# Presentation: 173860

## Intensive Case Management for Substance Dependent TANF Women: 24 Month Substance Use & Employment Outcomes

- Jon Morgenstern, Ph. D.
*The National Center on Addiction and Substance Abuse at Columbia University*

**Notes:**
Good morning!  I’m going to be presenting Nine month outcomes and initial costws of a public health approach for assisting substance abusing women on welfare.  This study is randomized clinical trial examining the effectiveness and cost effectiveness of an intensive case management program for substance abusing women on TANF in New Jersey.
My colleague, Jon Morgenstern, presented some aspects of this study at the plenary session yesterday on welfare to work.  I’m going to be presenting more baseline and outcome data on these women as well as sharing some initial data on costs of the intervention.  

## FUNDING SOURCES

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**Treating Substance Abusing Women on Welfare**

**FUNDING SOURCES**

- National Institute on Drug Abuse
- Administration for Children and Families
- Assistant Secretary for Planning and Evaluation
- Annie E. Casey Foundation
- New Jersey Department of Human Services

## BACKGROUND  

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**Treating Substance Abusing Women on Welfare**

**BACKGROUND **** **

- NJ’s planning to address substance abusing TANF recipients began in 1997
- Decision to implement statewide program
- Screening, assessment, and referral to AOD treatment
- Concern about effectiveness of screening and referral model
- Multiple problem/barrier clients
- Poor engagement in AOD treatment
- System fragmentation

**Notes:**
Preliminary findings indicate that ICM did not yield significantly higher PDA than in UC, but rates of absolute abstinence were significantly higher.  These mixed findings raise questions about why the very substantial increase in engagement and retention in substance abuse treatment for ICM did not yield a concomitant improvement in substance use outcomes as our model hypothesized.  Clearly, we will be considering this question in future analyses.  It may be that implementation problems with ICM limited its effectiveness and better implementation will result in clearly superior outcomes.  Alternatively, it may be that system fragmentation and modest effectiveness of outpatient community treatment severely limit what ICM can accomplish for this population.

Overall, findings point to the need to improve the existing  “clinical disease” model of substance abuse treatment.  Findings offer tentative support for public health approach interventions such as screening in welfare settings and ICM.  However, modest outcomes at nine months indicate the need for more research into how to strengthen community interventions in order to improve outcome for TANF women.  The very low rates of welfare system compliance and employment at nine months for substance abusers also raise strong concerns about how these women and their families will fare under existing welfare reform rules.

## BACKGROUND(continued)

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**Treating Substance Abusing Women on Welfare**

**BACKGROUND****(continued)**

- More intensive intervention should be tested
- SARD program began operations in 1998
- Essex and Atlantic counties
- Random assignment 9/1999-5/2002

**Notes:**
Preliminary findings indicate that ICM did not yield significantly higher PDA than in UC, but rates of absolute abstinence were significantly higher.  These mixed findings raise questions about why the very substantial increase in engagement and retention in substance abuse treatment for ICM did not yield a concomitant improvement in substance use outcomes as our model hypothesized.  Clearly, we will be considering this question in future analyses.  It may be that implementation problems with ICM limited its effectiveness and better implementation will result in clearly superior outcomes.  Alternatively, it may be that system fragmentation and modest effectiveness of outpatient community treatment severely limit what ICM can accomplish for this population.

Overall, findings point to the need to improve the existing  “clinical disease” model of substance abuse treatment.  Findings offer tentative support for public health approach interventions such as screening in welfare settings and ICM.  However, modest outcomes at nine months indicate the need for more research into how to strengthen community interventions in order to improve outcome for TANF women.  The very low rates of welfare system compliance and employment at nine months for substance abusers also raise strong concerns about how these women and their families will fare under existing welfare reform rules.

