Gwen H. struggled with drug addiction for 25 years and it was not until the morning she was evicted from her house and was standing on the corner with a trash bag filled with her belongings with no place to go that she realized that she needed some help.
Gwen enrolled in the Maximizing Participation Project (MPP), which helped her navigate the complicated drug treatment system and enroll in Horizon House Drug and Alcohol Program. She received transitional housing and successfully completed her 2-year drug and alcohol program.
As the pieces of Gwen’s life slowly began to fall back into place and she got back on her feet, she sought help finding employment. At first it was difficult; she began with very low self-esteem and there were a few times she considered quitting. She later said that sticking with it was one of the best decisions she ever made. Through hard work and perseverance on her part, and the help of supportive services, she prepared for the job search and landed full-time employment. Gwen found a job working for the Salvation Army After-School Program as a Teacher’s Aid and remains employed and drug-free to this day.
One Size Does Not Fit All
In 1996 President Clinton and the United States Congress replaced the previous, open entitlement welfare program, Aid to Families with Dependent Children (AFDC), with Temporary Assistance to Needy Families (TANF) and the policy that welfare recipients would have a limited period of assistance, within which they would have to begin to work their way toward self-sufficiency. Fifteen years later, the question of whether this shift has been successful is still debated and contingent on one’s definition of success. Certainly, states were able to reduce their TANF caseloads—at least prior to the recession. And aid recipients who could make a relatively easy transition to employment were arguably better off, though it is difficult to track TANF-leavers over an extended period of time so the long-term self-sufficiency of those without the skills to compete in a modern economy and without the safety-net benefits, such as Medicaid and child care assistance, that TANF provides is unclear.
Moreover, while TANF work requirements may be appropriate for those without health barriers, it leaves individuals with medical disabilities and those caring for family members without any safety-net. Those with extreme barriers to employment such as severe chronic or acute medical conditions typically become socially isolated and disengaged. They lose hope in gaining employment and stop taking care of their own health. The further a person continues on this trajectory the more the costs escalate, both to individual health and the healthcare and public welfare systems. A one-size approach to work requirements simply does not work with individuals facing severe medical barriers to employment, and nor is it cost-effective.
An Alternative Approach
Gwen’s story is fairly typical for the MPP program. Put simply, it’s a program that works. Established in 2001, the MPP helps individuals with medical disabilities and other significant barriers participate in training, education and alternative work activities as a way to re-engage the very hardest to serve in taking personal responsibility for their health and self-sufficiency.
The MPP program specifically serves medically-exempt TANF recipients: those who are exempt from meeting welfare work requirements due to a physical or behavioral health condition, or who care for a disabled family member. The program is voluntary for TANF clients who have not reached the 60-month limit but is mandatory for extended TANF clients who meet the medical exemption requirements of the program. Participants must be receiving TANF and have a valid medical exemption form completed by a physician.
MPP represents an innovative approach to helping medically-exempt welfare recipients get the medical help they need so that they can work and achieve self-sufficiency. For clients with severe medical exemptions, the program helps participants successfully apply for social security disability benefits. In most states, SSI benefits can be supplemented by Medicaid and food stamps. With a regular source of income and access to healthcare, participants are better able to meet their own needs, resulting is significantly reduced public welfare and healthcare costs.
The program utilizes a non-traditional approach to meet the needs of medically-exempt families that are receiving TANF. MPP is designed to offer an intensive assessment and service plan to serve clients that typically get lost in the system because of their physical health, mental health and/or drug and alcohol barriers. MPP takes a holistic approach when assisting the family by providing support, guidance and follow-up within the community to address the barriers limiting a person from becoming employed/self-sufficient. MPP case coordinators visit participants’ homes and work with community providers to assist the participant in stabilizing or alleviating the barriers that are causing them to need public assistance.
Holistic Intervention – the Key to Participant Success
Individuals with a long history of disengagement from employment never face just one barrier. Participants’ problems are usually multi-dimensional and require an in-depth approach that starts with meeting the participant where they are and working with them along a continuum of goals toward reaching their highest level of self-sufficiency. An MPP team works with participants in a holistic manner to help identify barriers that prevent them from moving toward self-sufficiency. MPP coordinates and facilitates payments for services and activities designed to help resolve barriers. Depending on the specific barriers identified, services might include identification of or confirmation of physical or mental health conditions, referrals for services from Office of Vocational Rehabilitation (OVR), Mental Health, Drug and Alcohol, or Domestic Violence agencies, scheduling and accessing needed treatments or services, help with the application process for Social Security and SSI, help to resolve problems that the participants’ children may be having in school, Department of Human Services (DHS), legal situations, disability services and locating and facilitating other services or treatments that may assist the MPP participant in moving off of welfare and toward self-sufficiency.
