PREFACE

In light of the transition in City government this year, reflecting the development of the new administration by Mayor Michael Bloomberg and the election of many new members to the City Council, the New York City Chapter of the National Association of Social Workers (NYC-NASW) has developed this briefing book as an aid in identifying selected critical issues of concern to the social work community.

In preparing this material, we were mindful of the tremendous fiscal challenges confronting the City. Many of the issues that are addressed here, however, are not new, and many of the proposals to cut programs further are likely to exacerbate problems in service delivery.

One of the guiding principles informing our perspective is that government officials need to begin now to develop long term approaches if we are going to see progress in the years ahead. NYC-NASW is prepared to offer the expertise of its members to work in collaboration with both branches of City government to address short and long needs.

We are also concerned that with deep budget cuts being proposed, too little attention is being given to raising revenues through selected tax increases which could lighten the burden of the health and human services community. We have included in an addendum to our briefing papers a list of fair tax revenue options identified by City Project. We strongly urge that these options be given serious consideration.

NYC-NASW is the largest organization of professional social workers in the five boroughs, representing 9,500 members.

NYC-NASW is unique within New York City in that its members are engaged in all forms of social work, including clinical practice, case management, group work, supervision, training and consultation, advocacy, community organization, research and evaluation, administration, policy, planning and program development, fund development, and social work education.

Social workers are engaged in these activities across every service delivery system in the City, in both the public and private sectors, including public schools, not-for-profit agencies, health care facilities, corporations, and labor unions.

For more information, contact Dr. Robert Schachter at (212) 668-0050.

WELFARE ISSUES

A. DEVELOP AN OPERATING PLAN TO IMPROVE ACCESS TO BENEFITS AND SERVICES FOR ALL FAMILIES IN NEED AND TO DOCUMENT CLIENT OUTCOMES

Since welfare reform started in NYC, tens of thousands of clients have lost their benefits by being pushed into temporary jobs or being cut off for insubstantial administrative reasons, without being informed of their right to reapply.

In one year, from 2000 - 2001, the rolls went down from 174,000 to 152,800 families. We know that of the 22,800 families who lost their benefits, many have disabilities preventing employment, others obtained jobs that leave them more impoverished than when they were on welfare, and many others are simply unaccounted for. When time limits started in December 2000 for 30,000 clients, 25,000 were reportedly transferred to the Safety Net Program, but what has happened to the missing 5000?

Recommendation: In order to insure that New Yorkers are not lost to needless impoverishment and homelessness, the new administration should develop a comprehensive welfare benefits program that fully utilizes all-available income, resources, benefits and education programs for welfare clients.

For example, fully utilizing the regulation that 20% of the current welfare caseload can be exempted from time limits due to disability could provide protection for the substantial number of disabled recipients. Any program should also maintain reliable records about the disposition of clients' cases.

B. DEVELOP A SEAMLESS TRANSITION TO THE SAFETY NET PROGRAM

The Safety Net Program was created to ensure that the state fulfills its mandate to provide for the needy. It was to be immediately available to families no longer eligible for Temporary Assistance to Needy Families due to time limits.

A reapplication process has been inserted into what was meant to be a seamless transition from TANF to the Safety Net Program. However, over ? of the recipients who are asked to reapply are in compliance with TANF requirements, and in fact, many are full or part time wage earners. Nevertheless, they are required to attend a face-to-face interview during business hours. The imposition of any readmission process has the potential pitfall of appointment notices never received and abrupt cutoffs not only of financial benefits, but also child care and rent subsidies, as well as food stamps.

Recommendation: The city administration should lobby the State Office of Temporary and Disability Assistance for a streamlined procedure for clients' transition to the Safety Net Program, which would include reapplication exemptions, for example, for full and part time wage earners and any recipient who has been in compliance with TANF regulations

C. REINSTATE PROVEN EDUCATION AND TRAINING INITIATIVES TO COUNT AS FULFILLING WORK REQUIREMENTS

Numerous studies have demonstrated that education and training programs improve welfare recipients' opportunities to secure and retain jobs. However, workfare-first policies have forced thousands of academically capable clients to leave promising college or training programs for time-limited public jobs with no career opportunities.

Recommendation: The Human Resources Administration must ensure greater flexibility in its one-size-fits-all, welfare-to-work programs and expand educational, training, and transitional employment options offered to clients.

A good faith assessment with each recipient is needed to determine what program path is most productive for their future. Even under the present restrictive state law, the city has latitude for authorizing a substantial amount of education and training.

