Providing Mental Health Services to TANF Recipients: Program Design Choices and Implementation Challenges in Four States. Oregon's Mental Health Services


Program origins. Oregon began to create a welfare program with a strong emphasis on work and supportive services in the mid-1980s. Beginning in 1992, Oregon started expanding the services provided to welfare recipients to include mental health and substance abuse services. The expansion of services was the result of a statewide analysis of client needs. There was special concern for those clients who were leaving and returning to welfare. Based on clients' needs analyses, the state found many clients could benefit from mental health and substance abuse services. The state purposely implemented a broad policy that gave local and district offices the flexibility to design mental health and substance abuse services based on the needs and resources of the local communities.

Scope of barriers targeted. Local welfare offices provide services to address mental health and substance abuse issues.

Eligibility for mental health services. All clients applying for cash assistance are eligible for mental health services. There is a 45-day assessment period where clients are required to look for employment prior to certification for TANF benefits. Clients in the assessment phase and those receiving cash assistance may be screened to assess their need for mental health services.

Strategies for identifying clients with mental health conditions. Local offices vary in how they identify clients to participate in mental health services. In most offices, clients are informed about services from multiple sources. The primary ways clients are identified for services are described below.

  • Intake. Some local offices have their most experienced case managers conducting intake and asking clients questions regarding the circumstances that brought them to the welfare office. The intake worker screens for eligibility, informs clients of services, including mental health and substance abuse services, and may refer clients to mental health services.
  • Orientation. Mental health specialists may screen clients for mental health and substance abuse issues during the welfare orientation. The orientation screening procedures vary across local offices. For example, in the St. John and Albina welfare offices, clients receive separate group screenings for substance abuse and mental health during their initial orientations. In Astoria, there is one mental health/substance specialist who administers a brief group screening for both mental health and substance abuse during orientation
  • Welfare Case Manager. Clients are most commonly referred to the mental health specialist through the welfare case manager. Typically, either the client will disclose mental health issues or the case manager will identify mental health needs after the client fails to participate in program activities or has trouble keeping a job.
  • Specialized Case Manager/Worker. In some local offices there are case managers who handle a caseload of clients with severe barriers to employment. These specialized case managers conduct more thorough assessments of clients' mental health and they work closely with mental health specialists.
  • Self-Referral. Clients may refer themselves to the mental health specialist directly after being informed about mental health services during orientation or by their case managers.
  • Clients in Sanction Status. Clients who are in sanction status and have indicators of mental health conditions are referred to mental health services and encouraged to participate in an assessment.

Types of mental health services provided. Once clients are identified, mental health specialists provide a wide range of services to both clients and welfare case managers. They are described below.

  • Screening and Assessment. Mental health screenings and assessments are the primary service provided by mental health specialists. Most of the mental health specialists do not use a formal assessment tool, but instead rely on their professional experience to guide the types of questions that they ask. Assessments typically consist of open-ended questions aimed at uncovering current problems. Information usually is gathered on the clients' mental health history, physical health, family history, and drug and alcohol use.
  • Connecting Clients with Mental Health Services. Mental health specialists link clients to treatment. The mental health specialists may refer clients to their own agencies (if they are employees of a contracted service provider), or other agencies within the community.
  • Short-Term Crisis Intervention. Mental health specialists handle crisis situations and work to stabilize clients before referring them to mental health treatment.
  • Training and Consultation for Welfare Case Managers. Mental health specialists provide in-service training for welfare staff and consult with case managers on a case-by-case basis, giving them guidance on ways to handle difficult behaviors and attitudes among clients.

The relationship between mental health services and work requirements. Oregon operates under a federal waiver that allows for flexibility in time limits for receiving cash assistance and work requirements. Most clients involved with mental health services have an individualized case plan developed by the case manager, mental health specialist, and client. The activities included in the individualized case plans are based on the severity of the client's mental health condition and may require fewer hours than a case plan without mental health services. Often, the focus of the work plan is to start the client out slowly with moderate activities, and gradually move into work activities. In most cases, even with mental health services, clients are required to do some work activities, such as a life-skills training workshop. Clients that are participating in an individualized work plan are not subject to the time limits.(20)

Administrative structure. The administrative structure of Oregon's mental health services is comprised of one state program analyst and local mental health and substance abuse specialists. The program analyst oversees the policy guidelines and training for mental health and substance abuse services. The program analyst also coordinates with the mental health contracted treatment providers and addresses contractual questions if they arise. In the local offices there is wide variation in the organization of mental health services. In two counties, there are local program coordinators who administer, monitor, and supervise the mental health and substance abuse services in their counties. Most counties have specialists in mental health and substance abuse who have extensive experience and strong clinical training. Some offices use separate specialists for mental health and substance abuse, while other offices have hired a specialist with expertise in both areas.

Most of the staffing for mental health services are handled by using contractors and, in general, are arranged in one of two ways. Contracting may be handled either by the AFS(21) (Adult and Family Services) district office or through the prime employment and training service contractor. For example, in Astoria, the AFS district office contracts directly with Clatsop Behavioral Healthcare for a part-time (20 hours a week) licensed counselor to provide mental health and substance abuse services to welfare recipients. This licensed counselor is co-located in the Astoria welfare office. In Multnomah County, the employment and training service providers, Mount Hood and Portland Community Colleges, hire the mental health specialists and subcontract with local mental health treatment providers for outstationed workers in the area.

Mental health treatment is provided by Medicaid providers. In general, the agencies provide a range of outpatient mental health treatment services, including assessment, case management, and individual and group therapy. In-patient treatment is limited to the urban areas, and throughout the state there is limited treatment for co-occurring mental health and substance abuse conditions.

Funding mental health services. Local offices determine how much of their TANF funds are allocated to mental health services. TANF funds cover the cost of the local mental health specialists and the district coordinators. Medicaid covers the cost of all mental health treatment.

For additional information please contact:

Christa Sprinkle
Coordinator, Mental Health/Alcohol and Drug Treatment Services
Mt. Hood Community College, Steps to Success Program
Phone: (503) 256-0432


Carol Ann Krager
Intervention Program Analyst
Oregon Department of Human Services
Phone: (503) 945-5931

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