is minimal evidence on the effectiveness of welfare agency efforts (as opposed to the efforts of people who treat AOD abuse clinically) to address substance abuse barriers to employment. We know almost nothing about the comparative effectiveness in improving client outcomes of one programmatic strategy versus another--for example, staff training for improved client screening versus establishing close linkages with treatment providers--and know very little even about the impacts that can be expected from a given program model. Several programs currently in design or operation include a rigorous evaluation component that will do much to increase our knowledge in this area (see individual program descriptions that follow). However, currently available evaluation findings tell us more about a program's impact on worker attitudes and skills, for example, than about client outcomes and there is not yet sufficient quantitative evidence on which welfare agencies can base important operational decisions. Nevertheless, while we may not know the effectiveness of an agency's programmatic approach, we do have ample evidence about the effectiveness of substance abuse treatment itself.

Substance abuse treatment, as provided by the alcohol and drug treatment system, is clearly effective in reducing negative behaviors related to employment, welfare dependency, and a number of other areas. Though much of the empirical evidence is based on data from the treatment system itself and therefore does not always pertain exclusively to the welfare population, there is sufficient evidence of consistent and positive outcomes for this group.

Effect of Substance Abuse Treatment on EMPLOYMENT(3)

  • Data from several states, including Minnesota, Colorado, Florida, and Missouri, indicate significant increases in rates of employment for welfare recipients who complete a treatment program (Young 1996).
  • Data from Kansas show that monthly employment earnings of those who completed treatment were 33 times higher than earnings received before treatment. Similarly, data from Oregon show that those who completed treatment earned 65 percent more than those who did not complete treatment (Young 1996).
  • Data from Ohio show a substantial decrease in the percentage of clients who missed work after completing treatment. While about 34 percent of treatment participants missed work before enrolling in treatment, only about 13 percent missed work after treatment. Participants also experienced decreases in other work-related problems, including interpersonal conflicts, mistakes, and completion rates (Young 1996).

Effect of Substance Abuse Treatment on WELFARE RECEIPT

  • Data from treatment programs in Oregon show that participation resulted in a number of impacts for those who completed treatment, including significantly less use of food stamps (Finigan 1996).
  • In Florida, more than half the participants in one treatment program reduced their receipt of public assistance within twelve months of leaving treatment (Young 1996).

Effect of Substance Abuse Treatment on OTHER AREAS

  • Data from treatment programs in Oregon also show that the group completing treatment experienced a 50 percent reduction in child welfare cases, a 58 percent reduction in hospitalization rates, a 45 percent decline in arrest rates during the three years after treatment, a 70 percent decrease in incarceration rates, and a 61 percent drop in the rate of homelessness for two or more days (Finigan 1996).
  • Data from a treatment program in Wisconsin showed that 65 percent of women who completed treatment had children returned from foster care (Young 1996).

Program Costs

We know very little about the costs to a welfare agency of operating a program designed to address employment barriers faced by welfare recipients with substance abuse problems. Each of the five program types listed above will undoubtedly have different costs. Some programs rely heavily on staff training, others on the administrative burden associated with agency coordination. In the absence of any comparative information, however, it is impossible to know whether one programmatic approach is more cost-effective than another.

What is known is the cost-effectiveness of actual substance abuse treatment--the ultimate objective of virtually all programs. So while we know almost nothing about the associated agency costs--whether for staffing, administration, training, or something else--we do know that the long-term societal savings, mostly from reductions in health care use and criminal activity, far exceed the amount spent on the actual treatment.

  • Data from the state of Washington showed that 23 percent of public costs for treatment participants who were on some form of public assistance were avoided in a subsequent year (Young 1996).
  • Calculations based on treatment costs in Oregon revealed that for every dollar spent on treatment, $5.60 was saved on other social services (Finigan 1996).
  • Calculations based on treatment costs in California--specifically for female welfare recipients with children--indicated that for every dollar spent on treatment, $2.50 was saved on other social services. (The cost savings for this group are somewhat lower than the savings for other populations, principally because these women initially commit fewer crimes than do others [Gerstein et al. 1997].)

