SummaryAs part of a 9-month study, women receiving support from the Temporary Assistance for Needy Families program who had one or more chronic health conditions and were also enrolled in a local welfare transition program received case management services from public health nurses to address mental and physical health needs. Nurses conducted health screenings, provided in-person and telephone support and education, and made referrals to mental and physical health providers. The women also received training on Medicaid benefits and how to access them. The program enhanced access to mental health care and knowledge and skills related to accessing Medicaid services, reduced depressive symptoms, and improved functional status.Strong: The evidence consists of a 9-month randomized, controlled trial involving 432 women from 1 rural and 1 urban county in north central Florida, including 214 who participated in the program and 218 who served as a control group. The trial compared access to mental health services, depressive symptoms, functional status, and knowledge and skills related to Medicaid benefits, using self-reported questionnaires administered at baseline and 3, 6, and 9 months.
Developing OrganizationsUniversity of Florida at Gainesville College of Nursing
Date First Implemented2007
Gender > Female; Vulnerable Populations > Impoverished; Insurance Status > Medicaid; Vulnerable Populations > Women
Problem AddressedLow-income women served by the Temporary Assistance for Needy Families (TANF) program often face mental and physical health problems and lack the skills and knowledge needed to access Medicaid services and transition successfully to the workforce.
- Mental and physical health problems: Between 25 and 42 percent of women served by TANF have been diagnosed with major depressive disorder, well above the 12 percent of women in the general population with depressive illnesses.1 In 2006, 13 percent were exempt from TANF work participation requirements because of a good-cause exception (e.g., disabled, in poor health, or other).2
- Difficulties accessing Medicaid, transitioning to workforce: Low-income, at-risk single mothers (a group reflective of TANF participants) often have difficulty understanding Medicaid benefits and how to access them. In addition, just under half (48 percent) of TANF recipients with a work barrier identified a health problem as the primary limitation to working.1
Description of the Innovative ActivityAs part of a 9-month study, women receiving TANF who had one or more chronic health conditions and were also enrolled in a local welfare transition program received case management services from public health nurses to address mental and physical health needs. Nurses conducted health screenings, provided inperson and telephone support and education, and made referrals to mental and physical health providers. The women also received training on Medicaid benefits and how to access them. Key program elements included the following:
- Marketing program: To identify potential candidates, researchers gave presentations during orientation sessions and posted flyers in common areas at two welfare transition program offices in north central Florida—one in an urban area and one in a rural area.
- Initial screening, enrollment, and goal setting: Working in space shared with transition program staff, public health nurses conducted an initial interview and visit with those expressing interest in the program, obtaining consent for and administering a health screening questionnaire that addresses the specific concerns of disadvantaged women. Nurses described the program in greater detail to those identified as having a chronic condition (e.g., diabetes, hypertension, obesity, depression) and formally enrolled those interested in participating. Nurses worked with enrollees to review their most pressing health-related issues, set goals and priorities, and develop an approach for addressing identified problems.
- Ongoing case management via inperson meetings and phone: The public health nurses provided care coordination, health education, and health and social service referrals to help participants meet agreed-on goals. Services generally focused on accessing care, including preventive services, screening, routine care, and primary care for newly identified symptoms. Nurses provided these services through both inperson meetings and phone calls, holding a minimum of four (typically 1-hour) sessions over the 9-month study period. In addition, they used text messaging, made home visits, and met with transition program case workers and employers as necessary to ensure that health-related needs were being met.
- Medicaid training: A community research assistant provided 2 hours of training designed to help participants use their Medicaid coverage most effectively. Training focused on enhancing knowledge about Medicaid benefits and teaching participants to engage in adaptive, emotion-based, or problem-based coping strategies to manage stressful situations when navigating Medicaid services. Training instructional techniques consisted of brief educational presentations, followed by participant role playing in response to scenarios commonly experienced by Medicaid beneficiaries.
