Intensive Case Management Improves Welfare Clients Rates of Entry and Retention in Substance Abuse Treatment. Background and Rationale


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., 1998; 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. States have adopted strict new work requirements and time limits on receipt of welfare benefits. Substance abusers face substantial barriers to employability. Most will require effective substance abuse treatment and additional services to address associated problems such as low basic skills, housing, mental health disorders, and domestic violence (Pavetti et al., 1997).

Studies have consistently shown that substance abuse impairs work performance and those receiving substance abuse treatment have better employment outcomes (Nakashian & Moore, 2000). For example, Wickizer et al. (in press) studied 5,664 substance abusing welfare recipients in Washington State. Recipients who remained in treatment were 25% to 100% more likely to become employed than those who did not receive treatment or dropped out of treatment early. Thus, research findings support the recommendations of treatment professionals that engaging clients in substance abuse treatment is critical to the process of promoting self-sufficiency.

States are struggling to develop innovative strategies to effectively address substance abuse in the context of welfare reform. A number of states have implemented systems to integrate substance abuse treatment into welfare-to-work programs. Typically these systems involve an expansion of funding for substance abuse treatment, screening for substance abuse within welfare contexts, triage and referral of recipients with problems to substance abuse treatment, and coordination of treatment with employment programming.

These approaches represent great strides in reducing the fragmentation that has existed between welfare and substance abuse treatment services, but continue to rely on the existing structure of substance abuse treatment. However, the literature is consistent in suggesting that the current structure of substance abuse treatment is poorly matched to the needs of disadvantaged, parenting women (e.g. Brindis et al., 1997; Gustavson & Rycraft, 1993). A primary concern has focused on issues of treatment engagement. Parenting women experience tangible (e.g., lack of child care) and psychological (e.g. denial of problems) barriers to entering treatment. In addition, parenting women present with an array of problems not addressed by substance abuse treatment programs. Recommendations for improving outcomes have focused on lowering treatment barriers and providing more comprehensive and coordinated care. Studies have suggested that augmenting existing substance abuse treatment with intensive case management services might improve treatment engagement and outcome (Laken & Ager, 1996). In addition, contingency management such as providing incentives to reinforce treatment tasks has improved outcomes over usual care (Iguchi et al., 1997).

Overall, the literature suggests that implementing a triage and referral system to coordinate care across welfare and treatment might not be sufficient to effectively address substance abuse among women on welfare and that a more comprehensive and intensive set of services may be needed. However, no studies have examined which approach would be most effective or determined their relative costs. In order to address this issue, officials at the New Jersey (NJ) Department of Human Services partnered with scientists from Mount Sinai School of Medicine and Rutgers University to design and implement a welfare demonstration project. The primary aim of this project is to evaluate the effectiveness and cost of two contrasting approaches to address substance abuse problems among women on welfare. One approach, Care Coordination (CC), represents the standard of care currently available in NJ to address substance abuse in welfare settings. The alternative approach, Intensive Case Management (ICM), augments standard care by adding intensive case management services and contingency interventions. This report provides preliminary outcomes on rates of engagement in substance abuse treatment for an initial cohort of participants.