Michelle K. Derr
|Prepared for and submitted to: |
Department of Health and Human Services
Assistant Secretary for Planning and Evaluation
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20024
Project Officer: Elizabeth Lower-Basch
|Submitted by: |
Mathematica Policy Research, Inc.
600 Maryland Avenue, SW
Washington, DC 20024
MPR Reference No.: 8736-403
Project Director: LaDonna Pavetti
The acronyms listed below are used throughout this report.
AFDC: Aid to Families with Dependent Children
AFS: Adult and Family Services
AWI: Agency for Workforce Innovation
CAGE: CAGE comes from the four-question substance abuse screening questionnaire used in Utah: Have you ever felt the need to Cut down on your using/doing? Have you ever felt Annoyed by people complaining about your drinking? Have you ever felt Guilty about your drinking? Do you ever drink an Eye-opener in the morning to relieve the shakes?
CalWORKs: California Work Opportunity and Responsibility to Kids Program
DCF: Department of Children and Families
DHS: Department of Human Services
DWS: Department of Workforce Services
FCS: Family and Children's Services of Greater Chattanooga
FSC: Family Services Counseling
LCSW: Licensed Clinical Social Worker
MPR: Mathematica Policy Research
MSW: Master's in Social Work
OFS: Office of Family Support
OPS: Other Personnel Services
PRWORA: Personal Responsibility and Work Opportunity Reconciliation Act of 1996
PTSD: Post-traumatic Stress Disorder
SAMH: Substance Abuse/Mental Health
SPED: Single-Parent Employment Demonstration
SSDI: Social Security Disability Insurance
SSI: Supplemental Security Income
TANF: Temporary Assistance for Needy Families
UT: University of Tennessee
This report would not have been possible without the cooperation we received from a variety of program administrators and agency staff. Mental health services program administrators Celia Wilson, Florida; Christa Sprinkle and Carol Krager, Oregon; Holly Cook, Tennessee; and Dan Thornhill, Utah, provided us with an overview of mental health services in their respective states and described their experience and the lessons they learned in designing and delivering these services. Administrators from the welfare office helped us to understand the general welfare environment in which mental health services are provided and how mental health and employment services are integrated. Mental health staff described the types of mental health conditions they see in their clients and shared with us even the smallest details involved in mental health services. Employment staff from the welfare office explained how they identify and refer clients to mental health services and how they monitor client participation in treatment. They also described the benefits of mental health services from the perspective of client employability. Administrators from community mental health agencies took time out of their busy schedules to talk with us about the types of mental health treatment available to welfare recipients and about their general perception of the program in their area.
The authors would also like to thank the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE). Martha Ross developed the project and contributed to its overall design. Elizabeth Lower-Basch, our project officer, also played an active role in shaping this project and helped us produce a report that we hope will be useful to program administrators and other individuals interested in learning about mental health services for welfare recipients. We also appreciate the thorough reviews that Nancye Campbell at the Administration for Children and Families and Evvie Becker at ASPE gave to this report. Their knowledge of the mental health and welfare systems have added a great deal to the overall quality of this report.
At Mathematica Policy Research, LaDonna Pavetti, project director, provided valuable guidance and helped to conceptualize this study and the final report. Henry Ireys, who has extensive experience in mental health treatment systems, reviewed several drafts of this report. Debbie Draper carefully reviewed an earlier draft and offered valuable suggestions. Donna Dorsey provided administrative support for the project, and Daryl Hall and Bernard Adelsberger provided editorial support.
The authors gratefully acknowledge these many contributions and accept sole responsibility for any errors that remain.
Introduction and Overview of the Study
Recent changes in federal and state policy reflect a dramatic shift in the nation's approach to supporting the income of poor Americans and improving their labor force participation. Before the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) was passed, poor families were entitled to cash grants through the Aid to Families with Dependent Children (AFDC) program as long as their income and assets remained below a specified level and they met procedural requirements. In 1996, AFDC was replaced by the newly created Temporary Assistance for Needy Families (TANF) program, which sets a lifetime limit on benefit receipt and emphasizes employment over public assistance as the primary means of support for poor families. In response to time limits and steadily increasing work participation requirements, most state TANF programs encourage participants to find employment as quickly as possible.
Unlike the legislation governing previous welfare employment programs, which were designed to serve a small share of families receiving cash assistance, PRWORA created new expectations and opportunities for nearly all poor families seeking government assistance, including individuals with behavioral or emotional disorders that can create formidable barriers to employment. In the past, such families were rarely required to participate in employment programs. As a result, few states had strategies in place to assist clients with significant barriers to employment. While efforts to address the needs of these individuals are still in their infancy, far more programs are in place today than before the advent of welfare reform.
It is estimated that between one-fourth and one-third of welfare recipients have a serious mental health condition that could affect their ability to find and/or maintain employment (Sweeney 2000). While mental health conditions represent only one of the many personal and family challenges faced by TANF recipients in search of work, the number of recipients affected by mental health conditions is large enough and the identification and treatment of such conditions is specialized enough to have attracted the attention of researchers and policymakers as well as practitioners and program administrators.
In this report, we profile the efforts of four statesВ В Florida, Oregon, Tennessee, UtahВ В to address the mental health needs of welfare recipients. The report is based on findings from a study conducted by Mathematica Policy Research (MPR) for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. The study was designed with three purposes in mind: (1) to describe in detail the design and structure of mental health services developed by state and local welfare offices(1) to address the mental health needs of welfare recipients, (2) to highlight different service delivery options in designing and implementing these services, and (3) to discuss the key challenges and lessons learned in providing mental health services to welfare recipients.
By highlighting the key choices involved in integrating mental health services into a work-oriented welfare system, this report offers practical guidance to program administrators who are interested in addressing the mental health needs of TANF recipients or other low-income families. It is not intended to prescribe a model for providing mental health services to welfare recipients. As shown in Table I.1, we identified seven key dimensions that define the study states' approaches to the mental health needs of welfare recipients:
- the types of mental health services provided,
- the target population,
- the range of needs addressed,
- strategies for identifying clients in need of mental health services,
- the integration of mental health services into TANF employment plans,
- the administrative structure for delivering services, and
- the approach to funding mental health services.
|Types of mental health services provided||Screening and assessment Linking clients to existing treatment Expansion of existing mental health services Intensive case management||Screening and assessment
Linking clients to existing treatment
Short-term mental health counseling (crisis intervention only)
Training/consultation for employment case managers
Intensive case management
Assistance in applying for SSI
|Screening and assessment
Linking clients to existing treatment
Short-term mental health counseling
Training/consultation for employment case managers
Intensive case management
Assistance in applying for SSI
|Screening and assessment
Linking clients to existing treatment
Short-term mental health counseling
Expansion of existing mental health services Training/consultation for employment case managers
Intensive case management
Assistance in applying for SSI
|Target population||Low-income families with incomes below 200 percent of poverty||Adults on TANF||Adults and children on and transitioning off TANF||Adults on and transitioning off TANF|
|Range of service needs addressed||Mental health
Child behavioral problems
|Strategies for identifying clients with mental health conditions||Formal presentations
Referrals by employment case managers
|Formal presentations Broad screenings
Referrals by employment case managers
|Formal presentations Broad screenings Referrals by employment case managers
Automatic referrals to mental health services (sanctions)
|Referrals by employment case managers
Automatic referrals to mental health services (sanctions and time limits)
|Integration of mental health services into employment plans||Up to 5 hours of mental health services per week in work plan||Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services)||Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services)||Modified work plans (Flexibility in types of activities and hours for clients participating in mental health services)|
|Agencies administering and providing mental health services||Mental health & substance abuse program offices
Contracted service providers
|Local employment service providers and welfare offices
Contracted service providers
|University of TN
Contracted service providers
|State welfare agency Contracted mental health service providers (minimal)|
|Funding Approach||$45 million statewide
|Varies by district
No designated funding, included in funding for
|$8 million statewide
|$1.7 million statewide
Designing programs to address the mental health needs of welfare recipients is a complex endeavor. Program design decisions made in one area may influence the design of other program dimensions. For example, programs that address a variety of barriers such as mental health, substance abuse, learning disabilities, and domestic violence require an administrative structure and staff skills that differ from programs that address mental health conditions exclusively. In weighing potential approaches to address the mental health needs of welfare recipients, careful consideration needs to be given to each key program dimension and how it might influence the overall approach to providing services.
In this introductory chapter, we discuss the context for this study, the prevalence and types of mental health conditions among welfare recipients, and how mental health conditions affect employment. We also describe the study, including our general approach to the work, the selection of the study sites, and the data collection procedures. Chapter II covers key program design issues, including how to define the types of services to be addressed and how to identify clients with mental health conditions. Chapter III discusses the key decisions involved in building an infrastructure to provide services, that is, deciding who will provide and administer services and how the services will be funded. Chapter IV highlights the issues involved in implementing mental health services for welfare recipients, and Chapter V summarizes the lessons learned from this early look at programs designed to address the mental health needs of TANF recipients. Appendix A includes a detailed description of each study site, and Appendix B provides contact information for obtaining copies of the program forms, including the screening and assessment tools used in the study states.(2)
Context for the Study
PRWORA gave states considerable flexibility in deciding how to spend their TANF block grant funds. States may use TANF funds to provide nonmedical mental health treatment services for welfare recipients and other low-income families at risk for TANF involvement. Such services might include specialized short- or long-term counseling services, or outreach, assessment, and case management intended to link clients to existing mental health services. In addition, TANF funds can be used to expand the capacity of treatment providers as long as the expansion covers only nonmedical services and is targeted to families who are eligible for TANF-funded services. States can also use funds from the Welfare-to-Work grants program to provide mental health services, although there are more constraints on who can be served with these funds.
Most welfare recipients qualify for Medicaid, so they can access mental health treatment through Medicaid-funded providers. While some TANF recipients may be receiving services through these providers, others may not know how to access such services, while still others may not be aware that they have a mental health condition. The flexibility of TANF allows states to fund efforts designed to identify clients in need of services and link them to existing Medicaid-funded mental health services. It is also possible that TANF recipients need services not easily accessed or offered by a Medicaid provider. Program administrators could address these needs by using TANF funds to expand existing services or to provide services not currently offered by Medicaid providers. The drawback is that TANF funds now available for mental health services may shrink as a result of either the outcome of the reauthorization debate or a downturn in the economy. (The latter would force states to use the funds to provide cash assistance and employment services to the families moving onto welfare because of the downturn.)
The states profiled in this report are leading the development of innovative approaches to providing mental health services to TANF recipients. In all of the approaches, existing services have been augmented, not replaced. In addition, all of the states have used TANF funds to identify recipients in need of mental health services and to link them with these services. Two of the states have created specialized mental health services that are delivered within the welfare system, and two have expanded the capacity of existing providers to serve TANF recipients or TANF-eligible families.
Medicaid-Funded Mental Health Treatment Providers
In most states, Medicaid covers a basic range of services for treating mental health conditions, such as individual or group therapy, crisis intervention, psychiatric evaluations, medications, day treatment, and inpatient care. States decide not only the type of Medicaid-funded mental health benefits, but also the amount, scope, and duration of benefits. In general, the type and amount of treatment for those accessing Medicaid often are more restricted than for those with private health insurance.
Within each community are Medicaid-funded mental health treatment providers, which are any mental health agency where welfare recipients can access mental health treatment using Medicaid assistance. Access to treatment through Medicaid-funded service providers tends to vary within and between states. For example, in some areas, frequent staff turnover and a limited number of staff have created difficulties in accessing treatment at the Medicaid service provider.
For TANF recipients referred to the Medicaid treatment providers, the treatment typically has a short-term orientation and tends to be provided in groups rather than individual therapy. Clients who are seen individually may be scheduled for treatment every other week. In addition, therapy may be geared toward those with diagnosable mental disorders, which may not include all TANF recipients referred to mental health services.
The advantage to using the Medicaid managed care providers for treatment is that state Medicaid funds can be used to draw down federal matching funds to help share the cost of treatment. This allows TANF funds to be used for other purposes. The drawback to using Medicaid treatment providers is that the types and amount of treatment are often restricted and, in some areas, clients have difficulty accessing treatment.
Rationale for Integrating Mental Health Services into TANF Programs
Although most states have made significant progress in moving families off welfare and into the labor force, many families continue to receive cash assistance. While some of these families are new to the TANF system, many have been receiving assistance for some time and may therefore be at risk of losing cash assistance due to approaching time limits. As legislators and TANF administrators assess the progress that has been made since the passage of welfare reform, it is becoming apparent that some individuals, especially those with mental health conditions, may need more job-related assistance than most welfare employment programs are designed to provide. Because mental health conditions are more common among low-income families in general and welfare recipients in particular than they are among the general population, addressing the mental health needs of welfare recipients is a priority for many program administrators. The goal of providing services to these individuals is to increase the likelihood that they will be able to make the transition from welfare to work and remain employed.
Higher-Than-Average Incidence of Mental Health Conditions among Low-Income Families and Certain Minority Groups
According to a report by the U.S. Surgeon General (1999), low-income families and certain minority groups have higher-than-average rates of mental disorders. Those in the lowest socioeconomic group are about two-and-a-half times more likely to have a mental disorder than those in the highest socioeconomic group (Holzer et al. 1986, Regier et al. 1993). In a study of mental health conditions among single mothers, Jayakody and Stauffer (2001) found that single mothers have significantly higher rates of psychiatric disorders than do married mothers, and that low-income single mothers and those receiving cash assistance have even higher rates of psychiatric disorders than do single mothers who earn more than $20,000 a year. In a review of depression and low-income women, Lennon et al. (2001) reported that the rates of depression among low-income families are approximately twice those in higher-income families. Poor women particularly those who have been exposed to traumatic experiences such as childhood abuse, domestic violence, rape, and other criminal behaviors are at even greater risk for mental health problems (Bassuk, Browne, and Buckner 1996; Bassuk et al. 1996; Brooks and Buckner 1996; Miranda and Green 1999).
African Americans and Native Americans also have higher rates of mental health conditions compared to whites. However, some researchers argue that most of these differences can be attributed to disparities in socioeconomic status (U.S. Department of Health and Human Services 1999). There are fewer differences in the rates of mental disorders between whites and other ethnic groups.
Though there are few differences in the overall rates of mental illness between men and women, women are more prone to certain mental health conditions such as depression, post-traumatic stress disorder (PTSD), and anxiety disorders (Ulbrich et al. 1989, McLeod and Kessler 1990, Turner et al. 1995, Miranda and Green 1999). It is estimated that the rate of depression among women is 1.5 to 3 times the rate among men (Lennon et al. 2001).