Context of the InnovationFounded in 1956, the University of Florida at Gainesville College of Nursing is one of six colleges in the University of Florida Health Science Center. The College of Nursing collaborates with other colleges at the center, including those dedicated to dentistry, health professions, medicine, pharmacy, and veterinary medicine, and with the Shands HealthCare System and other university-based health programs. The college has more than 80 faculty and serves roughly 700 undergraduate and 370 graduate students, including approximately 80 doctoral students. Dr. Shawn M. Kneipp, PhD, ARNP, an associate professor and clinician at the college, designed the public health nursing case management study to explore the lack of standards and tools for evaluating and addressing the mental and physical health needs of women participating in welfare transition programs. She saw the need to improve women's ability to successfully transition from welfare to work. Based on her extensive experience working with public health and health care providers, the local welfare transition program, and the African-American community, Dr. Kneipp conceptualized the program and garnered support for conducting the study.
ResultsThe program enhanced access to mental health care and knowledge and skills related to accessing Medicaid services, reduced depressive symptoms, and improved functional status.
Strong: The evidence consists of a 9-month randomized, controlled trial involving 432 women from 1 rural and 1 urban county in north central Florida, including 214 who participated in the program and 218 who served as a control group. The trial compared access to mental health services, depressive symptoms, functional status, and knowledge and skills related to Medicaid benefits, using self-reported questionnaires administered at baseline and 3, 6, and 9 months.
- Enhanced access to mental health services: During the 9-month study, participants were nearly twice as likely to have a first-time mental health visit as those in the control group. Those with a history of depression were twice as likely to schedule a first-time visit, while those with moderate or severe depressive symptoms were nearly three times as likely.
- Fewer depressive symptoms, better functional status: Participants experienced a significantly greater reduction in depressive symptoms and exhibited larger improvements in functional status than did members of the control group. They also moved into employment approximately 30 days earlier than women who did not receive the intervention.
- Improved ability to navigate Medicaid system: While gains in knowledge and skills related to Medicaid were relatively small, more than one-third (34 percent) of participants reported applying what they learned from the program during a real-life encounter with the Medicaid system.
- Better employment outcomes: During the 9-month study period, 73.4 percent of the intervention group became employed compared with 64.4 percent of the control group. Women in the intervention group also moved into employment 35 days earlier than those in the control group. In addition, these differences in employment outcomes were seen not only during the more prosperous economic period that preceded the 2008 recession, but also during the recession.3
Planning and Development ProcessKey steps included the following:
- Obtaining buy-in from transition program managers: Researchers from the University of Florida contacted managers of a local work transition program to explain the case management initiative. After hearing about the program, the managers offered their full cooperation and support.
- Designing study with group input: Researchers formed a Community Advisory Group composed of 17 diverse academic researchers, agency representatives, and members of the lay community to provide guidance on study design. This group emphasized the need for a health screening questionnaire that would be relevant and sensitive to all women who have experienced a culture of poverty and disadvantage, regardless of race.
- Submitting grant proposal: Researchers submitted a grant proposal to the National Institutes of Health (NIH) National Institute of Nursing Research, which agreed to fund the study.
- Hiring and training recent transition program participants: Researchers hired three women who had recently received services from the transition program as part of the study team, with two serving as research assistants and one as study coordinator. The principal investigator provided training to these individuals on their respective roles and monitored their work on an ongoing basis. These individuals brought insights to the project team and enhanced the team's credibility with program participants.
- Hiring and training public health nurses: To provide case management services, the program hired four part-time public health nurses who were trained to use a standardized questionnaire to assess study participants and plan interventions. In addition, each nurse received a compact disc that they reviewed for roughly 8 hours on their own. The disc provided guidance on best practices and standards of care for major physical and mental health conditions common to women in the program. They also learned about all local health care service agencies and became personally familiar with key staff at those agencies who were responsible for coordinating care.
- Proposing additional research: Dr. Kneipp has revised the intervention, based on study findings and recommendations from women who participated in the trial. She is currently seeking funding to test an enhanced version of the intervention.
