1. Identification & Referral for Persons with Substance Use Disorders: The North Carolina Work First/CPS Substance Abuse Initiative
Welcome to the orientation of the North Carolina Work First/CPS Substance Abuse Initiative. During this orientation several areas will be covered that will help to understand more fully the background and execution of this Initiative across the state. Areas will include the state laws and policies, the state and local collaborations and finally the role of the qualified professionals in substance abuse who provide direct services across the state in all 100 counties.
The orientation will take approximately 30 minutes to complete and will include opportunities to quiz yourself on the information provided. This orientation is a collaborative effort of the North Carolina Division of Mental Health/Developmental Disabilities and Substance Abuse Services and the UNC School of Social Work’s Behavioral Health Care Resource Program.

2. Learning Objectives
Ability to describe the state laws governing the Work First/CPS Substance Abuse Initiative.
Ability to explain the collaborative partnerships at the state and local level.
Develop an understanding of the state policies that inform the execution of this Initiative.
Ability to list the activities that encompass the role of the Qualified Professional in Substance Abuse for this Initiative.
At the completion of this orientation to the North Carolina Work First/CPS Substance Abuse Initiative, individuals will be able to describe state laws which established and govern this Initiative.
Additionally , individuals will have the ability to explain the collaborative partnerships at the state and local level and will demonstrate an understanding of the state policies that inform the execution of this Initiative.
Finally individuals completing this orientation will have the ability to list the activities that encompass the role of the Qualified Professional in Substance Abuse under this Initiative.

3. The Law
In 1997, the NC General Assembly passed N.C. General Statute 108A-29.1
The law states:
Each applicant or current recipient who is determined to be addicted to alcohol or drugs, and in need of substance abuse treatment, shall be required to participate in substance abuse treatment in order to receive Work First benefits; and
The applicant or recipient must submit to random toxicology screening as a part of their treatment.
The Federal Personal Responsibility and Work Opportunity Reconciliation Act (Public Law ) passed in 1996 changed what was historically Aid to Families with Dependant Children/AFDC to Temporary Aid to Needy Families-TANF
As a result of several sections of the federal law, States developed specific laws and subsequent policies around substance abuse, certain felonies and certain public benefits.
In North Carolina General Statute 108A-29.1 was passed in 1997, requiring the establishment of a system to determine if a person applying for or receiving Work First benefits is in need of professional substance abuse treatment services.
Each applicant or current recipient who is determined to be addicted to alcohol or drugs, and in need of substance abuse treatment, is required to participate in substance abuse treatment in order to receive Work First benefits; and the applicant or recipient must submit to random urine toxicology screening as a part of their treatment.

4. The Law General Statute 108A-29.1
Any applicant or recipient who fails to comply with treatment requirements becomes ineligible for cash assistance.
Applicants or recipients shall be considered to be receiving benefits for purposes of determining eligibility for Medicaid.
The children of any applicant or current recipient shall remain eligible for benefits, and these benefits shall be paid to a protective payee.
G.S. 108A-29.1 states that:
“An Applicant or current recipient who fails to comply with any requirement imposed pursuant to this section shall not be eligible for benefits or shall be subject to the termination of benefits, but shall be considered to be receiving benefits for purposes of determining eligibility for medical assistance.
The children of any applicant or current recipient shall remain eligible for benefits, and these benefits shall be paid to a protective payee pursuant to G.S. 108A-38.
An applicant or current recipient shall not be regarded as failing to comply with the requirements of this section if an appropriate drug or alcohol treatment program is unavailable.”

5. The Law General Statute 108A-29.1
An applicant or current recipient shall not be regarded as failing to comply with the requirements of this section if an appropriate drug or alcohol treatment program is unavailable.
Area mental health authorities (now Local Management Entities/LMEs) are responsible for administering the provisions of the law.
Requirements of the law may be waived or modified in the case of any individual applicant or recipient to comply with Medicaid eligibility.
When this general statute was written it was written as ‘area mental health authorities’, these are now the Local Management Entities or LME’s. They are responsible for provisions of this law.

