Jon Morgenstern1, Annette Riordan2, Barbara S. McCrady3,
Katharine H. McVeigh3, Kimberly A. Blanchard1, Thomas W. Irwin1
1Mount Sinai School of Medicine
2New Jersey Department of Human Services
Many of the families remaining on welfare caseloads face significant barriers to employability. Among the most significant of these is substance abuse. States are struggling to develop innovative strategies to effectively address substance abuse in the context of welfare reform. Some states have attempted to integrate substance abuse treatment into their welfare employment programs, but there are almost no data to guide states about what program features are most effective. One central problem any system will need to address is the difficulties most substance abusers have in entering and remaining in treatment. Studies have consistently demonstrated that those receiving substance abuse treatment have better employment outcomes (Nakashian & Moore, 2000), but it is necessary for clients to remain in treatment in order to achieve these effects (Wickizer et al, in press).
The purpose of this report is to present preliminary findings of a study conducted in New Jersey comparing the rates of entry and retention in substance abuse treatment for two contrasting intervention approaches: Care Coordination and Intensive Case Management. Preliminary findings clearly indicate the benefits of providing intensive case management services over a more limited triage and referral system. Clients referred to substance abuse treatment programs using the Intensive Case Management approach were much more likely to enter substance abuse treatment and were especially more likely to continue attending outpatient treatment sessions.
Care Coordination used a set of strategies similar to those of innovative programs currently being implemented in several states, including New Jersey. Welfare recipients were screened for substance abuse problems by caseworkers in welfare offices. Women screening positive were interviewed in welfare offices by specially trained addiction counselors to determine the need for substance abuse treatment and to coordinate treatment, if needed. Treatment coordination included arranging an initial appointment with a treatment program and subsequent utilization review. The alternative approach, Intensive Case Management, combined several strategies thought to be effective in enhancing substance abuse treatment retention and improving outcomes. In Intensive Case Management, welfare recipients screening positive and needing treatment were assigned to a case management team. In the initial phase of the intervention, case managers identified and attempted to resolve barriers to entering and remaining in treatment. Typically, these involved tangible barriers such as childcare or transportation and psychological barriers such as a client's denial that they needed treatment. In addition, clients in ICM received small incentives in the form of vouchers for attending treatment.
An initial cohort of 146 female TANF recipients screened positive for substance abuse and were determined to need treatment. These women were randomly assigned to Care Coordination (CC) or Intensive Case Management (ICM) and their attendance in substance abuse treatment was monitored over several months. ICM was significantly more effective than CC in facilitating treatment entry: 88% of clients in ICM entered substance abuse treatment versus 65% in CC (p < .001). Differences were especially marked for outpatient treatment: 86% of clients in ICM entered outpatient treatment versus 53% in CC. In addition, ICM was significantly more effective in retaining clients in treatment. Clients in ICM attended 42% of the days they were assigned to treatment versus 22% of days for clients in CC (p < .0001). Again, differences were especially marked for outpatient treatment. On average, ICM clients attended about five times more outpatient sessions (M=29.7, SD=30) than clients in CC (M=6.6, SD=13).
Although both CC and ICM appear to be useful strategies to integrate substance abuse treatment into welfare programming, preliminary findings clearly indicate the benefits of providing intensive case management services over a more limited triage and referral system. Intensive case management significantly increased rates of engagement in substance abuse treatment, especially outpatient care. Rates for outpatient treatment entry and retention in CC were low. For example, only 38% of CC clients attended more than 2 sessions of outpatient treatment. These figures raise concern because many states are relying on triage and referral systems like CC to enhance engagement in substance abuse treatment for welfare recipients. Findings indicate that intensive case management interventions are effective in lowering barriers to treatment engagement. Further study is clearly needed to examine rates of engagement in substance abuse treatment for welfare recipients in other systems. Study details are provided below.
Background and Rationale
Studies suggest a high prevalence of substance abuse among women receiving public assistance, with some studies reporting rates as high as 27-39% (CSAT, 1996; Klein et al., 1998; Sisco & Pearson, 1994). Substance abuse among parenting women has long been identified as a major public health problem (e.g. Reed, 1985). However, as states implement welfare reform attempts to address this problem take on greater urgency. States have adopted strict new work requirements and time limits on receipt of welfare benefits. Substance abusers face substantial barriers to employability. Most will require effective substance abuse treatment and additional services to address associated problems such as low basic skills, housing, mental health disorders, and domestic violence (Pavetti et al., 1997).
Studies have consistently shown that substance abuse impairs work performance and those receiving substance abuse treatment have better employment outcomes (Nakashian & Moore, 2000). For example, Wickizer et al. (in press) studied 5,664 substance abusing welfare recipients in Washington State. Recipients who remained in treatment were 25% to 100% more likely to become employed than those who did not receive treatment or dropped out of treatment early. Thus, research findings support the recommendations of treatment professionals that engaging clients in substance abuse treatment is critical to the process of promoting self-sufficiency.