Program Implementation

There is very limited information on strategies for effectively integrating substance abuse treatment into welfare programs. The summary below discusses implementation issues and approaches that people who operate (or plan to operate) programs face in three key areas: (1) program staff, (2) coordination of client information, and (3) service capacity. We also make recommendations about steps welfare agencies should take to serve clients facing substance abuse as a barrier to employment.

Program Staff

If program implementation is to be successful, welfare agencies must make a substantial commitment to staff training. As the urgency increases among welfare agency staff to address client substance abuse, so does the responsibility for implementing effective solutions. As a result, caseworkers are being given increasing responsibility and discretion over whom, how, and for how long to serve, but with minimal guidance. Caseworkers' natural tendency to feel discomfort in this area is likely to be exacerbated if there is no clear policy on when and for which clients an assessment is to be conducted, no detailed procedures for conducting and reporting the assessment, or no clear support from supervisors and managers for the assessment protocols.

Staff training should focus on at least two areas: (1) concerns and comfort with delving into substance abuse-related issues with clients, and (2) interviewing, screening, and referral skills (Legal Action Center 1997). In addition, if program implementation is to be successful, the screening and referral processes must contain clear and consistent procedures, coupled with supervisory recognition and support of the increased demands on caseworkers.

Coordination of Client Information

If program implementation is to be successful, welfare agencies need to develop coordinated systems for communicating client information. Procedures related to client identification and referral, monitoring of treatment participation, and client progress toward self-sufficiency have spurred the need for carefully coordinated systems of information. Successful implementation of all programs designed to address substance abuse barriers to employment requires some level of coordination between caseworkers and other agencies' staff. The success of coordination, however, depends on close working relationships between agencies--relationships that are often difficult to establish and that take focused attention and time to develop. Agencies frequently operate under different assumptions, use different assessment instruments, have incompatible reporting procedures, and even use different language when discussing clients.

Relationships need to be established with those who assess client needs, who provide treatment, who monitor treatment participation, who address the needs of clients' children while in treatment, and who potentially will employ clients once they complete treatment (a group often left out).

Service Capacity

If program implementation is to be successful, welfare agencies must assess the extent to which current local treatment capacity meets the need for services and, where gaps exist, take steps to address the shortage. In 1990, the Institute of Medicine estimated that 5.5 million Americans clearly or probably needed substance abuse treatment, while programs then in operation could treat roughly 1.4 million. In 1994, the federal government estimated that nearly 4 million Americans needed treatment for "chronic and persistent drug problems," but only 1.8 million received it (Legal Action Center 1997). Treatment capacity can be limited by a sheer lack of enough providers for those needing treatment, a lack of programs that address the unique problems of those needing services, and insufficient financial support, including obstacles that managed care poses to treatment. Estimates on the percentage of the welfare population in need of treatment but for whom treatment is not available are limited. In addition, estimates that do exist will be relevant only to a particular service delivery area. The anecdotal evidence strongly suggests, however, that an insufficient supply of local providers is a critical problem for many social service agencies. Sacramento County, California, estimated that the current local supply in that area was able to meet only 23 percent of the need for services.

With a large number of substance-abusing welfare recipients no longer eligible for SSI or SSDI and now subject to TANF work requirements, many more public assistance recipients than before will need effective substance abuse treatment if they are to become productively employed. And while sheer capacity itself must be addressed, many note that programs deter enrollment when they do not consider the unique needs of women and mothers (the need for child care, the fear of losing custody of a child, the need for a nonconfrontational approach to substance abuse treatment, the high rate of victimization from domestic abuse) (Legal Action Center 1997).

