Return to Previous page |
| PDF Version, Color |  |
ASSISTING TANF RECIPIENTS LIVING WITH DISABILITIES TO OBTAIN AND MAINTAIN EMPLOYMENT
Conducting In-Depth Assessments
BY LADONNA PAVETTI, MICHELLE DERR, AND EMILY SAMA MARTIN
February 2008
Assessment often is the first step in helping TANF recipients living with a disability find and maintain employment. While some TANF recipients living with a disability enter TANF fully aware of their disability, many do not. There are multiple strategies that TANF agencies can employ to identify recipients whose program participation or employment difficulties may be influenced by the presence of a disability or to develop an appropriate employment plan once a disability is identified. In this practice brief, drawing on the experiences of six different TANF initiatives targeted to recipients living with a disability, we describe five different approaches to assessment: disability screening, psychosocial assessments, clinical and psychological assessments, functional needs assessments and vocational assessments.
INTRODUCTION
The transformation of the nation’s cash assistance system into a work-oriented system that includes work requirements, sanctions for noncompliance, and time limits has increased the importance of quickly identifying the personal, family, and logistic challenges that may interfere with Temporary Assistance for Needy Families (TANF) recipients’ abilities to find and maintain competitive employment. To help identify potential barriers, many welfare offices require that TANF applicants and recipients complete an up-front self-assessment where they can identify any disabilities they might have or any other issues that might create barriers to employment. These assessments commonly ask recipients to provide information on their employment history, level of education, participation in education and training programs, physical health problems, mental health issues, substance abuse issues, current or previous domestic violence, learning difficulties, and involvement with the criminal justice system.
Upfront client self-reports serve an important purpose for TANF agencies as they provide TANF applicants an opportunity to disclose issues that might reduce their chances of finding and/or sustaining employment and TANF agencies an opportunity to identify recipients in need of specialized services quickly. However, they only go so far in identifying TANF recipients living with a disability. While recipients may disclose health issues, program staff report they do not disclose learning problems, mental illness, or substance abuse issues as easily and sometimes do not even acknowledge them to themselves. They also report that it is not uncommon for TANF recipients who have endured many challenging situations to minimize their struggles. As a result, disabilities that affect recipients’ ability to work often go undiagnosed and untreated for long periods of time. Thus, other approaches are needed to uncover disabilities that are hidden or not revealed through the routine self-reports. In this practice brief, we profile innovative state or local TANF initiatives that were designed to dig deeper to identify recipients living with a disability that impacts their ability to find or maintain employment and/or to understand the extent of their disability to provide better services to them. These in-depth and comprehensive assessment efforts are all part of larger efforts to provide individualized and specialized services and/or create work opportunities for TANF recipients living with a disability. The sites profiled were selected after a comprehensive effort to identify special employment initiatives for TANF recipients living with a disability.
ABOUT THIS SERIESThis is one of four practice briefs examining strategies TANF agencies may consider implementing to help TANF recipients living with a disability to realize their full employment potential. Other briefs in the series include, Creating TANF and Vocational Rehabilitation Agency Partnerships, Creating Work Opportunities, and Providing Specialized Personal and Work-Based Support. These briefs draw on case studies of nine programs that have been implemented by state or county welfare agencies to provide specialized services to TANF recipients living with a disability who have not succeeded in traditional job search programs. None of these programs has been rigorously evaluated, thus, their effectiveness remains unknown. Still, they provide important information on program design and implementation that program administrators can use to craft strategies that take into account their program goals and the unique features of their TANF caseload. These briefs were completed by Mathematica Policy Research, Inc. under contract to the U.S. Department of Health and Human Services (DHHS), Administration for Children and Families. |
THE POTENTIAL BENEFITS AND CHALLENGES OF CONDUCTING IN-DEPTH ASSESSMENTS
Conducting in-depth assessments often is the first step in helping TANF recipients living with a disability that affects their employment prospects realize their full potential. The information gathered from them can provide critical insights into why recipients are not progressing towards permanent competitive employment, and point to service strategies and accommodations that might increase recipients’ chances for success. As the program examples highlighted below demonstrate, there are many different ways to gather information to develop individualized service plans for TANF recipients living with a disability. Regardless of their structure, in-depth assessments can produce substantial benefits for recipients and program staff. But, there are challenges that must be overcome as well.
Potential Benefits
Identification of recipients who need specialized services to realize their full employment potential. There is growing interest in helping all working-age adults realize their full potential. In spite of clear and convincing evidence that individuals living with a disability can work and lead productive lives, employment levels among them are extremely low. For example, in 2006, the employment rate of working-age individuals living with a disability was 37.7 percent, less than half of the employment rate of 79.7 percent for working-age individuals without a disability.1 Staff who work with TANF individuals living with a disability indicate that although they have the same types of disabilities as individuals not on TANF, their circumstances often are far worse because their disabilities have not been identified and they are not connected to a service network that can help to mitigate some of the difficulties caused by their disabilities. In addition, because TANF recipients are raising children and have limited financial resources, the limitations from their disabilities often are exacerbated by the presence of other personal and family challenges, such as domestic violence and housing instability, and logistic challenges, such as child care and transportation. Without specialized services, many recipients living with a disability may never realize their full potential. Thus, identification of their disabilities is often a first step in getting them out of a failure cycle. In some cases, in-depth assessments help to identify recipients who may be eligible for federal disability benefits.