States are struggling to develop innovative strategies to effectively address substance abuse in the context of welfare reform. A number of states have implemented systems to integrate substance abuse treatment into welfare-to-work programs. Typically these systems involve an expansion of funding for substance abuse treatment, screening for substance abuse within welfare contexts, triage and referral of recipients with problems to substance abuse treatment, and coordination of treatment with employment programming.
These approaches represent great strides in reducing the fragmentation that has existed between welfare and substance abuse treatment services, but continue to rely on the existing structure of substance abuse treatment. However, the literature is consistent in suggesting that the current structure of substance abuse treatment is poorly matched to the needs of disadvantaged, parenting women (e.g. Brindis et al., 1997; Gustavson & Rycraft, 1993). A primary concern has focused on issues of treatment engagement. Parenting women experience tangible (e.g., lack of child care) and psychological (e.g. denial of problems) barriers to entering treatment. In addition, parenting women present with an array of problems not addressed by substance abuse treatment programs. Recommendations for improving outcomes have focused on lowering treatment barriers and providing more comprehensive and coordinated care. Studies have suggested that augmenting existing substance abuse treatment with intensive case management services might improve treatment engagement and outcome (Laken & Ager, 1996). In addition, contingency management such as providing incentives to reinforce treatment tasks has improved outcomes over usual care (Iguchi et al., 1997).
Overall, the literature suggests that implementing a triage and referral system to coordinate care across welfare and treatment might not be sufficient to effectively address substance abuse among women on welfare and that a more comprehensive and intensive set of services may be needed. However, no studies have examined which approach would be most effective or determined their relative costs. In order to address this issue, officials at the New Jersey (NJ) Department of Human Services partnered with scientists from Mount Sinai School of Medicine and Rutgers University to design and implement a welfare demonstration project. The primary aim of this project is to evaluate the effectiveness and cost of two contrasting approaches to address substance abuse problems among women on welfare. One approach, Care Coordination (CC), represents the standard of care currently available in NJ to address substance abuse in welfare settings. The alternative approach, Intensive Case Management (ICM), augments standard care by adding intensive case management services and contingency interventions. This report provides preliminary outcomes on rates of engagement in substance abuse treatment for an initial cohort of participants.
The following section provides a brief description of study methods. Additional details are available from the study authors.
The sample was a preliminary cohort of 146 women who were recruited into the study between September 1999 and July 2000. Selection criteria were designed to identify a sample of women receiving TANF benefits who were required to engage in employment activities and met criteria for a substance use disorder. Women on or requesting methadone maintenance treatment were excluded. A preliminary descriptive profile indicated that on average women were in their mid-thirties, were mothers to about 3 children, a little less than half had completed high school, and most were African-American. More than half reported a primary problem with either opiates or cocaine, most had been using substances regularly for several years, and about half had received prior substance abuse treatment.
Women were screened by caseworkers at local welfare offices using a brief nine item screening measure that assesses the presence of alcohol and other drug use problems, the CAGE-AID (Brown, 1992). Those whose screening results suggested a substance use disorder (screened positive) were referred to specially trained addiction counselors who completed a comprehensive assessment using a standardized battery of measures. Constructs assessed included substance use diagnoses, the American Society of Addiction Medicine (ASAM) Patient Placement Criteria, and need for services in a variety of domains. Women who met study criteria were then randomly assigned to one of two intervention conditions: CC or ICM. Very few women (less than 5%) refused study participation. Thus, it appears that the sample is representative of women on welfare who screen positive for substance abuse in a welfare setting and require, although not necessarily request, substance abuse treatment. Treatment programs provided attendance data on participants at least every other week.
Women randomized into CC met with a masters level addiction counselor who reviewed with the client the need for substance treatment and the type of treatment (e.g. inpatient) that was recommended. In addition, the counselor reviewed NJ welfare work requirement regulations and time limit statutes. According to these regulations women neither attending treatment nor engaged in a work activity were subject to benefit sanction. Initial appointments were scheduled with treatment facilities. Counselors contacted the treatment program regularly to review client's progress and authorize additional treatment. For clients failing to attend a first session, outreach was limited to several phone calls and letters. Women randomized to ICM met with a pair of case managers. In the first phase of ICM, case managers identified tangible barriers to treatment entry such as childcare, transportation, and housing problems and provided needed services. In addition, case managers addressed client's resistance to enter treatment using motivational counseling strategies. If needed, case managers engaged in extensive outreach efforts including home visits and contacting family members. Once clients entered treatment, case managers assisted treatment programs in coordinating needed services and met with clients weekly. Clients also received incentives for attending treatment in the form of vouchers that could be used to purchase certain items such as children toy's or cosmetics.
