Providing Mental Health Services to TANF Recipients: Program Design Choices and Implementation Challenges in Four States. Introduction and Overview of the Study

08/01/2001

Recent changes in federal and state policy reflect a dramatic shift in the nation's approach to supporting the income of poor Americans and improving their labor force participation. Before the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) was passed, poor families were entitled to cash grants through the Aid to Families with Dependent Children (AFDC) program as long as their income and assets remained below a specified level and they met procedural requirements. In 1996, AFDC was replaced by the newly created Temporary Assistance for Needy Families (TANF) program, which sets a lifetime limit on benefit receipt and emphasizes employment over public assistance as the primary means of support for poor families. In response to time limits and steadily increasing work participation requirements, most state TANF programs encourage participants to find employment as quickly as possible.

Unlike the legislation governing previous welfare employment programs, which were designed to serve a small share of families receiving cash assistance, PRWORA created new expectations and opportunities for nearly all poor families seeking government assistance, including individuals with behavioral or emotional disorders that can create formidable barriers to employment. In the past, such families were rarely required to participate in employment programs. As a result, few states had strategies in place to assist clients with significant barriers to employment. While efforts to address the needs of these individuals are still in their infancy, far more programs are in place today than before the advent of welfare reform.

It is estimated that between one-fourth and one-third of welfare recipients have a serious mental health condition that could affect their ability to find and/or maintain employment (Sweeney 2000). While mental health conditions represent only one of the many personal and family challenges faced by TANF recipients in search of work, the number of recipients affected by mental health conditions is large enough and the identification and treatment of such conditions is specialized enough to have attracted the attention of researchers and policymakers as well as practitioners and program administrators.

In this report, we profile the efforts of four statesВ В  Florida, Oregon, Tennessee, UtahВ В  to address the mental health needs of welfare recipients. The report is based on findings from a study conducted by Mathematica Policy Research (MPR) for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. The study was designed with three purposes in mind: (1) to describe in detail the design and structure of mental health services developed by state and local welfare offices(1) to address the mental health needs of welfare recipients, (2) to highlight different service delivery options in designing and implementing these services, and (3) to discuss the key challenges and lessons learned in providing mental health services to welfare recipients.

By highlighting the key choices involved in integrating mental health services into a work-oriented welfare system, this report offers practical guidance to program administrators who are interested in addressing the mental health needs of TANF recipients or other low-income families. It is not intended to prescribe a model for providing mental health services to welfare recipients. As shown in Table I.1, we identified seven key dimensions that define the study states' approaches to the mental health needs of welfare recipients:

  1. the types of mental health services provided,
  2. the target population,
  3. the range of needs addressed,
  4. strategies for identifying clients in need of mental health services,
  5. the integration of mental health services into TANF employment plans,
  6. the administrative structure for delivering services, and
  7. the approach to funding mental health services.

 

TABLE I.1
SUMMARY OF KEY PROGRAM DIMENSIONS
Program Dimensions Florida Oregon Tennessee Utah
Types of mental health services provided Screening and assessment Linking clients to existing treatment Expansion of existing mental health services Intensive case management Screening and assessment

Linking clients to existing treatment

Short-term mental health counseling (crisis intervention only)

Training/consultation for employment case managers

Intensive case management

Assistance in applying for SSI

Screening and assessment

Linking clients to existing treatment

Short-term mental health counseling

Training/consultation for employment case managers

Intensive case management

Assistance in applying for SSI

Screening and assessment

Linking clients to existing treatment

Short-term mental health counseling

Expansion of existing mental health services Training/consultation for employment case managers

Intensive case management

Assistance in applying for SSI

Target population Low-income families with incomes below 200 percent of poverty Adults on TANF Adults and children on and transitioning off TANF Adults on and transitioning off TANF

 

Range of service needs addressed Mental health

Substance abuse

Mental health

Substance abuse

Mental health

Substance abuse

Domestic violence

Learning disabilities

Child behavioral problems

Mental health
Strategies for identifying clients with mental health conditions Formal presentations

Broad screenings

Referrals by employment case managers

Community outreach

Formal presentations Broad screenings

Referrals by employment case managers

Formal presentations Broad screenings Referrals by employment case managers

Automatic referrals to mental health services (sanctions)

Community outreach

Referrals by employment case managers

Automatic referrals to mental health services (sanctions and time limits)

Integration of mental health services into employment plans Up to 5 hours of mental health services per week in work plan Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services) Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services) Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services)
Agencies administering and providing mental health services Mental health & substance abuse program offices

Contracted service providers

Local employment service providers and welfare offices

Contracted service providers

University of TN

Contracted service providers

State welfare agency Contracted mental health service providers (minimal)
Funding Approach $45 million statewide

Designated funding

Varies by district

No designated funding, included in funding for

$8 million statewide

Designated funding

$1.7 million statewide

Designated funding

Designing programs to address the mental health needs of welfare recipients is a complex endeavor. Program design decisions made in one area may influence the design of other program dimensions. For example, programs that address a variety of barriers such as mental health, substance abuse, learning disabilities, and domestic violence require an administrative structure and staff skills that differ from programs that address mental health conditions exclusively. In weighing potential approaches to address the mental health needs of welfare recipients, careful consideration needs to be given to each key program dimension and how it might influence the overall approach to providing services.

In this introductory chapter, we discuss the context for this study, the prevalence and types of mental health conditions among welfare recipients, and how mental health conditions affect employment. We also describe the study, including our general approach to the work, the selection of the study sites, and the data collection procedures. Chapter II covers key program design issues, including how to define the types of services to be addressed and how to identify clients with mental health conditions. Chapter III discusses the key decisions involved in building an infrastructure to provide services, that is, deciding who will provide and administer services and how the services will be funded. Chapter IV highlights the issues involved in implementing mental health services for welfare recipients, and Chapter V summarizes the lessons learned from this early look at programs designed to address the mental health needs of TANF recipients. Appendix A includes a detailed description of each study site, and Appendix B provides contact information for obtaining copies of the program forms, including the screening and assessment tools used in the study states.(2)

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