RATIONALE FOR ENGAGING TANF RECIPIENTS WITH DISABILITIES IN WORK ACTIVITIESBeginning in the early 1990’s, prior to the creation of TANF, states began expanding the pool of recipients expected to participate in work-related activities, with some states moving towards universal engagement where all recipients are expected to participate in activities that will prepare them for work. Although federal rules don’t include exceptions or modified requirements for TANF recipients living with a disability, states that have adopted a model of universal engagement often permit recipients with personal and family challenges, including, but not limited to, those living with a disability, to participate in a broader range of activities or for a reduced number of hours, acknowledging that their participation may not be sufficient to count toward the state’s work participation rate.2 The reasons for pursuing a universal engagement strategy include: (1) with time limits on the receipt of cash assistance, recipients cannot expect to rely on TANF in the long run; (2) paid employment is the surest path for achieving self-sufficiency for all, including recipients living with a disability; (3) the TANF system has an employment infrastructure in place that can be expanded and adapted to meet the needs of recipients who need more intensive services and employment accommodations; and (4) TANF agencies, like all public agencies, are required by the Americans with Disabilities Act to provide opportunities for recipients living with a disability to benefit from all the programs, services and activities they offer. |
Early identification of recipients who might otherwise lose benefits due to sanctions. Studies consistently show that TANF recipients who are sanctioned because they have not complied with work requirements report higher rates of disability than those who are not sanctioned.3 When full family sanctions are imposed, recipients will not only lose all of their cash assistance but may also lose access to services that could help them find and maintain employment. In-depth assessments that aim to identify those with a disability and are conducted early may reduce the number sanctioned. These assessments may be targeted to all recipients or to a smaller subset of recipients who are identified as being at high risk of being sanctioned for noncompliance.
SPECIAL INITIATIVES FOR TANF RECIPIENTS LIVING WITH A DISABILITY: SIX EXAMPLESDisability Screening Services in Louisiana uses trained counselors to screen TANF employment and training program participants for a range of learning disabilities, mental health conditions, and substance abuse problems. After screening, the counselor discusses the results with the recipient and provides a written report to the TANF case manager. Neuropsychological testing confirmed the accuracy of the screen in 95 percent of the cases. The state vocational rehabilitation (VR) agency accepts the screening results as initial evidence of eligibility for services. Partnerships for Family Success (PFS) in Anoka County, Minnesota, is designed to improve the service coordination and communication for families served by multiple departments within Anoka County Human Services. Case managers refer TANF recipients who are not progressing towards their employment goals to PFS for in-depth screening and intensive, personalized case management. Working with families for about a year, PFS staff provide in-home case management to prepare parents for employment, help them get and keep competitive jobs, and meet the demands of other human service departments in which they are involved (e.g., child welfare). WeCARE in New York City offers an employment-focused continuum of care for TANF recipients living with a disability. The goal of the program is to identify and treat clients’ physical and/or mental health conditions to increase their employability and help them achieve their maximum level of self-sufficiency. Clients reporting a disability during the TANF application process are referred to WeCARE, which uses the results of a comprehensive client assessment to inform caseworkers’ service planning, service delivery, and service referrals. The Department of Workforce Services Social Work Unit in Utah co-locates 21 licensed clinical therapists (LCTs) in employment centers across the state to support TANF recipients with mental health, substance abuse, and/or domestic violence issues. The social work unit is designed to help TANF recipients participate in required program activities and transition to competitive employment. To identify and address a recipient’s mental health disabilities, LCTs conduct clinical assessments, provide crisis intervention or short-term therapy to stabilize their condition, make referrals to mental health treatment providers, and provide clinical case management. Adult Rehabilitative Mental Health Services (ARMHS) providers in Ramsey County, Minnesota, offer in-depth clinical assessments and home-based intensive rehabilitative services to TANF recipients diagnosed with a mental health condition who are not progressing toward work. The goal of rehabilitation is to stabilize clients’ mental health conditions and prepare them for competitive employment. To provide ARMHS services to TANF recipients, Ramsey County offered funding to local providers for recipient outreach and to complete the ARMHS certification requirements. All direct rehabilitative services offered to TANF recipients are Medicaid-funded. The Reach Up/Vocational Rehabilitation (RU/VR) Partnership in Vermont links the services of Reach Up (RU), the state’s TANF program, and VR to provide specialized employment services to TANF recipients living with a disability. Eligible TANF recipients are referred to a specialized caseload at VR where they can receive screening, diagnosis, referrals to treatment, job placement and coaching, and other specialized services. |
Identification of unknown treatment needs. Staff in programs targeted to TANF recipients with disabilities report that it is not uncommon to discover disabilities, especially mental health and learning disabilities, that have not been previously identified. While the presence of these disabilities does not preclude recipients from working, staff report that linking recipients with appropriate treatment is often a critical step in helping recipients to find and, more importantly, maintain employment. Identification of these disabilities also helps to match recipients with appropriate jobs or other work activities that build on their strengths and take into account any limitations.
Provision of detailed information to guide employment planning and decision-making. In-depth assessments not only help uncover previously undetected disabilities but also provide a much more detailed picture of how the disability affects a recipient’s ability to perform key activities of daily living and how it impacts long-term employment prospects. It provides staff and recipients with the information they need to develop an individualized plan that defines the service strategies needed to reduce the impact of the disability, such as work accommodations. In-depth assessments also help identify recipients whose situations may need to be stabilized before they are work ready and whose disabilities are too severe to make work a reasonable goal in the short-term.