## STUDY DESIGNStudy Interventions 

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**Treating Substance Abusing Women on Welfare**

**STUDY DESIGN**Study Interventions

- _Usual Care _(UC)
- Screening in welfare office, clinical assessment, and feedback
- Referral to community substance abuse program

## STUDY DESIGNStudy Interventions 

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**Treating Substance Abusing Women on Welfare**

**STUDY DESIGN**Study Interventions

- _Intensive Case Management_ (ICM)
- Screening  and referral to community substance abuse program
- Intensive Case Management with enhanced funding for ancillary services
- Active outreach efforts
- Assessment and linkage to needed wraparound services
- Active coordination of treatment and employment training
- Continuity of care (up to 2 years)
- Contingencies
- monetary rewards for treatment attendance

## STUDY DESIGN

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**Treating Substance Abusing Women on Welfare**

- Women Screened for Substance Abuse in
- Welfare Offices

- Eligibility Assessed

- Eligibility for Comparison
- Sample Assessed

- Baseline Interview &
- Randomization

- Baseline Interview

- Intensive Case
- Management

- Usual Care

- Follow-ups for All Groups at 3, 9, 15, & 24 Months

- +

- -

**STUDY DESIGN**

- Comparison

**Notes:**
Participants recruited into the study at the local welfare offices in Essex and Atlantic Counties in NJ
Participants who screen positive for substance use are interviewed. If they meet substance dependence diagnoses and other study criteria, they are randomly assigned to the experimental and control conditions of the clinical sample
Participants who screen negative for substance use are interviewed.  If they do not meet criteria for a substance use disorder for the prior five years and meet other inclusion criteria, they are recruited into the comparison condition
All participants are interviewed in-person at baseline, and at four follow-up points: 3, 9, 15, 24 months

## STUDY DESIGNData Sources

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**Treating Substance Abusing Women on Welfare**

**STUDY DESIGN**Data Sources

- In-person assessments with all clients- intake, 3, 9,  15. 24 months
- 96% of women followed at 24 months
- Substance abuse treatment programs- daily attendance
- Clinical case workers- service activity logs

**Notes:**
In addition, the screening, triage and referral, women received ICM services designed to assist them in engaging and remaining in substance abuse treatment programs through outreach and the provision of wraparound services and then assisting them in transitioning into employment training.

In addition, modest monetary incentives were offered contingent upon attendance in substance abuse treatment.

## RESULTS 

**RESULTS**

- Client barriers to employability
- Impacts of ICM on
- -  Treatment engagement
- -	Abstinence months 1-24
- -  Employment months 1-24
- What are the determinants of employment outcomes?
- Barriers at baseline
- Substance abuse treatment
- Reduced substance use/abstinence

**Notes:**
Three sets of findings will be presented as above:

Represents the first two years of  study operation

Data on nine months outcomes is very preliminary

## DEMOGRAPHICS (n=452)

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**Treating Substance Abusing Women on Welfare**

**DEMOGRAPHICS (n=452)**

|  |  | Clinical
(n=302) | Comparison
(n=150) |
| --- | --- | --- | --- |
| Age **** |  |  36 (6.6) | 28 (8.1) |
| Ethnicity * | AA
Hispanic
Other |        95%
         3%
         2% |             84%
            13%
              3% |
| Marital
Status | Married
Div/Sep/Wid
Never Married |          2%
       19%
       79% |               5%
            19%
            78% |
| Years of Education |  | 11.1 (1.5) | 11.5 (1.2) |

- * p<.05, **p<.01,***p<.001,****p<.0001

**Notes:**

Women in the clinical sample were in their mid-30s, predominantly African American, not married and had not graduated HS, they lived in extreme poverty, were long-term welfare recipients and had between 3-4 children.  About half of women had a child under 6 years of age.

Overall, women in the comparison sample were significantly younger, spent less time on welfare, and had fewer children.

## DEMOGRAPHICS (continued)

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**Treating Substance Abusing Women on Welfare**

**DEMOGRAPHICS (continued)**

|  |  | Clinical
(n=302) | Comparison
(n=150) |
| --- | --- | --- | --- |
| Income | Extreme poverty
Poverty
Low income |          55%
         40%
          5% |             43%
            46%
            11% |
| Years on Welfare **** |  | 12.0 (8.5) | 5.8 (5.5) |
| Number of Children * |  |        3.2 (1.8) |           2.6 (1.5) |
| Percent of Women with a Child Under Age 6 **** |  | 53.7% | 46.2% |

- * p<.05, **p<.01,***p<.001,****p<.0001

**Notes:**
The income classes are derived from the ratio of the family’s income to the family’s poverty threshold for a single parent family with three children.  According to the US. Census 2000, $17,524 is the poverty threshold.  Extreme poverty is 50 percent of the poverty threshold (<$8762).  Poverty is between 50 and 99 percent of the poverty threshold ($8762-$17349).  Low income is between 100 and 199 percent of the poverty threshold ($17349-$34873).  Percentages for this sample represent approximates.  No participants in this sample had incomes above the low income threshold.  

