Child welfare agencies consistently report difficulty obtaining substance abuse treatment for clients who need it, particularly programs that are designed to meet the specific needs of women with children. The Child Welfare League of America reports that agencies can obtain timely treatment for only one-third of clients who need it, and only 10 percent of agencies report being able to find treatment within a month for most who need it. Also disturbing is the fact that many agencies report being unaware of whether treatment is available in their communities (CWLA, 1998). Until clients have access to treatment services it is unrealistic to expect significant improvement in problems surrounding their substance abuse.
Often a family crisis, such as a child protective services intervention, is the catalyst needed to prompt a substance abusing parent to seek treatment. The resolve of an addicted person is often short lived, however, and unless treatment is available promptly the opportunity for intervention may be lost. This is another issue on which different views of a problem may create misunderstanding between substance abuse and child welfare agencies. If, for instance, half of a child welfare agency's referred clients cannot locate treatment or are placed on long waiting lists which fail to result in services, the child welfare agency may very well consider those clients as treatment failures. The substance abuse agency, however, is likely to argue that they should not be held responsible for the "failure" of a client who has never entered their program or received a service. In addition, some treatment programs are reluctant to accept clients who may not be entering treatment voluntarily. Regardless, the reality is that the substance abuse has not been addressed and the client's problems continue.
Nationally there is a shortage in all varieties of publicly funded substance abuse treatment opportunities for those in need. As noted in Chapter 4, only 37 percent of mothers with problem levels of drug use who are living with children under age 18 and 48 percent of such fathers received treatment services in the past year (SAMHSA, 1997d). In addition, substance abuse patterns vary greatly regionally and locally. This fact, coupled with the significant gap between available treatment capacity and current demand, often impedes the ability of the existing treatment system to respond quickly to changing needs. Within States, the needs of a variety of treatment-seeking populations must be balanced. Competing demands for services for criminal justice clients, HIV+ clients, and others under conditions of service scarcity often result in unpredictable and inconsistent funding for treatment programs and force treatment providers to constantly pursue new funding streams rather than concentrate on the provision of quality services.
In addition to the general problem of treatment availability, programs addressing parents' needs are in particular shortage. The fact that parents, and in particular, mothers, have specific needs in treatment that most programs do not address has been widely observed (HHS/CSAT, 1994; Magura, 1998; Grella, 1997). These needs may include child care, services to address parenting stress, economic and educational issues, reproductive health care services, psychological services, domestic violence services and more. These services are generally not as applicable to male substance abuse treatment clients, but are essential for effective women's services.
Many comprehensive substance abuse treatment programs for women are the result of Federal grant initiatives from either the Substance Abuse and Mental Health Services Administration or the Administration for Children and Families, and most have very small client loads (Allen & Larson, 1998). As demonstration projects and new Federal funds have become less available, it is unclear the extent to which these programs will survive with other funding sources. Few States have extensive networks of substance abuse treatment programs geared toward women and children, and child welfare agencies spend little money to acquire substance abuse treatment for families. The Child Welfare League of America's recent survey found that nearly half of States report spending no child welfare money at all on substance abuse treatment; the most active State spent 2 percent of its child welfare funds for this purpose (Child Welfare League of America, 1998). When States were asked to identify the funding sources used for treatment for child welfare clients, State alcohol and drug agencies were such a minor funding source that they ended up in a category entitled "other," combined with a variety of funding sources that did not merit their own categories.
As Figure 7-1 illustrates, Medicaid is the funding source most often used by child welfare agencies to obtain treatment for clients. Indeed, a majority of States cover substance abuse services through mandatory and optional Medicaid service benefits. Medicaid coverage for substance abuse treatment is described at more length in Appendix A. States are increasingly submitting State plan amendments to cover substance abuse services, both for children and adults, primarily using the optional rehabilitation benefit, because of its flexibility.
During our consultation process, a number of experts pointed out that a significant limitation in Medicaid's coverage of substance abuse treatment services is the prohibition on payments to certain facilities classified as institutions for mental diseases (IMDs). As currently defined, an IMD is any facility of more than 16 beds that specializes in psychiatric care. This includes most residential substance abuse treatment programs. Thus, for clients aged 22 - 64 whose payment source is Medicaid, the IMD exclusion significantly limits access to the more intensive models of substance abuse treatment, which are often indicated for the most severely addicted clients.
The IMD exclusion, which dates back to the 1950s, applies to Alcohol, Drug Abuse, and Mental Health (ADM) inpatient facilities. Since the general trend in the total system has been to outpatient or partial care since 1972, the IMD policy now limits Medicaid payment for a smaller proportion of total ADM services today than it did in years past. The IMD statutory definition that exempts facilities of under 17 beds should further reduce this proportion. The two types of inpatient facilities most clearly meeting the IMD criteria are State and county mental hospitals, and private psychiatric hospitals.