6. The Law General Statute 108A-25.2
The law states: Individuals convicted of Class H or I controlled substance felony offenses are eligible to participate in the Work First and food stamp program: Six months after release from custody if no additional controlled substance felony offense is committed during that period & successful completion of or continuous active participation in a required substance abuse treatment program determined appropriate by the area mental health authority;
In 1997, the NC General Assembly passed N.C. General Statute 108A-25.2
Individuals convicted of Class H or I controlled substance felony offenses are eligible to participate in the Work First and food stamp program if certain conditions are met. Individuals convicted of all other felonies are ineligible to participate in the Work First or Food Stamp program.
The first condition is if it has been six months after release from custody, if no additional controlled substance felony offense is committed during that period and successful completion of or continuous active participation in a required substance abuse treatment program, determined appropriate by the area mental health authority;

7. The Law General Statute 108A-25.2
OR If not committed to custody, six months after the date of conviction, if no additional controlled substance felony offense is committed during that period, and successful completion of or continuous active participation in a required substance abuse treatment program determined appropriate by the area mental health authority.
Or if an individual has not been committed to custody, then six months after the date of conviction, if no additional controlled substance felony offense is committed during that period, and successful completion of or continuous active participation in a required substance abuse treatment program determined appropriate by the area mental health authority, then they are eligible to apply for services. Again, mental health authority now means Local Management Entity or LME.

8. Test yourself
Urine toxicology screening is part of the application process for Work First or Food and Nutrition Services.
True or False?
Individuals convicted of a Class H or I Controlled Substance felony will only be assessed for abuse of the substance they were convicted of having used/possessed. True or False? ?

9. Test yourself
Urine toxicology screening is part of the application process for Work First or Food and Nutrition Services. False, it may only be part of treatment under this Initiative.
Individuals convicted of a Class H or I Controlled Substance felony will only be assessed for abuse of the substance they were convicted of having used or possessed. False, the applicant will be assessed for all substances of abuse or dependence, including alcohol. ?

10. Collaboration and Coordination
The next section will look at collaboration and coordination of the Initiative
Collaboration and Coordination

11. State Level Collaboration & Coordination
State Memorandum of Agreement
Joint Responsibilities of the
DMH/DD/SAS and DSS
Develop and provide training for County DSS and LME/Provider re: Initiative.
Provide technical assistance to County DSS & LMEs/Providers re: Work First/CPS SA Initiative program development.
The North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services holds a memorandum of agreement or MOA, with the North Carolina Division of Social Services for the collaboration and coordination of this statewide Initiative. The joint responsibilities under this MOA are to 1) Develop and provide training for county DSS’s, LME’s and Providers regarding the Initiative and 2) To provide technical assistance to County DSS’s & LMEs/Providers re: Work First/CPS SA Initiative program development.

12. State Level Collaboration & Coordination
Responsibilities of the Division of MH/DD/SAS
Provide funding to LME’s to assist with hiring Qualified Professionals in SA and fund non-Medicaid reimbursable expenditures.
Develop consent for release of information in accordance with 42 CFR Part 2: Confidentiality of Alcohol and Drug Patient Records and HIPPA.
The responsibilities that fall under the Division of Mental Health/Developmental Disabilities and Substance Abuse Services in the MOA are to:
1) Provide funding to LME’s to assist with hiring Qualified Professionals in Substance Abuse & fund non-Medicaid reimbursable expenditures.
2) Develop consent for release of information in accordance with 42 CFR Part 2: Confidentiality of Alcohol and Drug Patient Records and HIPPA.

13. State Level Collaboration & Coordination
Responsibilities of the Division of Social Services
Develop policies and procedures for County DSS to follow in implementing and administering the Work First/CPS Substance Abuse Initiative requirements.
Implement standardized consent for release that is 42 CFR Part 2 compliant.
The responsibilities that fall under the Division of Social Services within this MOA include developing policies and procedures for county DSS’s to follow in implementing and administering the Work First/CPS Substance Abuse Initiative requirements, including requirements that impact Food and Nutrition Services applicants.
State DSS also distributes, as part of policy, a standardized consent for release that is 42 CFR part 2 compliant.

14. Local Collaboration & Coordination
Requirements of the LME and County DSS:
Development of Local MOA between LME and County DSS.
Establish Populations to be Served.
Establish Procedures Surrounding the Services of the QPSA.
Provider Contract Expectations.
Effective implementation and execution of the Initiative requires local level collaboration and coordination. The Local Management Entity or LME holds an MOA with each County DSS in its catchment area. This MOA establishes the populations to be served under this Initiative. It also establishes procedures surrounding the services of the contracted Qualified Professional in Substance Abuse/QPSA and QPSA provider contract expectations.

15. Memorandum of Agreement
DSS and LME jointly agree to:
Develop a reporting system of non-compliance by consumers.
Abide by confidentiality regulations.
Arrange for appointments for the consumer and coordinate planning for child care and transportation.
Inform the consumer about the method of payment for SA or MH treatment.
Maintain regular contact regarding consumers progress in treatment.
The county DSS and LME together agree to:
Develop a reporting system of non-compliance by consumers.
Abide by confidentiality regulations.
Arrange for appointments for the consumer and coordinate planning for child care and transportation. These are common barriers for getting to treatment and can be considered ‘good cause’ by DSS as reasons why someone isn’t making it to treatment consistently.
Inform the consumer about the method of payment for SA or MH treatment.
Maintain regular contact regarding consumers progress in treatment.

