This report provides a synthesis of research and existing ACF resources for serving at-risk youth. It describes what we know from research about at-risk youth. It then describes how at-risk youth are currently being served by ACF programs and by programs outside of ACF that have been shown to put youth on a path toward self-sufficiency. Based on the review of research and resources, it identifies issues to consider in creating conceptual frameworks for developing and enhancing ACF programs that can or do serve at-risk youth. In the remainder of this chapter, we state the key questions that guide the synthesis, define some key concepts, and describe a number of at-risk youth populations served by ACF programs. (author abstract)

Social policy evaluations usually use classical statistical methods, which may, for example, compare outcomes for program and comparison groups and determine whether the estimated differences (or impacts) are statistically significant — meaning they are unlikely to have been generated by a program with no effect. This approach has two important shortcomings. First, it is geared toward testing hypotheses regarding specific possible program effects — most commonly, whether a program has zero effect. It is difficult with this framework to test a hypothesis that, say, the program’s estimated impact is larger than 10 (whether 10 percentage points, $10, or some other measure). Second, readers often view results through the lens of their own expectations. A program developer may interpret results positively even if they are not statistically significant — that is, they do not confirm the program’s effectiveness — while a skeptic might interpret with caution statistically significant impact estimates that do not follow theoretical expectations.

This paper uses Bayesian methods — an alternative to classical statistics — to reanalyze results from three studies in the Enhanced Services for the Hard-to-Employ (HtE) Demonstration and Evaluation Project, which is testing interventions to increase employment and reduce welfare dependency for low-income adults with serious barriers to employment. In interpreting new data from a social policy evaluation, a Bayesian analysis formally incorporates prior beliefs, or expectations (known as "priors"), about the social policy into the statistical analysis and characterizes results in terms of the distribution of possible effects, instead of whether the effects are consistent with a true effect of zero.

The main question addressed in the paper is whether a Bayesian approach tends to confirm or contradict published results. Results of the Bayesian analysis generally confirm the published findings that impacts from the three HtE programs examined here tend to be small. This is in part because results for the three sites are broadly consistent with findings from similar studies, but in part because each of the sites included a relatively large sample. The Bayesian framework may be more informative when applied to smaller studies that might not be expected to provide statistically significant impact estimates on their own. (author abstract)

In the context of a public safety net focused on limiting dependency and encouraging participation in the labor market, policymakers and researchers are especially interested in individuals who face obstacles to finding and keeping jobs. The Enhanced Services for the Hard-to-Employ (HtE) Demonstration and Evaluation Project was a 10-year study that evaluated innovative strategies aimed at improving employment and other outcomes for groups who face serious barriers to employment. The project was sponsored by the Administration for Children and Families (ACF) Office of Planning, Research and Evaluation in the U.S. Department of Health and Human Services, with additional funding from the U.S. Department of Labor. This report describes the HtE programs and summarizes the final results for each program. Additionally, it presents information for three sites from the ACF-sponsored Employment Retention and Advancement (ERA) project where hard-to-employ populations were also targeted.

Three of the eight models that are described here led to increases in employment. Two of the three — large-scale programs that provided temporary, subsidized "transitional" jobs to facilitate entry into the workforce for long-term welfare recipients in one program and for ex-prisoners in the other — produced only short-term gains in employment, driven mainly by the transitional jobs themselves. The third one — a welfare-to-work program that provided unpaid work experience, job placement, and education services to recipients with health conditions — had longer-term gains, increasing employment and reducing the amount of cash assistance received over four years. Promising findings were also observed in other sites. An early-childhood development program that was combined with services to boost parents’ self-sufficiency increased employment and earnings for a subgroup of the study participants and increased the use of high-quality child care; the program for ex-prisoners mentioned above decreased recidivism; and an intervention for low-income parents with depression produced short-term increases in the use of in-person treatment. But other programs — case management services for low-income substance abusers and two employment strategies for welfare recipients — revealed no observed impacts.

While these results are mixed, some directions for future research on the hard-to-employ emerged:

• The findings from the evaluations of transitional jobs programs have influenced the design of two new federal subsidized employment initiatives, which are seeking to test approaches that may achieve longer-lasting effects.
  
  
• The HtE evaluation illustrates some key challenges that early childhood education programs may face when adding self-sufficiency services for parents, and provides important lessons for implementation that can guide future two-generational programs for low-income parents and their young children.
  
  
• Results from the HtE evaluation suggest future strategies for enhancing and adapting an intervention to help parents with depression that may benefit low-income populations.
  
  
• Evidence from the HtE evaluation of employment strategies for welfare recipients along with other research indicates that combining work-focused strategies with treatment or services may be more promising than using either strategy alone, especially for people with disabilities and behavioral health problems.