Resources Used and Skills Needed
- Staffing: In addition to the principal investigator and university-based research staff, the project used four part-time public health nurses to provide case management services, a full-time study coordinator, and two full-time, community-based research assistants. Public health nurses had a minimum of a baccalaureate of science nursing degree and experience working with disadvantaged women. For implementation purposes, a full-time public health nurse working a 40-hour week could probably maintain a caseload of 75 patients.
- Costs: Total program costs ran $1.4 million, much of which covered research-related expenses for the study. The main operating costs for the program include salaries and associated overhead costs for public health nurses.
Funding SourcesNational Institute of Nursing Research
NIH's National Institute of Nursing Research provided $1.4 million of funding for the initial study.
Tools and Other ResourcesThe program developer can provide a copy of the health screening questionnaire.
Getting Started with This Innovation
- Identify lead agency to conduct case management: Due to the nature of most welfare transition programs, mistrust may exist between participants and program staff. Therefore, would-be adopters may need to partner with another social service agency, such as a public health department, to conduct the screenings and provide case management services.
- Create advisory committee: This committee can provide valuable input to those developing the program, particularly if it includes members who have gone through transition programs and community-based professionals who work to reduce health disparities and promote workplace success for TANF recipients.
- Investigate potential funding streams: Would-be adopters should contact their State Medicaid agency and other potential sources of funding for the case management program.
- Hire experienced, committed nurses: The nature and variety of mental and physical health problems found in women served by the TANF program create the need for consistent case management services by highly skilled, sensitive public health nurses, preferably with a minimum of a bachelor of science degree. Ideally, participants should receive services from the same case manager throughout the program.
- Assess need for Medicaid training: Although Medicaid knowledge and skills improved for participants, most had a well-grounded knowledge of how the program worked before the training. Therefore, would-be adopters should consider assessing participant knowledge and skills before creating the training component of the program.
Sustaining This Innovation
- Track and report outcomes: To maintain funding and ensure program effectiveness, would-be adopters should track key outcomes on an ongoing basis and share results with major stakeholders.
- Obtain and respond to participant feedback: Would-be adopters should periodically solicit feedback from participants and respond to their suggestions in a timely manner to maintain program effectiveness.
Contact the InnovatorShawn M. Kneipp, PhD, ARNP
The University of North Carolina at Chapel Hill
School of Nursing
Health Care Environments Division
Carrington Hall, CB#7460, Office #5104
Chapel Hill, NC 27599-7460
Phone: (919) 966-5425
Fax: (919) 966-7298
Innovator DisclosuresDr. Kneipp has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesFagnoni C. Opportunities exist to help people with impairments become more self-sufficient: TANF and SSI. Washington, DC: U.S. Government Accountability Office; 2004:32.
Corcoran M, Danziger SK, Tolman R. Long term employment of African-American and white welfare recipients and the role of persistent health and mental health problems. Women Health. 2004;39(4):21-40. [PubMed]
Lutz BJ, Kneipp S, Means D. Developing a health screening questionnaire for women in welfare transition programs in the United States. Qual Health Res. 2009;19(1):105-15. [PubMed]
American Public Health Association Public Health Nursing Section. The definition and practice of public health nursing: a statement of the APHA Public Health Nursing Section. November 11, 2013. Available at: http://www.apha.org/NR/rdonlyres/284CE437-6AF3-4B23-88BA-52F2A0E329E6/0
/PHNdefinitionNov2013_final125142.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Kneipp SM, Kairalla JA, Lutz BJ, et al. Public health nursing case management for women receiving temporary assistance for needy families: a randomized controlled trial using community-based participatory research. Am J Public Health. 2011;101(9):1759-68. [PubMed]
Kneipp SM, Kairalla JA, Sheely AL. A randomized controlled trial to improve health among women receiving welfare in the U.S.: the relationship between employment outcomes and the economic recession. Soc Sci Med. 2013;80:130-40. [PubMed]
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Original publication: February 15, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 18, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: January 21, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.