|Vol. 6, No. 6 July 2002|
By Jan Kaplan
State welfare agencies increasingly face the
challenge of serving a caseload with multiple barriers to employment.
For example, a significant proportion of clients may have substance abuse
problems that hamper their ability to participate in required activities and
move toward self-sufficiency. Coordinating
and integrating welfare and substance abuse services can facilitate treatment
and recovery and help move these individuals into jobs.
Coordinating and integrating services enables welfare
and substance abuse agencies to maximize resources, reduce duplication, and
create new services that can enable them to address the co-occurring problems of
substance-abusing welfare clients. Their problems are often more complex and
numerous than those of nonsubstance-abusing welfare clients. In addition to poor
work skills, little work experience, low education levels, and transportation
and child care barriers, individuals with a substance abuse problem often suffer
from homelessness, domestic violence, and co-occurring mental health and chronic
States and localities are under pressure to find
innovative approaches to meet the needs of their changing caseloads, fulfill
their ongoing obligations to current clients, and comply with federal
requirements. Welfare agencies need to find ways to assist clients with multiple
employment barriers while emphasizing the work participation requirements of the
Temporary Assistance for Needy Families (TANF) program. They are especially
challenged to move long-staying clients off the rolls as lifetime limits on the
receipt of cash assistance approach. Providers of substance abuse treatment have
limited financial resources, but need to increase their treatment capacity. The
emerging caseload of TANF clients with serious drug and alcohol problems
requires them to modify core treatment interventions to include vocational,
employment-related and support services.
Service coordination and integration can expand the
capacity of both welfare and substance abuse agencies. This Issue
Note raises issues for policymakers and program staff to consider when
coordinating and integrating welfare and substance abuse services to overcome
barriers to treatment, employment, and economic independence. For more
information on substance abuse issues in welfare reform, visit the Welfare
Information Network’s web site on Substance
Abuse at http://www.welfareinfo.org/hard-subabuse.asp.
What goals do
welfare agencies and substance abuse treatment providers share? Both
substance abuse treatment providers and welfare agencies aim to help their
clients become self-sufficient. Welfare
agencies focus on clients achieving independence through job preparation and
employment; substance abuse agencies focus on clients achieving independence
through recovery. Several factors
account for the growing recognition of this mutual goal. First, the shift in
emphasis from cash assistance to work under TANF, reinforced by time limits and
work participation requirements, has resulted in new relationships between
welfare agencies and diverse public and private agencies and service providers.
Treatment providers and providers of related services are necessary players in
those new relationships.
Second, limited federal, state, and local financing
for substance abuse treatment programs has resulted in a lack of inpatient and
outpatient treatment options for women with children. Treatment providers are
being challenged further as TANF agencies turn to them for services for clients
who have, or are at risk of developing, a substance abuse problem. Finally, as
their caseload dynamics change, substance abuse agencies are beginning to use
TANF as a funding source for treatment services and a resource for employment
training and work support services to help their treatment clients move toward
screening and assessment approaches work better for TANF clients with substance
abuse problems? Welfare agencies can use
the screening process to determine the extent of the substance abuse problem in
the TANF caseload and to identify at-risk clients, clients who need treatment,
or clients who may be eligible for exclusions from work requirements. They will
need to determine which clients to screen and at what point during client
interactions those screens should occur. For example, they could screen all
clients during the initial intake process. Early identification, followed by
appropriate case management, can prevent more serious substance abuse problems
in the future. Alternatively, a state that wants to target only clients who
appear to have a substance abuse problem could conduct screens at any time
during TANF receipt. These screens are likely to uncover more serious problems
requiring immediate intervention.
TANF agencies have access to a number of brief,
well-tested screening tools. The
characteristics of individual clients and the skill and training of staff
administering the screen will influence the choice of screening tool. Other
considerations are the sensitivity of the instrument in identifying potential
abuse, its ease of administration, its cultural sensitivity, the length of the
screening process, and administration costs.
Agencies can train their TANF case managers or use
on-site professionals to conduct the screens. Those choosing to train their TANF
case managers will incur lower costs, but they may find that agency staff lacks
the expertise to address clients’ sometimes negative reactions to the
screening process. Agencies that choose to use on-site professionals to conduct
screens still need to ensure all TANF caseworkers are trained to recognize
outward signs of substance abuse and to be sensitive to clients’ common
reluctance to admit to a substance abuse problem.
