As welfare caseloads decline, states increasingly are faced with the challenge of addressing the needs of hard-to-serve families who experience a variety of barriers to employability. Substance abuse is one of the major problems affecting hard-to-serve families. Since welfare reform was adopted, estimates suggest that 15% to 35% of welfare recipients have a substance abuse problem. Although substance abuse among welfare recipients is thought to be a prevalent and serious problem, it is widely recognized that individuals with substance use disorders often fail to acknowledge that they have a problem or seek treatment. Therefore, developing effective screening, identification, and referral strategies are necessary components of any state plan to address substance abuse among welfare recipients.
The purpose of this report is to describe results of two approaches to screening for substance abuse among TANF recipients in New Jersey (NJ). Results of this report suggest that a generic approach to screening in welfare settings one that relies primarily on caseworkers administering paper and pencil measures as part of benefit eligibility determination is useful, but that specialized screening programs can substantially increase case identification rates. This study employed a program evaluation rather than an experimental design. Specifically, the first approach was implemented and outcomes were monitored. Based on an evaluation of these findings, a second approach was designed and implemented in an attempt to boost case identification rates. The first approach was implemented statewide in NJ beginning in 1998. In this approach, welfare caseworkers administered a brief paper and pencil measure to screen for alcohol and other drug use problems to all individuals being interviewed for initial or redetermination of TANF benefits. Those screening positive were then referred to a specially trained addiction counselor for further assessment. This approach is similar to that used by most states (e.g., California, Kansas, New York) attempting to implement innovative programs to address substance abuse among welfare recipients. The key features of this typical approach are: front-line caseworkers conduct the screening, screening occurs for all recipients at the point of benefit determination, and there is a reliance on paper and pencil screening measures. We label this approach "generic screening."
The generic screening approach has yielded disappointing results. Only about 1% of the welfare caseload in NJ received a referral for substance abuse assessment during the first six months of program operation. Referral rates increased to 4.4% in the succeeding 12 months, but these rates are much lower than estimates of 20%-30% prevalence rates for substance abuse reported in a study of NJ welfare recipients (Klein et al., 1998). Other states using the generic approach have reported similarly low rates of identification (Health Systems Research, 1999; Nakashian & Moore, 2000).
The second approach is "specialized screening." Specialized screening is designed to augment, but not replace generic screening. There are three key features of specialized screening: high-risk populations (those among welfare recipients who are most likely to have a substance abuse problem) receive more intensive screening, screening is conducted by specially trained staff, and interview methods are used to establish rapport and facilitate self-disclosure.
Two specialized screening programs were implemented. In one program, all sanctioned clients in one NJ county were required to be assessed by an addictions counselor as part of the process of restoring benefit eligibility. Results indicated that 49% or about half of sanctioned clients who were interviewed met criteria for a substance use disorder. A second specialized screening program was implemented in the NJ county with the largest caseload. Two welfare caseworkers with a special interest in helping substance abusers were assigned to conduct specialized screening interviews. These caseworkers interviewed high-risk clients such as those requesting emergency assistance or clients responding positively to items on a paper and pencil screening measure. Results suggest that this specialized screening program was effective. The rate of referrals for substance abuse assessments in this county was 10.3% versus 4.4% for other NJ counties during the same time period. Thus, specialized screening appeared to more than double the rate of referral for assessment.
Overall, results of this report suggest that a generic approach to screening in welfare settings one that relies primarily on caseworkers administering paper and pencil measures as part of benefit eligibility determination is useful, but that specialized screening programs can substantially increase case identification rates. The finding that 49% of sanctioned clients interviewed met criteria for a substance use disorder is notable because it suggests that the prevalence of substance abuse among clients failing at work activities may be especially high. This study did not employ an experimental design. Thus, although findings are promising, causal inferences about the effectiveness of specialized screening approaches have not been established. Further details of the study are provided below.