摘要：Objective. We tested the effectiveness of a long-term coordinated care strategy—intensive case management (ICM)—compared with usual care (UC) among a group of substance-dependent women receiving Temporary Assistance for Needy Families (TANF). Methods. Substance-dependent women on TANF (N=302) were recruited from welfare offices. They were assessed and randomly assigned to ICM or UC; follow-up was at 3, 9, and 15 months. UC consisted of a health assessment at the welfare office and a referral to substance abuse treatment and TANF services. ICM clients received ICM services in addition to UC services. Results. ICM clients had significantly higher levels of substance abuse treatment initiation, engagement, and retention compared with UC clients. In some cases, ICM treatment attendance rates were double those of UC rates. Additionally, almost twice as many ICM clients were abstinent at the 15 month follow-up compared with UC clients ( P <.0025). Conclusions. ICM is a promising intervention for managing the chronic nature of substance dependence among women receiving TANF. Future research should refine long-term care strategies—such as ICM—that address the chronic nature of substance dependence among low-income populations. Substance abuse is a national health problem that creates serious personal impairment and major social and economic burdens. Addressing substance abuse among low-income mothers may be especially important because of its impact on children, who face a much greater risk for becoming substance abusers themselves. 1 – 3 Additionally, the combination of substance abuse and poverty fuels an inter-generational pattern of severe personal and social dysfunction that creates barriers to resolving substance use disorders. 4 Substance abuse is a highly stigmatized behavior. Stigma and concealment issues are especially pronounced among low-income mothers, who may fear loss of welfare benefits or involvement with child protective services if they provide accurate reports about their substance use. 5 Thus, accurate data on prevalence rates of substance abuse among low-income women are lacking; however, studies have consistently found that low-income women have significantly higher rates of illicit drug use and substance abuse compared with the rates of other women. 6 – 8 Additionally, recent studies that used self-reports of women on Temporary Assistance for Needy Families (TANF) have yielded rates of substance dependence (alcohol and illicit drugs) that range from 5% to 11%, with an additional 5% to 8% engaged in regular heavy drinking or illicit drug use. 5 Some studies have suggested that these ranges may significantly underestimate the true prevalence of this problem. 9 Studies have shown that community substance abuse treatment, especially outpatient treatment, is poorly matched to the needs of substance-dependent low-income mothers. 10 , 11 These women fail to enter and engage in treatment, and studies have reported poor outcomes. An evolving science-based model that views substance dependence as a chronic illness suggests that in order to improve outcomes, treatment must provide greater coordination of social and other health care services beyond just treating substance abuse. 12 Additionally, long-term care strategies—similar to those used for other chronic diseases—must replace the current system of disconnected episodes of acute care. 12 Substance abuse among low-income mothers has been a public health priority for more than 2 decades, and welfare reform legislation passed in 1996 has raised new concerns. Under TANF regulations, women who fail to participate in mandated work activities face sanction and loss of benefits. Current welfare reform emphasizes finding a job quickly and is not likely to be effective among substance-dependent women; however, simply referring these women to substance abuse treatment also is insufficient for reasons already noted. Indeed, studies have shown that substance-dependent women on TANF have significantly more social and health care problems that are barriers to employment: they are less likely to be employed, they are more likely to be sanctioned, and they have substantially higher rates of involvement with child protective services compared with women who do not have a substance use disorder. 13 Despite rising concern, there is an absence of research for guiding policy and program development in this area. Intensive case management (ICM) may be a promising approach for substance-dependent women on TANF. ICM is consistent with a chronic disease management strategy that augments current disconnected episodes of acute care with longer-term care strategies and cross-systems coordination that addresses other health and social needs and provides relapse monitoring and support during extended time periods. To date, studies that have examined the effectiveness of ICM among substance abusers have had mixed findings. 11 , 14 – 17 Thus, in spite of the intuitive appeal, there is limited support for the hypothesis that longer-term care strategies and better service coordination actually improve treatment compliance and outcomes among substance abusers. No reported study has tested the effectiveness of ICM among substance-dependent women on TANF. We conducted a randomized field trial to test the effectiveness of 2 models of care. Substance-dependent women were identified in welfare offices with routine self-report drug use screening procedures, which were part of determining TANF benefit eligibility. One group of women received referrals to a treatment program and welfare services (usual care [UC]). UC is often referred to as the “screen and refer” model and was the standard of care in New Jersey at the time of our study. The other group of women received ICM—coordinated social and health care services and long-term support and monitoring—in addition to the substance abuse treatment and other services available to the UC group.
