U.S. Department of Health and Human ServicesU.S. Department of Health and Human Services
This report was prepared under contract #HHS-100-95-0021 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Urban Institute. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, William Marton, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is: William.Marton@osaspe.dhhs.gov.
The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders.
Welfare reform efforts in the 1990s focused primarily on recasting the nation's cash assistance system into a work-based, time-limited assistance system. To accomplish this objective, states have used the flexibility first granted under federally approved waivers and then under the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 to make a wide array of changes in welfare policies and practices. The combination of these changes and a strong economy has contributed to unprecedented welfare caseload declines, with particularly dramatic declines occurring since the passage of the 1996 federal welfare reform law. Still, many who continue to receive cash assistance possess serious barriers to work, including various types of disabilities. In the post welfare reform environment of time limits and strict work requirements, creating and implementing effective welfare reform policies and strategies to help those with disabling conditions obtain and retain employment is a tremendous challenge.
This report examines key operational issues and implementation challenges associated with serving welfare recipients with disabilities. The term disabilities is used broadly in this report and includes limiting physical conditions, substance abuse and mental health problems, and learning disabilities. These are sometimes referred to as "hidden disabilities" and are generally considered to be a subset of a broader range of barriers faced by "hard-to-serve" TANF recipients. In order to serve this population, the two primary issues that TANF agencies must address are (1) how to identify disabilities among TANF recipients, and (2) how to create and structure services to assist in their transition from welfare to work. These issues provide the conceptual framework for our study.
Our findings are based primarily on interviews conducted December 1998-April 1999 with local welfare agency administrators, front-line staff and service providers in four localities: Phoenix (AZ), Chicago (IL), Providence (RI) and Portland (ME). The local level perspective provided in this report is intended to complement state level information provided in an earlier companion report entitled State Welfare-to-Work Policies for People with Disabilities: Changes Since Welfare Reform which reviews state work participation and time limit policies as applied to TANF recipients with disabilities in all 50 states.1
Work requirements and time limits imposed by federal welfare reform help shape state decisions regarding how to design and implement their TANF programs. Although states have the flexibility to define their own work activities, they often choose the same set of work activities that PRWORA allows to count toward the federal participation rate. State choices regarding participation requirements and exemptions are often also guided by considerations concerning the 60-month lifetime limit on federal assistance and, in some states, a shorter state imposed time limit.
According to our earlier research, 30 states (including the four reviewed here--Maine, Arizona, Illinois, and Rhode Island) have changed their work participation policies in ways that involve more TANF recipients with disabilities in work and self-sufficiency activities than under the Jobs Opportunities and Basic Skills Training (JOBS) program that preceded TANF.
Because federal welfare reform gave states considerable flexibility and latitude, any review of how a single dimension of reform is implemented must be considered in the context of key elements of that state's TANF system. In this report, we discuss decisions regarding participation among and services provided to TANF recipients with disabilities within the larger context of that states' policies (time limits, exemptions, etc.) and operational factors affecting its implementation (staff experience, individual caseload sizes, duration of reform, etc.).
TANF agencies may be motivated to identify disabilities among welfare recipients for different reasons: (1) to determine if a disability is hindering a recipient's ability to obtain employment, (2) to determine if a recipient could be exempted from work participation or time limits due to a disability, and/or (3) to determine whether additional services or supports are necessary to assist in the transition from welfare to work.
When considering how to identify disabilities among welfare recipients, states face a number of choices. Our site visits to different localities in four states illustrate that there is no common criteria for defining what constitutes a disability, no single method or process used to identify disabilities, no single point when identification occurs, and no one person responsible for making all identifications. One common strategy is to build in-house staff capacity so that staff are better trained and equipped to detect disabilities, another is to rely on the expertise of third parties and still another involves some combination of the two. While there is still heavy reliance on recipients to self-report disabilities that may inhibit participation in work or work-related activities, there is also increased interest in and use of formal screening and assessment techniques and in-depth interviewing as a part of the case management process.
Screening and assessment can include short questions intended to identify a disability, or a longer set of questions intended to collect information about the individual's situation, including the existence of a disability or other barrier to employment. Targeted screening and assessment instruments provide additional tools to uncover barriers to employment, including disabilities. While welfare-to-work programs have often relied on formal instruments to assess reading and math levels and general occupational interests/aptitudes, reliance on structured assessment tools designed to identify disabilities is much less common.
Many states are looking to case management as a general service approach that will enable welfare-to-work programs to better identify recipients' needs (including disabilities) and tailor services accordingly. While staff interviewed for this study generally affirmed that formal screening and assessment instruments could assist in their efforts to identify various barriers and disabilities, they tended to place greater value on the ability of the case management process--talking to and developing a relationship with recipients, keeping up with their progress or lack thereof, and being on the alert for signs of potential problems--to uncover barriers/disabilities.