D. CHANGE THE ADVERSARIAL CULTURE AT WELFARE CENTERS

Studies about the consequences of welfare reform have rightfully focused on its impact on recipients. However, almost no publicity has been given to the impact on the city's network of non-profit social services agencies, which have been undermined and directed away from providing a range of community services by the need to focus on families on welfare regularly put into crisis.

Most frustrating and time consuming has been the unavailability of welfare workers to resolve emergencies. This has involved workers withholding policy information, workers chronically unreachable by phone, and even, at times, dismissively hanging up on clients and their advocates.

Recommendation: Training, supervision and administrative regulations and procedures establish the work objectives and tone for workers in city agencies. The new administration and commissioner can promote a changed work culture based on respect for clients and their advocates, which includes communicating policies, responding to requests for information, and fail-safe mechanisms that assure that clients are not left stranded in impoverishment due to administrative error.

Communication between welfare offices and not for profit organizations could be facilitated by appointing a liaison in each welfare office who could provide information regarding policy and case status in situations where the welfare worker is unavailable.

E. REQUIRE PROFESSIONAL CLIENT ASSESSMENTS

Under the present welfare system, recipients are screened in terms of their income eligibility for assistance and inadequate attention is paid to who they are. Requiring professional assessments of clients' capacities, interests, and problems could contribute to a relevant welfare system that promotes actual avenues for financial well-being as well as one that offers appropriate services as needed. Professional evaluations in consultation with clients could identify who would benefit from workforce or academic options, as well as identifying people with mental or physical problems that need specific services. In particular, long term aid recipients whom studies show can have a high incidence of undiagnosed medical, psychiatric or developmental difficulties and/or poor literacy skills, could benefit from professional assessments and referral to appropriate services.

Recommendation: Each center should have a unit of professionally trained assessment workers who develop with each client an appropriate work, education, or service plan that addresses either eventually achieving financial independence or documents the issues and problems that compel continued public assistance.

Welfare workers to whom clients would be assigned would have the job of helping clients implement mutually agreed upon plans.

F. DEVELOP AN ADVISORY GROUP FOR THE ADMINISTRATOR OF HRA

In past administrations, HRA administrators have used advisory groups to obtain a broad range of perspectives on practice and policy issues from an array of community resources. The makeup of an advisory group could include, among others, clients, representatives from organized client groups, social work and legal advocates, and social welfare historians.

Recommendation: The Commissioner of HRA should develop an advisory group representing a broad range of perspectives on practices and policies.

HEALTH CARE ISSUES

A. SHORE UP THE FINANCIAL CAPACITY OF THE HEALTH AND HOSPITAL CORPORATION TO PROVIDE QUALITY HEALTH CARE

The Health and Hospital Corporation's ability to provide quality care is impaired by several factors.

There are 1.8 million uninsured New Yorkers - 28% of the non-elderly population. Public hospitals, which in 2000 treated 560,000 uninsured patients, are mandated to provide for their health care, but are not reimbursed for these services. Voluntary hospitals are required to provide care for the uninsured only in emergency circumstances.

Medicaid patients, whose hospital visits are reimbursable, are increasingly attracted to the option of using voluntary hospitals instead of public hospitals. The decline in Medicaid reimbursable patients, coupled with a mandate to provide care for non-reimbursable, uninsured patients, places the public institutions under serious financial stress.

Recommendation: Ensure the integrity of the public hospital system and its ability to serve its patients, including the uninsured, by expanding the budget of the Health and Hospitals Corporation.

B. EXPAND COMMUNITY-BASED SITES THAT CAN ENROLL UNINSURED AND UNDOCUMENTED NEW YORKERS IN THE CHILD HEALTH INSURANCE AND MEDICAID PROGRAMS

Access to primary and/or specialty care for undocumented and uninsured New Yorkers is daunting.

For people who are undocumented, fear of problems with the Immigration and Naturalization Service prevents them from using health care services except in emergencies. Even for those who are eligible for Medicaid, the complicated and lengthy application process at the Medicaid offices is a serious obstacle to enrollment.

Also, the limited linguistic capabilities at Medicaid offices often confuse and discourage non-English speaking applicants.

Recommendation: "Facilitated enrollment", which provides contracts to selected community based organizations to enroll patients for the Child Health Insurance Program and Medicaid program, is an excellent model. However, enrollment sites should be expanded to include proven enrollment facilities such as hospitals and community health centers.

C. RETAIN THE STREAMLINED MEDICAID APPLICATION PROCESS

The recent experience with "disaster Medicaid" demonstrated the way to provide insurance coverage to tens of thousands of New Yorkers. The long, complex application procedure can be successfully shortened and the dignity of applicant families can be preserved without undo cost to the system. This would permit a major change in the culture of Medicaid offices to one of providing service.

