文章基本信息

标题：Improving 24-Month Abstinence and Employment Outcomes for Substance-Dependent Women Receiving Temporary Assistance for Needy Families With Intensive Case Management
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作者：Jon Morgenstern ; Charles J. Neighbors ; Alexis Kuerbis 等
期刊名称：American journal of public health
印刷版ISSN：0090-0036
出版年度：2009
卷号：99
期号：2
页码：328-333
DOI：10.2105/AJPH.2007.133553
语种：English
出版社：American Public Health Association
摘要：Objective. We examined abstinence rates among substance-dependent women receiving Temporary Assistance for Needy Families (TANF) in intensive case management (ICM) over 24 months and whether ICM yielded significantly better employment outcomes compared with a screen-and-refer program (i.e., usual care). Methods. Substance-dependent (n = 302) and non–substance dependent (n = 150) TANF applicants in Essex County, New Jersey, were recruited. We randomly assigned substance-dependent women to ICM or usual care. We interviewed all women at 3, 9, 15, and 24 months. Results. Abstinence rates were higher for the ICM group than for the usual care group through 24 months of follow-up (odds ratio [OR] = 2.11; 95% confidence interval [CI] = 1.36, 3.29). A statistically significant interaction between time and group on number of days employed indicated that the rate of improvement over time in employment was greater for the ICM group than for the usual care group (incidence rate ratio = 1.03; 95% CI = 1.02, 1.04). Additionally, there were greater odds of being employed full time for those in the ICM group (OR = 1.68; 95% CI = 1.12, 2.51). Conclusions. ICM is a promising intervention for managing substance dependence among women receiving TANF and for improving employment rates among this vulnerable population. Substance use disorders are among the most prevalent and costly national health problems. Addressing substance use disorders among low-income mothers has special importance because of the vulnerable nature of the population and the higher prevalence rates of substance use disorders than for other women.^{1 – 4} The passage of welfare reform legislation heightened concerns about the well-being of low-income mothers with substance use disorders and opened new opportunities for system change. Under Temporary Assistance for Needy Families (TANF) regulations, women who fail to participate in mandated work activities face sanction and loss of benefits. At the same time, welfare reform granted much greater latitude to states to develop comprehensive support services, including funding substance use disorders treatment.⁵ Recent reviews note that women with substance use disorders represent a minority of TANF populations but experience more severe and persistent barriers to employment and are less likely to become employed than are their counterparts without substance use disorders.^{6 , 7} There is a consensus that women with substance use disorders who receive TANF need services that are more intensive than the rapid labor force attachment approach typically found in welfare settings.⁸ However, there is an absence of research to guide states in evaluating policy and program options. In an earlier study, we reported on substance use outcomes comparing 2 policy-relevant options for women receiving TANF who were diagnosed with substance dependence: (1) a substance use disorders screen-and-refer program, and (2) a substance use disorders screen-and-refer program augmented by intensive case management (ICM) and vouchers.⁹ Substance use disorders screen-and-refer models screen applicants in welfare offices for substance use disorders with paper and pencil screening measures. Applicants screening positive are assessed for substance use disorders, and if treatment is deemed necessary, clients are mandated to a substance use disorders treatment program. This screen-and-refer approach for women with substance use disorders who apply for benefits is the most common strategy that states employ.¹⁰ Although screen-and-refer programs focus on case identification and triage to substance use disorders treatment, evidence strongly supports the consideration of more-intensive interventions. Studies of women with substance use disorders who receive TANF indicate high rates of co-occurring mental health and social problems that are not likely to be addressed in substance use disorders treatment.^{11 , 12} In addition, newer conceptualizations of substance use disorders as a chronic illness suggest that interventions should provide extended monitoring over time; coordination of services may improve outcomes when added to standard substance use disorders treatment.^{13 , 14} In our earlier study, we found that substance-dependent women receiving TANF in ICM had significantly higher levels of access and retention in substance use disorders treatment and were almost twice as likely to be abstinent 15 months following study entry than were those assigned solely to a screen-and-refer option. In our current study, we had 2 primary aims: to examine whether early group main effects for abstinence were sustained over longer-term follow-up (16–24 months) and to test whether ICM yielded significantly better employment outcomes when compared with screen and refer. To the best of our knowledge, no previous study has reported employment outcomes among women who formerly received TANF either in substance use disorders screen-and-refer programs or in ICM. Testing the effectiveness of policy-relevant interventions for low-income mothers with substance use disorders is vitally connected to health issues post–welfare reform. Women who fail to achieve employment are subject to sanction and loss of social safety net benefits, including Medicaid coverage. Also, programs with demonstrated effectiveness in helping women with substance use disorders gain employment, rather than simply become abstinent, are more likely to receive additional resources from welfare agencies.¹⁵ In addition, we had 1 secondary aim. We examined whether previous abstinence predicts later employment outcomes. A guiding supposition among welfare and substance use disorders treatment professionals is that abstinence from mood-altering substances is a necessary first step toward gaining employment.¹⁶ Surprisingly, previous studies have not reported a strong relationship between abstinence and employment outcomes.¹⁷ However, no study has examined this hypothesis in a post–welfare reform context.