Potential Challenges
Integration of assessment processes into existing service delivery systems. Now that TANF has been in place for more than 10 years, most local welfare offices have well-established procedures for gathering information through initial self-reports and for developing employment plans. The more entrenched those procedures become, the more difficult they are to change. In addition, because program staff often carry large caseloads, it is difficult for them to carve out time to conduct in-depth assessments or even to identify recipients who should be referred for such assessments. However, now that workers are required to monitor recipients’ work activities more closely to meet the more stringent reporting standards required by the Deficit Reduction Act of 2005 (DRA), they are likely to have more ongoing contact with recipients which may provide more opportunities to identify areas of concern.
Use of information gathered to individualize services. In-depth assessments’ real value comes when the results are used to develop individualized service plans that build on recipients’ strengths and address or accommodate their limitations. Good individualized plans require a variety of employment assistance and treatment activities, and work modifications, and staff that have the skills and time to carry the plans out to support steady progression toward the workplace. TANF agencies are sometimes reluctant to allow such flexibility because they are concerned that workers may overuse it, thereby reducing the number of recipients meeting the work participation requirement. They also are concerned that offering flexibility to some recipients could weaken the program’s emphasis on work.
Obtaining sufficient funding. In-depth assessments require additional funding because they need to be completed by highly skilled or specially trained staff and they take more time to administer than self-administered assessments. In a system where many different programs are competing for limited funds, in-depth assessments may not be perceived as a priority. To contain costs, the number of in-depth assessments that can be conducted over a given period may be limited. However, if the demand exceeds the capacity to complete them, bottlenecks may occur, substantially reducing some of the benefits.
STATE AND LOCAL PROGRAM EXAMPLES
Unlike other work program components, such as job search assistance and work experience programs that may look very similar from one TANF agency to the next, in-depth assessments often look very different. The reasons for this are twofold. First, there are many different kinds of assessments. In some cases, a single assessment might be administered, while in others multiple assessments of different types might be completed to develop a more comprehensive picture of a recipient’s disability and how it might influence his or her employment prospects. Assessments whose primary purpose is to help identify the disability may be different from those used to develop a plan on how to work with disability. Second, there are many decisions that states or local TANF offices make to determine how the in-depth assessment process gets integrated into TANF office procedures. Key decisions include: (1) purpose, (2) content, (3) timing, (4) target population, (5) use of information, and (6) staffing.
Below, we describe five types of assessments that are used by employment programs for TANF recipients living with a disability: (1) specialized disability screening protocols, (2) psychosocial assessments, (3) clinical and psychological assessments, (4) functional needs assessments, and (5) vocational assessments. For each type, we provide a brief description, focusing on the purpose and the content of the assessment. We then describe how the assessment is integrated into the TANF service delivery system, focusing on the purpose of the assessment, what it covers, when it is administered, to whom it is targeted, how the information is used, who conducts the assessment, and how it is funded. We draw on examples from six different programs. In some cases, we describe more than one type of assessment from the same program. We do so when the assessments are used at different points in the program and serve a different purpose.
Specialized Early Disability Screening Protocol
Few TANF agencies have comprehensive processes in place to identify recipients living with a disability, although some agencies do routinely screen for mental health conditions or learning disabilities. Louisiana, which has been systematically screening for "hidden disabilities" since June 2002, provides an example of a comprehensive disability screening protocol. This screening started in six TANF offices in and around the New Orleans area and has now been expanded to 25 TANF offices across the state. A unique feature of this assessment project is that during the pilot phase, psychological assessments were conducted to validate the results of the screening protocol; the concurrence rate was 95 percent.
BRIEF GUIDE TO DIFFERENT TYPES OF IN-DEPTH ASSESSMENTSDisability Screening Tools help to identify the presence of a disability, making it possible to identify recipients who may benefit from more specialized services. They may be conducted for all recipients upon application or might be targeted to recipients who are not making progress towards self-sufficiency. Screening tools may be designed to uncover a broad range of disabilities or might be targeted to just one or two. With special training, most TANF case managers can administer disability screening tools, however, more experienced staff might have greater success at noticing red flags that may signal the presence of a disability and developing a rapport with recipients that encourages them to disclose information they may be reluctant to share with staff they do not know. Psychosocial Assessments help to put recipients’ disabilities into context, identifying ways in which disabilities have affected important parts of their lives and other circumstances that may influence their ability to manage their disability. They offer important information for developing a comprehensive service plan that acknowledges the presence of multiple potential barriers to employment. They are usually completed for all recipients who have been identified as needing specialized services by more experienced case managers who often have master’s degrees in counseling or social work. Clinical and Psychological Assessments provide more in-depth information on the type and extent of the disability. They also provide diagnoses based on DSM-IV criteria that may help recipients to qualify and pay for specialized services. These assessments are usually reserved for recipients with very complex circumstances that cannot be easily untangled through a standard screening tool or a psychosocial assessment. Clinical assessments are used to diagnose and treat recipients with mental health conditions while psychological assessments are used to uncover and understand cognitive functioning and mental health issues. They are conducted by staff with specialized training and advanced degrees. Functional Needs Assessments focus on gathering information to assess how recipients function on a daily basis. They move beyond identifying a disability to assessing ways in which an individual’s disability influences his or her ability to carry out routine functions that are critical for living independently and for succeeding at work. While functional needs assessments can be conducted in an office setting, they are most often conducted in clients’ homes so that the person conducting the assessment can observe the client in their usual environment doing tasks of daily living. With training, staff at various skill levels can conduct functional needs assessments; however, in agencies that specialize in working with individuals living with a disability, they are often conducted by occupational therapists who work with disabled individuals to develop strategies and accommodations to overcome limitations associated with the disability. Vocational Assessments are conducted to help individuals living with a disability establish realistic vocational goals and a plan to achieve them. The vocational assessment process is designed to assess the unique strengths, resources, and experiences of an individual in order to match that person’s abilities and preferences to appropriate work placements, jobs, or training programs. The process is interactive; the intent is for staff to learn about the recipient and the recipient to learn about themselves. Vocational assessments are conducted when a psychosocial assessment does not produce sufficient information to develop an employment goal and a plan for reaching it. |
Louisiana Disability Screening Services. The Louisiana Disability Screening Services project was initiated by the Louisiana Department of Social Services, Office of Family Support (the state TANF agency) in order to better identify and serve recipients who were not succeeding in the state’s usual welfare employment programs. The TANF agency contracted with the University of New Orleans Training, Resource, and Assistive-technology Center (TRAC) to develop an assessment tool and to conduct assessments using the tool in local TANF agencies. TRAC enlisted the University of New Orleans Department of Psychology to assist with the development of the assessment tool.
