In most of the study sites, the goal of mental health services is to help clients manage mental health conditions that may be limiting their ability to find and retain a job. Typically, mental health services are included in the client's employment plan and count toward the TANF work activity requirement. The purpose of monitoring and tracking client participation in mental health services is to ensure both that clients are participating in mental health services when they are included in the employment plan and that they are progressing toward employment. Contracted mental health treatment providers tend to be more responsive than Medicaid providers in reporting client participation and progress to employment case managers in the welfare office. This may be the case because the contract reporting requirements stipulate that treatment providers provide employment and mental health staff with feedback about clients' involvement in mental health treatment.
Employment case managers and mental health staff typically work together to monitor and track client participation and progress in mental health services. However, in most of the study sites, the employment case manager is ultimately responsible for ensuring that the client is participating in mental health services. In Tennessee, family services counselors submit weekly participation reports to the employment case manager. The employment case manager sanctions clients who do not participate in mental health services if the services are included in an employment plan. In Salt Lake City, social workers provide a monthly report to employment counselors summarizing each client's level of employability, participation in mental health treatment, and recommendations for modifying the employment plan. In the Florida sites, contracted service providers reported directly to the state and to regional TANF substance abuse and mental health program administrators, since few clients included mental health services in their employment plans. In Oregon, responsibility for tracking and monitoring client participation often is left to the employment case manager, with some help from mental health staff.
According to agency staff in most of the study states, monitoring and tracking client participation and progress in mental health treatment has been a difficult challenge for the three reasons explained below.
To protect client confidentiality, mental health treatment providers are cautious about the kinds of information they share with employment case managers. For the most part, mental health treatment providers share information about clients with employment case managers whether or not the client is participating in mental health services. Some employment case managers said they would like more information about the employability of clients than many of the treatment providers give them. According to mental health staff in the welfare office, mental health treatment providers are more comfortable talking with them than with employment case managers about clients.
Finding Private Office Space to Protect Client Confidentiality
Most mental health staff have years of experience as counselors. They have been oriented to confidentiality issues as part of their professional training and their experience in providing mental health services. Overall, maintaining client confidentiality is handled professionally in all study sites. However, one confidentiality issue that did emerge was the availability of private office space to conduct assessments and therapy, particularly when mental health counselors are co-located in the welfare office. In some sites, mental health counselors have been able to negotiate for their own private office. In other sites, mental health counselors use private conference rooms to meet with clients. Given the sensitive nature of their interactions with clients, mental health counselors indicated that access to private office space is essential to successful, confidential service provision.
Many of the mental health treatment providers, especially those funded through Medicaid, do not fully understand the work participation requirements associated with welfare receipt. In Utah, for example, mental health staff had difficulty obtaining feedback about clients from the Medicaid mental health treatment provider. After meeting with the Medicaid agency staff to explain TANF work requirements and to discuss ways to improve communication between the agencies, the process and frequency of feedback from the treatment providers improved.
In some areas, mental health treatment providers, especially Medicaid-funded providers, have high staff turnover and a limited number of staff, which makes it more difficult to provide feedback in a timely way. In some parts of Utah and Oregon, the staff turnover at the Medicaid-funded service agency made the monitoring and tracking of client participation more difficult. In recent years, for example, the number of Medicaid-funded mental health clients served by Valley Mental Health in Salt Lake County, Utah, has increased sharply, straining already limited resources. This has increased staff workload, which has contributed to high staff turnover.(16)