In addition, Medicaid and managed care policies complicate service provision. The federal regulation that prohibits Medicaid spending on services to people between 21 and 65 in an "institution of mental diseases" with more than 16 beds in effect precludes residential treatment for substance abuse. As a result, many clients needing inpatient treatment are limited to short-term detoxification and emergency services provided through hospitals. Managed care policies and procedures also make treatment difficult to obtain (Pavetti et al. 1996). Managed care reportedly often results in denial of appropriate treatment, inaccurate diagnoses, referrals to inaccessible providers, and retroactive denial of benefits (Legal Action Center 1997).

Though these are not issues welfare agencies will generally address, it is important to acknowledge the extent to which they complicate efforts to overcome this employment barrier. In meeting the needs of their clients, agencies must increase staff awareness of providers' programs and evaluate the appropriateness of each program. Finally, understanding and anticipating the limitations posed by both Medicaid and managed care might help to avoid additional complications with client referrals.

Program Models(4)

  • What are welfare agencies doing to address this issue?
  • Whom can I contact?

The following programs are presented alphabetically by state. The reader can determine the relevance of a program by noting its primary program strategy and geographic location and then refer to the brief descriptions and contact information on the subsequent pages. We have used primary objective(s) to assign program strategies, though a program may have many objectives.


County of Sacramento Department of Health and Human Services

Alcohol and Other Drug Treatment Initiative (AODTI)

Sacramento, California

Program strategy: Increased service capacity, through caseworker training

Location: Available to agencies throughout the state


Kansas Department of Social and Rehabilitation Services

Alcohol and Other Drug Screening Assessment and Treatment (AODAT)

Topeka, Kansas

Program strategy: Service coordination with external agencies

Location: Statewide


New Jersey Department of Human Services Work First New Jersey Substance Abuse Research Demonstration Project

Trenton, New Jersey

Program strategy: Enhanced case management

Location: One urban location; one rural/suburban location


The National Center on Addiction and Substance Abuse at Columbia University FamilyWorks

New York, New York

Program strategy: Employment integration

Location: NA (sites not yet selected)


Oregon JOBS Program

Oregon Adult and Family Services

Salem, Oregon

Program strategy: Service coordination with on-site substance abuse counselors

Location: Urban


Oregon Department of Human Resources Office of Alcohol and Drug Abuse Programs

Training Unit

Salem, Oregon

Program strategy: Client identification, through caseworker training

Location: Statewide


Program Name/Contact

County of Sacramento Department of Health and Human Services

Alcohol and Other Drug Treatment Initiative

Sacramento, California

Guy Howard Klopp

Special Projects

Alcohol and Drug Bureau

916-874-9754

Program strategy: Increased service capacity, through caseworker training

Location: Available to agencies throughout the state

Brief Program Description

The Sacramento County Department of Health and Human Services has developed the Alcohol and Other Drug Treatment Initiative (AODTI) to address the limited treatment capacity of county agencies to serve people with substance abuse problems. Officials determined that local capacity was able to meet only 23 percent of demand. AODTI includes three areas of effort:

1. To Train Staff to Recognize, Assess, and Work with Clients Who Have Substance Abuse Problems. The department has developed materials for three distinct and successively more advanced levels of training designed to enable frontline workers to screen for substance abuse.

2. To Expand Treatment Resources. The AODTI trains workers to provide informational, educational, and pre-treatment group services. More than 450 new treatment slots have been added.

3. To Monitor and Access Available Treatment Resources Through an Automated Service Requisition and Client-Tracking System. This computer-based system, still in the design stages, will coordinate information on treatment availability and client status from all community-based and in-house service providers.

The AODTI training program and consultation are available to other jurisdictions. Services provided to interested sites include training an agency's designated trainers, providing on-site training and curriculum materials, and consultation. The cost ranges from $40,000 to $75,000.

Evaluation

Children and Family Futures has provided consultation to assist with the evaluation of this program. Preliminary findings are based on a pre- post-training questionnaire administered to all staff who complete the first two levels of training. The evaluation is designed to determine the training program's impact on workers' ability and comfort in dealing with substance-abusing clients, on clients' entrance into and completion of treatment, and on the expansion of treatment capacity.