The assessment that TRAC developed is administered in an interactive individual interview format by trained staff, most with master’s degrees in counseling or social work. All assessment staff are employees of the University of New Orleans. The interview takes at least an hour to complete. Because Louisiana has many small TANF offices, most assessment staff work in multiple offices. They maintain a set schedule in each office which allows TANF case managers to schedule appointments for when the assessment specialist is in the office.
The screening instrument developed by the University of New Orleans assesses symptoms consistent with disabilities commonly found among TANF recipients, including learning disabilities, mental health issues, and alcohol and drug problems. The portion of the instrument that screens for learning disabilities (reading, mathematics, written language, and attention deficit hyperactivity disorder) consists of a checklist of DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) symptoms. For mental health issues, the assessment protocol uses the Symptom Assessment 45 checklist to screen for anxiety, depression, hostility, interpersonal sensitivity, obsessive-compulsivity, paranoid ideation, phobic anxiety, and other mental health symptoms. The instrument utilizes the CAGE and CAGE-AID to screen for alcohol and drug problems. The structured interview also addresses medical history, educational history, and work history.
Assessment staff analyze and interpret the results of each screening assessment and write a report with recommendations to the TANF case manager. When a documented disability exists, clients are referred to Louisiana Rehabilitation Services; when there is an indication of a current substance abuse problem, clients are referred to the Office of Addictive Disorders. If the report indicates there may be a learning disability, a referral is made for additional assessment and screening that is completed through Louisiana Rehabilitation Services. It is the TANF case manager’s responsibility to follow-up on any referrals that are recommended through the assessment.
Although staff from the University of New Orleans recommend that all TANF recipients be referred for screening, case managers have some flexibility and usually refer those who are having difficulty finding employment or otherwise meeting their work requirements. TANF case managers also use results from their upfront assessment and observation of job readiness classes to identify recipients who may need special assistance to find and maintain employment. Between June 2002 and June 2005 when the assessments were only being completed in New Orleans and the surrounding areas, 1,557 TANF recipients were screened. Of those, 22 percent screened positive for a mental health disorder, 33 percent screened positive for a learning disability, 11 percent had a previously-identified disability (primarily physical health issues) and 1 percent had a substance abuse issue; 33 percent showed no evidence of a disability and were not referred for specialized services.
Psychosocial Assessments
TANF programs that have special initiatives in place to address the treatment, support, and employment needs of recipients living with a disability often identify these recipients by conducting a more in-depth psychosocial assessment after a recipient has failed to make progress toward employment. Several characteristics distinguish these efforts from the initial assessments that are conducted routinely in many welfare offices. First, they are completed by staff who have received special training, including how to establish a rapport with individuals who may be reluctant to disclose personal information and how to recognize red flags that might signal the presence of a disability. Second, they are conducted through a one-on-one interview that may take as long as four hours. Third, the assessment instruments have been developed by professionals with expertise in identifying individuals with a disability or with an expertise in conducting strength-based assessments for high-risk families.
THE PREVALENCE OF DISABILITIES AMONG TANF RECIPIENTSSince the creation of TANF, numerous studies have estimated the prevalence of personal and family challenges, including disabilities, among the TANF population. While the estimates of the fraction of the recipients living with a disability are not consistent across these studies, they all suggest that a substantial portion of the TANF caseload is living with a disability. While the majority of these recipients eventually may be able to find and sustain employment, they may need more specialized assistance and take more time to do so. The disabilities that are reported most commonly among TANF recipients are mental health conditions, learning disabilities and physical health problems. Results from a common survey fielded in six states found that the fraction of TANF recipients reporting a mental health condition ranged from 21 to 41 percent, a learning disability ranged from 8 to 18 percent, and a physical health condition ranged from 16 to 26 percent. Across the six states, recipients with physical and mental health conditions were significantly less likely to be employed than those without these conditions.4 A recent study that uses the Survey of Income and program Participation (SIPP) to compare the characteristics of TANF recipients before and after the implementation of TANF found that the proportion of TANF recipients reporting a work-limiting condition has increased over time. For example, in 1996, 16 percent reported a work-limiting condition compared to 21 percent in 2007.5 |
Partnerships for Family Success, Anoka County, Minnesota. In Anoka County, MN, TANF recipients who are not progressing toward work and are involved with more than one department within Anoka County Human Services may be referred to the Partnerships for Family Success Program for special services. TANF case managers make the initial program referral; however, recipients who are referred must go through a formal intake process, which includes a psychosocial assessment, to determine if they are appropriate for the program. A designated intake worker completes the psychosocial assessment with the client during a one-hour home visit. The intake worker relies on a series of standardized measures and screening tools and direct observations of the client’s home. Standardized tools include: (1) a comprehensive screening tool to uncover the client’s work history, educational background, social supports, and barriers to employment; (2) a learning disability screening tool; and (3) an employability measure tool designed to identify strengths and weaknesses.
