Does coordinated care management improve employment for substance-using welfare recipients?
Morgenstern J., Hogue A., Dauber S. et al. Journal of Studies on Alcohol and Drugs: 2009, 70, p. 955–963.

In New York intensive case management coordinating multiple sources of support helped resolve the substance use problems of welfare applicants, but only among the women – who faced the greatest barriers to working – did this promote employment. Perhaps men would have done better being helped to rapidly enter the job market.

Summary
Focusing on employment and training outcomes, the featured report complements an earlier report from the same US study which focused on substance use treatment participation and substance use outcomes.

The study tested whether relatively intensive case management support helps welfare applicants overcome substance use problems and gain employment. A particular issue was whether welfare recipients who despite recent reforms have yet to find work can be helped to do so, or whether this caseload faces barriers too great to overcome, even with intensive help. Implemented in New York's Bronx district in partnership with the city's welfare agency, it was designed to be a practical trial which maximised real-world applicability while maintaining research integrity.

Participants were 421 substance using single adults and adults with dependent children applying for welfare benefits. They were selected from 1519 such applicants on the basis of their reporting a substance use problem and being motivated to receive treatment. Initially they had been identified by welfare workers using a short questionnaire which screened applicants for substance use problems. Depending solely on where the next assessment slot was available, the workers transferred substance users for further assessment at one of the two offices in the study.

One of the offices offered usual assessment and care services: assessment by an addiction counsellor focused on substance use problems in relation to employability, followed by allocation to a generic welfare worker whose role was to assess eligibility for welfare payments and deal with non-compliance with the welfare system's requirements. They also referred the beneficiary to services, but only during infrequent meetings limited by a large caseload.

At the other office, more rounded and detailed assessments were conducted by a multidisciplinary team. After referring applicants to a range of services to meet identified needs, they transferred them to case managers. Their role was to maintain intensive contact with the beneficiary and with the agencies providing them with services, and to ensure that these agencies matched the individual's needs and performed acceptably. In the usual care option, quarterly reassessments focused on welfare system requirements, but in the case management option the focus was on client progress and adjusting the service mix accordingly.

All 108 applicants who were in methadone maintenance treatment during the study were already in this treatment at the time they applied for benefits, and generally simply continued. Beyond these existing methadone patients, there were few if any heroin dependent applicants who might benefit from initiating treatment. Welfare case workers had more latitude to initiate or change other sorts of substance use treatments.

Diagnostic interviews found that about 6 in 10 of the sample met criteria for substance dependence, mainly in respect of cocaine, alcohol or heroin, and another fifth for substance abuse. Psychological problems and criminal justice involvement were common. About 1 in 6 had some degree of responsibility for dependent children.