After the screen identifies a substance abuse
problem, an alcohol and drug abuse professional must conduct an in-depth
assessment to determine the appropriate level of treatment and other services.
Onsite assessments can expedite the development of a comprehensive case
management plan that addresses treatment and self-sufficiency issues. In
contrast, referrals to off-site professionals for assessments increase the risk
of gaps in services and can lead to low treatment participation levels.
Agencies using this approach should establish follow-up procedures to
ensure clients receive needed services. For more information, see Kirby and
What types of
services can help individuals overcome a substance abuse problem and become
welfare clients have different treatment and service needs depending on the
severity of their alcohol or drug problem, their level of job readiness, and the
extent of related family and domestic issues. In addition, the mix of services
they receive will be determined by
federal and state TANF work and time-limit requirements that dictate the type
and duration of allowable services.
Substance abuse treatment services typically include
some or all of the following: assessment and diagnosis, detoxification,
medication management, outpatient or inpatient services, counseling and case
management, and aftercare. Treatment modalities include various pharmacological,
psychological, and social service interventions. For more information, see Kirby
and Anderson, 2000.
Although the preferred treatment regimen often
consists of a combination of short- or long-term residential services and
intensive outpatient therapy, substance-abusing women with young children may
not have access to residential services. First, few residential treatment
providers accept women with children; those that do may only allow the parent to
bring one child below age six. Second, child care is often a barrier to
participation for this group, as it is for the general TANF population, so
community-based outpatient treatment may be a more suitable service option.
Finally, access to treatment depends on people’s ability to pay for the
Activities aimed at helping hard-to-employ clients
become job-ready could be integrated with substance abuse treatment in a service
package that includes basic education, vocational assessments, employment
preparation classes, job placement services, transportation and child care
assistance, and post-employment support. In addition, clients who are ready to
work could be placed in community service jobs; in supported work or other
subsidized job situations that provide ongoing training within a highly
structured environment; or in part- or full-time unsubsidized jobs that are
accompanied by job coaching and other work supports.
Finally, ancillary or wrap-around services can help
prevent clients from relapsing to substance abuse and provide
employment-readiness support. Housing, transportation, and child care are
critical to a successful transition from treatment to employment and
independence. Other services may be needed, including mentoring, health care,
parenting education, literacy training, child welfare services, domestic
violence services, life skills training, mental health counseling, and probation
and court services.
How can the
public and private sectors work together to improve the employment prospects of
welfare clients with substance abuse problems? Strong partnerships among TANF agencies,
substance abuse agencies, and other private and public entities can increase
access to job preparation and placement services, work experience opportunities,
and workplace support services. For example, states can use agency partnerships
created under the federal Workforce Investment Act (WIA) to help clients meet
their TANF work and time-limit requirements and address their substance abuse
problems. Services provided through the WIA one-stop employment centers can help
clients find jobs, training and educational opportunities, and other support
services. Moreover, agencies likely to be involved in WIA partnerships—labor,
transportation, child care, child welfare, mental health, and vocational
rehabilitation—can be resources for ancillary services for individuals with
substance abuse problems.
In addition, agency partnerships with community-based
substance abuse and employment-related service providers can increase access to
a range of services, including respite care, child care and transportation
programs, one-on-one mentoring and case monitoring, ongoing life skills
training, and others. Partnerships can also be established with private
treatment facilities, universities and community colleges, domestic violence
agencies, and community mental health centers to provide training, employment
opportunities, and support services. Many of these organizations may already be
partnering in WIA-initiated efforts to improve employability and job retention
at the local level.
In addition, many private employers are already
participating in federal, state, and local welfare-to-work efforts by offering
employment training and job opportunities to TANF clients. A growing number of
employers also are providing subsidized employment, apprenticeships, job
coaching, and other job training activities as a result of WIA and federal
Welfare-to-Work grants. These types
of initiatives could be pursued with other private-sector employers.