To supplement the screening tool, the intake worker records observations about the home environment and clients’ parenting skills, which are based on direct interaction with the children. Finally, the intake worker relies on experience and intuition to probe about sensitive personal and family challenges, such as mental health conditions, drug and alcohol abuse, child protective services involvement, and domestic abuse. Assessment results are compiled into a written report that is reviewed during a case conference with a clinical supervisor and a senior case manager to determine if the client is appropriate for the program and to match her to an intensive case manager based on her service needs. Once a recipient is matched with the correct case manager, s/he uses the information from the psychosocial assessment to develop an initial service plan.
WeCARE, New York City. New York City’s WeCARE program provides a comprehensive biopsychosocial (BPS) assessment, conducted by a team of social workers, primary care physicians, and, when needed, specialty physicians, including psychiatrists, to identify a TANF recipient’s physical and mental health conditions, assess employability, and recommend an appropriate service path. To ensure timeliness, WeCARE providers are required to complete the assessment within 12 days of the referral in order to receive payment.
Master’s level social workers, many of whom are licensed, conduct the initial psychosocial assessment which is the first phase of the BPS assessment. Using a standardized assessment tool developed for the program and their own skills and experience, they gather information on all major life domains, including medical and mental health issues, domestic violence, housing needs, family stability, legal issues or criminal involvement, support networks, involvement with child protective services, drug or alcohol addictions, learning disabilities, and ease of completing activities of daily living (ADLs). Given the high volume of clients referred to WeCARE, psychosocial evaluations are completed quickly, in roughly 30 minutes to an hour. Despite only spending a relatively short time with recipients, the experienced clinicians report they are able to get a clear picture of the client’s mental and social functioning. Results from the psychosocial evaluation are summarized in an electronic file, which is sent to the primary care physician, who completes the next phase of the BPS assessment.
As standard practice, clients also undergo a complete medical assessment as part of the initial evaluation. They complete lab work and meet with a primary care physician the same day they complete the interview with the social worker. The assessment process may require additional time if the primary care physician refers the client to one or more specialists (e.g., cardiologist, psychiatrist, orthopedist) for further evaluation. The primary care physician is responsible for reviewing the psychosocial evaluation, results from the physical examination, lab and other tests, reports and recommendations from the specialty providers, and any medical documentation the recipient might bring in. The physician then makes a determination about the client’s employability, triaging them into one of four categories: (1) work ready, (2) employable with limitations, (3) temporarily unable to work due to unstable clinical conditions requiring treatment, and (4) unable to work for 12 or more months and potentially eligible for SSI benefits. Recipients who are employable with limitations are referred for a specialized vocational evaluation (described below).
Diagnostic Clinical and Psychological Assessments
When TANF agencies suspect that a recipient may be living with a disability, one way to obtain more detailed information that can be used to develop an appropriate employment and/or treatment plan is to obtain an in-depth diagnostic clinical assessment. Diagnostic information is helpful because it helps staff to more easily identify the most appropriate treatment options. Such information is also required for medical and mental health services to be provided through Medicaid and for vocational rehabilitation services that are targeted to individuals with specific disabilities. One difficulty with completing diagnostic clinical assessments is that recipients often do not show up for these appointments if they are conducted in a location that is unfamiliar to them. A second is that TANF staff sometimes have difficulty obtaining the information they need from the agency completing the diagnostic assessment. Utah overcame these issues by hiring staff who could conduct clinical health mental assessments in-house. Vermont overcame these issues by identifying psychologists to whom they could refer recipients on a regular basis and by driving recipients to their appointments. Below, we describe each of these initiatives in more detail.
In-House Licensed Clinical Therapists, Utah Department of Workforce Services. Utah’s Department of Workforce Services relies on 21 Licensed Clinical Therapists (LCTs) co-located in employment centers across the state to conduct in-depth clinical assessment and, if appropriate, provide a DSM-IV-based diagnosis. LCTs may also uncover drug or alcohol addictions or other barriers, and can then link recipients to appropriate services and/or treatment.
TANF case managers may refer a client to an LCT based on the initial assessment or if the client is not progressing toward work. In most employment centers, LCTs train TANF case managers to identify behaviors that indicate a client may have a mental health disability (e.g., flat affect, lack of self-esteem, poor body care, or involvement with the child welfare system).
Each LCT has his or her own style and approach for conducting the clinical assessments. They spend between two and four hours with the client over multiple sessions. More complicated clinical issues or conditions may require additional evaluation time. Assessments typically include topics such as life stressors, coping mechanisms, family and social background, support systems, mental and physical health history, level of education, emotional level of functioning, work and legal background, history of physical abuse, and drug and alcohol use. LCTs may use a specific mental health inventory to detect conditions such as major depression, generalized anxiety, personality disorders, or suicide risk, based on clients presenting symptoms. LCTs consider verbal responses and nonverbal cues, such as appearance, cognition, and affect. Assessments may be conducted at the employment center, in the client’s home, or at another location convenient to the client.
LCTs develop two assessment summaries—a short summary for the TANF case manager and a more detailed evaluation for the Medicaid or contracted mental health treatment provider. After the assessment, LCTs work with TANF case managers to determine the types of activities and number of hours to include in the client’s employment plan. They may also provide ongoing guidance for interacting effectively with the customer. In addition, LCTs will link those with a mental health disability to a mental health treatment provider in the community where they monitor clients’ ongoing progress.
