Many of the families remaining on welfare caseloads face significant barriers to employability. Among the most significant of these is substance abuse. States are struggling to develop innovative strategies to effectively address substance abuse in the context of welfare reform. Some states have attempted to integrate substance abuse treatment into their welfare employment programs, but there are almost no data to guide states about what program features are most effective. One central problem any system will need to address is the difficulties most substance abusers have in entering and remaining in treatment. Studies have consistently demonstrated that those receiving substance abuse treatment have better employment outcomes (Nakashian & Moore, 2000), but it is necessary for clients to remain in treatment in order to achieve these effects (Wickizer et al, in press).
The purpose of this report is to present preliminary findings of a study conducted in New Jersey comparing the rates of entry and retention in substance abuse treatment for two contrasting intervention approaches: Care Coordination and Intensive Case Management. Preliminary findings clearly indicate the benefits of providing intensive case management services over a more limited triage and referral system. Clients referred to substance abuse treatment programs using the Intensive Case Management approach were much more likely to enter substance abuse treatment and were especially more likely to continue attending outpatient treatment sessions.
Care Coordination used a set of strategies similar to those of innovative programs currently being implemented in several states, including New Jersey. Welfare recipients were screened for substance abuse problems by caseworkers in welfare offices. Women screening positive were interviewed in welfare offices by specially trained addiction counselors to determine the need for substance abuse treatment and to coordinate treatment, if needed. Treatment coordination included arranging an initial appointment with a treatment program and subsequent utilization review. The alternative approach, Intensive Case Management, combined several strategies thought to be effective in enhancing substance abuse treatment retention and improving outcomes. In Intensive Case Management, welfare recipients screening positive and needing treatment were assigned to a case management team. In the initial phase of the intervention, case managers identified and attempted to resolve barriers to entering and remaining in treatment. Typically, these involved tangible barriers such as childcare or transportation and psychological barriers such as a client's denial that they needed treatment. In addition, clients in ICM received small incentives in the form of vouchers for attending treatment.
An initial cohort of 146 female TANF recipients screened positive for substance abuse and were determined to need treatment. These women were randomly assigned to Care Coordination (CC) or Intensive Case Management (ICM) and their attendance in substance abuse treatment was monitored over several months. ICM was significantly more effective than CC in facilitating treatment entry: 88% of clients in ICM entered substance abuse treatment versus 65% in CC (p < .001). Differences were especially marked for outpatient treatment: 86% of clients in ICM entered outpatient treatment versus 53% in CC. In addition, ICM was significantly more effective in retaining clients in treatment. Clients in ICM attended 42% of the days they were assigned to treatment versus 22% of days for clients in CC (p < .0001). Again, differences were especially marked for outpatient treatment. On average, ICM clients attended about five times more outpatient sessions (M=29.7, SD=30) than clients in CC (M=6.6, SD=13).
Although both CC and ICM appear to be useful strategies to integrate substance abuse treatment into welfare programming, preliminary findings clearly indicate the benefits of providing intensive case management services over a more limited triage and referral system. Intensive case management significantly increased rates of engagement in substance abuse treatment, especially outpatient care. Rates for outpatient treatment entry and retention in CC were low. For example, only 38% of CC clients attended more than 2 sessions of outpatient treatment. These figures raise concern because many states are relying on triage and referral systems like CC to enhance engagement in substance abuse treatment for welfare recipients. Findings indicate that intensive case management interventions are effective in lowering barriers to treatment engagement. Further study is clearly needed to examine rates of engagement in substance abuse treatment for welfare recipients in other systems. Study details are provided below.