Outcome time frames for this report varied from 4 weeks to 53 weeks depending on the date of participant recruitment. On average, the outcome period was 21 weeks. t-tests and chi-square analyses were used to test for differences between intervention conditions. ICM was significantly more effective than CC in facilitating treatment entry: 88% of clients in ICM entered substance abuse treatment versus 65% in CC (p < .001). Overall, 46% of the sample was assigned to receive inpatient treatment: either detoxification or brief residential treatment. ICM and CC did not significantly differ in rates of entry to inpatient treatment (78% versus 69%). All participants were assigned to outpatient treatment either directly or following inpatient care. Differences were significant for outpatient treatment: 86% of clients in ICM entered outpatient treatment versus only 53% in CC (p < .001).
In addition, ICM was significantly more effective in retaining participants in treatment. Clients in ICM attended 42% of the days they were assigned to treatment versus 22% of days for clients in CC (p < .0001). Differences were especially marked for outpatient treatment. On average, ICM clients attended about five times more outpatient sessions (M=29.7, SD=30) than clients in CC (M=6.6, SD=13). Differences were significant even when comparing only clients who entered outpatient treatment: ICM clients attended M=34.5 (SD=29) sessions, versus M=12.3 (SD=15.7) for CC clients (p < .0001).
CC and ICM appear to be useful strategies to integrate substance abuse treatment into welfare programming. For example, 65% of clients in CC entered treatment after receiving an evaluation and referral. At the same time, intensive case management was significantly more effective than a triage and referral system in engaging clients in substance abuse treatment. Significant differences occurred in outpatient treatment. Rates of entry and engagement in outpatient treatment appeared low in CC. About half of CC participants (47%) did not attend a single outpatient session and only 38% attended more than 2 sessions of outpatient treatment. These low rates occurred even though about half of CC clients were assigned to an episode of inpatient care before being referred to an outpatient program. ICM was more effective in getting participants to attend a first session and remain in outpatient treatment once they began.
Findings strongly support the literature indicating that standard substance abuse treatment may be poorly matched to the needs of disadvantaged parenting women, but that augmenting services through case management can substantially increase treatment engagement. Results are preliminary and future reports will present more sophisticated methods of analysis and other outcomes such reduction in substance abuse and increases in employment.
Brindis, C.D., Berkowitz, G., Clayson, Z., & Lamb, B. (1997). California's approach to perinatal substance abuse: Toward a model of comprehensive care. Journal of Psychoactive Drugs, 29: 113-122.
Brown, R.L. (1992). Identification and office management of alcohol and drug disorders. In M.F. Fleming, K.L. Barry (Ed.s). Addictive Disorders, (25-43). St. Louis: Mosby Year Book.
Center for Substance Abuse Treatment. (1996). Alcohol and Other Drug Treatment: Policy Choices in Welfare Reform. Report in collaboration with NASADAD. Washington, DC: U.S. Government Printing Office.
Gustavson, N.S. & Rycraft, J.R. (1993). The multiple service needs of drug dependent mothers. Child and Adolescent Social Work Journal, 10(2): 141-151.
Iguchi, M.Y., Belding, M.A., Morral, A.R., Lamb, R.J. & Husband, S.D. (1997). Reinforcing operants other than abstinence in drug abuse treatment: An effective alternative for reducing drug use. Journal of Consulting and Clinical Psychology, 65: 421-428.
Kline, A., Bruzios, C., Rodriguez, G. & Mammo, A. (1998). Substance Abuse Needs Assessment Survey of Recipients of Temporary Assistance for Needy Families (TANF). Trenton, NJ: New Jersey Department of Health.
Laken, M.P. & Ager, J.W. (1996). Effects of case management on retention in prenatal substance abuse treatment. Journal of Drug & Alcohol Abuse, 22: 439-448.
Nakashian, M. & Moore, A.E. (2000). Identifying Substance Abuse Among TANF-Eligible Families. Washington, DC: Center on Substance Abuse Treatment.
Pavetti, L., Olson, K., Pindus, N. & Pernas, M. (1997). Designing Welfare-to-Work Programs for Families Facing Personal or Family Challenges: Lessons From the Field. Washington, DC: The Urban Institute.
Reed, B.G. (1985). Drug misuse and dependency in women: The meaning and implications of being considered a special population or minority group. International Journal of the Addictions, 20: 13-62.
Sisco, C.B. & Pearson, C.L. (1994). Prevalence of alcoholism and drug abuse among female AFDC recipients. Health & Social Work, 19: 75-77.
Wickizer, T., Campbell, K., Krupski, A. & Stark, K. (In Press). Does substance abuse treatment improve employment outcomes for welfare recipients? Evidence from Washington state. Health Affairs.
|Support for this study was provided by the National Institute on Drug Abuse, the Administration for Children and Families, the Assistant Secretary for Planning and Evaluation, and the Annie E. Casey Foundation.|
Correspondence to:Jon Morgenstern, Ph.D.
Associate Professor of Psychiatry and Health Policy
Mount Sinai School of Medicine
One Gustave L. Levy Place, Box 1230
New York, NY 10029-6574
Tel (212) 659-8722