Finally, many employers have established employee
assistance programs (EAPs) to address personal and occupational issues that
could affect job performance. EAPs can also provide assistance with potential
relapse or other problems that recovering former welfare clients may face at
their work site. States and localities should encourage more employers to
establish EAPs. For more
information, see National Clearinghouse for Alcohol and Drug Information, 2002;
or visit the Welfare Information Network web site on Workforce
Development at http://www.welfareinfo.org/workforc.htm.
treatment and employment-related services be coordinated? States
and localities can use several approaches to coordinate and integrate treatment,
employment, and support services. Clear articulation and acceptance of policy
and programmatic goals can increase the effectiveness of coordination efforts by
preventing turf conflicts and duplication of effort.
Cross-training of substance abuse and welfare staff can
facilitate an understanding of roles and responsibilities, overcome resistance
to change in service delivery approaches, foster cooperation and agreement on
intervention strategies, and address gaps in staff expertise. Training can give
welfare agency staff skills to identify substance abuse problems and insights
into the issues women with substance abuse problems face. TANF staff could
receive training on key behavioral and physical indicators of substance abuse,
assessment and screening strategies, treatment options, methods of referral to
treatment, and case planning for individuals with substance abuse problems.
Training can give substance abuse treatment providers
information on TANF. For example, they could be told about TANF program
participation requirements, sanctions and time-limit policies, the scope of case
managers’ roles, the role and availability of ancillary services, and policies
and procedures for developing and monitoring case management plans or personal
Collocation of treatment staff in welfare offices, one-stop
career centers, or workforce development offices can be an effective way to
integrate treatment into a work-oriented system. This staffing arrangement
enables clients to obtain substance abuse assessment and referral services, as
well as TANF and employment assistance, in a single site and enhances the
capacity of the welfare and workforce development staff to address client needs
comprehensively. However, collocation may not be ideal for some agencies,
particularly those that do not want to incur extra costs, have small caseloads,
or have invested in extensive training of case managers in screening and
Collocation arrangements vary. Substance abuse
professionals can be located in the TANF or workforce office full or part time
as agency employees or as contract staff. When
employed by the agency, they strengthen the service integration and prevent
conflicts of interest in treatment approaches and referrals. Contracting with a
local treatment provider may strengthen relationships with treatment providers,
facilitate ongoing case monitoring, and be more cost-effective. In addition,
this arrangement enables the contract employee to maintain professional
connections with the alcohol and drug abuse field. However, contractual staff
may limit referrals to their own treatment facilities, potentially reducing
options for the client or influencing the treatment plan. Some agencies have
established contracts with organizations that are not connected to a particular
treatment provider to avoid this possible conflict of interest. For more
information, see Kirby et al., 1999.
Cross-agency tracking and information systems
are critical to efforts to coordinate treatment and welfare-related services.
States and localities are making great strides in building integrated data and
management information systems that enable them to serve clients across several
programs. Yet many systems do not include all the agencies necessary to address
the diverse needs of welfare clients with substance abuse problems. States and
localities could expand their cross-agency information networks to enable
agencies to integrate their intake systems and to improve their ability to track
client participation and progress in treatment and work-related activities. In
addition, expanded networks can increase the resources available through
automated information and referral directories. Furthermore, networked
information systems can ease access to information that may be needed for
federal and state reporting, agency budgeting, and program evaluation purposes.
States can use in-house information technology
specialists or rely on outside consultants to enhance their information systems
capability. Federal funds to support information technology efforts are
available, for example, through the federal TANF, Food Stamp, Medicaid, child
care, child welfare, and child support enforcement programs. In addition, states
can use their general funds to support information technology initiatives. For
more information, see Public Interest Breakthroughs, 2000.
Coordinating substance abuse treatment and
welfare-related funds can greatly increase the capacity of both systems to meet their
respective and mutual goals of client recovery and self-sufficiency. Careful
planning and resource allocation will enable many clients to receive the
treatment and services they need.
States commonly use a combination of federal and
state general funds to finance their substance abuse treatment programs. The
Substance Abuse Prevention and Treatment Block Grant, administered by the
Substance Abuse and Mental Health Services Administration (SAMHSA), is the
primary federal funding source for treatment. The grant can be used for
prevention, treatment, and rehabilitation. SAMSHA also administers smaller
discretionary grant programs that address specific populations or gaps in
The Medicaid program is the next largest source of
funds for public substance abuse treatment programs. All states are required to
cover inpatient and outpatient hospital services, such as detoxification, under
their Medicaid program. States may provide other medical and nonmedical
treatment services, such as screening, methadone maintenance, and day treatment,
but they may not cover residential treatment in a nonmedical facility for adults
between the ages of 22 and 64.