Psychological Assessments: Vermont TANF/Vocational Rehabilitation Partnership. Some TANF programs that have special initiatives in place supplement psychosocial assessments with psychological assessments. These assessments, conducted by a licensed psychologist, provide additional information on recipients who are suspected of living with a disability. Psychological assessments are especially helpful in identifying whether recipients have any cognitive or intellectual limitations or a mental health condition. Psychologists are trained to administer several different types of tests including: (1) achievement and aptitude tests to measure what recipients know or have the ability to learn; (2) intelligence tests that measure recipients’ basic ability to understand the world around them, assimilate its functioning, and apply this knowledge to enhance the quality of their lives; (3) neuropsychological tests to measure deficits in recipients’ ability to think, speak, or reason; (4) personality tests to measure basic personality style; and (5) occupational tests to identify occupational interests. While staff other than a psychologist can administer achievement, aptitude and occupational tests, psychologists are specially trained to administer intelligence, neuropsychological and personality tests.
Programs refer recipients for psychological testing when they do not fully understand a recipient’s circumstances and what factors might be contributing to employment difficulties or functional limitations. In the case of cognitive or intellectual limitations, information from tests can be more objective and accurate than from a clinical interview. The information obtained from psychological tests is standardized, making it possible to directly compare one individual’s circumstances with another. In the case of mental health conditions, psychologists are trained to be able to distinguish one mental health condition from another, but their ability to make an accurate diagnosis is dependent on their ability to gather sufficient and accurate information from a recipient.
Programs selectively refer TANF recipients living with a disability for psychological assessments. For example, in Vermont, TANF recipients referred to the VR agency are referred for psychological assessments when the case manager needs additional information to develop a realistic vocational employment plan. Recipients are referred to psychologists with whom the staff have developed strong working relationships and the assessments are paid for with TANF funds. Psychologists are paid on a fee-for-service basis. They complete a detailed written report of their findings and send it to the case manager who requested the assessment. Case managers use the information along with other information they have gathered to develop an appropriate service plan.
KEY CONSIDERATIONS FOR DEVELOPING AN ASSESSMENT STRATEGYWhat is the purpose of the assessment? In-depth assessments can serve several different purposes. Thus, one of the key initial steps in developing an assessment strategy is to be clear on the purpose of the assessment. Is it to identify recipients with a disability? To determine how the disability affects their functioning? To identify the types of employment or work placements where a recipient is most likely to succeed? What areas should the assessment cover? Studies have shown that a number of disabilities are common among TANF recipients. A critical issue is deciding what areas the assessment should cover. Assessments that cover only one area have the advantage of being more specialized and focused, but the disadvantage is that some recipients in need of specialized services will be missed. If designed properly, assessments that cover a broad range of disabilities can serve an important triage function, making sure that each recipient receives the kind and level of service that s/he needs. Assessments that aim to uncover a broad range of disabilities require more skill to administer. When should the assessment be conducted? Assessments can be conducted at many different points in the service delivery process. A common strategy is to conduct quick self-administered screens for all recipients during intake and to conduct more in-depth screens later. The advantage of such a process is that it reserves limited resources for recipients that have a greater likelihood of living with a disability. The disadvantage is that recipients who are unable to comply with program requirements may not be identified early enough and end up being sanctioned or become discouraged because they are unable to meet program expectations. As a middle ground, programs might supplement self-assessments with a process for better identifying "red flags" that might suggest the presence of a disability. The earlier recipients living with a disability are identified, the earlier an appropriate service and employment plan can be developed. To whom should the assessment be targeted? The target population for an in-depth screen will vary with its purpose and its timing. Disability screening protocols that aim to identify recipients living with a disability will be targeted to a larger pool of recipients than those aimed at gaining a better understanding of a recipient’s disability or their employment prospects. Decisions regarding who should be assessed need to be closely linked with decisions about how the information will be used. How will the information be used? TANF offices often collect much more information than they use. In order to serve their intended purpose, in-depth assessments need to be designed with a clear plan for how the information will be used. If a disability is identified, will recipients be referred for special services? Provided with special employment opportunities? Will their employment requirements be modified? Will they be referred for additional assessments? Who will conduct the assessment? While some assessments require specialized knowledge and training, others can be administered by staff with a broad range of skills. The advantage of using more highly skilled staff is that they possess specialized knowledge that most TANF case managers do not have. Through a combination of training and experience, more highly skilled staff also have developed stronger skills for developing a rapport with individuals and identifying red flags that might signal the presence of a disability. |
Functional Needs Assessments
Many programs targeted to individuals living with a disability routinely complete functional needs assessments (FNAs), but their use in TANF offices is not very common. As the name suggests, FNAs focus on gathering information to assess how recipients function on a daily basis. They move beyond identifying a disability to assessing ways in which an individual’s disability influences his or her ability to carry out routine functions that are critical for living independently and for succeeding at work. While FNAs can be conducted in an office setting, they are most often conducted in clients’ homes so that the person conducting the assessment can observe the client in their usual environment doing tasks of daily living, Unlike TANF assessments that often are designed to discern the presence of a challenge that might affect a client’s ability to work, these assessments are intended to identify how such challenges affect a client’s ability to conduct tasks associated with daily living and employment. With training, staff at various skill levels can conduct FNAs; however, in agencies that specialize in working with individuals living with a disability, they are often conducted by occupational therapists who work with disabled individuals to develop strategies and accommodations to overcome limitations associated with the disability.