Higher-Than-Average Incidence of Mental Health Conditions among Welfare Recipients
Compared to the general population, welfare recipients have higher-than-average rates of mental health conditions (see Table I.2). Approximately 6.5 percent of the general population is diagnosed with major depression in a given year. Fewer individuals are diagnosed with PTSD (3.6 percent) or generalized anxiety disorder (3.4 percent) (U.S. Department of Health and Human Services 1999).
|Disorder||U.S. General Adult Population||Female Welfare Recipients in Michigan||Long-Term Welfare Recipients in Utah|
|Post-Traumatic Stress Disorder||3.6%||14.6%||15.1%|
|Sources: U.S. Department of Health and Human Services (1999), Danziger et al. (1999), Barusch et al. (1999).|
There is wide variation in the reported rates of mental health conditions among welfare recipients. Estimates differ depending on how mental health conditions are defined and measured, and by the population studied. In the National Survey of America's Families, 35 percent of low-income families reported having poor mental health using scales measuring anxiety, depression, loss of emotional control, and psychological well-being (Zedlewski 1999). Researchers in Michigan found similar rates of mental health conditions (36 percent) among welfare recipients (Danziger et al. 1999). In a look at the prevalence of mental health, substance abuse, and domestic violence issues among California's CalWORKs participants, Chandler and Meisel (2000) found that more than one-third of these individuals had at least one diagnosable mental disorder in the previous 12 months, and about 20 percent had two or more. Of those with a mental disorder, more than one-fourth indicated their disorder interfered "a lot" with life or daily activities.
Major depression is the most common mental disorder among welfare recipients, followed by PTSD and generalized anxiety disorder. The prevalence of depression is startlingly high. In a Michigan study of barriers to employment faced by female welfare recipients, 27 percent of the study sample screened positive for clinical depression (Danziger et al. 1999). Researchers in Utah, using the measure for depression used in the Michigan study, found that 42 percent of long-term welfare recipients in Utah had clinical depression in the year before the interview (Barusch et al. 1999). This rate is nearly seven times that of the general adult population. Barusch et al. also found that 57 percent of these long-term welfare recipients were currently at risk for depression. Other researchers have found sizable differences in the rates of depression between welfare recipients and nonrecipients (Olson and Pavetti 1996, Leon and Weissman 1993).
While it is clear that depression is the most widespread mental health condition among the welfare population, what is not clear is the extent to which the depression precedes unemployment and receipt of cash assistance or vice versa, the depression being a product of the stress and frustration associated with those experiences. Regardless of which comes first, the symptoms of depression sleeplessness, loss of self-esteem, social withdrawal, apathy, and fatigue often interfere with the ability to find and keep a job and to support a family.
In addition to depression, generalized anxiety disorder and PTSD are prevalent among the welfare population and are often a result of childhood maltreatment, domestic violence, and other traumatic experiences. Welfare recipients experience generalized anxiety disorder and PTSD at rates substantially higher than the general population (see Table I.2). In-person interviews of women on welfare in Michigan revealed that the incidence of PTSD is four times that of the general population (Danziger et al. 1999). And the rate of generalized anxiety disorder among these women is twice as high as in the general population. Using the same measures as the researchers in Michigan, researchers in Utah found similar results among long-term welfare recipients (Barusch et al. 1999).
Strong Relationship between Mental Health and Employment
Overall, there is a strong relationship between mental health and employment. Those with mental health conditions are more likely to have poor and sporadic work histories, to be unemployed, and to be receiving cash assistance. Nationally, between 70 and 90 percent of working-age adults with serious mental illnesses are unemployed (Baron et al. 1996, National Institute on Disability and Rehabilitation Research 1993). Other studies focusing more broadly on mental disorders have also found that the presence of a mental disorder is associated with a decreased likelihood of working. Mintz et al. (1992), who looked at the relationship between depression and the general capacity to work, found that about half (52 percent) of depressed patients said that they had some level of functional work impairment. Lennon et al. (2001) concluded that depression may interfere with an individual's capacity to retain employment. In a review of research, Johnson and Meckstroth (1998) reported that mental health conditions not only result in lower rates of labor force participation but also in reduced work hours and lower earnings among those who are working.
Examining the link between mental health conditions and employment in welfare recipients, Danziger et al. (1999) found that major depression significantly decreased the likelihood that a woman on welfare would work, although other conditions such as generalized anxiety disorder and PTSD had no noticeable effect on employment. Focusing on the relationship between mental health conditions and welfare receipt, Jayakody et al. (1999) found that the presence of one or more of four psychiatric disorders increased the likelihood of receiving cash assistance by 32 percent.(3) In a related study, researchers reported that those who were diagnosed with major depression were 40 percent more likely to receive cash assistance than those not so diagnosed (Leon and Weissman 1993). Finally, Olson and Pavetti (1996) found that welfare recipients without a mental health condition were almost twice as likely to be employed throughout the year compared to those with a mental health condition.
Mental health conditions may affect employment in various ways, creating, for example, an inability to concentrate, fatigue, poor interpersonal skills, and difficulty sustaining a job. The stigma associated with mental health conditions may prevent a person from requesting workplace accommodations such as a flexible work schedule to manage a mental disorder.
Description of the Study
This study was designed to be exploratory in nature. Our primary goal was to gather as much information as possible on mental health services for welfare recipients in selected states and to identify the key decisions involved in providing these services and the options for delivering them. We were also interested in documenting the challenges faced, and lessons learned, by state and local welfare administrators and program staff in implementing and providing these services. This study is based on in-depth site visits to eight communities, including a rural and an urban location in each of four study states Florida, Oregon, Tennessee, and Utah. Here we explain how we identified candidate programs for the study, our approach to site selection, and our data collection methods.
Initial Identification of Programs Designed to Address the Mental Health Needs of Welfare Recipients
To begin this study, we gathered information on a broad range of programs and agencies that provide mental health services to welfare recipients or other low-income populations. To identify these programs, we reviewed several recently published reports on programs for the hard-to-employ, searched the Internet for such programs, and consulted with other researchers and program administrators who we knew were knowledgeable about and/or were providing mental health services to welfare recipients. In addition, the National Governor's Association sent an announcement to key state contacts notifying them that we were looking for programs designed to address the mental health needs of welfare recipients. From these sources combined, we identified 23 programs that were providing mental health services to welfare recipients and other low-income families; 16 of these programs were operating state- or countywide.(4)
After we developed a list of programs, we held brief telephone conversations with each of the program administrators providing mental health services at the state or local level. Calls typically lasted 30 minutes and covered a range of topics, including client characteristics, program staffing, number of clients served, types of services provided, ways clients are informed about services, length of time the state or community had been offering services, and general experience in delivering these types of services.
Selection of the Sites
Our goal in selecting the sites was to include a range of programs that were operating at the state or county level, had sufficient experience in serving welfare recipients, and that varied in how they structured and provided services. We also wanted to include a mix of rural and urban sites. Specific site-selection criteria included the following:
Provision of Mental Health Services to Welfare Recipients Statewide or Countywide. Programs designed to address the mental health needs of welfare recipients vary in scale. Some operate at the state or county level and are integrated into the full range of services provided to welfare recipients. Others are individual programs run through one agency that serve a narrowly defined group of clients. We selected only programs operating on a state or county level, but they could be run out of the welfare, workforce development, or mental health systems.
Operating Before or Since the Implementation of PRWORA in 1996. Most of the programs we identified were implemented in response to state and federal welfare reform efforts. However, several programs were designed before the passage of federal welfare reform. Our goal was to include programs that, together, would represent a range of experience. For instance, from the programs that have been in operation for a longer period of time, we hoped to gather more information about how they have evolved. From the more recently established programs, we hoped to gather information on program design in the context of a work-based assistance system and a block grant funding arrangement.
Service Provision to a Relatively Large Number of Clients. We wanted to include programs that have substantial experience in providing mental health services to welfare recipients, as defined by the number of clients served. We selected statewide programs that had served at least 500 clients and countywide programs that had served at least 200 clients since inception.
Variation in the Structure and Delivery of Services. States and localities can structure and deliver mental health services to welfare recipients in a variety of ways. For example, some programs provide all of the services in-house, others use contracted service providers, and still others use a combination of the two. We attempted to include programs that would represent this variation in service type, structure, and delivery. In addition to the administrative framework for providing mental health services, we also considered the administrative structure for providing employment services, staffing for mental health services, the approach to identifying clients with mental health conditions, and the location at which mental health services are provided.
Rural/Urban Mix of Study Sites in Each State. We wanted to include an urban and a rural site for each state to learn how location, community demographics and infrastructure may influence the way mental health services are structured and delivered. In choosing the urban sites, we wanted to include at least one site with a very large and demographically diverse TANF population. In general, we let program administrators recommend sites. We were also looking for urban and rural sites in close proximity to one another or sites that may have implemented an innovative approach to providing services.(5)
Based on these criteria, we selected eight study sites a rural and an urban site in each of four states (Table I.3). A detailed description of each state's approach to providing mental health services to welfare recipients appears in Appendix A.
|State||Urban Sites||Rural Sites|
|Site||TANF Cases||Site||TANF Cases|
(Palm Beach County)
|Utah||Salt Lake City
(Salt Lake County)
We collected data for this study primarily through two- to three-day site visits. In addition to collecting information on service delivery, types of services provided, and implementation challenges and lessons, we gathered information about the environment in which these services are provided, including the state welfare system (e.g., policies and administrative structure) and the mental health service delivery system for low-income families.
During each site visit, a two-person team conducted 60- to 90-minute semi-structured interviews with a wide range of welfare and mental health program staff, including staff from the welfare office, mental health treatment providers, and other key players involved in identifying and treating mental health conditions. In addition, we collected organizational materials (e.g., program descriptions, organization charts, service delivery pathways, etc.), screening and assessment tools, reporting and tracking forms, outcome and evaluation reports, and other types of materials at each site. We synthesized all of this information in in-depth descriptive program summaries for each state.
1. For the purpose of this report, welfare office is used as a generic term to describe a place that serves welfare recipients, which, in some areas, may be a combined welfare/workforce development system.
3. Psychiatric disorders included in the study: (1) major depression, (2) generalized anxiety disorder, (3) agoraphobia, and (4) panic attack.
4. Ten of the programs were operating statewide. Programs varied in the extensiveness of the services they provide.
5. For example, in Utah, St. George (Washington County) was selected because the program uses a Welfare-to-Work competitive grant to expand the capacity of existing mental health services.
Designing a Mental Health Service System for TANF Recipients
Each of the study states has a distinctive approach to addressing the mental health needs of welfare recipients. In Oregon and Utah, mental health services were implemented in the early 1990s, before welfare reform, as a part of a range of services to address barriers to employment faced by welfare recipients. Since the passage of welfare reform, Florida and Tennessee have developed statewide systems for addressing the mental health needs of TANF recipients. More specifically, all four states vary with respect to the decisions they have made regarding four key program elements: (1) the types of services provided, (2) the population targeted for services, (3) the range of personal and family challenges addressed, and (4) strategies for identifying clients in need of assistance. In this chapter, we explore these decisions states have made in each of these areas.
Types of Services
There is great variation in the types of mental health services provided by the study states to TANF recipients (see Table II.1). In Oregon, mental health specialists primarily screen and assess TANF clients for mental health conditions and link them to a mental health treatment provider in the community. In Tennessee, family services counselors conduct in-depth assessments and provide crisis intervention and short-term mental health treatment. Individuals with more severe mental health treatment needs are linked with Medicaid-funded treatment providers. In Florida, outreach workers identify and screen clients who appear to need mental health services and link them to Medicaid-funded providers or to contracted mental health treatment providers that are paid through TANF funds. In Utah, clinical social workers stationed in the local welfare offices conduct clinical assessments and make diagnoses and recommendations for mental health treatment. They also provide some crisis intervention and short-term, employment-focused mental health treatment.
|Screening and assessment||X||X||X||X|
|Linking clients to existing treatment||X||X||X||X|
|Targeted short-term mental health counseling||**||X||X|
|Expansion of existing mental health services||X||X|
|Resource/consultation for employment case managers||X||X||X|
|Intensive case management*||X||X||X||X|
|Assistance in applying for SSI||X||X||X|
|Note: * In all of the study states, intensive case management is provided in some of the local welfare offices (or contracted mental health service providers).|
|Note: ** Mental health counselors in Oregon provide crisis intervention only.|
The choice of which mental health services to offer is often based on the needs of clients and the resources available in the local communities. This section explores the types of mental health services provided through the local welfare office and describes some of the ways that these types of services are delivered. Most programs include one or more of the following services: (1) screening and assessment, (2) linking clients to existing treatment, (3) targeted short-term mental health counseling, (4) expansion of existing mental health services, (5) resource or consultation for employment case managers, (6) intensive case management, and (7) assistance in applying for Supplemental Security Income (SSI).
Screening and Assessment
All of the programs use some variation of screening and assessment to identify clients and link them to mental health services. In general, this process occurs in two stages. In the first stage, TANF clients are screened to detect individuals more likely to face mental health conditions. This may be a broad screening during TANF orientation or an individual screening by employment or mental health staff. In the second stage, clients are assessed through a more in-depth examination of the nature and extent of the mental health condition. Assessments may also include a recommendation about the number of hours and types of activities to include in the client's employment plan. The box on the next page more fully describes the screening and assessment tools and the techniques used to identify TANF recipients in need of mental health services.
The study states approach screening and assessment in several ways. Florida is the only state that has hired outreach staff to identify and screen welfare recipients and other low-income families to determine those who may need mental health services.(6) These outreach staff are not licensed mental health professionals; they use a standardized screening instrument and are expected to make referrals to treatment providers in the community based on the results of the screen. Further assessment and treatment planning is provided by licensed mental health professionals after the referral is made. Oregon, Tennessee, and Utah have hired primarily licensed mental health staff, who are highly skilled in conducting mental health assessments, to carry out a screening and assessment before a treatment referral is made. The screening and assessment process in these three states is designed to identify persons in need of mental health treatment, determine the most appropriate treatment provider, assess the client's ability to participate in work activities, and develop a plan for addressing the client's mental health and employment needs. In Utah, staff also use standardized assessment inventories to diagnose specific mental health disorders.
Linking Clients to Existing Community Mental Health Treatment Services
In Florida and Oregon, the primary purpose of mental health services is to identify clients with mental health conditions through an assessment and link them to mental health treatment providers within the community. In Utah and Tennessee, mental health counselors provide short-term therapy to some clients and link others to mental health treatment agencies. However, mental health counselors who have high caseloads or are working with clients with extensive mental health needs typically link clients to other treatment providers. The complexity of the process for linking clients to mental health services depends on the availability and structure of mental health services in the local community; the process is often streamlined when the mental health counselor is an employee of the agency to which the client is referred.
One of the primary challenges faced by mental health counselors in linking clients to services is obtaining access to treatment in a timely manner. The wait time for treatment is particularly problematic under managed care arrangements. In some sites, clients are required to wait up to a month before they see a mental health counselor, and sometimes even longer to see a psychiatrist. The ability to access treatment in a timely manner appears to be worse in the urban than in the rural areas. According to mental health professionals, as the wait for treatment increases, so does the likelihood that the client will no longer participate in treatment. Mental health counselors often provide short-term mental health treatment until a mental health treatment provider can see the client.
Screening and Assessment Tools or Techniques
Overall, there are two primary advantages to having mental health counselors link clients to services: clients have someone to guide them through the process of accessing mental health treatment, and according to some workers, counselors can actually help clients access treatment more quickly, especially when it is provided through Medicaid providers. One of the challenges for mental health counselors is that their role requires them to be aware of different treatment options in the community.