The necessary enabling legislation to promote streamlining the application process has been passed by the State Legislature.

Recommendation: New York City should comply with the recently enacted legislation and fully implement use of the streamlined Medicaid application process.

D. ASSURE THAT ELIGIBLE, TERMINATED WELFARE RECIPIENTS CONTINUE TO RECEIVE MEDICAID COVERAGE

The Federal Center for Medicare and Medicaid Services, (formerly known as the Health Care Financing Agency), has documented the widespread failure in New York City to inform clients who are terminated from welfare, but are still eligible for Medicaid, that their health coverage will continue.

Recommendation: An oversight process, involving continuous review, should be established to assure that clients terminated from welfare, but still eligible for Medicaid, do not illegally lose their health benefits.

E. IMPROVE CHILD WELLNESS BY EXPANDING SCHOOL-BASED AND COMMUNITY-BASED CLINICS

There are 672,000 uninsured children in New York State, at least half of who live in New York City. One in four of these children either use the emergency room as their regular source of medical care or have no regular source at all.

Recommendation: To ensure access to care, the number of school- based clinics should be increased and direct services to children in community-based clinics should be expanded.

F. INCLUDE SOCIAL WORK SERVICES AS A REQUIRED BENEFIT OF MEDICAID MANAGED CARE PLANS

Current Medicaid Managed Care plans do not include social work services as a reimbursable part of the benefit package. The plans, therefore, employ very few social workers because the expense comes out of their administrative budget.

Without access to social workers, many who need concrete support services and help with the social or emotional issues that prevent them from fully utilizing medical care, do not receive this needed assistance.

Another function that social workers perform is helping patients reenroll in Medicaid. Social workers are in a unique position to address the endemic problem of staggering numbers of Medicaid patients regularly cycling out of the health system because they did not renew their eligibility on time.

Recommendation: The city's governing bodies must work with the New York State Department of Health to assure inclusion of social work services as a required element in Medicaid Managed Care Plans.

GERONTOLOGICAL ISSUES

A. INCREASE, PROFESSIONALIZE, AND ASSURE A CULTURALLY DIVERSE WORKFORCE

It is widely agreed that there are insufficient numbers of trained and experienced social service workers available in the community to provide a wide range of services for older people and their families.

Workers in senior centers, adult day care and case management programs, as well as workers in protective care settings, often do not have the professional training needed to meet older clients' multiple and complicated needs. They do not have the clinical skills to complete comprehensive biopsychosocial assessments, to make appropriate care plans, and to work collaboratively with family members as well as with other involved professionals, e.g., physicians, nurses, lawyers and accountants.

Furthermore, professionally trained social workers (MSW's) are not choosing gerontological social work as their field of practice nor are those who are in this field sufficiently reflective of the cultural diversity of New York City's senior population.

Recommendations: Priority should be given to professionalizing the gerontological workforce through recruitment of professionally trained social workers as well as by offering scholarships and promoting loan forgiveness programs to increase the number of professional social workers entering the field.

This workforce initiative should also focus on expanding the cultural diversity of the workforce. Ongoing, in-service worker training should become regularized, emphasizing assessment and counseling skills, interdisciplinary collaboration, and the effects of culture on behavior.

B. IMPROVE WORKING CONDITIONS TO ATTRACT QUALIFIED STAFF

A comprehensive planning process needs to be undertaken on how to attract and retain professional and qualified workers. Three essential elements that planning should address are:

1. increasing salary levels to attract and retain competent staff;
2. reducing caseloads to enable workers to provide comprehensive assessments, develop care plans, and to provide quality social service intervention; and
3. providing adequate supervision and training.

Recommendations: Establish a "blue ribbon" committee to develop short and long-term recruitment and retention strategies, which would address increasing salary levels, reducing caseload size, and providing supervision and training.

The committee should include representatives from graduate schools of social work, administrators of programs for the aged from the public and voluntary sector, and representatives from senior advocacy organizations.

C. FULLY SERVE THE MOST VULNERABLE ELDERS

The most vulnerable group of elders, often without immediate family or friends, are those already in protective services or those in jeopardy of needing protection unless appropriate supports are introduced. This population needs professional workers and multiple services, with an emphasis on daily money management within the context of social service case management.

Recommendations: Establish the objective of professionalizing Protective Services staff through mechanisms such as recruitment, scholarships and loan forgiveness programs.

