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

08/01/2001

Program origins. Utah began providing mental health services in 1990 when the Office of Family Support (OFS) hired two licensed clinical social workers to help clients with mental health needs access treatment. In 1993, OFS implemented the Single Parent Employment Demonstration (SPED) program(24), which allowed a broad range of activities to count as required self-sufficiency activities and gave case managers flexibility in determining the number of hours clients had to participate in self-sufficiency activities. Under SPED, two additional social workers were hired to identify mental health and substance abuse problems, provide brief therapy and work on the conciliation process for families who were noncompliant and being recommended for sanctioning. Eventually, social workers were hired statewide and the types of services social workers provided were determined locally.

In 1996, Utah consolidated the six separate agencies that handled employment, job training and welfare functions into the Department of Workforce Services (DWS). At this time DWS administrators decided to reorganize and centralize social work services. In 1998, the social work unit was formed with a program manager at the state level and a uniform statewide set of policies, procedures, and reporting forms were developed.

Scope of barriers targeted. Social work services focus on mental health conditions. The social workers may address substance abuse and other needs of the client by linking them to service providers in the community.

Eligibility for mental health services. All TANF clients qualify for mental health services and may continue to receive services up to a year after TANF case closure. In general, social work services are geared toward the welfare recipient rather than the entire family receiving cash assistance.

Strategies for identifying clients with mental health conditions. Clients are informed and identified for social work services in a variety of ways and at different points while on cash assistance.

  • Orientation Video.During the first meeting with an employment counselor, clients are shown a computerized slide show that gives an overview of the FEP and outlines the services available, including mental health services. This is typically the client's first introduction to mental health services.
  • Client Assessments/Case Managers. All employment counselors complete a standardized assessment with each client to gather information about the client's background, including work, family, legal, and medical history. Case managers refer clients to mental health treatment based on the assessment results and if a client demonstrates signs of a mental health condition.
  • Automatic Referrals. The CAGE questionnaire is administered during the client assessment to screen for possible substance abuse conditions. If the customer responds "yes" to two or more of the four CAGE questions then the employment counselor is required to make a referral to the social worker. The client may chose not to participate in mental health services.
  • Conciliation Process and Time Limit Extension Reviews. If a client is not participating in program activities or is nearing their time limit, a social worker may be included in case staffings and recommend social work services.

Types of mental health services provided. Once clients are identified and referred to mental health services, they are given an appointment with a social worker. The types of services social workers provide are described below.

  • Clinical Assessments. A primary function of the social worker is to provide clinical assessments. Most social workers use mental health inventories in their clinical assessments, but they vary in the types of inventories they chose to use. The inventories selected typically detect mental health conditions, such as clinical depression, generalized anxiety, personality disorders, and suicide risk. Assessments are performed at the DWS office, in clients' homes, or at other locations convenient to clients. Summaries of the assessments are distributed to the employment counselors to assist them in negotiating realistic and effective employment plans with their clients. The more detailed clinical assessments are shared with the Medicaid or contracted treatment provider.
  • Link Clients to Mental Health Treatment. Social workers have two different options for linking clients with mental health treatment. First, social workers may refer clients to the local Medicaid provider. The Medicaid mental health provider is used for all clients needing long-term treatment or medication management. The social workers facilitate the process of accessing treatment through the Medicaid provider. On average, clients may wait up to one month to see a therapist from the Medicaid provider. Social workers can typically get a client into treatment with the Medicaid provider in less time. In cases where TANF recipients would be required to wait longer than 10 days for treatment or where clients would benefit from a particular treatment(25), social workers may refer clients to a contracted treatment provider in the area. The contracted service providers offer outpatient individual and group treatment as well as psychological assessments. Therapy is short-term and focused on helping the client meet employment goals.
  • Crisis Intervention. Social workers deal with immediate crises among clients. Social workers help to stabilize clients and link them with inpatient or crisis intervention treatment.
  • Short-Term Therapy. In some offices social workers will conduct short-term therapy with clients who have less severe mental health treatment needs. Typically, treatment lasts 6 to 10 sessions and is focused on helping clients become more employable.
  • Consultant/Resource for Employment Case Managers. Based on the assessment, social workers makes treatment recommendations and general recommendations regarding other barriers or issues identified during the clinical evaluation process. Employment case managers report that they often rely on the clinical expertise of the social workers in making decisions about the types of activities and amount of hours they should include in clients' self-sufficiency plan. Social workers may also provide guidance to employment counselors for strategies in interacting with the customer and may provide in-house training. Social workers in all the employment centers frequently participate in case staffings.

The relationship between mental health services and work requirements. DWS administrators allow case managers flexibility in deciding the types of activities and participation hours required of clients. In the client's self-sufficiency plan, the employment counselors can include any activity, including mental health, that will help the customer become employed. The 36-month time clock does not stop for clients participating in mental health treatment, but clients may receive an extension for a mental health or physical health condition, a substance abuse problem, or other severe barriers to work. Extensions are determined at 32 months during a mandatory extension review with the client, employment counselor, supervisor, and social worker. Extensions are conditional on clients participating in program activities. Extensions are reviewed monthly.

Administrative structure. All social work services staff are DWS state employees. There is a state social work program manager who implements, administers, and monitors the social work services and acts as a liaison to coordinate social work services among employment center administrators. The program manager also negotiates and monitors the social work treatment provided by the mental health treatment contractors. The social workers are typically licensed clinical social workers (LCSWs) with extensive experience in providing clinical treatment. Social workers may also be experienced bachelor's level staff members, certified social workers with a master's of social work degree or interns(26) that are supervised by an LCSW.

Funding mental health services. Federal TANF and state maintenance of effort funds pay for mental health services administrative staff, DWS social workers and contracted mental health treatment services. Statewide, approximately, $1.2 million is allocated for social work services staff and $456,000 for contracted mental health treatment. The majority of nonmedical mental health treatment is paid for with Medicaid funds. All medical-related services are covered through Medicaid.

For additional information please contact:

Dan Thornhill
Manager, Social Work Services
Utah Department of Workforce Services
Phone: (801) 526-9767
E-mail: dthornhi@ws.state.ut.us

Endnotes

17.  For the child or anyone in the household that meets the income eligibility requirements.

18.  DCF is responsible for the state's economic and self-sufficiency, family safety system, mental health and substance abuse services and adult and developmental services.

19.  The Office of Economic Self-Sufficiency is responsible for determining eligibility for TANF and other public assistance programs for low-income families.

20.  In Oregon, a client not participating in an individualized work plan can not receive cash assistance for more than 24 months out of 84 months. The time limit applies only to nonparticipating clients.

21.  AFS operates Oregon's welfare programs, which has a strong emphasis on employment and work supports.

22. Tennessee developed the Families First program in 1995. The program emphasizes education and training for families on cash assistance to move them toward self-sufficiency. Since the implementation of Families First, there has been a 38 percent reduction in the number of families receiving cash assistance, from 91,499 in 1996 to 56,690 in 2000.

23.  TennCare is Tennessee's Medicaid program.

24.  In 1996, the SPED program was expanded statewide and renamed the Family Employment Program (FEP).

25.  For example, clients with PTSD are frequently referred to the Trauma Awareness and Treatment Center, an agency that specializes in treatment for survivors of physical and sexual abuse.

26.  There are 20 social workers and 6 interns across the state for 2001. DWS has an arrangement with the Graduate School of Social Work at the University of Utah to provide clinical internships to master's of social work students in local employment centers.

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