Findings

Findings assessing the program's impact on workers' skills have shown significant changes in knowledge, capacity, and comfort level in addressing substance abuse issues. Preliminary findings from the client evaluation indicate increased levels of family stability, reduced substance use, and improved use of other systems of support. Similar findings have been found in other sites. The evaluation of systemwide impacts has not yet begun.

Program Name/Contact

Kansas Department of Social and Rehabilitation Services

Alcohol and Other Drug Screening Assessment and Treatment (AODAT)

Topeka, Kansas

Katie Evans

Welfare Reform Coordinator

785-296-0147

Program strategy: Service coordination with external agencies

Location: Statewide

Brief Program Description

The Kansas Department of Social and Rehabilitation Services has made Alcohol and Other Drug Assessment and Treatment (AODAT) a mandatory component for Employment Preparation Services (EPS) participants who meet certain criteria. The department's approach is based on a close working relationship with Regional Alcohol and Drug Assessment Centers (RADACs).

EPS case managers initially determine whether clients should be referred for additional assessment and treatment based on specific criteria, including a positive outcome from the CAGE instrument that they administer.(5) Where warranted, clients are then referred to a RADAC. The RADAC closely monitors clients' participation and treatment and is responsible for determining and reporting noncompliance and status changes to the EPS case managers. Some counties have designated a liaison to handle coordination and communication issues between the two agencies. Those clients who do not comply with treatment are subject to sanction, based on a determination by the EPS case manager. Clients who are in outpatient treatment for less than 20 hours per week are also required to participate in additional program activities.

Evaluation

At present, there are no plans to evaluate this program.

Program Name/Contact

New Jersey Department of Human Services Work First New Jersey Substance Abuse Research Demonstration Project

Trenton, New Jersey

Annette Riordan

Project Manager

609-292-9686

Program strategy: Enhanced case management

Location: One urban location; one rural/suburban location

Brief Program Description

The New Jersey Department of Human Services plans to implement and evaluate the Substance Abuse Research Demonstration (SARD) Project in Essex and Atlantic counties. The goal of SARD is to test innovative strategies that address issues substance abuse clients face.

Strategies for addressing substance abuse issues will include specially trained case managers; collaboration between client and case manager in development of a treatment plan; creative, low-cost incentives (gift certificates for clothing, home accessories, hair cuts, cosmetics) to provide additional motivation and increase self-esteem; and low-intensity support services to assist clients in the transition from treatment to community life.

The case managers will conduct a thorough assessment of the professional and social support needs of each client (including mental health, medical care, child care, housing, and transportation). They will link clients to appropriate treatment programs, provide outreach and crisis assistance, coordinate aftercare treatment, develop and coordinate supportive housing options, and establish formal and informal linkages among relevant organizations. These linkages are designed to facilitate cross training and to establish consistency in planning and implementing services.

Evaluation

SARD will undergo a rigorous evaluation based on an experimental design that entails random assignment of clients to control and treatment service groups. The evaluation, to be conducted by researchers at the Rutgers University Center on Alcohol Studies, will compare the effectiveness of this enhanced service model to the state's Substance Abuse Initiative (SAI), which provides a much more limited set of services.

Findings

Information on program impacts and costs is not yet available.

Program Name/Contact

The National Center on Addiction and Substance Abuse at Columbia University

New York, New York

Diana D. Woolis

Co-principal Investigator

212-841-5200

Program strategy: Employment integration

Location: NA (sites not yet selected)

Brief Program Description

The National Center on Addiction and Substance Abuse at Columbia University (CASA), through funding from the Robert Wood Johnson Foundation, is developing an intervention strategy that will combine substance abuse treatment and job training for welfare mothers. The initiative will be implemented and evaluated in ten states, which CASA will identify and select.

The initiative is designed to integrate employment and sobriety goals in a comprehensive approach delivered by a unified service team. The main program goals will be to (1) help participants get and keep their jobs, (2) prevent further psychological and physical risk to children, (3) foster healthy families, (4) facilitate productive participation in society, and (5) develop participants' life skills. The demonstration will also be designed to determine appropriate and effective assessment techniques and instruments, establish a coordinated support system, enlist the involvement of area employers, and develop mechanisms for ongoing dissemination of information relevant to policy or program development.