Whether a state chooses one or some combination of these approaches, states should consider the level of experience and skill required of staff involved in the identification process. If staff responsible for identification do not possess the required skills or experience, training is in order. In the four study sites, training was most commonly provided in conjunction with a specific disability-related initiative. However, none of the study sites had provided comprehensive training on how to identify the range of possible disabilities that exist among the welfare population.
Given TANF agencies' lack of experience in serving individuals with disabilities, the predominant strategy involves increasing the TANF agency's institutional capacity by developing new organizational linkages with providers that have expertise in serving this population.
Efforts to develop new or expanded linkages are increasingly being accomplished through formal arrangements such as contracts or interagency agreements. Increased referrals to and use of outside organizations with whom the TANF agency has no formal agreement is also an important part of expanding and strengthening this infrastructure. The ability to implement new strategies depends in part on the availability of providers, services, and resources in a given community. These may vary considerably by the specific type of disability in question.
Progress in establishing organizational linkages on behalf of this population tends to be uneven across disabilities. TANF agencies may find it too difficult to simultaneously take on developing service strategies and linkages for all the disabilities and barriers experienced by recipients. In fact, they typically lack sufficient data to determine which disability is more prevalent among their existing caseload.
There is no one organizational model or service delivery approach for identifying and serving recipients with disabilities. As states and localities expand their welfare-to-work programs to include more service options, they will need to consider the skills and expertise of existing in-house staff; the availability of services and resources in the community which can be accessed; and the ability to spend TANF dollars for different types of supportive services, such as counseling and substance abuse treatment, or cover these expenses through other funding sources (e.g., Medicaid).
As structural and institutional changes are put in place, TANF agencies may be able to devote more attention to developing and refining service mix and content, and to implementing more or different models that could assist recipients in becoming self-sufficient. At this point, however, the primary challenge is to develop an organizational and service delivery infrastructure that brings these types of providers and their services into the welfare-to-work world.
While there appears to be a general consensus that the most job-ready recipients have left welfare and those remaining are more likely to experience disabilities and other barriers to employment, states and localities are still in the early stages of developing and implementing practices which identify and respond to the needs of these recipients in a proactive and systematic fashion. Expanding organizational linkages with organizations with greater expertise than TANF agencies in assessing and serving individuals with disabilities has both created more opportunities for recipients to receive needed services, while also making the TANF service delivery system and its administration more complex. Developing such linkages and effectively overcoming the coordination issues that inevitably arise when one organization relies on another to provide needed services presents a major ongoing implementation challenge.
Relying on different types of service providers to more effectively serve recipients with disabilities does not eliminate the need for further training and development of TANF in-house staff. In many places, TANF agency staff have been given primary responsibility for service planning and case management. Both of these responsibilities require a range of skills, including the ability to determine when a disability might exist and where it is appropriate to refer a client, how to effectively interview recipients and assess their needs (or determine when additional assessment is warranted), and to serve as an effective broker between service providers on behalf of the client. It is unrealistic to assume that TANF staff can fulfill these roles without sufficient experience and/or training. In addition, the amount of individualized case management that can actually occur will be severely constrained, if staff are expected to carry large caseloads.
In part because states are still in the relatively early stages of building this infrastructure, the degree to which different types of disabilities in a given state or locality have received attention in terms of policy, resources, assessment, or services varies considerably. Given the range of possible disabilities, and the fact that TANF clients often experience multiple barriers and disabilities, it will be important for states and localities not to focus their efforts too narrowly on one disability at the expense of others. That is, while each disability may require different services and supports, the overall approach adopted must be comprehensive in scope.
Given the overall declines in TANF caseload size since PRWORA was first implemented, states that have not done so may want to focus more attention on cases currently exempt or deferred from participation due to disability as well as practices associated with granting deferrals and exemptions. These recipients can still benefit from the opportunity to engage in self-sufficiency activities and services. This may be a particularly important strategy for states which do not stop a recipient's time limit "clock" when they have been exempted/deferred from participation in work activities. In addition, given the pivotal role medical personnel play in the disability-related exemption/ deferral process, states may want to make a greater effort to educate medical professionals about the importance and implications of the documentation they provide regarding a recipient's condition. For example, doctors may not understand that, at least in some states, the time limit continues to be in effect even though a recipient may be exempt/deferred from work participation due to a disability.
Under PRWORA, states have the flexibility to define their own participation requirements and may permit recipients to engage in a broader range of activities than considered allowable for federal work participation calculation purposes. There is variation in the extent to which states have taken advantage of this flexibility as opposed to replicating the list of countable activities as defined by PRWORA. Given the types of disabilities and service needs experienced by many on welfare, states that have not already done so should consider broadening their participation requirements or, alternatively, proactively working with and providing services to those they have deferred from participation due to disability. Broadening countable activities for federal work participation rate calculation purposes should also be taken up as a matter of consideration when TANF is reauthorized in FY2002.
| The full report is also available from the DALTCP website (http://aspe.hhs.gov/daltcp/home.htm) or directly at w2wimp.pdf to go directly to it. [The full report is in the Portable Document Format. You will need a copy of the Acrobat Reader in order to view it.] |