Targeted Short-Term Mental Health Counseling Services
The study states provide two types of short-term mental health counseling services to TANF recipients through the welfare system crisis intervention and short-term employment-focused counseling. Crisis intervention services are typically and more easily provided when a mental health clinician is co-located, and therefore readily available, in local welfare and employment service offices. Crisis intervention services are offered in the welfare office in all of the study states except Florida. These services are provided when a client is extremely emotional (e.g., crying, angry, etc.) or when a client has told mental health or employment staff of a plan to harm themselves or others. The goal of crisis intervention is to stabilize a client and link him or her to appropriate services (such as hospitalization or a crisis unit at a local mental health agency).
Utah and Tennessee hire or contract with licensed mental health professionals to provide short-term mental health therapy to welfare recipients. On average, short-term therapy consists of 6 to 10 sessions and may be provided individually or in groups. In general, the therapy is employment-focused and is designed around addressing barriers to employment. Those with long-term mental health needs are referred to a Medicaid provider.
Expansion of Existing Mental Health Services
Two of the study states, Florida and Utah, have used TANF funds to expand community mental services. Florida contracts with a wide variety of community providers to provide the full range of mental health services to TANF recipients, including individual and group counseling, marital therapy, intensive case management, substance abuse treatment, and numerous other nonmedical treatment options. These services are also available to those at risk for TANF involvement. Florida is the only state that provides funding to existing providers to provide long-term therapy for TANF clients. Utah uses a more targeted approach to expanding the services available to TANF recipients. Generally, clients who need extensive mental health treatment are referred to Medicaid-funded providers. However, if the wait for services at a Medicaid provider is longer than two weeks, or if the services needed are not available, the client can be referred to a mental health professional who is not funded through Medicaid. Contracting out mental health treatment also allows the program administrator to determine the treatment model or approach used by the contractor, which they cannot do with a Medicaid-funded service provider.
Tennessees Solution-Focused Brief Therapy
In Tennessee, in-house mental health counselors are trained extensively in solution-focused brief therapy and are expected to use it in providing treatment to TANF clients referred to their program. The objectives of solution-focused, brief therapy are to identify the problems that keep a client from becoming employed and to explore options for resolving those problems. Solution-focused therapy is based on four major concepts:
Training/Consulting for Employment Case Managers
Except in Florida, mental health counselors in the study states provide consultation and training for employment case managers in how to identify and manage clients with mental health conditions. The types of consultation vary by local office, but mainly include the following:
- In-Service Training. Mental health counselors in some offices provide in-service training to new and experienced workers in how to identify clients with mental health conditions and in how to handle difficult behaviors.
- Case Staffings. Mental health counselors are often included in case staffings for clients who are about to be sanctioned or who are nearing the end of their time limit. Employment case managers with whom we talked indicated that they often rely on the expertise of the mental health counselors to make recommendations for how to handle cases and to identify resources in the community to which a client may be referred.
- Recommendations for Employment Plans. Mental health counselors frequently provide initial and ongoing recommendations to employment case managers about the types and volume of activities to include in clients' employment plans. Recommendations are based on client assessments completed by mental health counselors.
- Individual Consultation with Employment Case Managers on Difficult Cases. Employment case managers often consult with a mental health counselor when faced with a difficult case, such as a client with a personality disorder. Mental health counselors tell case managers about certain behaviors they can expect to see with certain conditions and about ways to handle these behaviors.
Intensive Case Management
Mental health counselors or other mental health staff may also provide more intensive case management that includes working with clients to develop basic life skills such as managing their time, setting goals, and budgeting their money. It may also include linking clients to other types of services in the community (e.g., substance abuse treatment, domestic violence service, homeless shelters, food pantries, etc.). In Clarksville, Tennessee, and St. George, Utah, master's level mental health clinicians are paired with bachelor's level workers to provide intensive case management and mental health services. In these arrangements, the bachelor's level workers primarily provide the intensive case management, leaving the clinicians more time to conduct assessments and provide short-term treatment. Western Palm Beach County Mental Health Clinic, a contracted mental health service provider in Belle Glade, Florida, hired one intensive case manager exclusively for welfare recipients.
Assistance in Applying for SSI (Supplemental Security Income)
Mental health staff may also provide assistance in applying for SSI (Supplemental Security Income) to clients with a diagnosed mental health condition that prevents them from working. In Utah, social workers coordinate psychological evaluations and walk clients through the often long and difficult application process. Assistance in applying for SSI is also extended to TANF recipients in Tennessee and parts of Oregon. Providing this kind of service requires mental health staff to act as advocates for clients and to be informed about the policies and procedures for accessing SSI. In general, mental health counselors estimate that 5 to 10 percent of the clients who are referred to mental health services may be eligible for SSI.
Types of Mental Health Conditions and Other Challenges Among Welfare Recipients
According to mental health providers, welfare recipients who participate in mental health services exhibit a wide range of mental health conditions that act as barriers to work. The most prevalent of these conditions are depression, PTSD, generalized anxiety, and adjustment disorders. A small percentage were reported as having more challenging mental health conditions such as personality disorders or psychotic disorders (e.g., schizophrenia).
In addition to these conditions, welfare clients participating in mental health services face a host of other barriers to work. For instance, mental health counselors indicated that many clients have been emotionally, physically, and/or sexually abused during childhood, or have experienced other types of major trauma. Still others face such challenges as domestic violence, low self-esteem, limited parenting skills, homelessness, lack of supportive networks (such as family or friends), and poor coping and problem-solving skills. It is unclear whether the mental health conditions are results of the families poverty and dysfunction, or whether the poverty and dysfunction are products of the mental health conditions.
The Population Targeted for Services
The population targeted for TANF-funded mental health services differs by state, reflecting, for the most part, whether program administrators chose to provide services only to TANF recipients, to those considered "at risk" for TANF involvement, and/or to those who once received TANF services. Program administrators also considered whether to serve only adults on TANF or to extend mental health services to children. These decisions about the target population influence not only who might be eligible for mental health services, but also how many individuals might be eligible.
Adults on TANF
All of the study states provide mental health services to adult TANF recipients. However, Oregon was the only state to provide mental health services only to adults receiving TANF. The other states expanded eligibility by continuing mental health services for some period after the TANF case closed by providing services to children in the household or by defining eligibility using income criteria rather than TANF receipt. The decision to restrict eligibility to adults on TANF reflects primarily resource constraints, but it also reflects the goals of the program. In Oregon, the primary goal is to identify clients in need of services and link them with resources in the community. The hope is that by the time clients leave assistance, they will be solidly connected with mental health providers who can provide ongoing services that are not tied to their TANF eligibility. In addition, providing mental health services to the head-of-household on TANF reflects Oregon's belief in the importance of helping the primary breadwinner become employed. In Multnomah County (which includes Portland), mental health staff already carried high caseloads. Families outside of TANF could only have been served at the expense of TANF recipients or by allocating additional funds to the program.
Adults Transitioning off TANF
The transition from welfare to work creates a new set of challenges for nearly all families. For adults with a mental health condition, the transition can be even more challenging. To provide parents with extra support if they need it, Tennessee and Utah extend eligibility for mental health services to TANF recipients for a year after their TANF case closes. Because Tennessee and Utah also provide short-term mental health counseling services directly to TANF recipients, it is possible that many of these individuals would not be receiving services from other mental heath providers, making it especially important to continue to deliver services through the TANF program to clients leaving TANF. Providing support to families during the transition to work could help to improve job retention.
Children in TANF Households
According to the U.S. Department of Health and Human Services (2000a), at least one in five children and adolescents age 9 through 17 has a diagnosable mental health disorder in a given year. Mental disorders among children can lead to failure in school, alcohol or drug use, violence, and suicide. Furthermore, the responsibilities and emotional stress associated with managing a child with a mental health condition can limit a parent's employability.
Two of the study states, Tennessee and Florida, extend eligibility for mental health services to children living in a TANF household regardless of whether the household head is receiving mental health services. The decision to provide mental health services more broadly to children of TANF families requires program administrators to think differently about the types of services offered. For instance, the mental health needs of children differ from those of adults, so an entirely different set of treatment options must be offered. This approach may be more costly than restricting services to adults on TANF, but it addresses the needs of the entire family.
Another advantage of extending mental health services to children is that it may actually encourage parents who need treatment to participate in treatment. Mental health counselors indicated that parents may feel more comfortable accessing treatment for their children than for themselves and that being exposed to and involved in treatment through their children frequently decreases parents' anxiety about their own participation in mental health treatment.
Florida has taken full advantage of the flexibility to use TANF funds to serve families who may not be receiving cash assistance. For instance, TANF recipients and their children, former TANF recipients, households with a child-only TANF case, and non-TANF families that meet income and eligibility guidelines are eligible to receive TANF-funded mental health services. Non-TANF families include (1) a parent, caretaker, relative, or child in a family with an income less than 200 percent of the federal poverty level, (2) families receiving services in the Family Safety system (Florida's child welfare agency), (3) noncustodial parents where there is a court-ordered child support requirement and both custodial and non-custodial parents earn less than 200 percent of the federal poverty level and live in Florida, and (4) individuals receiving SSI or Social Security Disability Insurance (SSDI). Because many families move on and off of TANF, this "preventive" approach may reduce the number of families who receive cash assistance by helping parents stay employed. In addition, providing mental health services more broadly improves access to mental health services for sanctioned families, those who have reached their time limit, and families at-risk for TANF involvement.
Defining the Range of Needs to be addressed
Several researchers have found that a substantial proportion of welfare recipients have multiple barriers to employment and that the presence of multiple barriers decreases the probability of finding and keeping a job (Danziger et al. 1999, Zedlewski 1999, Olson and Pavetti 1996). Thus, an important decision in designing a system to address the mental health needs of welfare recipients is whether to address mental health issues separately or in combination with other personal and family challenges. The advantage of the latter approach is that it could address other issues that may be preventing clients from finding employment. However, it is likely to be difficult to find staff who are expert in assessment and treatment in multiple areas.
Decisions about how broadly to address service needs influence the kind of staff hired, how clients are identified for services, and the types of services provided. Among the study states, there are three different models, or approaches, to defining the range of needs to be addressed: (1) primary focus on mental health conditions, (2) primary focus on mental health and substance abuse issues, and (3) broad focus on a variety of personal and family challenges. This section describes each model and its associated strengths and weaknesses.
Primary Focus on Mental Health
Programs designed to address mental health needs exclusively tend to provide intensive, comprehensive mental health services through experienced clinical staff. Utah's program focuses primarily on identifying mental health conditions and providing the services to address those conditions. Mental health staff may address other conditions (e.g., substance abuse, domestic violence, and child behavioral problems) as they arise, but staff mostly refer clients to agencies in the community to deal with other types of service needs. The advantage of this approach is that employment and mental health staff can focus exclusively on identifying and treating mental health conditions. In addition, staff in these programs typically have extensive experience in providing mental health treatment. They have a solid understanding of the mental health system and ways to access mental health treatment. The downside of this approach is that mental health staff may be so specialized that other conditions that may affect work go undetected and untreated.
Primary Focus on Mental Health and Substance Abuse
In general, there are high rates of co-occurrence between substance abuse and mental health conditions. A study conducted by Reis (1995) estimates that more than half of those with a mental health disorder also have problems with substance abuse. Individuals with co-occurring conditions often have treatment needs that addresses both substance abuse and mental health issues. Unfortunately, there is a shortage in most communities of treatment that addresses both conditions (U.S. Department of Health and Human Services 1999).
Oregon and Florida focus on both mental health and substance abuse needs. In Oregon, the staffing is structured in one of two ways. In some areas, one worker handles both substance abuse and mental health conditions. For example, in Astoria, the specialist has a Ph.D. in clinical psychology and is a certified substance abuse treatment provider. In other areas of the state, specialists in either function work as a team. In Multnomah County, for instance, individuals hired as either mental health or substance abuse specialists meet weekly to staff cases and coordinate the mental health and substance abuse treatment of clients.(7)
Given the prevalence of co-occurring substance abuse and mental health conditions, the service model addressing both may be especially effective. The primary challenge in implementing this model is to find staff who are clinically proficient in both areas. Typically, it is easier to find individuals with training in one area or the other. In most communities, hiring staff who perform separate functions is easier than hiring staff with combined expertise. However, in some areas, particularly in rural locations, there are not enough clients to justify the need for two specialists. For instance, the Florida state Mental Health and Substance Abuse Program Offices contract with mental health and substance abuse agencies to provide services, relying on outreach workers to link clients to these services.
Broad Focus on a Variety of Personal and Family Challenges
Tennessee is the only state in this study that provides mental health services as one of several services targeted to hard-to-employ welfare recipients. Family services counselors in Tennessee address mental health, substance abuse, domestic violence, learning disabilities, and child behavioral conditions in welfare recipients. According to program administrators, identifying learning disabilities and providing services to address them has been the most difficult challenge for family services counselors.
Program administrators in Tennessee attempt to hire staff with expertise in at least two of the five service areas. In addition, the program director coordinates extensive training in how to identify the various mental health needs and in the types of services available in the community for addressing them. The advantage to this "holistic" approach to service provision may be an increase in the employability of TANF clients to the extent that none of the conditions interfering with employment goes unaddressed. The primary challenge in using this approach is finding staff with expertise in most of the service areas.
Identifying Clients in Need of Assistance
One of the first steps in providing mental health services is identifying clients who would benefit from the services and who are willing to participate in mental health treatment. Not only do programs vary in how clients are identified for mental health services, local offices within the same program frequently vary in their approach to identifying clients. Overall, there is no evidence to suggest that one approach is better than another for identifying clients in need of mental health services. Using multiple approaches in combination appears to be the most effective strategy and the one used by most local offices. Some of the primary ways that clients are identified for or informed about mental health services are discussed below.
Broad Screening for Mental Health Needs and Informing Clients about Services
Broad screenings during client orientation to employment services and job club workshops are one way in which clients are informed about and identified for mental health services. In some local offices, mental health staff administer screening tools to all welfare recipients during orientation to identify those at risk for mental health conditions. Welfare recipients in Miami, Florida, who receive employment services from the AWI (Agency for Workforce Innovation) Hialeah One-Stop Center, are screened by a bachelor's level outreach worker. A licensed clinical social worker in the St. John's welfare office in Portland, Oregon, talks with new welfare recipients during orientation and administers a depression scale and a general mental health screening.
A local welfare office in Astoria, Oregon, which has a unique approach to screening, identifies clients as candidates for mental health services during the initial intake. For instance, when clients first apply for cash assistance, they meet with the lead staff person, who has more than 20 years of experience as a welfare case manager. This lead staff person screens for TANF eligibility, informs clients about mental health services, and conducts a brief assessment to identify clients who may have a mental health condition. This type of approach may be more realistic in rural areas, where the caseloads are relatively small and staff are familiar with the families who receive cash assistance.
The advantage of broadly screening welfare recipients in the welfare office ensures that clients are identified and linked to services. The drawback of broad screening is that clients who may not need mental health services or who are not willing to participate in treatment are referred to mental health staff, which may overload mental health staff.
Clients also are informed about mental health services during formal presentations given during individual or group orientations, or during other meetings in the welfare office. Clients may then self-refer to mental health services. In Tennessee and Utah, mental health services are described to new and returning clients as part of their standard orientation. Clients receiving employment services in the Caleb One-Stop Center in Miami, Florida, learn about mental health services during the job club workshop. Clients may refer themselves to the program based on the information they obtain during the presentations.