The FamilyWorks Guide Book, available from CASA in summer 1998, provides guidance on each of the initiative's strategic objectives for programs addressing the dual goals of substance abuse treatment and job training. The book answers key questions about program design, addresses issues concerning developing standards and measures, and includes specific exercises for those who want to use the CASA approach to service.

CASA plans to offer technical assistance to states not selected for their demonstration. Assistance can include training, implementation support, and general consulting.

Evaluation

CASA will be selecting an external evaluator for this demonstration.

Program Name/Contact

Oregon JOBS Program

Oregon Adult and Family Services

Salem, Oregon

April Lackey

Oregon Adult and Family Services

Office of Alcohol and Drug Abuse Programs

Salem, Oregon

503-945-6197

 

Christa Sprinkle, Coordinator

Mental Health/Alcohol and Drug Treatment Services

Portland, Oregon

503-256-0432

Program strategy: Service coordination with on-site substance abuse counselors

Location: One urban site

Brief Program Description

Since 1992, Oregon has included substance abuse diagnostic, counseling, and treatment programs in its JOBS program. Oregon was the first state to require abusers to attend treatment as a condition of welfare receipt. Responsibility for referral and intervention for client substance abuse is shared among case managers, substance abuse counselors, and treatment providers.

There are some differences in how local programs operate. The following description is based on operations in Portland. All assistance applicants complete an initial two-hour Addictions Awareness class, during which they are screened for substance abuse by completing the Substance Abuse Subtle Screen Inventory (SASSI). If results of the screening indicate a high probability of substance abuse, the client is referred to a substance abuse counselor located in the same welfare office as the caseworkers. The substance abuse counselor helps the client get into treatment and then coordinates information between the treatment provider and the caseworker. Treatment, if determined necessary, is mandatory and subject to sanction. Clients are responsible for tracking treatment participation through the use of signed time cards. Referrals can be made to approximately 40 substance abuse treatment providers, and the state's Medicaid program--Oregon Health Plan--provides coverage for all nonresidential services. Residential treatment, which about one-third of the substance abuse clients need, is paid for by separate mechanisms, including funds from the federal Substance Abuse Block Grant and state and county funds.

Evaluation

No evaluation of the agency's effectiveness in addressing the needs of substance abusing clients has been conducted. A forthcoming evaluation by the Manpower Demonstration Research Corporation evaluates the Oregon JOBS program, but does not include a specific analysis of the agency efforts above. Michael Finigan, of the Northwest Professional Consortium, has evaluated substance abuse treatment in Oregon for the Office of Alcohol and Drug Abuse Programs, the Oregon Department of Human Resources, and the Governor's Council on Alcohol and Drug Abuse Programs.

Program Name/Contact

Oregon Department of Human Resources Office of Alcohol and Drug Abuse Programs

Training Unit

Salem, Oregon

Frank Munson

503-373-1650

Program strategy: Client identification, through caseworker training

Location: Statewide

Brief Program Description

The Office of Alcohol and Drug Abuse Programs (OADAP) within the Oregon Department of Human Resources has designed a substance abuse training program to retrain the state's entire staff of about 750 welfare caseworkers to act as service brokers between the welfare and treatment agencies. Specific goals of the training include an increased understanding of alcohol and drug dependency, an ability to identify problems and to make referrals to appropriate resources, improved skills for intervening when and where appropriate, and encouraging the establishment of local interagency networks. The state has chosen to invest in such comprehensive staff training because an increasing proportion of its welfare caseload has a substance abuse problem (as the more self-sufficient clients exit from the rolls), and caseworkers, who have been given enormous discretion, have limited skills in addressing this issue.