TANF Adult Rehabilitative Mental Health Services Project, Ramsey County, MN. Functional needs assessments are a key component of Ramsey County’s TANF Adult Rehabilitative Mental Health Services (ARMHS) project. TANF recipients are referred to ARMHS if they have a mental health condition and are not progressing towards employment. They first receive a diagnostic assessment that is administered by a licensed clinician. After the diagnostic assessment, the ARMHS practitioner conducts a functional assessment focused on 13 areas of daily functioning. It includes a rating of one (no problem) to five (extreme problem) on areas that include vocational functioning, educational functioning, social functioning, interpersonal functioning, self-care and independence, medical health, dental health, obtaining and maintaining housing, use of transportation, and legal issues. During a FNA, recipients may be asked to complete a specific task or they may be asked how they would complete a task. Regardless of the format, the goal is to gather as much information as possible on how recipients function on a day-to-day basis. Sample questions and tasks include: (1) How far can you walk without stopping to rest? (2) Can you climb stairs? How many? (3) Can you tell me what these coins are? These bills? (4) How do you get to where you need to be? (5) Can you fill out this sample job application for me? (6) Have you worked in the past? At what type of job? (7) What type of clothing would you wear to an office? (8) Do you have a calendar? Do you plan your day? Your week?
Recipients are appropriate for ARMHS if they score a three (marginal or inadequate) or above in at least three different areas. The FNA takes about an hour and is typically carried out during one of the program’s series of weekly home visits. The results of the assessments are used to determine if children are receiving proper care, identify work limitations that need to be addressed, develop an individualized treatment plan, and identify clients who may be eligible to apply for SSI benefits.
Specialized Vocational Assessments
Unlike diagnostic and psychosocial assessments that are conducted primarily to identify a disability, specialized vocational assessments are conducted to help individuals living with a disability establish realistic vocational goals and a plan to achieve them. The vocational assessment process is designed to assess the unique strengths, resources, and experiences of an individual in order to match that person’s abilities and preferences to appropriate work placements, jobs, or training programs. The process is interactive; the intent is for staff to learn about the recipient and the recipient to learn about themselves.
Vocational assessments are comprehensive, gathering information on recipients’: (1) occupational likes and dislikes; (2) aptitudes, including things they can do now and things they have the capability to do in the future; (3) work style and preferences; (4) learning style, including how they receive and process information;
(5) work-related behaviors, such as work habits and skills; (6) vocational or occupational skills; and (7) functional or life skills. In addition to helping a recipient develop a vocational plan, the information is used to evaluate the need for assistive technology or accommodations, and to evaluate recipients’ abilities to engage in informed choice and decision-making.
Vocational assessment specialists or vocational evaluators conduct vocational assessments. They are specially trained and certified to obtain and assemble the information needed to make reasonable work and training decisions. In order to be certified, staff must pass a comprehensive exam offered through the Commission on Certification of Work Adjustment and Vocational Evaluation Specialists. Evaluators must demonstrate competencies in job analysis, occupational information, functional aspects of disability, work samples, psychometric testing, individualized vocational planning, situational assessment, learning style assessment, report development and communication, functional living skills, vocational interviewing, and adaptation of jobs and vocational training. Most vocational evaluators learn these skills through a master’s degree training program and an internship and work experience. Some universities offer bachelor’s degree programs, but those graduates may not be qualified to provide services at the same level as those who have attained a master’s degree.
Vermont TANF/Vocational Rehabilitation Partnership. Vocational assessments are a key component of the services that the Vermont VR provides to TANF recipients. The vocational assessment is conducted after a recipient has been referred to VR and after a VR case manager, who works only with TANF recipients, conducts an in-depth psychosocial assessment that focuses on understanding a recipient’s disability and how it influences various aspects of his or her life, including employment prospects. For recipients continuing towards an employment plan (i.e., those whose disability is not severe enough to qualify for SSI), the VR/TANF case manager administers some basic assessments of interests, values, and career-related skills. They may then refer the recipient to a vocational evaluator if more information is needed to help them define a vocational goal and a plan for achieving it.
The battery of intensive assessments administered by the vocational evaluator takes several hours (and is often spread over several appointments to limit fatigue). The vocational evaluator is responsible for determining the level of assessment that is needed given the recipient’s disability, previous work experience, and career aspirations. The evaluator often administers a brief intelligence test; assessments of reading, math, and writing; aptitude tests; and other assessments as necessary. Most testing is conducted individually. The results, used in conjunction with other assessments such as psychological and medical assessments, help the VR counselor identify how much clients can work and the types of jobs that would best match their abilities and interests. The information is used to develop a vocational plan for each recipient. The vocational evaluators are staff of the VR agency. TANF recipients are eligible for the assessments because they are VR clients and therefore eligible for all the services that VR provides. No TANF funds are used to pay for the services of the vocational evaluator.
WeCARE, New York City. After completion of a biopsychosocial assessment, recipients who have been referred to New York City’s WeCARE program and are determined to be employable with limitations complete a three to five day diagnostic vocational evaluation (DVE) designed to assess their strengths and limitations and ability to function in a work setting. The purpose of the DVE is to provide a more comprehensive picture of the client’s assets and limitations to employment and the specific accommodations and supports necessary to help the client obtain his or her highest level of self-sufficiency. The DVE has a number of components including a more comprehensive exploration of the client’s work and educational history, testing (academic achievement tests, interest inventories, aptitude tests), work samples in three occupational clusters that correlate with the client’s assessment of reasoning and learning style, behavioral observations, and career exploration. Supplemental screening and situational assessments are provided as needed. Much of the testing is completed in a group setting with 10 to 22 clients. Assessments are conducted in English and Spanish; if the recipient needs services in another language, the vendor will provide it.