Formal presentations ensure not only that clients are informed about mental health services, but also that they receive the same information about the services. Furthermore, it brings clients and mental health staff together, creating a direct link to services, rather than relying on a referral from employment staff. One challenge is obtaining permission from local welfare administrators to participate in client TANF orientation or during job search workshops to talk about mental health services.
Referrals by Employment Case Managers
Most programs rely heavily on employment case managers to identify clients in need of assistance and to refer them to mental health services. Employment case managers may be trained to identify mental health conditions as part of their own orientation when they are hired, during in-service meetings or case staffings, or individually by mental health counselors.
According to employment case managers, clients vary in how and when they disclose a mental health condition, but whether they even do so depends on the level of trust between the case manager and the client. This principle of trust is also critical to getting a client into treatment insofar as it also operates in the relationship between the employment case manager and the mental health counselor. Case managers report that they are more likely to make a referral if they trust the mental health counselors and believe the services they provide will benefit the client. In some local offices, a few case managers referred a large proportion of clients to mental health services. In other offices, the number of referrals was more evenly represented across case managers.
To find out more about how clients needing assistance are identified, we asked employment case managers about which behaviors or characteristics acted as a red flag for a mental health condition. Employment case managers cited extreme displays of emotion (such as anger or crying), no emotion at all (flat demeanor), lack of concentration or focus, unkempt appearance, children with behavioral problems, lack of participation or reluctance to participate in program activities, recent eviction from public housing, and making decisions not based on current conditions or with an eye toward the future. In general, most of the employment case managers we interviewed were able to describe some client behaviors and characteristics that signaled a mental health condition.
The advantage of relying on employment case managers to make the referral is that they have the most contact with clients and can therefore more accurately identify those who may have mental health needs. The drawback is that some employment case managers may be uncomfortable talking about mental health issues with clients and so may not refer clients to mental health services. For this reason, it is important to use a variety of approaches to link clients to mental health services.
Automatic Referrals to Mental Services
In some states, certain subgroups of the TANF population are automatically referred to mental health services. These subgroups include families who have been sanctioned for noncompliance in work activities, families nearing the end of their time limit on cash assistance, and clients with a potential drug or alcohol addiction. In Tennessee, sanctioned families are referred to the Family Services Counseling program. In Utah, licensed clinical social workers participate in extension hearings for families nearing their time limit. In addition, welfare recipients in Utah who respond "yes" to two or more questions on the four-question CAGE(8) substance abuse screening questionnaire are automatically referred to mental health services by the employment case manager.
The advantage of automatic referrals to mental health services is that clients most in need of these services are likely to get them. That is, the automatic referrals apply to people who are sanctioned or who are reaching their time limit but have not found employment, and we would assume that these clients are in this position because they face more severe barriers to employment, one of which could be a mental health condition. The challenge for the system is getting these clients to participate in mental health services. Some of the same barriers that prevented them from working or from participating in their employment plan may also be obstacles to participating in mental health treatment.
The welfare/employment services local offices are not the only avenue through which clients are informed about mental health services. Some programs use extensive community outreach campaigns as well. Fliers, pamphlets, and formal and informal presentations are part of this "social marketing" effort. Florida and Tennessee's outreach efforts are noteworthy.
In Florida, outreach workers are the link between welfare clients and the mental health service delivery system. These individuals, who have at least a bachelor's degree, are employed by the contracted mental health and substance abuse treatment providers who screen clients and link them to services within their agency or with another contracted service provider. Outreach workers regularly visit community service providers (such as health clinics, day-care centers, food stamp offices, homeless shelters, and other agencies), leaving brochures about the program and talking with staff at these organizations. Outreach workers may be co-located in the welfare office or in other agencies, such as the local Head Start program and the health clinic.
In Tennessee, the program director, district coordinators, and welfare administrators have developed an intense and widespread social marketing effort. Tennessee's social marketing effort mostly consists of presentations and training sessions for welfare staff and other community partners, such as vocational rehabilitation, and education and training providers. The purpose of these efforts is to educate employment case managers and other agency workers who serve TANF recipients about the mission, goals, and successes of the Family Services Counseling program. According to the program director, the intense social marketing campaign not only informs people about the services, but also creates a sense of pride and enthusiasm among program staff members about providing these services.
The advantages of community outreach are that it informs service providers outside of the welfare office about mental health services and helps to cultivate collaborative relationships between agencies. For states that base eligibility for mental health services on income as well as TANF receipt, community outreach helps to identify low-income families who are at risk for TANF involvement. The drawback to this approach is that it is time-consuming and resource-intensive.
6. How broadly clients are screened varies by local office.
7. One specialist has combined mental health and substance abuse responsibilities.
8. The name of the CAGE test comes from an acronym of first letters from questions used in the instrument. For example, the first letter "C" comes from the question, "have you ever felt the need to Cut down on your using/doing?"
Creating an Infrastructure to Provide Mental Health Services
A key challenge faced by program administrators is to create an administrative infrastructure through which appropriate mental health services are cost-effectively delivered to those in need. Such an infrastructure must draw on the strengths of the mental health resources in the local community and successfully integrate mental health services with employment services for welfare recipients. However, because TANF program administrators are not experts in the design and delivery of mental health services, it is usually necessary for them to rely on other agencies, organizations, or specialized staff for these functions. Cross-agency coordination is therefore critical to program success. In this section, we examine the key decisions made by the study states in their efforts to create a service delivery structure to address the mental health needs of TANF recipients. These decisions fall into four areas: (1) developing an administrative structure for the program, (2) defining staffing needs, (3) determining where services will be provided, and (4) allocating program funds.
Developing an Administrative Structure for the Program
Each study state developed a very different administrative structure for delivering mental health services to TANF recipients. In three of the study states Oregon, Tennessee, and Utah the TANF agency maintains primary oversight for the program, although the extent to which the TANF agency is actively involved in the delivery of services varies considerably. In Florida, the responsibility for program oversight was transferred to the agencies that deliver and/or monitor mental health and substance abuse services. These differences in administrative structure reflect differences in the structure through which employment services are provided to TANF recipients as well as differences in the scope of mental health services provided.
Utah: TANF Agency Provides Mental Health Services
Utah is the only study state in which mental health services for TANF recipients are provided primarily in-house through the TANF administrative agency. For over 10 years, licensed clinical social workers hired as welfare staff have been providing mental health treatment to welfare recipients in the welfare office. In 1996, Utah consolidated the six agencies that handled employment, job training, and welfare functions into the Department of Workforce Services (DWS). In 1998, a social work unit was formed within DWS to provide mental health services, and a uniform statewide set of policies, procedures, and reporting forms was developed. All mental health staff that serve welfare clients are DWS state employees. A state program manager administers and monitors the mental health services and acts as a liaison with welfare administrators to coordinate mental health services. Although most mental health services are provided by DWS staff, the state contracts with other mental health professionals to provide more extensive services when a Medicaid provider is not available to provide them in a timely manner.
The benefit of an in-house service delivery system is that program staff can be easily integrated into the agency's employment program, which may improve the communication between employment case managers and mental health staff and increase the number of referrals to mental health services. One of the drawbacks is that social workers can become professionally isolated within the local offices, making it difficult for them to obtain professional consultation from other mental health counselors. In Utah, the mental health program administrator in Salt Lake City provides supervision for all of the mental health workers. Social workers in rural areas communicate by E-mail and telephone when they need clinical consultation and support.
Oregon: Contracted Provider or Employment Services Agency Provides Mental Heath Services
Oregon has a state-administered TANF system, but local (district) offices have considerable flexibility to decide how to structure and provide employment-related services to TANF recipients. A program analyst in the state TANF agency acts as the statewide coordinator for mental health services. 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. In the local offices, there is wide variation in the organization of mental health services. In two counties we visited, local program coordinators administer, monitor, and supervise the mental health and substance abuse services in their counties. Most counties have specialists in mental health and substance abuse treatment who have extensive experience and strong clinical training. Some offices have separate specialists for mental health and substance abuse treatment, while other offices have a specialist with expertise in both areas.
Most mental health services are staffed by contractors, and, in general, contracting arrangements are handled either by the Adult and Family Services (AFS)(9) 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 and Clatsop Behavioral Healthcare. In Multnomah County, the employment and training service providers, Mount Hood and Portland Community colleges, hire mental health specialists directly. Through a subcontract with local mental health treatment providers, these specialists work within the local welfare offices. Mental health treatment is provided by Medicaid providers. In general, the Medicaid-funded mental health agencies provide a range of outpatient mental health services, including assessment, case management, and individual and group therapy. In-patient treatment is limited to the urban areas, and treatment for co-occurring mental health and substance abuse conditions is limited throughout the state.
The advantage of this model is that local communities can develop an administrative structure that works best for them. In addition, it provides district offices with an opportunity to fully integrate their mental health services into their welfare employment services program.
Tennessee: Contracted Agencies Administer and Deliver Mental Health Services
Tennessee's Family Services Counseling (FSC) program is under the purview of the TANF agency. However, the TANF agency has a contract with the College of Social Work at the University of Tennessee (UT) to administer the FSC program. In January 2000, UT hired a director to design and implement the FSC program. Family services counselors began receiving referrals in February 2000. FSC program staff are hired through both UT and local contracted service providers. The FSC program director and district coordinators are university employees. Within each district, the TANF agency contracts with local not-for-profit agencies to provide family services counselors and clinical supervision. In some of the communities, the local agencies had formed collaborative relationships prior to the FSC program. These relationships were instrumental in implementing the program in these areas. For example, DHS contracted with Family and Children's Services of Greater Chattanooga (FCS) to provide family services counselors for Hamilton County because FCS has been administering programs such as life skills training, parenting classes, employee assistance programs, and outpatient mental health treatment for over 120 years.
When clients need services, they are referred to the TennCare mental health providers in addition to FSC counselors. The types of providers vary across the state. For example, urban Hamilton County has a variety of treatment providers, including a residential and an outpatient substance abuse treatment center, while rural Montgomery County has only one mental health center and several not-for-profit agencies that provide primarily group treatment to low-income families.
The advantage of this model is that it allows the welfare office to delegate responsibility for administering and providing mental health services to mental health professionals while maintaining some oversight over the program. Contracting with UT and local providers has made it possible for Tennessee to develop a statewide program model while drawing on community resources to deliver services at the local level. In addition, since the program was developed under the auspices of the TANF agency, it has been well integrated with welfare employment services from the start. The co-location of the mental health program director in the state welfare office and the co-location of district coordinators and mental health counselors in local welfare offices have also helped to integrate services.
Florida: Mental Health Agency Administers the Program and Contracts with Providers to Deliver Services
Florida is the only study state to transfer full responsibility for the operation of its mental health services program to an agency that has no direct ties to the welfare or the employment services system. The program is housed within the Department of Children and Families (DCF)(10) and operates under both the Mental Health and the Substance Abuse Program offices but collaborates on policy issues with the Office of Economic Self-Sufficiency.(11) A program director and three staff members in the state office administer the program. In each DCF district or region, at least one specialist oversees program activities in the local office. All program employees are hired as "other personnel services" (OPS) employees, which are temporary positions renewed every six months, without employment benefits (such as health insurance, sick leave, and retirement).
The DCF district or region administrator selects and contracts with mental health and substance abuse treatment providers in each local community. The terms of these contracts are negotiated with the TANF specialists and local district administrators. In some communities, there is one primary contractor, and in others there are many contractors. Contracted service providers include a range of organizations such as substance abuse and community mental health centers, residential treatment providers, faith-based organizations, and hospitals. The contracted service providers hire outreach workers, conduct clinical assessments, and provide mental health and substance abuse treatment.
The advantage of transferring administrative responsibility to a mental health agency is that the state can bring into play the agency's in-depth understanding of the local mental health system that the TANF agency does not have. The drawback is that it can be much harder to integrate mental health services into existing welfare employment services, and, indeed, Florida's system is the least integrated of the four study states. The integration of services is further complicated by the fact that the employment services system that serves TANF recipients is locally administered, making the employment expectations and service delivery structure different in every local office.
Communication and Collaboration between Agencies and Workers
A recurring theme in each study site is the importance of communication and collaboration among agency administrators and mental health and employment staff. Three strategies or factors appear to foster or improve communication and collaboration.
The types of staff who provide mental health services are directly related to the types of mental health services provided to welfare recipients. The study states differ not only in the types of staff who provide mental health services but also in the roles and responsibilities of staff with similar job titles. For example, mental health counselors in Oregon primarily assess clients and link them to mental health treatment, whereas mental health counselors in Tennessee assess clients and provide short-term mental health treatment. Staff roles and responsibilities may also vary by local office within the same program. In addition, state regulations sometimes dictate the type of staff who can be hired. For example, only licensed clinical social workers can deliver certain mental health services, such as clinical assessments and mental health treatment. Based on the programs in this study, we have identified four types of staff who provide mental health services: outreach workers, mental health counselors/specialists, interns in a master's of social work (M.S.W.) program, and intensive case managers. Some of their responsibilities and the services they provide are described below.
In Florida, more than 100 outreach workers have been stationed throughout the state to screen TANF recipients and other low-income families and to link them with mental health and substance abuse treatment. Typically, outreach workers are bachelor's level staff with training in psychology, social work, or other social service-related fields. Outreach workers inform clients about the social services available to them and community agencies about social services offered.
The drawback to using outreach workers to screen TANF clients is that this creates an additional step in linking clients to services. In addition, the workers may not be professionally trained to handle intense traumatic experiences that may be disclosed to them by clients (such as having been raped, witnessing a murder, or physical or sexual abuse during adulthood or childhood). Outreach workers indicated that when they heard of these kinds of experiences, they quickly referred the clients to licensed mental health professionals.
Mental Health Counselors/Specialists
Mental health counselors are mostly licensed clinical social workers (LCSWs), certified social workers(12) supervised by an LCSW, or other licensed mental health professionals (such as psychologists and marriage and family therapists). The credentials required by the state depend on the types of mental health services provided. For example, in Tennessee, which provides a wide range of services, mental health staff are required to have expertise in at least two of five areas (mental health, substance abuse, domestic violence, child behavior, or learning disabilities). In some areas of Oregon, staff are required to have expertise in both mental health and substance abuse.
In addition to their clinical training, mental health counselors in the study states have extensive experience in providing mental health treatment and a deep understanding of the mental health service delivery system. Both professional credentials and experience are a key consideration in the hiring decisions of program administrators. In most states, licensure is required to conduct in-depth psychosocial assessments and mental health therapy. Certified social workers may provide these services only under the supervision of an LCSW or other licensed mental health professional.
Social workers have a range of responsibilities associated with providing mental health services to welfare recipients. These responsibilities may include performing client assessments, providing or linking clients to mental health treatment, making recommendations for the volume and types of activities to include in an employment plan, consulting with employment case managers, and monitoring and tracking client participation in mental health treatment. Caseload sizes, which vary by site, are influenced by the types of services provided, number of TANF clients served in the local welfare office, and the length of time case managers hold on to a case.