The OADAP Training Unit is currently pilot-testing the training in Portland. Caseworkers will attend four separate one-day training sessions over the next 18 months. Human services agencies pay OADAP approximately $85 for each of their caseworkers to attend one day of training. OADAP will also work with other Oregon agencies interested in improving the skills of staff who work with substance abuse victims.

Evaluation

There are plans to evaluate this program.

Further Information

Further information on issues related to substance abuse is available from the following

Organizations

The Substance Abuse and Mental Health Services Administration

U.S. Department of Health and Human Services

301-443-8956

Website: www.samhsa.gov

The Substance Abuse and Mental Health Services Administration (SAMHSA) supports research and disseminates information on the prevention, treatment, financing, and design of services to address substance abuse and mental health issues.

National Clearinghouse for Alcohol and Drug Information

1-800-729-6686

Website: www.health.org

The National Clearinghouse for Alcohol and Drug Information, a service provided by SAMHSA, provides information on screening tools and other substance abuse assessment instruments, as well as on substance abuse prevention and treatment.

Center for Substance Abuse Prevention

Rockville, Maryland

301-443-0365

Website: www.samhsa.gov

The Center for Substance Abuse Prevention, funded by SAMHSA, provides information about substance abuse prevention, treatment in general, and treatment for women specifically.

Center for Substance Abuse Treatment

Rockville, Maryland

301-443-5700

Website: www.samhsa.gov

The Center for Substance Abuse Treatment, funded by SAMHSA, works to identify, develop, and support policies and programs that expand treatment services to address substance abuse.

The National Center on Addiction and Substance Abuse at Columbia University (CASA)

New York, New York

212-841-5200

Website: www.casacolumbia.org

The National Center on Addiction and Substance Abuse at Columbia University (CASA) provides information on the economic and social costs of substance abuse; assesses what works in prevention, treatment, and law enforcement; and provides assistance to agencies that aim to serve substance abusers.

Further information on issues related to substance abuse is available in the following

Documents

Legal Action Center. "Making Welfare Reform Work: Tools for Confronting Alcohol and Drug Problems Among Welfare Recipients." New York, NY, and Washington, DC: Legal Action Center, 1997.

This document provides a comprehensive summary of the available data on substance abuse, of the cost-effectiveness of treatment, and of treatment capacity and funding issues. Information on state policies and, to a lesser degree, state practices are provided based on results from a recent survey of state welfare directors, state alcohol and drug directors, and drug and alcohol treatment program staff.

Young, Nancy K. "Alcohol and Other Drug Treatment: Policy Choices in Welfare Reform." Washington, DC: Center for Substance Abuse Treatment and the National Association of State Alcohol and Drug Abuse Directors, 1996.

This document summarizes the findings on the extent of substance abuse among those receiving public assistance, presents state-level data on treatment program outcomes, and reviews the primary policy issues facing federal and state legislators, policymakers, and service providers.

Young, Nancy K., and Sidney L. Gardner. "Implementing Welfare Reform: Solutions to the Substance Abuse Problem." Irvine, CA: Children and Family Futures; and Washington, DC: Drug Strategies, 1997.

This document discusses key policy issues that states should consider in their efforts to improve the employment prospects of substance-abusing clients and outlines critical steps states should take toward this goal. It describes the experiences of a number of states in addressing substance abuse. Appendixes include information on screening and assessment instruments and on drug testing.

1. Some of this gap in estimates is due to differences in demographic characteristics between welfare recipients and the general population, as discussed above (Olson and Pavetti 1996).

2. Oregon staff point out that spending for more expensive services has been more than offset by savings from recent declines in caseloads.

3. Reported impacts are not always impacts that have occurred exclusively for welfare recipients.

4. For an explanation of how programs were selected, please refer to the discussion included in the Introduction under the paragraph heading "Program Models."

5. Case managers in several counties have begun to use the Substance Abuse Subtle Screening Inventory (SASSI), and staff from the Kansas Department of Social and Rehabilitation Services have indicated that additional counties will begin to make this shift in screening instrument from the CAGE to SASSI.