D. THE COMMISSIONER AS ADVOCACY SPOKESPERSON

In addition to administering the Department for the Aging, the Commissioner is well placed to get media attention and can focus public interest and action on a range of advocacy issues. This could include issues such as assuring the integrity of the Social Security system and the need to provide a full range of services to Alzheimer patients and their families.

Recommendation: We urge the Commissioner to heighten his role as an advocate, taking advantage of public interest in the new administration, to speak out on issues that advantage the elderly, particularly the elderly poor.

E. APPROPRIATELY USE FEDERAL PROGRAM TO SUPPORT FAMILY CAREGIVERS

A recently enacted Federal program, Title 3E of the Older Americans Act, which provides support for family caregivers, will be administered through the state, but implemented by localities.

Recommendation: The Department for the Aging should maximize the program's impact by integrating new programs with appropriate existing services. The new funding should also be protected from use for unconnected existing services recast as caregiver services.

CHILD WELFARE ISSUES

A. ENSURE THAT PREVIOUS ADMINISTRATION FOR CHILDRENS SERVICES' INITATIVES ARE CONTINUED AND THAT FUTURE PROGRESS IS SUPPORTED

Since ACS was created in 1996, a number of significant reforms have been implemented. Prominent among these are Neighborhood Based Services as well as expansion of preventive services, increased accountability of providers, and family team conferences. ACS has also developed an MSW scholarship program, expanded training and education opportunities, and created a new civil service title series.

Recommendation: These important initiatives have strengthened services. Ground gained must not be lost and further progress is critical. Key to achieving this objective is ongoing support from the NYC government.

B. INCREASE PREVENTIVE CHILD WELFARE SERVICES

One of the primary goals of the child welfare system is to do everything possible to keep families together. However, funding for removal and protection is significantly greater than funding for preventive services, which currently receives only 10-12% of the ACS budget. While removal and protection may, at times, be unavoidable, it is important to target resources toward communities where the rates of removals are highest and toward families at high-risk for removal.

Increasing resources for aftercare services to youth who age out of the system, as well as youth who are adopted or reunited with their families, should be another major focus for preventive services.

Recommendation: Expand resources available for preventive services to be applied to targeted communities, families and children at risk, and aftercare services. Develop benchmarks for best practices and advocate at the city and state level for adequate funding.

C. ACKNOWLEDGE AND ADDRESS RACIAL AND CLASS DISPARITIES IN REMOVAL AND PLACEMENT DECISIONS

Racial disparities among children in the foster care system are striking: 70.4 % are African-American; 24.9% Latino, 3.2% White, and 1.5% "other". The enormous challenges imposed by poverty likely accounts for a significant portion of this disparity and calls for addressing inadequate and limited income, housing, health care, and child care.

In addition, decisions at every level of the child welfare system may be influenced by inadequate knowledge of the interplay of poverty, culture and bias in society in understanding family life, as well as by attitudes about the potential for families to respond to help. This refers to decisions in both the public and voluntary sectors in budgeting, in policy and program development, in administration and organizational governance, as well as in decisions of whether to remove a child from his or her family.

Recommendation: Give priority attention to racial and class disparities in the child welfare system, especially in terms of ameliorating the effects of poverty on family well-being. Assure that all decisions at every level of the goal of doing everything possible to keep families together.

D. ENSURE THAT VOLUNTARY CHILD WELFARE AGENCIES RECEIVE ADEQUATE FUNDING

Voluntary child welfare agencies provide a continuum of care to neglected and abused children and families. This important work is severely under funded. The combination of budget decreases, New York City's economic downturn, and the swing in charitable contributions toward World Trade Center victims, have further diluted services aimed at strengthening families.

With limited resources, voluntary child welfare agencies are often unable to provide their direct service staff and front line supervisors with adequate training and educational opportunities. The consequence is that families and children in the foster care system do not receive the level of support that can be offered by trained personnel.

Recommendation: Child welfare financing must be structured to increase funding for voluntary child welfare agencies with an emphasis on training and educational opportunities for their front line staff.

E. ENSURE ADEQUATE MENTAL HEALTH SERVICES FOR CHILDREN IN FOSTER CARE.

The majority, if not all children in the foster care system; have been subjected to significant psychosocial trauma. Mental health services are needed to facilitate stable psychological development. Experts in the field have repeatedly cited the lack of adequate mental health services for children in foster care as a serious problem.

Recommendation: The City should advocate for state legislation to increase funds for mental health services for children in the foster care system.