The benefit of hiring licensed mental health professionals is that they are trained to deal with the challenging behaviors and mental health conditions often exhibited by TANF clients. Accessible to employment staff, they can also serve as resources for the client and employment case managers. The drawback is that qualified mental health professionals may be difficult to find and expensive to retain compared with bachelor's level staff.(13)
Utah is the only study state that uses M.S.W. student interns to provide mental health services to TANF recipients under the supervision of an LCSW. Interns are trained by the program manager and perform many of the same functions as the full-time social workers, such as performing clinical assessments, consulting with employment case managers, attending staffings, referring and monitoring treatment, and conducting short-term therapy. The advantage of using interns is that they are a less costly way to expand staff capacity. The challenge, at times, is providing the supervision and mentoring support that interns require.
Intensive Case Managers
Intensive case managers, also known as specialized case managers, may be employment case managers with a reduced TANF caseload of hard-to-employ clients or bachelor's level mental health staff who work with LCSWs to link clients to services. Intensive case managers in Utah's welfare-to-work-funded GROW(14) program teach clients basic living and problem-solving skills, link clients to mental health and other services, and monitor and track client participation in mental health services. In Clarksville, Tennessee, a bachelor's-level intensive case manager assists the LCSW by coordinating services, and by monitoring and tracking client participation in mental health and other activities. Western Palm Beach County Mental Health in Belle Glade, Florida, hired an intensive case manager to assist clients receiving mental health services with housing referrals, immigration paperwork, and SSI applications and to teach clients about job search activities and resume-writing skills.
The advantage of intensive case managers is that they can provide some of the linking and monitoring responsibilities performed by the mental health counselor, allowing the mental health counselor to focus on client assessments and mental health treatment. The drawback is that, at times, limited funding restricts the amount of social work staff that can be hired to provide mental health services. Typically, intensive case managers are used to augment, rather than to replace, clinical workers.
Where mental health services are provided influences how and the extent to which clients are connected with mental health services. We observed several variations among sites with regard to where mental health services are provided. Except for Tennessee, which co-locates all mental health counselors in the welfare office or with contracted employment service providers (e.g., a local housing project), most states vary by local office as to where services are provided. In some of the study sites, mental health workers co-located in the local office that serves welfare recipients provide services in that office. In other study sites, mental health workers are co-located and provide services in other agencies that serve low-income families (e.g., public health centers, Head Start offices, etc.). Contracted mental health counselors often work out of the agency where they are employed.
Welfare Office/Employment Center (Co-located Workers)
Most mental health workers, regardless of where they work, indicated that being co-located in the welfare office is the ideal arrangement for providing mental health services. Tennessee and some offices in Utah, Oregon, and Florida co-locate mental health staff in the local welfare office. Providing mental health services in the welfare office by co-locating mental health staff has several advantages:
- Mental health staff are more integrated into the employment service delivery system. According to mental health workers, co-location helps them build a relationship with employment staff, which tends to increase the number of referrals to mental health services.
- Client access to mental health services is improved, and a direct link is created for referring clients to the program. Providing mental health services in the welfare office gives clients direct access to mental health staff because they do not have to rely exclusively on employment case managers to refer them to mental health services (especially in offices where the mental health counselor participates in orientation).
- Fewer clients may drop out of mental health treatment. Providing mental health services at the local welfare office may increase the likelihood that clients continue in treatment, especially when clients regularly attend job search workshops or other activities at the welfare office.
- Mental health counselors become an immediate resource for employment staff. The closer proximity of the two types of staff gives mental health counselors an opportunity to educate employment staff about how to handle clients with mental health conditions, to participate in agency meetings and case staffings, and to deal readily with client crises.
The primary challenge in providing mental health services in the welfare office is finding enough office space in which mental health counselors can meet privately with clients.
Contracted Service Providers
In some local offices, mental health services are provided in the contracting agency's office by a mental health counselor. The screening and assessment services provided by the mental health counselor are paid for with TANF funds, but the treatment may be paid for either by TANF or Medicaid funds. In this arrangement, the employment case manager refers clients with mental health conditions to the contracted mental health service provider. Outreach workers in Florida and some mental health counselors in Oregon provide services out of the agency where they are employed.
One advantage of providing mental health services out of the contracted service provider's offices is that clients "look like" other nonwelfare individuals receiving mental health services, removing the stigma of being identified as welfare recipients and thereby making it more likely that they will stay in treatment. The drawback is that, unless clients are directly and quickly linked to mental health staff, they may not participate in mental health services, or they may miss appointments because of the inconvenience of traveling to a location apart from the welfare office, especially if they are ambivalent about participating in mental health services to begin with.
Mental health services are also provided at locations other than the welfare office or contracted service provider agency. In Florida, outreach workers co-located in community health clinics and local Head Start offices identify families that may benefit from mental health services. In St. George, Utah, where private office space is limited in the local employment center, mental health counselors provide services in a DWS administrative office three blocks from the local employment center welfare office. Services are typically provided at these other locations when it is not possible to co-locate mental health counselors in the welfare office.
One advantage to this approach is that it allows mental health staff to network with staff at other agencies. It also helps to identify clients who are at risk for welfare involvement who may otherwise be overlooked. For the social worker in the St. George welfare office, the advantage to being co-located at the administrative office is that she has access to private office space. The drawback to providing mental health services in other locations is that it may make it more difficult to link the employment case manager's clients to mental health services staff.
The study states primarily used their TANF block grant and state MOE (Maintenance-of-Effort) funds to pay for mental health services. These funds are distributed in two ways. Under the first model, the state welfare agency or state legislative body allocates TANF or MOE funds specifically for the purpose of providing mental health services. In Florida, the state legislature allocated $45 million in TANF/MOE funds to provide mental health and substance abuse treatment to welfare recipients and low-income families at risk for TANF involvement. The state welfare office in Tennessee designated $8 million for mental health and other services for welfare recipients. Programs for which funds have been earmarked in this way appear to have a distinct program identity with a centralized program administrator and some uniformity in how the program operates.
Under the second model for funding mental health services, which is used in Oregon, the money is part of a pool of funds designated for services designed to help TANF recipients find employment. In Oregon, the decision about the amount of funds to allocate to mental health services is made primarily at the local level.
Both approaches to funding have strengths and limitations. The first model guarantees that a certain amount of resources will be used to provide mental health services. It also requires strong centralized leadership at the state level to develop a service delivery structure and process. This model can be limited insofar as it makes it more difficult to integrate mental health and employment services. So while a program with an independent funding arrangement has more autonomy, it also requires more effort to integrate mental health and welfare policies and service delivery. Under the second funding model, integration of mental health and employment services becomes easier, as mental health services exist as one of a range of options to help welfare recipients become employed. The drawback is that mental health services compete with other services for funding, making the availability of funds more tenuous.
In addition to TANF and MOE funds, states may use funds from the Welfare-to-Work grants program to provide mental health services.(15) Washington County (St. George), Utah, is 1 of 11 counties participating in a competitive Welfare-to-Work grant. Part of the funding for this grant has been used to hire additional social workers and intensive case managers to expand social work services in the southern area of the state. The advantage of Welfare-to-Work funds is that they offer program administrators another way to pay for mental health services. These funds can be used to pay for client assessments and mental health treatment, and for supportive services while clients receive treatment. The drawback is that the narrow eligibility criteria for welfare-to-work programs restrict the types of clients who may participate in mental health services paid for with these funds.
9. AFS operates Oregon's welfare programs, which have a strong emphasis on employment and work supports.
10. DCF is responsible for the state's economic and self-sufficiency services, family safety system services, mental health and substance abuse services, and adult and developmental services.
11. The Office of Economic Self-Sufficiency is responsible for determining eligibility for TANF and other public assistance programs for low-income families.
12. Certified social workers have completed a master's degree in social work but do not have clinical licensure.
13. Salaries range from $30,000 to $35,000 per year for a licensed mental health counselor compared to between $18,000 and $23,000 for bachelor's level staff.
14. GROW stands for Gain immediate employment, Reach needed training, Opportunities for improved wages, and Work toward career goals.
15. Welfare-to-Work funds were authorized by the Department of Labor in 1998. Competitive and state formula Welfare-to-Work grants are no longer available.
Key Implementation Issues
Even with a strong program design and a well-developed administrative structure, implementing programs to address the mental health needs of welfare recipients presents ongoing challenges. In this chapter, we examine some of these key implementation challenges and present the innovative strategies used by the study sites to meet these challenges. The chapter covers (1) strategies to encourage employment case managers to refer clients to mental health services, (2) strategies to encourage clients to participate in mental health services, (3) ways to integrate mental health services into work activities, (4) options for creating a support network for mental health staff, and (5) approaches to monitoring and tracking client participation in mental health services. We conclude with a discussion of implementation issues that are specific to rural areas.
Strategies to Encourage Employment Case Managers to Refer Clients to Mental Health Services
Addressing the mental health needs of welfare recipients represents a dramatic shift in the focus of welfare programs. Before welfare reform, there was little emphasis on encouraging welfare recipients to find employment and even less on helping individuals resolve personal and family challenges that may form obstacles to work. While some welfare staff have adapted easily to the new emphasis on work and mental health, using all of the resources at their disposal, others not yet comfortable delving into recipients' personal lives may not see the value of programs designed to address the mental health needs of their clients. In addition, some staff may be overwhelmed by their broad range of responsibilities unrelated to client mental health needs, while still others with high caseloads may be able to accomplish only tasks that require immediate attention.
Given that the system is still in flux, the study sites, acknowledging that referrals from welfare staff are critical to the success of their programs, make a concerted effort to educate welfare staff about the availability and usefulness of mental health services. The most common strategies for encouraging referrals include the following:
Training workers to identify a mental health condition. For employment case managers to refer clients to mental health services, they must be able to identify clients who may have mental health conditions that prevent or restrict employability. Mental health staff frequently work with employment case managers individually and in groups to teach them how to recognize some of the behaviors or characteristics that may signal the need for mental health services.
Developing a simple referral process or a "clear pathway" for linking clients to mental health services. Most of the study sites have developed a simple and quick process for referring clients to mental health services. Typically, employment case managers submit a short form to the mental health counselor to refer clients to treatment. Some mental health staff have used flow charts to illustrate for employment case managers the process for referring clients to mental health services.
Keeping caseloads manageable. The size of an employment case manager's caseload often influences the relationship between the case manager and client, which may affect the number of referrals to mental health services. According to some case managers, clients are more likely to disclose mental health conditions once they have developed trust in the case manager, which is more likely to happen when a caseload is small and the manager has more time for each client. A manageable caseload also allows the employment case manager to follow up with clients who are referred to mental health services.
Stationing mental health and welfare staff closer together. In general, the more accessible mental health staff and service providers are to welfare staff, the greater the likelihood of referrals. According to program staff at all levels, co-locating mental health staff in welfare offices and employment centers (one-stop centers) is the most efficient way to make mental health workers accessible to welfare staff. The physical proximity encourages more contact, more communication, and, hence, more trust on the part of welfare staff in mental health staff. Because of this trust, welfare staff feel more comfortable about, and are therefore more inclined to, refer their clients to mental health services. Mental health staff members who are not co-located in the welfare office may find other ways to develop relationships with the employment case managers. In St. George, Utah, where the social worker is not co-located in the employment center that serves welfare recipients, the social worker regularly attends staff meetings, participates in agency functions, and finds ways to interact with agency staff on an individual and ongoing basis.
Strategies to Encourage Clients to Participate in Mental Health Services
Even the most well-designed mental health services are successful only insofar as clients participate in them initally and on an ongoing basis. For program staff, the challenge is therefore to encourage participation. In most of the study sites, participation in mental health services is voluntary, but it becomes mandatory if the client includes it as an activity in his/her employment plan. Family services counselors in Tennessee estimate that the initial no-show rate for clients referred to their agency is about 50 percent but that more clients participate over time. Statewide, two-thirds of clients who have been referred to the program have completed the initial assessment. Other states reported similar participation rates. Client participation rates in mental health services vary by local office and often are influenced by such factors as how quickly clients are linked to services, the accessibility of services, stigma associated with participation in mental health treatment, and the relationships between clients and employment and mental health staff. The following are some of the strategies that successfully increased client participation in mental health services in the study sites:
Addressing the stigma associated with mental health treatment. The stigma associated with mental illness and treatment may deter some employment case managers from talking with clients about mental health services and referring them to the program. The stigma may also make clients less willing to participate in mental health services. To address the stigma and thus encourage greater participation in mental health services, the study sites sought ways to educate clients and case managers about mental health conditions and services.
Mental health staff in some sites talk candidly with clients and employment case managers about mental health conditions. For instance, mental health counselors in the St. John's and Albina welfare offices in Portland, Oregon, talk with clients for typically 90 minutes during orientation about the signs of a mental health condition, how mental health problems may affect their behavior, and ways to treat mental health conditions (such as exercise, medication, mental health therapy, etc.). Social workers in Utah provide in-service training to case managers and discuss mental health treatment with individual managers to make them more knowledgeable about and comfortable with mental health services. Partly to "de-mystify" the treatment process, mental health staff in Florida replaced words such as "treatment" with "life-management help."
Offering flexibility in service location. Tennessee and some welfare offices in Utah are flexible in where they conduct client assessments and provide short-term mental health treatment. Services are provided at the welfare office, in the client's home, at a community-based agency, or at any other location convenient to the client. According to mental health staff in these states, providing services in the welfare office or at locations other than the local mental health agency makes clients less apprehensive about participating and improves access to treatment, especially in rural areas.
Providing supportive services such as transportation and child care while delivering mental health treatment. All of the study states provide child care and transportation assistance for clients participating in mental health services when those services are included as an activity in employment plans. Without supportive services, some clients may not be able to take advantage of the mental health services available to them.
Modifying existing policies or creating new ones to ensure that they support clients participating in mental health services. Flexibility in TANF work requirements (volume and types of activities) appears to encourage both employment counselors to include mental health treatment in an employment plan and clients to participate in mental health services. In Florida, where no more than five hours of mental health services per week can count toward the work requirement, few employment case managers include mental health services in employment plans. The other study states (Oregon, Tennessee, and Utah) do not restrict the number of hours or types of mental health services that count toward the work requirement. Instead, this decision is left to the employment case manager or mental health counselor. These mental health counselors suggested that the modified employment plan encourages clients to participate in mental health services.
Another policy that may influence participation in mental health treatment is extending or temporarily suspending time limits for families in treatment. Utah extends the time limit for families facing severe personal and family challenges who are participating in mental health treatment. In Tennessee, the month of assessment does not count toward the time limit, and families with severe mental health conditions may request an "interruption," or a temporary stop in the "clock" ticking toward the time limit. Currently, about half of the clients participating in mental health treatment have been granted such interruptions.
In most states, clients who include mental health services in their employment plan are subject to grant sanctions if they do not participate in mental health program activities. However, sanctions are not used to force clients to participate in mental health treatment against their will. In general, participation in mental health services is voluntary, and clients may also choose to include treatment in their employment plan.
Providing services that consider and address cultural differences. An ongoing challenge for program managers and mental health staff is to provide mental health services that are sensitive to cultural and language differences. Mental health staff in the study states identified three primary ways in which cultural and language differences may influence mental health service delivery. First, if ethnic and racial differences are not considered by counselors, they may act as a wedge in the relationship between the client and mental health counselor, eroding the trust that is central to this relationship. In the absence of this trust, the effectiveness of mental health services may be reduced. Second, bilingual children are sometimes expected to serve as translators between the mental health counselor and a parent or parents. Children cast in this role are exposed to life stressors and personal details of the parents' lives otherwise "reserved for" adults. The result, according to mental health staff, may be an emotionally unhealthy environment for the children. Third, cultural differences in how mental illness and mental health treatment are perceived can influence the level of comfort in participating in mental health services and therefore the decision to participate at all.