## SUBSTANCE ABUSE (n=302) 

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**Treating Substance Abusing Women on Welfare**

**SUBSTANCE ABUSE (n=302) **

| Primary Dependence
Diagnosis |  | Alcohol
Cocaine
Marijuana
Opiates |               21%
              34%
                6%
              36% |
| --- | --- | --- | --- |
| Met 6 or more dep. criteria |  | 56%    |  |
| Days Used Last 30 |  | 20.2 (11.4) |  |
| Years of Regular Use
 |  | Alcohol
Opiates
Cocaine |            13.1 (8.6)
             8 (8.6)
             9.3 (5.9) |
| Prior Treatment |  | 66.7% |  |
| ASAM Levels | Inpatient Hospital/Residential
Intensive Outpatient
Outpatient |  | 30%
67%
2% |

**Notes:**
Overall, women in the substance abuse sample reported serious and chronic substance abuse problems.  Most were addicted to heroin (all were heroin snorters, not injectors) or cocaine.  On average women drank heavily or used drugs frequently prior to screening and had extensive histories of prior substance abuse.  Women required intensive treatment placements to address their problems including one-third who required inpatient treatment.  Despite the severity and chronicity of substance abuse problems, half of women had not received prior substance abuse counseling. 

## Human Resources and Situational Barriers

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**Treating Substance Abusing Women on Welfare**

**Human Resources and Situational Barriers**

|  |  | Clinical
(n=302) | Comparison
(n=150) |
| --- | --- | --- | --- |
| Usual Employment Pattern- past 3 yrs**** | Employed-   (full or part-time)
Unemployed | 18.5%

81.5% | 44.9%

55.1% |
| Job Skills ** | Skilled labor
Unskilled labor
None | 12.9%
26.5%
60.4% | 14%
31.3%
54.6% |
| Homeless- past 3 months ** |  | 17.1% | 11.3% |
| Severe Transportation Problems ** ** |  | 39.5% | 10.1% |

- * p<.05, **p<.01,***p<.001,****p<.0001

**Notes:**
One important assumption justifying the delivery of ICM was that women in the clinical sample would experience a range of other problems beyond just substance abuse and that substance abusers would experience more of these problems than other women on welfare.   Findings provided strong support these assumptions and the following two slides illustrate some of those findings across different psychosocial domains.

Overall, susbtance abusing women experience a marked lack of labor market skills and high levels of basic needs.

## Health and Behavioral Health Barriers

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**Treating Substance Abusing Women on Welfare**

**Health and Behavioral Health Barriers**

|  | Clinical
(n=302) | Comparison
(n=150) |
| --- | --- | --- |
| Mental Health |  |  |
| Current PTSD Diagnosis*** | 19.7% | 2.9% |
| Depressive Symptoms-Moderate/Severe**** | 45.1% | 8.7% |
| Physical Health |  |  |
| Chronic Health Problems* | 40.9% | 23.2% |
| Health or child’s health limited ability to work | 17% | 21.3% |

- * p<.05, **p<.01,***p<.001,****p<.0001

**Notes:**
Substance abusing women experience high levels of mental health problems and medical problems.

## Health and Behavioral Health Barriers (cont)

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**Treating Substance Abusing Women on Welfare**

**Health and Behavioral Health Barriers (cont)**

|  |  | Clinical
(n=302) | Comparison
(n=150) |
| --- | --- | --- | --- |
| Legal |  |  |  |
| Ever Arrested**** |  | 55.6% | 14.5% |
| Need for Legal Services- Recommended/ Necessary** |  | 20.1% | 2.9% |
| Family/Social |  |  |  |
| Domestic Violence- Severe*** |  | 38.3% | 13.0% |
| Child Welfare Investigation
 | Ever ****
Current** | 84.3%
34.0% | 48.3%
13.3% |

- * p<.05, **p<.01,***p<.001,****p<.0001

**Notes:**
In addition, substance abusing women experience legal and family and social problems.  Rates for child welfare involvement are especially high.

