Program/Practice Description: The New Jersey Department of Human Services, Division of Family Development's WFNJ–SAI/BHI program co–locates licensed clinicians (i.e., care coordinators) in the 21 county welfare offices in New Jersey to provide comprehensive co–occurring assessment and case management services to welfare recipients whose substance and/or mental health problems interfere with their ability to get or keep a job. These services include scheduling referrals, conducting assessments, arranging patient placements, developing service plans, conducting clinical service reviews, requesting welfare transportation and childcare supports for clients, and tracking client treatment participation and utilization management. The program adheres to a philosophy of client–centered treatment that informs all clinical service decisions. Specifically, care coordinators assess clients and arrange placement in one or more levels of care according to the client's diagnosis and integrate service planning with social services and work activities. WFNJ–SAI/BHI offers a continuum of treatment options to clients with substance abuse, mental health and co–occurring disorders.

Background/Program History: In 1998, the National Council on Alcoholism and Drug Dependence - New Jersey (NCADD–NJ) was contracted by NJDHS–DFD to provide substance abuse services for welfare clients in all 21 counties. From 1999 through 2003, as part of a randomized research evaluation project, two counties offered both Intensive Case Management (ICM) and Care Coordination services to Temporary Assistance for Needy Families (TANF) clients. The outcomes of the research evaluation indicated that ICM was more effective in reducing substance abuse as a barrier to employment for the hard–to–serve clients. Based on those findings, DFD expanded ICM to 14 counties with the largest TANF and child welfare populations. Lessons learned from the research evaluation include: (a) the importance of community stakeholders' input when designing service delivery systems; (b) the value of cross–systems coordination to develop integrated service plans; (c) establishing a lead agency responsible for overseeing and managing care; and (d) significantly expanding treatment capacity to meet clients' multiple service needs. In 2009, due to the increasing number of clients with co–occurring substance abuse and mental health disorders, WFNJ–SAI implemented the Behavioral Health Initiative. SAI/BHI serves WFNJ (TANF) participants with substance abuse and/or mental health disorders.

Innovations and Results: WFNJ–SAI employs an online case management and care coordination system to track clients from initial referral through successful completion of services, along with any potential future need for follow–up treatment. The state–of–the–art case management system was designed from the ground up with considerable input from frontline workers resulting in minimal operating system changes and extensive quality assurance reporting mechanisms to ensure efficient and responsive quality service delivery. With care coordinators embedded in welfare agencies throughout the counties, along with strong collaboration with Division of Youth and Family Services and the WFNJ–SAI provider network, the program is able to address the multitude of needs that clients present with, integrate treatment services delivery, and coordinate cross–agency networking. Frequent drug screening and the use of a voucher incentive system tied to continued successful substance–free functioning enable care coordinators to better monitor treatment progress and be more responsive to client needs for more or less intensive substance abuse treatment. Additionally, these measures provide feedback to WFNJ about client progress toward employability or maintaining employment.