Some of the study sites have attempted to address these cultural and language differences. For example, in Belle Glade, Florida, paraprofessionals from the community are paired with licensed mental health counselors to facilitate the relationship between the client and mental health counselor. For instance, bilingual paraprofessionals may translate in counseling sessions, build relationships with clients in the community, and link clients to mental health services. In Miami, program administrators at contracting agencies have hired mental health outreach workers and counselors who are racially and ethnically similar to communities in which they work.
Protecting client confidentiality. According to mental health staff, protecting the confidentiality of clients creates a trusting relationship, which encourages client to participate in mental health services. Mental health counselors take several precautions to protect the confidentiality of clients. In general, mental health counselors begin the process of working with clients by clearly explaining the steps they take to protect the confidentiality of clients' information. Counselors then ask clients to sign release-of-information forms allowing the exchange of information between mental health counselors and other agencies. In some areas, mental health counselors store all client records in a locked filing cabinet.
Integrating Mental Health Services into Work Activities
One of the distinguishing features about programs designed to address the mental health needs of welfare recipients is the strong emphasis on employment. In all of the study sites, mental health program workers reiterated that the goal of mental health services is to help the client move from welfare to work. Some of the ways states integrate work into mental health services include the following.
Counting participation in mental health services toward the TANF work requirement. All of the study states allow mental health services to be counted as a work activity in the client's employment plan. This policy not only creates an incentive for clients to participate in treatment but also encourages employment and mental health staff to work together in helping the client progress toward self-sufficiency.
States vary in who can modify employment plans. In Tennessee, the mental health counselor is the only person who can modify the client's employment plan, whereas in Utah and Oregon, mental health counselors make recommendations about the types and amount of activities, but the employment case manager makes the final decision. In most cases, the employment case manager accepts the recommendations of the mental health staff. When mental health is written into the employment plan, the employment case manager is also responsible for ensuring that the client participates in treatment.
Educating treatment providers about work and participation requirements. At many of the study sites, mental health staff help mental health treatment providers understand the TANF requirements for receiving cash assistance, such as work requirements, time limits, sanctions, etc. In Multnomah County, Oregon, mental health counselors specifically said that educating treatment providers about TANF requirements is one of their job responsibilities. This educational experience not only strengthens the relationship between mental health and employment staff but also brings dual-system support to the effort to move welfare recipients into jobs by building the treatment providers' understanding of the circumstances of welfare recipients and the demands placed on them to become employed.
Allowing Mental Health Activities in Client Employment Plans
PRWORA requires states to meet increasingly higher work participation rates and specifies which work-related and mental health activities can count toward that requirement. However, because of substantial caseload declines, states actually have considerable flexibility in defining the types of mental health activities that can count toward the work requirement. In fiscal year 1999, states were required to have 35 percent of all families participating in work activities, less any caseload reduction credit. On the basis of caseload declines, 23 states were not required to have families participating in work activities, and only 2 states were required to have 20 percent or more of their TANF caseload participating in work activities (U.S. Department of Health and Human Services 2000). This loosening of the work requirement has allowed states to approve participation in activities such as mental health counseling or to temporarily defer clients from participation in work activities while they address issues that may be interfering with their ability to find or maintain employment. The biggest challenge states are likely to face in permitting mental health activities to be included in employment plans is overcoming the belief by policymakers that participation in mental health counseling or other similar activities may weaken the emphasis on work. This need not be the case if these activities are provided with an eye toward helping clients find and maintain employment. Oregon and Utah are two states that have broadly defined the activities that can be included in a clients self-sufficiency plan, and neither their participation rates nor their program emphasis has been negatively affected.
Using a short-term, employment-focused and/or solution-focused mental health treatment model. Some states, such as Tennessee and Utah, have encouraged mental health counselors and treatment providers to use a short-term, employment-focused mental health treatment model for working with TANF clients. In fact, family services counselors in Tennessee have been trained to use a short-term, solution-focused mental health treatment approach. District coordinators in the state review case files at random to ensure that mental health counselors use this approach. Similarly, mental health counselors in Utah work closely with contracted mental health treatment providers to ensure that treatment is short-term and employment-focused. Mental health counselors in Tennessee and Utah indicated, however, that some clients require a different approach However, in general, mental health staff believe that the short-term, solution-focused method is effective for welfare recipients with less severe mental health conditions.
Providing employment services in mental health treatment facilities. In Florida, where mental health treatment is provided by using TANF funds, some of the mental health treatment facilities have developed employment-focused activities exclusively for welfare recipients referred to them. For example, Western Palm Beach County Mental Health, a contracted treatment provider in Belle Glade, developed a job-seekers club, in which TANF recipients receiving mental health services meet to talk about life skills such as prioritizing, balancing work and family responsibilities, and child rearing.
Developing a plan to transition clients from mental health treatment to work. Mental health staff at most of the sites work closely with employment case managers to monitor client progress in treatment and to recommend ways for gradually increasing work activities. Recommendations may be given during case staffings or during informal conversations between employment case managers and mental health staff.
Creating a Professional Support Network for Mental Health Staff
In general, mental health counselors working with welfare recipients have a difficult job. The people they see have experienced severe trauma such as childhood abuse, domestic violence, rape, homelessness, and other personal tragedies. The ability to deal with these complex life circumstances requires not only intense clinical and/or problem-solving skills but also a knowledge about the other mental health resources available in the community. Many mental health counselors working with welfare recipients may not have an obvious link to a professional support network, especially in rural locations, where professional support networks may be limited.
Mental health staff in some of the study sites have developed professional support networks to help solve difficult cases and to establish a source of ongoing training and consultation. For example, in Multnomah County, the program coordinator convenes weekly meetings with mental health and substance abuse specialists to discuss agency business and to staff difficult cases. In addition, specialists consult each other or their supervisor when they need professional guidance or support. In Tennessee, the program director holds regular training sessions for mental health counselors and district coordinators. In addition, local contracted mental health agencies provide clinical support to counselors on their staff who are co-located in the welfare office. In Utah, social workers meet every month, alternating each month with statewide and half-state meetings, to staff difficult cases and to talk about ways to improve mental health services. The program director at the state level provides clinical support to the social workers.
Monitoring and Tracking Client Participation in Mental Health Services
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)
Considerations in Providing Mental Health Services in Rural Areas
Although urban and rural areas face many of the same challenges in addressing the mental health needs of welfare recipients, some aspects of service provision are easier in rural areas, while others are more difficult. In general, we observed four primary considerations when providing mental health services in rural areas.
Clients in rural areas compared with those in urban areas have less difficulty accessing mental health treatment in a timely manner, but they have more difficulty accessing certain types of treatment. In two of the study states, Oregon and Utah, clients in rural sites find it easier to access mental health treatment in a timely way than do clients in the urban sites. Clients seeking Medicaid-funded mental health treatment in urban areas have had to wait up to a month to see mental health therapists, which is substantially longer than the wait experienced by clients in the rural sites. However, in most of the rural sites, clients had more difficulty accessing certain types of treatment, such as psychiatric evaluations, residential treatment, and treatment for co-occurring mental health and substance abuse conditions.
In Tennessee, the proportion of referrals to mental health services is substantially higher in rural than in urban areas. According to researchers at UT, two-thirds of the referrals to the FSC program come from rural areas even though the number of inndividuals referred account for one-third of the state's welfare population. It is unclear why there is a difference in referrals between rural and urban areas. However, employment case managers in the rural areas suggested that they get to know the clients well and tend to have strong collaborative relationships in their own offices and with other agencies. The other study sites had less data than Tennessee on this issue.
Some mental health staff and clients are required to travel long distances to provide or to access services. Mental health staff in rural areas typically provide services in multiple welfare offices and over a large geographical area compared to staff in urban sites. For example, one social worker in Utah provides services to welfare recipients in five counties, which limits the accessibility of the social worker in each of the offices and reduces the time the social worker can meet with clients. Mental health staff in other rural communities have similar arrangements and face similar challenges. Furthermore, some clients living in remote areas have difficulty accessing mental health services and participating in mental health treatment because of the distances they are required to travel.
According to mental health staff, the stigma associated with mental illness and mental health treatment is particularly strong in rural areas. The stigma of participating in mental health services is frequently discussed among mental health counselors and clients in rural areas, where there is concern that neighbors and friends might "find out" that clients are receiving mental health services. Mental health counselors in rural areas also suggested that, in general, employment case managers and clients themselves are more biased about mental illness and more uncomfortable about participating in mental health treatment.
16. Valley Mental Health is the county's sole Medicaid-funded mental health treatment provider and is paid under a capitated managed care funding arrangement.
This review of programs designed to address the mental health needs of welfare recipients was intended to be exploratory in nature. We identified the types of mental health services provided to welfare recipients and how these services are administered and delivered by state and local welfare offices. We outlined the key decisions involved in designing and providing mental health services as well as the types of service delivery options associated with each decision. We also documented many of the primary implementation issues. Our overall goal was to create a guide for program administrators in other states and communities interested in delivering mental health services to welfare clients. This guide is also intended to assist researchers who are interested in evaluating mental health service programs for welfare recipients. Through our investigation, we have arrived at several conclusions about what is involved in providing mental health services to welfare recipients and about the relationship between these services and the work-related thrust of welfare reform.
- Mental health services can be a valuable resource for employment case managers seeking to move hard-to-employ individuals from welfare to work.
Employment case managers said that mental health services help them to address the personal and family challenges faced by hard-to-employ welfare recipients. Mental health staff offer specialized services that employment case managers are not trained to provide. Mental health staff also help employment staff understand mental health conditions and how these conditions may affect the clients' ability to find and keep a job.
- There are a variety of ways to address mental health needs of welfare recipients; there is no evidence to suggest that one model for providing services is better than any other.
In each local community, Medicaid-funded mental health services are available to welfare recipients. However, some recipients may not be aware that they have a mental health condition that affects their employability. And even those aware of their condition may not know how to access treatment. In the study states, TANF and Welfare-to-Work funds have been used to link clients to existing mental health treatment or to expand treatment options or create new ones. The experience of the four states suggests that the mental health needs of welfare recipients may be addressed in a variety of ways.
Florida. In Florida, TANF funds have been used to purchase mental health treatment for welfare recipients and those at risk for TANF involvement. These funds have also been used to hire outreach staff who link individuals to these services. Mental health services are administered and coordinated by mental health and substance abuse agencies, which operate outside the welfare office and workforce development system. Operating mental health services out of an agency outside of the TANF eligibility and TANF employment services system has made integration difficult.
Oregon. In Oregon, the focus is on assessing clients and linking them to Medicaid-funded mental health treatment providers. Oregon has integrated mental health services into the welfare system by co-locating mental health staff in most local welfare offices and allowing each district office to develop an administrative structure that reflects the mental health resources available in the community.
Tennessee. The Family Services Counseling program in Tennessee provides assessment and short-term, solution-focused mental health treatment for welfare recipients using an approach that is uniform statewide. Through this statewide model, Tennessee is striving for maximum integration of mental health services into the welfare office by co-locating program administrators in the state welfare office. Family services counselors and district coordinators are co-located in the local welfare offices. Individuals with more intensive mental health needs are linked to a Medicaid-funded mental health treatment provider.
Utah. Social workers in Utah conduct clinical assessments and some short-term therapy. They also link clients to Medicaid-funded mental health treatment and to some contracted mental health treatment providers. Hiring mental health staff members as employees of the welfare agency has more solidly integrated mental health services into the workforce system that serves TANF recipients.
- Regardless of program design and administrative structure, it is a challenge to integrate mental health and employment services.
Mental health services are delivered most effectively when they are integrated into employment services. Connecting the two influences not only the process for identifying and linking clients to services but also the monitoring and tracking of client participation in mental health services. In addition, integrating services fosters strong collaborative relationships between mental health and employment staff, improving the exchange of information between agencies about mental health services and welfare requirements and ultimately benefiting clients by serving a broader range of their needs.
Regardless of the administrative structure through which mental health services are provided, however, it is a challenge to fully integrate these services into a welfare employment program. Some employment service staff are skeptical of any service that appears to detract from the immediate goal of getting clients employed. Others are simply too busy to identify and refer clients who might benefit from mental health services. The single most effective strategy for fostering integration appears to be co-locating employment services and mental health services staff. When it is not possible to do this, extra efforts are necessary to build trusting relationships between mental health and employment services staff.
Integrating mental health and employment services is especially difficult when the mental health service delivery structure is completely separate from the TANF employment structure. In Florida, for instance, mental health treatment providers rely on outreach workers to link clients to services, and they rely on district coordinators at the local level to coordinate mental health and employment services. The state has developed an expansive set of mental health services for TANF recipients and those at risk for TANF involvement. However, except in a few communities, integration of mental health and employment services is limited. Program administrators attribute the lack of integration to the fact that the workforce development system, the agency that provides employment services to welfare recipients, was not included in the initial planning stages for the mental health services. Efforts at the local level (such as co-locating mental health workers in the one-stop centers) have improved the coordination of services in some communities.
- Identifying clients in need of mental health services is more art than science.
Florida is the only study state that has developed a standardized screening tool used by outreach staff to identify clients who may need mental health services. Most of the study states rely on employment case managers to identify clients in need. Once clients are referred for services, highly skilled licensed mental health professional conduct in-depth psychosocial or clinical assessments with clients. The purpose of the assessment is to identify those for whom mental health treatment may be appropriate and to recommend the types and volume of services to include in the client's employment plan. Tennessee is the only study state that uses a standardized tool to conduct the in-depth assessment. The assessment format and process in the other study states varies by mental health counselor. When hiring mental health counselors, many program coordinators or managers place a very high value on experienced mental health workers with very strong assessment skills.
- As in many welfare-related programs, it is a challenge to get clients to participate in mental health services, although this challenge varies by site.
The initial no-show rate is estimated to be around half in most of the study states, although this varies some by site. There is no evidence to suggest that certain groups of clients are more likely than others to miss appointments. However, mental health staff suggest that no-show rates tend to be lower when the mental health counselor is co-located in the welfare office. In addition, clients who are identified through broad screenings may be less inclined to show up for the initial assessment because broad screenings may incorrectly identify clients as needing services. Mental health staff indicate that even though the initial no-show rate is high, many clients referred to mental health services over time complete the in-depth assessment with the mental health counselor.
- Use of TANF funds to pay for mental health treatment increases the flexibility in the types of nonmedical mental health services provided and allows program administrators to purchase or provide mental health treatment that focuses on employment.
In most areas and with the help of mental health staff, clients are able to access mental health treatment through the local Medicaid-funded mental health service provider. However, in some areas, there is a delay in accessing treatment and/or some limitations on the types of services provided (e.g., therapy is provided in groups rather than in individual sessions). Using TANF funds to pay for mental health therapy increases the flexibility in the types of nonmedical mental health services that can be provided. It also allows program administrators either to purchase therapy that is structured around the goal of moving welfare recipients into work and/or to create new services that work toward this goal.