TANF, WIA, and the Social Services Block Grant are
other federal welfare-related funds that can be used for treatment and
employment-support services. Federal TANF funds can be used only for nonmedical
treatment services, such as case management and individual and group counseling.
State maintenance-of-effort (MOE) funds can be used for both medical and
nonmedical services, so long as these funds are kept separate from federal TANF
funds. Individuals served through MOE funds are not subject to TANF program
participation requirements. The Social Services Block Grant can also be used for
nonmedical treatment as well as medical services provided during initial
detoxification. States could transfer a portion of their TANF block grant funds
to the Social Services Block Grant to fund a greater array of services and avoid
the imposition of TANF work participation requirements.
Finally, WIA funds can support workforce development
activities for individuals with substance abuse problems and other barriers to
employment. The law allows states to test and sanction clients for substance
abuse. However, states could instead establish partnerships between substance
abuse treatment providers and workforce development systems to address both
treatment and workforce development service needs.
Although combining federal and state funds can expand
the services available to individuals with substance abuse problems, different
program participation and reporting requirements can be administratively
burdensome. States need to be diligent in their accounting procedures to ensure
program and reporting requirements are met and funding streams are kept
separate, if necessary.
to case management work for these clients? State
implementation of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996 (PRWORA) radically changed the culture of the welfare
office from one focused on determining eligibility for cash benefits to one
focused on promoting self-sufficiency through work. The concepts of case
management and care coordination are not new to TANF agencies. However, the
effectiveness of standard case management techniques may be limited for clients
with substance abuse problems. In particular, care coordination that involves
the development of an integrated treatment and employment plan, referrals to
treatment, and some followup to monitor participation in the treatment regimen
may not address all the barriers that can impede participation in treatment and
Instead, agencies could use intensive case management
(ICM) techniques to provide more individualized services and aggressive
interventions on the client’s behalf. ICM uses one point of contact for the
client and the system of providers. Under this model, a case management team,
consisting of staff from TANF, substance abuse, and other agencies, develops a
unified service plan for each substance-abusing client. The plan outlines a
treatment regimen, recommends a treatment provider, establishes an appropriate
level of work-related activity, and identifies and addresses barriers to
treatment and work. Case managers are advocates for their clients, requesting
child care, transportation, and housing resources as well as ancillary services.
They also address psychological barriers, such as denial or other forms of
resistance, through mentors, home visits, motivational counseling, and small
cash incentives. Finally, they oversee client participation in
employment-related or vocational services and maintain regular contact with the
Can a state
meet TANF work participation requirements while integrating substance abuse
treatment and work activities? PRWORA limits states’ ability to include many
components of an integrated substance abuse treatment and employment-readiness
plan in the calculation of their federal work participation rate. For example,
the law only allows short-term participation in job-readiness, vocational
education, and work experience activities and does not allow states to count
certain “barrier reduction” interventions, including substance abuse
treatment, as a work activity. However, states can provide services to this
population without being subject to federal penalties.
First, most states have met their federal work
participation requirements and received a federal caseload reduction credit that
reduced their work participation rate in proportion to the reduction in their
overall TANF caseload. Because PRWORA gives states that have met their federal
work participation requirements flexibility to define their own allowable work
activities, many broadened their participation policies to allow for substance
abuse treatment, vocational services, and ancillary services.
Second, the law allows states to use MOE funds to
provide treatment and job-readiness or vocational services to substance-abusing
clients. States that do not combine MOE and federal TANF funds are able to
provide services without being subject to federal program requirements. For more
information, see U.S. General Accounting Office, 2002; or visit the Welfare
Information Network web site on TANF Work
Requirements at http://www.welfareinfo.org/workreq-policies.asp.
Finally, states may exclude up to 20 percent of their
clients from both work requirements and time limits because of hardships,
including substance abuse. States could provide lengthy exemptions for
individuals with a long-term, debilitating drug or alcohol problem or shorter
exemptions for clients seeking to achieve self-sufficiency through treatment.