MENTAL HEALTH ISSUES

A. ENSURE THAT THE SERIOUSLY MENTALLY ILL RECEIVE ADEQUATE TREATMENT

Inpatient hospital units are under tremendous pressure to discharge patients. Rising costs for hospital stays and restricted insurance reimbursements place pressure on hospitals to discharge patients quickly. Rapid discharges before patients are psychiatrically stable or before establishing important community supports such as housing, can be disastrous. The consequence of this is that vast numbers of the mentally ill become homeless or incarcerated.

Recommendation: Determine whether existing policies and practices regarding discharge are adequate. Ensure that patients are discharged into the community with planning that includes identifying housing, community supports, and outpatient services.

B. INCREASE SUPPORTIVE HOUSING

A significant proportion of the homeless are mentally ill. Perhaps the single most daunting obstacle facing the mentally ill is the lack of access to supportive housing.

Recommendation: The City should develop short and long range plans for developing housing for the mentally ill. Shorter range plans would involve converting, where feasible, city owned housing, but a longer range plan for new housing development is essential if the problem of the homeless mentally ill is to be addressed.

C. INCREASE FUNDING FOR COMMUNITY MENTAL HEALTH AGENCIES AND IMPROVE WORKING CONDITIONS AND SALARIES TO ATTRACT QUALIFIED STAFF

The community mental health infrastructure is frayed, largely because of the failure of funding to keep pace with inflation. The mental health sector is not eligible for an automatic cost of living adjustment (COLA), contributing to a 50% annual staff turnover, with the inevitable result that client care suffers. A weak community mental health infrastructure undermines the goal of successful client stabilization and contributes to the risk of clients falling through the cracks, recycling through expensive inpatient stays, and becoming homeless or incarcerated is exacerbated.

Recommendation: The City should advocate that State funding for the community-based mental health programs be subject to COLA increases and Medicaid reimbursement formulas need to be raised in order to attract and retain a qualified workforce to provide quality client services.

D. ADDRESS THE LONG TERM MENTAL HEALTH NEEDS OF NEW YORKERS POST SEPTEMBER 11TH.

The disaster of the World Trade Center will have a long-term impact on the mental health needs of many New Yorkers, even for those who had limited direct involvement with the attack. Populations who are already at risk for problems such as substance abuse, domestic violence and suicide are likely to experience long term affects related to trauma. Lessons learned from places like Oklahoma City suggest that the mental health needs may be pervasive and affect a larger section of the population than those directly impacted by the disaster.

Recommendations: Extend Project Liberty while developing a long-term plan for mental health service provision for all New Yorkers. To improve access and availability, convene a panel of experts to study the mental health needs of New Yorkers and create a plan for providing services to meet those needs over the next five years. Increase public education about the long-term affects of the World Trade Center on all New Yorkers.

E. ENSURE THAT THE MERGER OF THE DEPARTMENT OF HEALTH WITH THE DEPARTMENT OF MENTAL HEALTH, MENTAL RETARDATION AND ALCOHOLISM DOES NOT NEGLECT SUPPORT FOR COMPEHENSIVE MENTAL HEALTH SERVICES

In the recent NYC election, voters approved an amendment to the New York City charter that merges the Department of Mental Health, Mental Retardation and Alcoholism with the Department of Health.

In principle, linking a health and mental health approach to social problems such as domestic violence and HIV can be creative. However, historically, merged departments in New York City have proven to be problematic, necessitating later corrective actions, such as separating the Administration for Children's Services and homeless services from the Human Resources Administration.

The recent merger must not be made at the expense of mental health services and it is crucial that mental health issues receive adequate attention and resources.

Recommendation: Develop a plan that establishes organizational structures and strategies to assure improved integrated services. Issue regular reports that document the outcome for service delivery of a merged department.

F. INCREASE APPROPRIATE UTILIZATION OF KENDRA'S LAW

Kendra's Law was signed into law by Governor Pataki in 1999 in order to reduce the tragic events that can occur when seriously mentally ill patients do not receive treatment. Kendra's Law gives family members and significant others, as well as mental health professionals, the ability to petition the court to mandate outpatient care when seriously mentally ill patients who are dangerous to themselves and others and non-compliant with outpatient treatment. Statistics from the Office of Mental Health suggests that utilization of this program is limited and that very few families seek referrals. Limited public awareness of this program may be one reason for its relatively limited use.

Recommendations: Develop a public education campaign directed toward the families and loved ones of the mentally ill to increase awareness of Kendra's Law. The state Office of Mental Health and its counterpart city department should sponsor public hearings to provide information about the implementation and efficacy of Kendra's Law.