Key to the success of this program is comprehensive and thorough assessment resulting in an individualized plan for each participant. We collect the assessments already done, get people to the right doctors or specialists and then use this information to determine capacity to work. The real value in this approach is that our case coordinators work side by side with the clients to navigate the public welfare and health system on their behalf in order to help them get the services and care they need so that they can participate more fully in work activities.
Thorough assessment combined with access to medical care results in one of two paths: 1) the individual demonstrates the capacity for employment with barrier reduction support, or 2) the individual has a medical condition or disability that legitimately prevents him or her from working. Increasing access to social security benefits is a strategy that has been used very effectively with homeless or at-risk homeless by SSI/SSDI Outreach, Access and Recovery (SOAR). SOAR focuses on applications that are completed right the first time resulting in very high SSI approval rates (73 percent). MPP participated in a targeted demonstration project in 2009-2010 resulting in 100 percent SSI approval for clients who completed the SOAR process.
Taking MPP to Scale – Lessons for Replication
In July 2009, JEVS expanded the MPP model to the state of Delaware. Elements of the SOAR program described above have been implemented in Delaware and have already increased SSI approval rates from 10 percent in FY10 to 32 percent at the half-way point of FY11. The Transitional Work Program (TWP) operates statewide in Delaware, offering the same intensive and holistic services for those facing extreme barriers to employment.
Running the program successfully in Philadelphia for 8-plus years allowed us to design the Delaware program with best practices and reliable outcome predictions because we knew what worked with MPP clients. This allowed us to bypass the kinks that come with new pilot design. High predictability of outcomes meant we could confidently budget for needed staff and operational costs without guessing. This is critical in replicating performance-based programs. While replicating programs in different states requires responsiveness to state policies, funding requirements and local customs, our efforts were greatly enhanced by having strong Total Quality Management (TQM) practices in place and exceptional IT strength to allow us to roll out program operations immediately upon a signed contract. This is particularly important for tracking client outcomes, invoicing and establishing credibility up front.
Additionally, for south Delaware, the challenges of a rural environment adds cost, limits productivity (fewer visits per day) and makes referral to services and employment more difficult as public transportation is difficult to find.
We attribute much of the success of the MPP model to working closely with the Department of Public Welfare’s Bureau of Employment and Training on the design conceptualization and being responsive to their needs for an alternative approach to engaging long-term public assistance clients with medical disabilities in work activities.
It is also essential to have the right people on board. Experience with the Philadelphia MPP program helped us to know exactly the desired traits and qualifications of staff we would need to replicate a quality program in Delaware. This resulted in a much slimmer margin of error for hiring the right people to lead the new program to successful outcomes. And ultimately, it was relationships on the ground in Delaware that helped us build the groundwork for replication. This aided in helping us navigate local policies and customs to be responsive to those needs in our program design. This also helped immensely when it was time to determine location and physical facilities for housing the TWP.
Public Policy Implications
Combined with a robust economy, the changes in welfare policy related to 1996 TANF law appeared to be successful in reducing state welfare caseloads. The easiest to place, those who were essentially work-ready, did enter employment, thus removing the easiest cases from the public welfare system. The individuals that remained in the system were the ones with severe and multiple barriers, including physical and mental disabilities and a host of other barriers to employment. As the economic crisis deepens and state funding cuts increase, public assistance caseloads are increasing and the hardest to serve are still with us.
Because the medical exemption requirement does not force work activity, many medically-exempt TANF clients end up isolated and not making progress toward improved health and self-sufficiency while their health deteriorates and barriers to employment and self-sufficiency continue to mount at great cost to both the public welfare system and the private healthcare system. When the needs of the very hardest to serve are not addressed thoughtfully, punitive programs actually end up costing society more, not less.
The program is attractive to state and local policymakers because it is designed to increase engagement and ultimately work participation. In cases of permanent disability, clients receive SSI/SSDI, shifting local costs to the federal level and removing non-compliant clients from the work participation rate calculation. The program results in substantial cost-savings including: 1) healthcare cost-savings when chronic conditions become managed, resulting in fewer visits to the emergency room, 2) state savings when individuals go on SSI, and 3) workforce participation rate increases when people get chronic health conditions under control and participate in work activities.