For more information, visit the Welfare Information Network web site on Time
Limits at http://www.welfareinfo.org/limits.asp.
confidentiality issues should be addressed when integrating TANF-related and
substance abuse services? Federal confidentiality law and regulations protect individuals who
enter federally supported substance abuse treatment from inappropriate
disclosure of information about their condition that could impact the success of
their treatment and their future ability to obtain a job and become
self-sufficient. The law specifies that information may be disclosed only when
there is written consent by the client, a court order, an allegation of child
abuse and neglect, or a medical emergency. Disclosure also is permitted when
there is no identifying information, when the individual has committed a crime
against a program or staff member, or when the information is part of internal
agency communications or an approved research project.
The law’s protections apply to information related
to a formal diagnosis of a substance abuse problem, a referral to treatment, the
provision of treatment services, and a client’s participation in a treatment
program. Information related to a substance abuse screen may be shared without
Federally required written consent forms maintain
client confidentiality, but they also enable the sharing of client information
among relevant employment and treatment staff. States need to ensure that their
written consent forms meet federal requirements. They also need to specify which
welfare program staff can receive disclosed information and identify the types
of information that may be shared. Welfare and treatment agencies could develop
written agreements to address how and what information is shared. For more
information, see Center for Substance Abuse Treatment, 1999.
Research on the extent of substance abuse among
welfare clients is hampered by differences in the definitions of use, abuse,
and dependency and by data collection methods that rely on self-reporting of
drug or alcohol use. Despite frequent underreporting of use, particularly among
pregnant women, individuals enrolled in treatment programs, and individuals in
public assistance programs, analyses of national survey data indicate that the
prevalence of drug and alcohol abuse is higher among welfare clients than in the
general population. However, use among both groups declined during the past
decade. According to these analyses, approximately 20 percent of the 1998 TANF
caseload used illicit drugs, compared with 12.5 percent of those not receiving
cash assistance; 4.5 percent of welfare clients were dependent on illicit drugs,
compared with 2.1 percent of those not receiving cash assistance. Alcohol
dependency among welfare clients also was slightly higher, but the difference
was not statistically significant (Pollack et al., 2001).
A recent study examining the prevalence of
employment barriers among substance-abusing welfare clients found that they
face significantly more barriers to work than the general population of TANF
clients. On average, these women experience six of 14 barriers examined,
including generalized anxiety disorder and a lack of transportation, education,
work experience, and job skills. Only 28 percent of those with four to six
barriers and 19 percent with seven or more barriers had found jobs after 12
months of TANF receipt, compared with 47 percent with less than three barriers
(see Gutman, in press). Researchers also have compared the barriers facing
welfare clients affected by substance abuse and barriers facing nonaffected
welfare clients. Legal, family, and mental health problems were worse among the
first group. The study concluded that welfare clients who are dependent on
alcohol or other drugs experience high levels of psychosocial impairment and
family dysfunction and are unlikely to successfully make the transition from
welfare to work (Morgenstern, et al., in press).
An evaluation of screening methods found that
universal substance abuse screening by frontline caseworkers during initial TANF
intake produced a low identification rate of between 1 percent and 4 percent.
Researchers believe client distrust of the welfare system and inadequate
caseworker training were causes for the low rate. By comparison, identification
rates doubled when specialized screenings were used. Those screens focused on
individuals at risk of substance abuse problems, such as sanctioned clients, and
were conducted by trained staff who established a rapport with clients and used
interview techniques that facilitated self-disclosure (Morgenstern, et al.,
A study of employment and welfare outcomes for TANF clients who
received substance abuse treatment in Florida found that almost a
third of treatment participants moved from welfare to work. In contrast, only 15
percent of substance-abusing clients who did not receive treatment found jobs.
Positive outcomes increased for each additional month in treatment and with more
intensive treatment; individuals who received residential treatment for 24
months had the most positive outcomes and were least likely to relapse. The
women who successfully completed treatment earned higher wages (Metsch, 2002).
Evaluations of programs that integrate treatment, employment-related,
and support services indicate a high degree of positive employment and
earnings outcomes. For example, after 12 months of participation in the
integrated services program CASAWORKS, 75 percent of clients were completely
abstinent; 40 percent were working, compared with 16 percent at the time of
initial enrollment; and 13 percent were continuing to receive cash assistance (McLellan,
in press). For more information about CASAWORKS, see the Innovative Practices
section of this Issue Note. Researchers
analyzing the effectiveness of integrated programs’ elements found that
the augmentation of standard substance abuse treatment with support services
through the ICM model had a higher success rate in engaging clients in treatment
and promoting self-sufficiency. The study compared ICM with approaches that
coordinate care through triage and referral systems (Morgenstern, 2001).