(author abstract)

In 2010, it is estimated that there were 45.9 million adults in the United States with mental illness. Of these 45.9 million adults, 32.9 percent received mental health services. NSDUH presents the results of interviews conducted with household residents, non-institutionalized individuals, and civilians living on military bases ages 12 and older from January to December 2010. These interviews measured the frequency of mental illnesses, treatments for depression, and mental health service utilization.

TANF potentially serves as a portal for a wide array of programs that provide cash income support, in-kind nutrition and housing assistance, tax credits, and other services to families with low-incomes. This research brief summarizes what we know about the connections between TANF and other important safety net programs. It reviews the size and scope of the various programs, the receipt of other safety net benefits by TANF families, and the implications for policy and research. (author abstract)

This paper describes several additional analyses and results that go beyond the basic impact findings from the evaluation of the Working toward Wellness (WtW) program in Rhode Island. WtW was a one-year telephone care management intervention for depressed parents who were Medicaid recipients. To encourage individuals with depression to seek treatment from mental health professionals, the WtW program randomly assigned depressed Medicaid recipients to a program group, which had access to telephone care management for up to a year, or to a control group, which had access to the usual mental health services available to Medicaid recipients. Results from the study found that telephone care management modestly increased in-person treatment for depression during the year of the intervention but not after that point. No impacts on average depression severity were observed for the sample as a whole. 

To understand which individuals showed reduced depression over time, the paper examines the relationship between participants’ characteristics and changes in depression scores from baseline to six months and to eighteen months. The results do not, however, suggest a clear means of targeting services like WtW to those who are least likely to improve on their own. Other than baseline depression severity, few participant characteristics were found to be associated with reduced depression over time. This suggests that most subgroups of participants could have benefited from a more effective intervention. 

Also, because only about 40 percent of the study population participated in in-person mental health treatment, the paper examines which factors contributed to receiving treatment and the intensity of that treatment. The results suggest that a number of factors were associated with seeking mental health treatment. In particular, treatment occurred more frequently for those who were more severely depressed, those who were not working at baseline, white sample members, and those who had received treatment for depression prior to random assignment. This may suggest providing more resources and supports to encourage those groups to receive treatment who are least likely to participate, for whom the program might make a larger difference. It may also suggest excluding individuals with prior treatment for depression from future studies of similar interventions. 

Lastly, because the eighteen-month results showed that there were significantly fewer program group members in the very severely depressed group, the paper investigates which baseline characteristics are associated with being very severely depressed at follow-up. It was found that although some characteristics are associated with having severe depression at follow-up, the impacts on depression severity for this high-risk subgroup are not statistically significant. (author abstract)

The 1996 federal welfare reform law, which sets time limits on benefits and requires increasing numbers of clients to participate in work-related activities, was designed to encourage families to leave cash assistance for work and thereby reduce the welfare rolls. Aware of the possibility that the new legislation might negatively affect access to Medicaid, policymakers enacted Section 1931 to de-link Medicaid from welfare. Nevertheless, Medicaid enrollment has declined at a rate higher than expected since 1996, leading federal and state policymakers to become concerned that enrollment has indeed been affected by changes in cash assistance programs. Similar concerns have been raised in regard to the dramatic drop in participation in the Food Stamp Program. In response to these concerns, the U.S. Departments of Health and Human Services and Agriculture contracted with Mathematica Policy Research, Inc. (MPR) to identify state policies and procedures that appear to promote enrollment in Medicaid and/or the Food Stamp Program in the post-welfare reform era. We selected Indiana as the site for this study because the state increased Medicaid enrollment by almost 15 percent between 1998 and 1999. This report documents the results of our examination of Indiana's efforts to promote enrollment, primarily for children, in Medicaid and SCHIP and to begin to identify strategies for increasing enrollment
in the Food Stamp Program. (author abstract)

The National Academy for State Health Policy (NASHP) hosted a webinar on February 9, 2012 from 2:30 to 4:00 p.m. Eastern time. The webinar was designed to help States improve enrollment and eligibility systems by providing an overview of State progress towards updating their systems. Speakers included: Alan Weil, Executive Director, National Academy for State Health Policy; Alice Weiss, Co-Director, Maximizing Enrollment; Judith Arnold, Director, Division of Coverage and Enrollment, New York Department of Health; Manu Tandon, Secretariat Chief Information Officer, Massachusetts Health and Human Services; and Tracy Turner, Applications and Operational Support Manager, Oklahoma Health Care Authority.

The National Academy for State Health Policy (NASHP) authored this report, which was developed as part of the National Workgroup on Integrating a Safety Net into Health Care Reform Implementation. As a result of the Workgroup, this report provides ten key issues that policymakers, who are concerned with the safety net, should consider in order to reach the health care reform’s goals for vulnerable populations.