Despite the IMD exclusion, a number of States and localities have found ways, within the existing rules, to make residential-like substance abuse treatment services eligible for Medicaid reimbursement. Exhibit 7-A describes a number of these methods which may be used to expand treatment access.
State Methods Used to Ease the Effect of the Institutions for Mental Diseases (IMD) Exclusion
Many States looked to the following methods as a way to address treatment access and lessen the effect of the IMD exclusion in order to provide substance abuse services to their Medicaid population.
Size Limits. Psychiatric hospitals and psychiatric nursing facilities that have fewer than 17 beds are not IMD's and are not subject to the exclusion. Patients in facilities, such as many substance abuse treatment facilities, continue to be Medicaid funded for covered services if the facility has fewer than 17 beds. Larger facilities are being legally divided into a number of smaller facilities with fewer than 17 beds each.
Mergers. Psychiatric hospitals are merging with general hospitals that are somewhat larger so that the resulting entity is not an IMD, but a general hospital with a large psychiatric "wing." This type of merger can be accomplished largely via legal paperwork and seems to be an increasingly popular way to negate IMD status. If a psychiatric hospital is larger than the general hospital, a portion of the psychiatric hospital that is smaller than the general hospital merges with the general hospital — or just uses a general hospital for all psychiatric care.
During the 1990s, five States (MD, MA, NY, SC and WA) expanded services for pregnant substance abusing women using Medicaid waivers initiated as demonstration projects. The demonstrations varied widely, but included the following components:
- Outreach to pregnant substance abusers;
- Screening for substance abuse and assessment of the severity of substance abuse;
- Case management to link women with appropriate services, including prenatal care and substance abuse treatment;
- Expanded Medicaid coverage for substance abuse treatment and an enriched package of support services provided during treatment; and
- Efforts to better integrate the prenatal care and substance abuse treatment system.
Most States chose to modify and enhance existing substance abuse treatment programs; none developed entirely new programs. Howell and colleagues (1988) have described the projects in detail. Each site had significant difficulty engaging clients in program services. The experiences of these projects may be a source of insight for others considering service expansions. The significant differences in program designs across States made the detection of cross-site results difficult.
Some States have begun to address treatment access issues by building networks of treatment programs, sometimes with services specifically designed for women and parents. In Missouri, for instance, the State has invested in a series of programs called the Comprehensive Substance Abuse Treatment and Rehabilitation program (CSTAR). CSTAR is a flexible model emphasizing community-based service provision in an intensive outpatient model, beginning with programming seven days per week, ten hours per day that tapers off as recovery is established. Case management, family therapy and co-dependency counseling are among the components included in addition to more traditional substance abuse counseling. Child care and supported housing are also available. Using this model the State treats approximately 2,000 women and over 6,000 children annually and has achieved good recovery rates and satisfaction ratings from clients (Jordon, 1997).
Eight States have also begun using some of their funding under the Promoting Safe and Stable Families Program (formerly the Family Preservation and Support Program), authorized under title IV-B, subpart 2 of the Social Security Act, to pay for substance abuse assessment and treatment services for some clients. While substance abuse services are among the relatively minor uses of these funds (in contrast, thirty States support parent skills training, 23 States support respite care and 17 support recreation programs using these funds), such services are a growing category of State spending under this program (Kaye and Ensign, 1998). These funds are a flexible source of funds States use to serve families, primarily those at risk of child abuse or neglect.
Another opportunity for States to expand treatment access is through Child Welfare Demonstration Waivers. These demonstrations are intended to allow States the flexibility to try alternative means of addressing the child welfare needs of families through use of existing foster care and related funding streams for activities that are not usually allowable under titles IV-E and IV-B of the Social Security Act. The announcement to States soliciting applications for the Fiscal Year 1998 and Fiscal Year 1999 application cycles have included a Federal priority for addressing the substance abuse treatment needs of families in the child welfare system. Among the initial ten States receiving Child Welfare Demonstration Waivers, only one (Delaware, described above in the section on assessment and referral) identified itself as intending to address the problem of substance abuse and its relationship to child maltreatment. Among the Fiscal Year 1998 demonstrations, one addresses substance abuse as its main focus (New Hampshire) and one more includes it as a sub-focus (Kansas). The remainder address it only indirectly. States may wish to look toward the use of this demonstration waiver mechanism in the future as they seek innovative ways of addressing substance abuse in families where child maltreatment occurs. The Department of Health and Human Services has the statutory authority to grant additional waiver demonstrations, up to ten per fiscal year. Demonstrations may last up to five years (although under some circumstances they may be extended), must be cost-neutral to Federal child welfare programs over five years (that is, they must cost no more to these programs than would be spent under current law, although funds may be spent in alternative ways), and must have strong evaluations.