States and localities are using various approaches to
coordinate and integrate their substance abuse treatment, TANF and
employment-related services. For
more examples, see Golonka, 2001, and Kirby, 2000; or visit the Welfare
Information web site on Substance Abuse
an integrated, comprehensive model to help drug- and alcohol-addicted mothers on
welfare achieve self-sufficiency. The model provides a single six- to 12-month
course of treatment and training that incorporates drug and alcohol treatment,
job-readiness and employment-related services, parenting and social skills,
violence prevention, health care, and family services. Intensive case management
is used to coordinate services and increase progress toward abstinence and
employment. Collaborating partners at each site include treatment and training
facilities. They may also include
employers, universities, housing authorities, government agencies, child care
centers, chambers of commerce, and community mental health centers. The program
is funded with foundation, federal, and local funds. Contact Kamla Wolsky, firstname.lastname@example.org;
or see http://www.welfareinfo.org/casaworks.htm.
Substance Abuse Research Demonstration (SARD) program aims to move
substance-abusing welfare clients toward self-sufficiency through intensive case
management and enhanced services. The state’s TANF program regards treatment
as a work activity in which TANF clients must participate. Clients who do not
meet participation requirements are sanctioned. Trained TANF case managers
screen all clients and refer those who screen positive to collocated SARD
workers for assessment and referrals. The program provides outreach and linkages
to wrap-around services, active coordination of treatment and work activities,
and case management services for 18 to 24 months. Contact Annette
Riordan, 609/292-9686 or email@example.com.
Office of Alcoholism and Substance Abuse Services (OASAS) requires treatment
programs to provide their clients with employment preparation services. State,
TANF block grant, and federal substance abuse block grant funds are used to
increase vocational services; expand wrap-around services; foster collaborations
between local social services districts and local mental hygiene departments;
and support credentialed addiction counselors and qualified health professionals
in local social services offices to screen public assistance applicants for
addiction problems. Contact OASAS at firstname.lastname@example.org;
or visit http://www.oasas.state.ny.us/.
North Carolina uses
TANF block grant funds to collocate “Qualified Substance Abuse
Professionals” in county Work First agencies. These professionals conduct a
full assessment of any adult who has been screened by a Work First caseworker
and deemed at risk of substance abuse. The Work First case managers and the
Qualified Substance Abuse Professional jointly develop a treatment plan and
track the individual’s progress through treatment. Treatment plans include
support services, self-sufficiency skills training, and vocational support. The
state also has implemented a work-site Enhanced Employee Assistance Program (EEAP)
demonstration initiative. EEAP expands traditional EAP services to provide
support to Work First participants through gender-sensitive substance abuse
assessment, two-year aftercare for relapse prevention, and work-site monitoring
programs. Contact Joan Radford at 919/733-4555 or visit
American Public Human Services Association, Gary
Center for Substance Abuse Treatment, Substance Abuse
and Mental Health Services Administration, call 301/443-5700; or visit
Joint Center for Poverty Research, Sheldon Danziger,
Legal Action Center, Ellen Weber, 202/544-5478.
Mathematica Policy Research, Inc., LaDonna Pavetti,
National Center on Addiction and Substance Abuse at
Columbia University, call 212/841-5200; or visit http://www.casacolumbia.org.
National Governors Association, Susan Golonka,
Substance Abuse Policy Research Program, Treatment
Research Institute, call Marjorie Gutman, at 215/399-0980; or visit http://www.saprp.org/programinformation/npo.htm.
Publications and Electronic Resources
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Review, in press. Visit http://www.tresearch.org.
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Identification of Substance Abuse Problems among Welfare Recipients.
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Available at http://aspe.hhs.gov/hsp/njsard00/screenng-rn.htm.
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The Welfare Information Network is supported by grants form the Annie E. Casey Foundation, the Charles Stewart Mott Foundation, the David and Lucile Packard Foundation, the William and Flora Hewlett Foundation, the Ford Foundation, and the Administration for Children and Families, U.S. Department of Health and Human Services.