The first day recipients receive an orientation to the process and goals of the DVE and complete the following: (1) writing sample to assess written communication skills, (2) self-assessment to examine perceptions about their functional limitations, (3) math and reading achievement tests to determine literacy levels, (4) English language tests for non-English speakers, and (5) tests to identify preferred work environments. Day two includes: (1) manual dexterity assessments; (2) a computerized assessment inventory; and (3) an aptitude test that examines spatial, numerical, clerical, and word meaning. Throughout the DVE, clients are closely observed by trained rehabilitation specialists to assess a client’s basic employability skills, motivation, socialization skills including relating to peers and supervisors and learning styles.
On the third day, the recipient and evaluator review the results of the DVE and develop an individualized plan for employment (IPE). The IPE outlines the steps the client must take to reach his employment goal, including the clinical treatment services required. It informs the selection of an appropriate work experience placement consistent with the client’s interests and goals and the type and amount of work accommodations and supports required. The assessment specialist and/or the certified rehabilitation counselor meet with the recipient and the work experience placement coordinator to discuss potential work experience sites, and what to expect at the selected site. The IPE also informs when and which other work activities are appropriate for the client including job search activities, education and occupational skills training. Clients also meet with the WeCARE job developers at the time the IPE is developed so they can identify companies that can provide appropriate employment opportunities for the client with the accommodations required. Throughout the DVE process and while client participate in their required vocational rehabilitation activities specified in the IPE, clients receive support from their vocational case manager, who help them comply with the program’s requirements.
WeCARE providers have up to 40 days to complete the DVE and IPE. Most clients complete the process within five days. However, no shows and scheduling issues may delay the process. The vocational evaluators are partially paid with TANF funds as a part of a contract for providing services to recipients referred to WeCARE. The evaluators are on staff at the contracted service provider.
CONCLUSION
Although they differ on many different dimensions, the in-depth assessments conducted within the context of special initiatives for TANF recipients living with a disability served one or both of two broad purposes: (1) to identify TANF recipients living with a disability, or (2) to develop an individualized service and/or employment plan. While there is no evidence to suggest that one approach to assessment is better than another, an important lesson learned from these initiatives is that assessments serve different purposes and an assessment approach should be chosen to fit the purpose for which it is intended. All the assessments were designed to gather additional information that could be used to provide more individualized and specialized services to TANF recipients who need more assistance than traditional job search assistance programs provide to succeed in competitive employment. While some programs focused on providing additional personal support, others focused on making appropriate job matches for recipients required to participate in work experience programs, or linking recipients with appropriate treatment services. Regardless of the approach taken, well-implemented assessments provide TANF recipients living with a disability and the staff who work with them greater insight into a recipient’s disability and its influence on their home and work life which can then be used to craft an employment plan that is within reach of the recipient.
PROJECT BACKGROUND AND SITE SELECTIONThis study was conducted by Mathematica Policy Research, Inc. under contract to the Administration for Children and Families at the U.S. Department of Health and Human Services (DHHS). There were two objectives of the study. The first was to provide TANF program administrators with information on strategies they could consider implementing to help TANF recipients living with a disability reach their full employment potential. (For purposes of the study, a disability was defined as any mental, physical, or cognitive limitation that has the potential to affect TANF recipients’ employment prospects.) The second was to identify potential opportunities to advance our understanding of the most effective strategies for helping TANF recipients living with a disability find and sustain paid employment through rigorous random assignment evaluations. To accomplish these objectives, MPR conducted a process and implementation analysis in nine sites utilizing qualitative case study methods. To identify sites for the study, MPR attempted to uncover as many programs as possible using four sources of information: (1) available documents (such as reports, journal and Internet articles, and newsletters); (2) recommendations from TANF and disability experts; (3) recommendations from federal officials; and (4) ongoing MPR studies for DHHS on TANF employment programs and for the Social Security Administration (SSA) on promising strategies for promoting employment among persons with disabilities. From the full list of programs, MPR and DHHS collaboratively selected a smaller set that would likely be of most interest to other states and localities, as well as be most feasible to implement. We conducted in-depth, in-person visits to seven sites and telephone interviews with program administrators and staff in two. The site visits and telephone interviews were structured to gather detailed information on program design and implementation, focusing on the issues that would be of most interest to program administrators. |
1 Rehabilitation Research and Training Center on Disability Demographics and Statistics. "2006 Disability Status Report." Ithaca, NY: Cornell University. 2007. (back)
2 Kauff, Jacqueline, Michelle K. Derr, and LaDonna Pavetti. "A Study of Work Participation and Full Engagement Strategies." Washington, DC: Mathematica Policy Research, Inc., September 2004. (back)
3 Pavetti, LaDonna, Michelle K. Derr and Heather Hesketh. "Review of Sanction Policies and Studies." Washington, DC: Mathematica Policy Research, Inc., March 2003. (back)
4 Hauan, Susan and Douglas, Sarah. "Potential Liabilities Among TANF Recipients: A Synthesis of Data from Six State TANF Caseload Studies." Washington, D.C.: U.S. Department of Health and Human Services. 2004. (back)
5 Bavier, Richard. "Prevalence and Dynamics of Disadvantaged Recipients in the TANF Caseload." Washington, D.C.: Office of Management and Budget. September 2007. (back)
| Return to Previous page |