- More research is needed on the effectiveness of mental health services in improving the employability and general well-being of welfare recipients.
In general, most of the study sites have not heavily emphasized evaluating the overall success of mental health services. Program administrators typically track the number of referrals and types of services used. However, few have examined how mental health services affect clients' employability or general level of well-being. Some sites have shared success stories about how clients who participated in mental health services have found and kept a job, but this evidence is anecdotal. Only Tennessee has an extensive evaluation study underway.
Evaluation of Tennessees Family Services Counseling Program
The College of Social Work at UT is evaluating the Family Services Counseling program. The evaluation has several components, including (1) an analysis of administrative data collected from the case files of mental health counselors; (2) focus groups with district coordinators; (3) mail surveys to local service providers, district coordinators, and Department of Human Services case managers; and (4) phone interviews with 400 welfare recipients who participated in mental health services.
For more information, contact: Deborah Goodwin Perkins, Ph.D., Evaluation Research Specialist, University of Tennessee; Phone: (865)974-4636; E-mail: firstname.lastname@example.org.
In the absence of evaluation research and outcome data, it is difficult to determine the success of these programs in improving the employability of welfare recipients. However, even with an evaluation, the outcomes of mental health services are not always easy to measure. Relying strictly on employment outcomes does not capture other benefits of mental health services, such as general family functioning and individual and family well-being. Still, it is important to evaluate mental health programs for welfare recipients to determine the effectiveness of these services in moving welfare recipients to work. In addition, evaluation research can reveal ways to improve the quality of mental health services in terms of addressing mental health needs that may be specific to welfare recipients.
Baron, R.C., Raudenbush, D.J., Wilson, K., and Marinelli, J. (1996). "Strengthening the Work Incentive Provisions of the Social Security Act to Encourage Persons with Serious Mental Illness to Work at Their Potential. Employment and Return to Work for People With Disabilities": A conference sponsored by the Social Security Administration and the National Institute on Disability and Rehabilitation Research, Office of Special Education and Rehabilitative Services, U.S. Department of Education October 31-November 1, 1996, National Press Club. Washington, DC.
Barusch, A., Taylor, M.J., Abu-Bader, S., and Derr, M.K. (1999). "Understanding Families with Multiple Barriers to Self-Sufficiency." Report submitted to the Utah Department of Workforce Services. Salt Lake City, UT: Social Research Institute, University of Utah.
Bassuk, E.L., Browne A., and Buckner, J.C. (1996). "Single Mothers and Welfare," Scientific American, vol. 275, no. 4, 60-67.
Bassuk, E.L., Weinreb, J.C., Buckner, J.C., Browne, A., Solomon, A., and Bassuk, S.S. (1996). "The Characteristics and Needs of Sheltered Homeless and Low-Income Housed Mothers." Journal of the American Medical Association, vol. 275, no.8, 640-646.
Brooks, M.G., and J.C. Buckner (1996). "Work and Welfare: Histories, Barriers to Employment, and Predictors of Work Among Low-Income single Mothers." American Orthopsychiatric Association, vol. 66, no. 4, 526-537.
Chandler, D., and Meisel, J. (2000) "The CalWORKs Project: The Prevalence of Mental Health, Alcohol and Other Drug & Domestic Violence Issues among CalWORKs Participants in Kern and Stanislaus Counties." Sacramento, CA: California Institute for Mental Health.
Danziger, S., Corcoran, M., Danziger, S., Heflin, C., Kalil, A., Levine, J., Rosen, D., Seefeldt, K., Siefert, K., and Tolman, R. (1999). "Barriers to the Employment of Welfare Recipients" (Revised version). Ann Arbor, MI: University of Michigan, Poverty Research and Training Center, School of Social Work.
Holzer, C., Shea, B., Swanson, J., Leaf, P., Meyers, J., George, L., Weissman, M., and Bednarski, P. (1986). "The Increased Risk for Specific Psychiatric Disorders among Persons of Low Socioeconomic Status." American Journal of Social Psychiatry, 6, 259-271.
Jayakody, R., Danziger, S., and Pollack, H. (September 1999). "Welfare Reform, Substance Use, and Mental Health." Ann Arbor, MI: University of Michigan School of Social Work.
Jayakody, R., and Stauffer, D. (2001). "Mental Health Problems among Single Mothers: Implications for Work and Welfare Reform. Journal of Social Issues, 56, 617-634.
Johnson, A., and Meckstroth, A. (1998). "Ancillary Services to Support Welfare-to-Work." Princeton, NJ: Mathematica Policy Research, Inc.
Lennon, M.C., Blome, J., and English, K. (2001). "Depression and Low-Income Women: Challenges for TANF and Welfare-to-Work Policies and Programs." New York, NY: Columbia University, Research Forum on Children, Families and the New Federalism, National Center for Children in Poverty, Mailman School of Public Health.
Leon, A.C., and Weissman, M.W. (1993). Analysis of NIMH's Existing Epidemiologic Catchment Area (ECA) Data on Depression and Other Affective Disorders in Welfare and Disabled Populations. Washington, DC: U.S. Department of Health and Human Services, Office of the Assistance Secretary for Planning and Evaluation.
McLeod, J.D., and Kessler, R.C. (1990). "Socioeconomic Status Differences in Vulnerability to Undesirable Life Events." Journal of Health and Social Behavior, 31, 162-172.
Mintz, J., Mintz, L.I., and Phipps, C.C. (1992). "Treatments of Mental Disorders and the Functional Capacity to Work." In R.P. Liberman (Ed.), Handbook of Psychiatric Rehabilitation, 290-316. New York: Macmillan.
Miranda, J., and Green, B.L. (1999). "The Need for Mental Health Services Research Focusing on Poor Young Women." Journal of Mental Health Policy and Economics, 2, 73-89.
National Institute on Disability and Rehabiliation Research (1993). "Strategies to Secure and Maintain Employment for People with Long-Term Mental Illness. Strategies... Employment... Mental Illness: Bringing Research Into Effective Focus," 15(10). Washington, DC: National Institute on Disability and Rehabilitation Research Office of Special Education and Rehabilitative Services Department of Education. http://www.cais.com/naric/rehab_b/rb-15-10.html.
Olson, K., and Pavetti, L.A. (1996). Personal and Family Challenges to the Successful Transition from Welfare to Work. Washington, DC: The Urban Institute.
Regier, D.A., Narrow, W.E., Rae, D.S., Manderscheid, R.W., Locke, B.Z., and Goodwin, F.K. (1993). "The de facto US mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services." Archives of General Psychiatry, 50, 85-94.
Ries, R. (1995). "Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse." Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment.
Sweeney, E.P. (February 2000). "Recent Studies Make Clear that Many Parents Who Are Current or Former Welfare Recipients Have Disabilities and Other Medical Conditions." Washington, DC: Center on Budget and Policy Priorities.
Turner, R. J., and Lloyd, D.A. (1995). "Lifetime Trauma and Mental Health: The Significance of Cumulative Adversity.", Journal of Health and Social Behavior, 36, 360-376.
Ulbrich, P.M., Warheit, G.J., & Zimmerman, R.S. (1989). "Race, Socioeconomic Status, and Psychological Distress: An Examination of Differential Vulnerability.", Journal of Health and Social Behavior, 30, 131-146.
U.S. Department of Health and Human Services (2000a). "Healthy People 2010." Rockville, MD: U.S. Department of Health and Human Services, National Institutes of Health, Substance Abuse and Mental Health Services Administration.
U.S. Department of Health and Human Services (2000b). "Temporary Assistance to Needy Families Program." Third Annual Report to Congress. Washington, DC: U.S. Department of Health and Human Services.
U.S. Department of Health and Human Services (1999). "Mental Health: A Report of the Surgeon General." Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National Institutes of Health, National Institute of Mental Health.
Zedlewski, S. (1999). "Work Activity and Obstacles to Work Among TANF Recipients." Washington, DC: The Urban Institute.
Appendix A: Profile of the Study Sites
Florida's TANF Substance Abuse/Mental Health Program
Program origins. In 1998, the Florida legislature allocated $20 million from the TANF block grant for mental health and substance abuse services. By the end of 1999, most of the local welfare offices around the state had fully implemented the TANF Substance Abuse/Mental Health (SAMH) Program for participants in the state welfare program, known as WAGES. Eligibility for the TANF SAMH Program was expanded in 2000 to target families at risk of becoming WAGES participants. Non-WAGES participants are distinguished from WAGES participants administratively, but there is no distinction in the amount or types of services they can receive. In 2001, funding for the TANF SAMH Program was increased to $45 million. The TANF SAMH Program served over 24,000 people in 2000 and the state estimates that 25,000 people will be served during 2001.
Scope of barriers targeted. The TANF SAMH program targets individuals with substance abuse or mental health conditions.
Eligibility for mental health services. Individuals eligible for the TANF SAMH Program are WAGES recipients and their family members and also non-WAGES families with incomes less than 200 percent the Federal Poverty Level. Services can be provided to noncustodial parents as long as both custodial and noncustodial parents are below the income requirement and are permanent residents of Florida. Also eligible for services are individuals who have left WAGES within the past 12 months, child-only cases(17), families receiving services in the Family Safety system (the child welfare agency) and individuals receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI).
Strategies for identifying participants with mental health conditions. There is wide variation among the local one-stop welfare offices for informing and identifying participants of the TANF SAMH program. The primary approaches used by the outreach workers are described below.
- Referrals by WAGES Staff. Statewide, TANF SAMH outreach workers are co-located in most of the one-stop centers at least part time. Being co-located within the office appears to help develop relationships between the outreach workers and WAGES staff, which tends to increase the number of referrals.
- Presentations during WAGES Orientation and Job Club Workshops. Presentations during orientation and job club workshops are one way outreach workers inform WAGES participants about the TANF SAMH Program. The frequency of these presentations varies by local office. At the Caleb One-Stop Center in Miami, participants learn about the TANF SAMH Program during the employment services provider's job club.
- Community Outreach. In areas where the outreach worker is not co-located within the one-stop center, there is an emphasis on developing community outreach activities to inform low-income families about the TANF SAMH Program and to encourage participation in screening and treatment. In some areas, outreach workers make home visits and work with other agencies, such as community health clinics, day-care centers, and food stamp offices, to gain access to TANF participants and low-income families. Additionally, some contracted service providers have negotiated with community agencies to co-locate outreach staff within their agencies.
Types of mental health services provided. The TANF SAMH program provides screening, assessment, and treatment for participants with mental health and substance abuse conditions.
- Screening. TANF SAMH outreach workers use a standard 32-item survey to conduct screenings. The screening tool includes CAGE questions to detect drug and alcohol abuse and a mental health screening tool. A scoring system for the screening tools allows outreach workers to determine whether a client should be referred to treatment. There are also two emergency referral questions and seven automatic referral questions. The state requires use of the uniform TANF SAMH Program Survey, but additional questions can be added to the screening. Discretion for how broadly to screen participants is left to the local one-stop administrator. Some centers screen all WAGES participants during orientation. Others screen only participants referred by the WAGES case managers, other community agencies, or those self-referred.
- In-Depth Psychosocial Assessments.The outreach workers schedule intake appointments for in-depth psychosocial assessments with licensed mental health or substance abuse counselors typically within 10 days of the initial screening. The psychosocial assessments vary by treatment provider, but counselors usually speak with participants about their health status, employment and economic circumstances, drug and alcohol use, legal status, family history, and family/social relationships. In most cases, outreach workers refer participants to their own agencies. However, when the participant requires treatment that an outreach worker's agency does not provide or if there is a wait for treatment, the participant is referred to other mental health and substance abuse treatment providers within the area. Referring participants to other agencies occurs primarily in urban areas where there is more than one treatment provider.
- Mental Health Treatment.In general, there are few restrictions on the types of services provided under the TANF SAMH contracts. Treatment plans are negotiated with the participant and contracted mental health/substance abuse treatment provider and approved by the TANF SAMH specialist. Some agencies offer a wide variety of mental health and substance abuse services, while other agencies contract to provide a very narrowly defined service. For example, one Miami treatment provider offers outpatient mental health treatment for adults only. A second, larger, treatment provider in Miami offers an extensive range of mental health and substance abuse services for children and adults including outpatient, in-home/on-site, outreach, residential treatment, and case management for addressing substance abuse and mental health needs.
The relationship between mental health services and work requirements. Florida requires participation in at least 30 hours a week of work activities, which includes job search, vocational training, work experience, adult basic education and up to five hours per week of mental health and substance abuse treatment. Participants also are assigned to one of two time limit tracks. Participants who are work-ready can receive cash assistance for 24 out of 48 months; those with more serious barriers to employment are allowed cash assistance 36 out of 72 months. Additional months may be added to a participant's time limit to compensate for months that they are actively involved in mental health or substance abuse treatment. The lifetime limit for all participants is 48 months.
Participants also may obtain an exemption from the time limit. Hardship exemptions are granted when a client has been participating diligently in work activities but still has a barrier to employment or is enrolled and participating in a program that extends beyond the time limit. Participants awaiting SSI approval also are exempt from the time limits. However, most participants are granted a deferral rather than an exemption. A deferment lasts up to 90 days and allows the client to be temporarily relieved from the work requirement. Deferments are granted when there are serious barriers that limit the client's ability to work. Typically, the client must obtain a written statement from a doctor to receive a deferral. Participants who are deferred from the work requirements are still subject to the time limit.
Administrative structure. The TANF SAHM Program is housed within the Department of Children and Families(18) (DCF) and operates under both the Mental Health and the Substance Abuse Program Offices but works in collaboration on policy issues with the Office of Economic Self-Sufficiency.(19) A program director and three staff members in the state office administer the TANF SAMH Program. Within each of the DCF districts or regions, there is at least one TANF SAMH specialist to oversee program activities within the local offices. All of the TANF SAMH employees are hired as OPS (Other Personnel Services) employees. These are temporary positions, renewed every six months, without employment benefits (such as health insurance, sick leave, and retirement).
The DCF district or region administrator selects and contracts with mental health and substance abuse treatment providers within each of the local communities. These contracts are negotiated with the TANF Specialists and local district administrators. In some communities there is one primary contractor, and in others there are multiple providers. Contracted service providers include a range of agencies, including substance abuse and community mental health centers, residential treatment providers, faith-based organizations, and hospitals. The contracted service providers hire the outreach workers, conduct clinical assessments and provide mental health and substance abuse treatment.
Funding mental health services. The Florida legislature allocated $45 million to the TANF SAMH Program for 2001. TANF SAMH dollars are used to pay for the administration and most nonmedical services provided through the TANF SAMH Program. Medicaid covers the cost of medical services, such as medications and psychiatric assessments. Approximately 4 percent of the TANF funds are for administrative overhead and the rest is for direct services. Funding is distributed to each of the 13 DCF districts and 1 regional office using a formula based on the welfare population within the district or region. Funds from the DCF district or regional offices flow down to the local service providers, with whom contract amounts and types of services are negotiated. Monetary reimbursements may vary among the different service providers. Overall, local offices are given broad flexibility in how the funds are spent.