## Percent with Barriers to Employability 

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**Treating Substance Abusing Women on Welfare**

**Percent with Barriers to Employability **

## AOD TREATMENT ENGAGEMENT

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**Treating Substance Abusing Women on Welfare**

**AOD TREATMENT ENGAGEMENT**

- * p<.05, **p<.01,***p<.001,****p<.0001

**Notes:**
Slide represents treatment utilization data for the first three months after recruitment into the study.  ICM significantly improved initial engagement in treatment.  For example, only half of women in UC attended even one outpatient session whereas 83% did in ICM.

ICM significantly improved treatment retention as well, with those in ICM attended about twice as many treatment sessions as those in CC.

Although 67% of UC women did engage in treatment the overall amount of treatment was much less than recommended with women in UC attending only 24% of recommended sessions based on ASAM criteria.  ICM was significantly better, but even here women attended less than half of recommended sessions.

Another measure of compliance is NJ’s welfare-to-work  attendance requirement that specifies that women should attend 75% of the time in required activities (either work, training or treatment).  Only 5% of UC women and 17% of ICM women met that requirement during the first three months in the program.  Thus, overall welfare-to-work compliance was very low during this first period.  

## E/C Impacts 

- E/C Impacts

- Generalized Estimating Equations
- Abstinence Outcomes
- -  DV – percent abstinent in each month
**E> C, Odds ratio 1.94, ***** p*****<.*****0001***
- Employment Outcomes
- -  DV - Days employed per month
**E>C, IRR 1.40,  *****p*****<.*****001***

**Notes:**
Three sets of findings will be presented as above:

Represents the first two years of  study operation

Data on nine months outcomes is very preliminary

## Treating Substance Abusing Women on Welfare

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**Treating Substance Abusing Women on Welfare**

## Treating Substance Abusing Women on Welfare

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**Treating Substance Abusing Women on Welfare**

## Treating Substance Abusing Women on Welfare

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**Treating Substance Abusing Women on Welfare**

## Baseline Barriers Predictive of Employment Outcomes

| Variable | Significance (p<) |
| --- | --- |
| High School Education  | .0001 |
| Work Experience | .001 |
| Housing | NS |
| Legal Involvement  | .0001 |
| Child welfare involvement | .0001 |
| Physical Health | NS |
| Severity of Drug Use | .0001 |

## Post-randomization Factors Predictive of Employment Outcomes

| Variable | Significance (p<) |
| --- | --- |
| SUD Treatment Attendance | .01 |
| Abstinence post-randomization | .0001 |

**Notes:**
Re: Recent work experience—Full time was significant at p<.001 and Part time was significant at p<.05.

## SUMMARY 

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**Treating Substance Abusing Women on Welfare**

**SUMMARY**

- On average, substance abusing TANF women experience multiple & persistent barriers to employability
- Findings provide strong support for ICM relative to “screen & refer” models
- Findings support policy of engagement in AOD treatment as strategy to increase employment
- However, overall rates of abstinence & employment were modest

**Notes:**
Much less is clear about employment.

Modest prediction from barriers analyses, especially for substance abusers suggesting we don’t  understand much about determinants of employment
Might be other factors, location, welfare office policies, etc

We anticipated ICM, TX, and Abst would lead to employment, but that was not really the case,  as many participants // this is especially surprising and reuqires more thought and analysis, may be several trajectories towards employment and  not simply  through treatment recovery to employment, but perhaps in other ways, we know little about women who are using regularly – need more definition

## Jon Morgenstern, Ph.D.

**jm977@columbia.edu**
**The National Center on Addiction and Substance Abuse at Columbia University**

## Treating Substance Abusing Women on Welfare

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**Treating Substance Abusing Women on Welfare**

## Treating Substance Abusing Women on Welfare

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**Treating Substance Abusing Women on Welfare**

## Cost Projections by Program 6 Month Case Management Model

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**Treating Substance Abusing Women on Welfare**

**Cost Projections by Program ****6 Month Case Management Model**

|  | Intensive Case Management | Care Coordination |  | Streamlined Case Management |
| --- | --- | --- | --- | --- |
| Annual Clinical Staff Costs per Team/CC/CM | $239,101 | $165,236 |  | $151,031 |
| Estimated Case Load | 60 | 100 |  | 60 |
| Estimated Cost Per Client | $3985 | $1652 |  | $2517 |

**Notes:**
Treatment compliance refers to percentage of treatment that clients attended 

WFNJ Participation Requirement (75%) Refers to the percentage of people who attended at least 75% of their required treatment sessions.