For additional information please contact:Celia Wilson
TANF SAMH Program Administrator
Mental Health/Substance Abuse Program Offices
Phone: (850) 410-1187
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
orCarol Ann Krager
Intervention Program Analyst
Oregon Department of Human Services
Phone: (503) 945-5931
Tennessee's Family Services Counseling Program
Program origins. In 1999, the director of Families First Services(22) initiated an assessment of the types and prevalence of work barriers among TANF recipients. Based on local welfare administrators' reports, Tennessee's Department of Human Services (DHS) determined that a portion of families on cash assistance needed more intensive clinical case management and counseling services. This prompted the creation of a statewide program, Family Services Counseling (FSC), to assist families with barriers to move from welfare to work. DHS contracted with the College of Social Work at the University of Tennessee (UT) for the administration of the FSC program. In January 2000, UT hired a director to design and implement the FSC program. Family services counselors began receiving referrals in February 2000.
Scope of barriers targeted. The FSC program targets TANF customers and family members with mental health conditions, learning disabilities, or substance abuse, domestic violence, or child behavioral problems, but will also provide services to families with other types of challenges, such as parenting difficulties and homelessness.
Eligibility for mental health services. Services are available to all family members on the TANF case. Families may receive FSC services while on cash assistance and up to 12 months after case closure.
Strategies for identifying customers with mental health conditions. Tennessee uses a multifaceted approach to identify and connect customers to the FSC program.
- Orientation. TANF clients first are made aware of the FSC program at their group orientations. During orientation, a family services counselor explains the FSC program and provides an outline of the types of services offered and how to access these services.
- Case Managers. TANF clients are commonly referred to the FSC program by DHS case workers. During the development of a customer's personal responsibility plan, the case worker may recommend FSC services. The DHS case workers are educated about the FSC program, and they are trained to identify substance abuse problems, mental health conditions, and domestic violence.
- Referrals by Employment Service Providers or Community Agencies. The local contracted employment and education agencies are informed about FSC services. They may refer customers to the program through the DHS case worker or directly to a family services counselor.
- Mandatory Referrals. DHS case workers are mandated to offer referrals to sanctioned clients. Sanctioned clients who chose FSC as an activity to remedy a sanction are required to meet with family services counselors during the two-week compliance period before they can begin receiving cash assistance again.
- Community Outreach. The FSC program has a widespread social marketing effort. Presentation and training sessions for DHS staff and other community partners help educate workers statewide about the FSC program mission, goals, and success. Some areas have outlocated family services counselors to inform clients about the FSC program. In Chattanooga, for example, there is a family services counselor located at the Harriet Tubman Housing project.
Types of mental health services provided. There is a range of mental health services available to customers in the FSC program. They are described below.
- Standardized Assessment. All customers receive a statewide standardized assessment with a family services counselor to determine the appropriate treatment for the client.
- Solution-Focused Therapy. Family services counselors provide solution-focused therapy to their clients. Family services counselors receive extensive training on using a solution-focused brief therapy approach, which identifies and uses client strengths and resources to identify and solve problems.
- Linkage with Local Mental Health Providers. Customers that require intensive long-term treatment or medication management are referred to mental health centers accepting TennCare.(23) Family services counselors also refer customers with learning disabilities or domestic violence, substance abuse, and child behavioral problems to other agencies for assessment and treatment.
- Intensive Case Management. The family services counselors provide customers with individualized assistance to address barriers to self sufficiency. Family services counselors may assist customers with supportive services such as housing and transportation.
- Consultation with DHS Case Workers. The family services counselors make recommendations to DHS case workers for modified work plans based on their work with clients. Because family services counselors are co-located in the local welfare offices, DHS case workers frequently consult with them about difficult cases and most family services counselors provide training for DHS staff to identify barriers to work among clients.
- Assistance with Applying for SSI. The family services counselors help to coordinate psychological evaluations and walk customers through the Supplemental Security Income application process.
The relationship between mental health services and work requirements. While the Families First program emphasizes employment, it allows customers to participate in other activities such as mental health treatment, education, or training before going to work. Customers referred to the FSC program are not required to participate in self-sufficiency activities until a family services counselor has assessed them. The month of the client's assessment does not count against their time limit for receiving cash assistance, and a family services counselor may request a time limit interruption for clients with severe mental health conditions. There is a broad range of activities that may be included in the client's self-sufficiency plan, including mental health treatment. Most customers participating in the FSC program blend work activities, such as life skills workshops, with mental health treatment. The goal is to gradually move customers into work, but work is not required as a first activity.
Administrative structure. Staff members for the FSC program are hired through UT and local contracted service providers. The FSC program director and district coordinators are university employees. Within each district, DHS contracts with local not-for-profit agencies to provide family service counselors and clinical supervision. In some of the sites, the local agencies had formed collaborative relationships prior to the FSC program. These relationships were instrumental in implementing the FSC program in these areas. For example, DHS contracted with Family and Children's Services of Greater Chattanooga (FCS) to provide family services counselors for Hamilton County because they have been administering programs such as life skills training, parenting classes, employee assistance programs, and outpatient mental health treatment for over 120 years.
When customers need services, in addition to family services counseling, they are referred to the TennCare mental health providers. The types of agencies providing treatment vary across the state. For example, the urban area of Hamilton County has a variety of treatment providers including a residential and an outpatient substance abuse treatment center, while rural Montgomery County is more limited, with one mental health center and several not-for-profit agencies that provide primarily group treatment to low-income families.
Funding mental health services. The operating budget for the FSC program is approximately $8 million. Most of the money allocated is used to contract with UT for program administration and with local not-for-profit agencies to hire family services counselors. Most TANF families can access mental health treatment through their TennCare assistance. Families who leave cash assistance generally qualify for transitional TennCare benefits, which cover mental health treatment.
For additional information please contact:Holly Cook
Program Director Families Services Counseling Program
University of Tennessee
Phone: (615) 313-5465
Utah's Mental Health Services
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
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.
Appendix B: Program Forms for Screening and Assessment
Screening and Assessment Tools
Utah's Department of Workforce Services (DWS) uses the Mental Health Services Clinical Evaluation as the basis for making a clinical diagnosis and recommendations for mental health treatment and other types of services. However, social workers at DWS are given discretion to use their own inventories. Most social workers incorporate components of the clinical evaluation with a variety of other tools in their clinical assessment. Two assessment tools used in Utah are presented in this appendix. The first is the standard DWS form, which is used by some social workers around the state, and the second is an example of a modified assessment tool used by a social worker in Salt Lake County.
Purpose of the screening/assessment tool: The purpose of the assessment tool is to provide a clinical diagnosis and recommendation for mental health treatment and other types of services.
Target population: The clinical evaluation/assessment instrument is administered to TANF recipients referred to mental health services, clients in sanction status, clients reaching their time limit on cash assistance, and clients who screen positive on the CAGE substance abuse questionnaire.(1)
Who administers the assessment: The assessment is administered by licensed clinical social workers (LSCWs) who have extensive experience providing clinical treatment and by certified social workers, under the supervision of an LCSW, who have earned an M.S.W.
Time required to complete the assessment: The assessments can take anywhere from two to fours hours to complete and may be done in one or more sessions.
Information collected/issues addressed: The following information is collected through the assessment: basic demographic characteristics, current situation, social and family history, alcohol and drug history, legal issues, physical and mental health, and family violence. A recommended treatment plan is also included in the assessment.
Utah's Screening/Assessment Instrument [in PDF format]
The Family Services Counseling (FSC) Assessment Form is a standard tool used statewide by all family services counselors. The assessment was developed by the program director with input from welfare and FSC program staff. Family services counselors may use additional inventories but are required to complete the basic assessment form for all clients referred to the FSC program. Copies of completed assessment forms are sent to the College of Social Work, Office of Research and Public Service at the University of Tennessee for use in the FSC program evaluation.
Purpose of the screening/assessment tool: The purpose of the assessment is to determine the service needs of TANF recipients participating in the FSC program. Results from the assessment are used to design the types and volume of activities included in the client's employment plan. This assessment is also used in a statewide evaluation of the FSC program.
Target population: The FSC Assessment Form is administered to TANF recipients referred to the FSC program, which includes those with mental health and substance abuse problems, victions of domestic violence, individuals with learning disabilities, and/or children with behavioral problems. Clients in sanction status are automatically referred to FSC (participation in services is voluntary).
Who administers the assessment: The assessment is administered by family services counselors, who are either licensed mental health professionals or individuals supervised by a licensed mental health professional.
Time required to complete the assessment: On average, assessments take about two hours to complete.
Information collected/issues addressed: The FSC Assessment Form collects information on demographics, family situation, sources of stress, problems the client is struggling with, school/work history, physical health, counseling history, drug and alcohol use, current functioning, and on issues covered in the Adult Strength Scale.(2) Counselors also recorded their impressions and recommendations on the form. In addition, the form includes four supplemental screenings: (1) learning needs screening, (2) drug and alcohol screening, (3) family violence screening, and (4) functional assessment.(3) These screenings are only used if certain "red flag" questions on the assessment are answered positively or if the counselor believes that additional questions may help the client open up and disclose more information.
Tennessee's Screening/Assessment Instrument [in PDF format]
The Florida TANF SAMH (Substance Abuse/Mental Health) Program Screening is a standard 32-item screening tool used statewide by TANF SAMH outreach workers. The TANF SAMH program director developed the screening tool with input from TANF SAMH district specialists, and mental health and substance abuse contracted service providers. Questions can be added to the basic screening tool, but the 32 core questions may not be modified.
Purpose of the screening/assessment tool: The purpose of the screening is to identify clients at risk for mental health and/or substance abuse issues.
Target population: The screening/assessment tool is administered to TANF clients and other low-income families with an income less than 200 percent of the federal poverty level. Clients are screened in one-stop employment centers, public health centers, public schools, county courthouses, WIC offices, Head Start offices, and other locations that serve TANF recipients and other low-income families.
Who administers the assessment: Bachelor's level outreach workers administer the assessment to TANF recipients and other low-income families. The outreach workers, staff from the contracted mental health and substance abuse service providers, have a background in psychology, social work, or other social service-related fields.
Time required to complete the screening: The screening can be completed in 45 minutes to an hour.
Information collected/issues addressed: The screening tool begins with two open-ended questions: (1) "How is your life going for you right now?" and (2) "How is life going for your children?" The tool also includes the CAGE to detect drug and alcohol abuse, and a DSM IV-based mental health screening tool that addresses 10 disorders including, among others, depression; suicidal ideations; anxiety; history of sexual, physical, or emotional abuse; and domestic violence. A scoring system for the screening tools allows outreach workers to determine whether a client should be referred to treatment. A "yes" response to any one of seven specified questions indicates an automatic referral.
Florida's Screening/Assessment Instrument [in PDF format]
Utah's Department of Workforce Services Referral for Services Form. Employment counselors use the Referral for Services form to link clients with mental health and other services such as medical, housing, transportation, and legal services. Employment counselors send the forms to the Department of Workforce Services social worker assigned to the local welfare office. Social workers may also use this form to access mental health treatment for the client. The form takes approximately 10 to 15 minutes to complete.
Tennessee's Family Services Counseling (FSC) Referral Form. Tennessee's FSC Referral Form was developed exclusively for the FSC program. Employment case manager complete this two-page form to refer a client to the FSC program. The form includes basic demographic information, reason for referral, referral source, TABE test results, the employment case manager's name, and potential barriers to employment. The form takes between 20 and 25 minutes to complete.
Florida's TANF SAMH Program Certification (Referral) Form. Contracted service providers use this form to obtain authorization to provide mental health and substance abuse services to TANF recipients and other low-income families. Clients may be identified by outreach workers or referred directly to contracted service providers for mental health and substance abuse treatment. Contracted service providers complete this referral form and fax it to the TANF SAMH district specialist for approval. The form takes 10 to 15 minutes to complete.
Florida's TANF SAMH Services and One-Time Payment, Purchase of Service, Request/Approval Form. Florida's TANF SAMH specialists monitor and approve the services provided through the contracted TANF SAMH treatment agencies. Every six months, a TANF SAMH specialist reviews each case. These specialists are given wide latitude in deciding which services should be provided and for how long.
Referral forms for all sites [in PDF format]
Confidentiality and Consent Forms
Although the layout of the confidentiality forms are unique to each state, there is little variation across the states with regard to content and use. Every state requires a client to sign a release of information allowing mental health staff to share information with the welfare agency and other service providers. Clients are also notified about the types of information that are kept confidential. In some states, clients are required to sign a statement declaring that they are voluntarily participating in mental health services. In each state, licensed mental health professional (or mental health staff under the supervision of a licensed mental health professional) complete the forms. The forms used in the study states include:
- Utah: Disclosure/Verification Form and Authorization for Release of Information Form
- Tennessee: Consent for Release of Confidential Information Form and Informed Consent Form
- Oregon: Authorization for Release of Information Form
- Florida: Consent for the Release of Confidential Information Form.
Confidentiality and Consent forms for all sites [in PDF format]
Service Delivery Pathways
Florida, Tennessee, and Utah have developed service delivery pathways to illustrate the process for accessing mental health services. The service delivery pathways also provide a basic overview of the mental health services from the point of referral to the completion of services.
Service Delivery Pathways for all sites [in PDF format]
Service Planning and Tracking Forms
Tennessee has separate service planning forms for its Family Services Counseling (FSC) program (mental health services) and its Families First program (welfare). Counselors in the FSC program complete the following series of forms for each client:
Initial Feedback and Change Feedback Forms. Both the Initial Feedback Form and the Change Feedback Form are used to indicate a client's current status in the FSC program and to document any modifications in a client's work plan (such as time limit interruptions).
Service Plan. The Service Plan Form is used to identify the types of services or treatment and amount of time spent in each activity.
Progress Notes and Contact Log. The Progress Note and Contact Log are used to record client contacts with the family services counselor and the client's progress in the FSC program.
All family services counselors are required to use these forms. FSC district coordinators periodically review case files to ensure that the forms are completed accurately and in a timely manner.
Tennessee's service plan/tracking form [in PDF format]
Florida has developed a set of forms to track outreach activities, the number of screenings and referrals, and the number of clients accessing treatment. These forms, listed below, are completed by the TANF SAMH contracted service providers and submitted to the TANF SAMH specialist:
TANF SAMH Screening and Referral Analysis Form. This form, submitted by contracted service providers to the TANF SAMH specialist at the end of each month, reports on the number of clients referred for different reasons (e.g., substance abuse referrals, domestic violence referrals, outreach contacts made that month, etc.).
Log of Outreach Activities Form. This form is a monthly reporting form completed by the contracted service provider. Types of services, total units of services, and number of persons served are some of the data reported on this form.
SAMH Treatment Verification Form. This form was developed to approve time limit extensions for clients successfully completing treatment. TANF SAMH treatment providers indicate the amount of time a participant has spent in treatment. This information is used to determine whether a time limit extension should be granted for the number of months spent in treatment.
TANF SAMH Client Log. The client log is used to track individual client information such as name, social security number, TANF participant status, and status date.
Florida's service plan/tracking form [in PDF format]
1. Employment counselors are required to refer clients to mental health services if they respond, "yes" to two or more of the four CAGE questions asked during the general employment assessment.
2. The Adult Strength Scale includes questions on home, work/school/training, emotional, and social resources and strengths.
3. Sections in the functional assessment are understanding and memory, sustained concentration and persistence, social interaction, and adaptation.