16. Memorandum of Agreement
DSS Agrees to:
Explain to consumer the substance abuse assessment and services provided by QPSA.
Adhere to Confidentiality and completing proper release forms.
Screen all Work First applicants for possible substance abuse.
Offer voluntary screening for mental illness.
Refer all eligible applicants for services with an H or I Controlled Substance Felony to the QPSA for a substance abuse assessment.

17. Memorandum of Agreement
DSS Cont…
Make appropriate referrals to QPSA.
Arrange for child care and transportation for consumers with children, who are receiving substance abuse services.
Inform QPSA when ‘protective payee’ status becomes effective.
Designate staff person to serve as liaison under this MOA.

18. Memorandum of Agreement
LME agrees to:
Arrange for appointment for assessment of consumer.
Provide assessment of substance abuse and mental health for Work First consumers as needed.
Refer for treatment when assessment indicates.
Authorize appropriate level of treatment recommended by QPSA.
Items in orange carried out by contracted QPSA provider
Items appearing in orange are those that are carried out by the QPSA provider that is contracted by LME, typically a private behavioral health provider in the community.

19. Memorandum of Agreement
LME cont…
Provide case support services for consumer.
Provide treatment compliance reports to DSS staff.
Participate in interagency staffing with DSS.
Liaison between treatment providers and DSS.
Provide SA and MH training to staff by QPSA.
Items in orange carried out by contracted QPSA provider

20. Test yourself ?
If a WF recipient does not have transportation to mandated treatment, WF will cease. True or False?
The QPSA is not an employee of DSS. True or False?

21. Test yourself ?
If a WF recipient does not have transportation to mandated treatment, WF will automatically cease. False. DSS and the QPSA work with the recipient to address barriers to treatment.
The QPSA is not an employee of DSS.
True. In certain circumstances, DSS has been contracted by the LME to provide the QPSA services, but in general the QPSA is an employee of a private behavioral health agency.

22. Now policies of the entities involved will be reviewed.
Policy

23. Populations served Food and Nutrition Services Work First
Child Protective Services
So far we have looked at the laws that direct this Initiative and the collaborations which enable it to work. Now we will look at the specific policies of three different entities of the Department of Social Services that specify the populations to be served.
To review it is the Work First applicants and Food and Nutrition Services Class H or I Controlled Substance Felons applicants who are the mandated populations served under this Initiative.
Qualified Professional in Substance Abuse Assessment

24. North Carolina DSS Work First Policy 104B
Required Substance Abuse Screening Of All Adult Work First Applicants/Recipients
Conducting the Screening for Substance Abuse: DSS staff responsible for administering verbal screening to all applicants.
Screening Tools for Substance Abuse: Audit and DAST 10 validated verbal screening tools.
Behavioral Indicators: Behavioral Indicator Check list.
Substance abuse and mental health issues can be significant barriers to employment for Work First participants. This Initiative can assist families in becoming employed and maintaining employment. The DSS staff generally are the ones to administer the verbal screening tools, the Audit and the DAST 10, both are validated screening tools. Additionally they are able to utilize behavioral indicators as triggers for a referral to the QPSA for a substance abuse assessment. These tools are used at the time of application and can also be utilized at anytime during the Work First case.

25. Expansion of the Initiative
Mental Health Services 2001
Voluntary mental health screenings were added as a part of the Initiative.
The mental health screening tool used is the Emotional Health Inventory (EHI).
QPSAs will provide screening, case support, facilitate assessment, and communicate compliance with treatment to WF as requirement of the Mutual Responsibility Agreement (MRA).
The DSS staff offer this voluntary mental health screening at the time of application.

26. Referral from Work First to QPSA
Work First Application or at any other time considered appropriate
Emotional Health Inventory
Negative Positive
Audit Screening and DAST Screening
Negative Positive Negative Positive
Behavioral Health Indicator Checklist
No Check One or more
This flow chart helps to demonstrate from the time of application how an applicant may get to the QPSA for an assessment.
No Referral
Qualified Professional in Substance Abuse
No Referral
Work First Benefits Policy 104B

27. North Carolina DSS Work First Policy 104B Non Compliance
Non-Compliance for Applicants and Recipients of SA Treatment.
Non Compliance for SA for Applicants & Recipients who have Previously Received WF Assistance.
In the case that an individual is unable to comply with the treatment component of the MRA, and ‘ good cause’, as defined by DSS policy, can not be established, the participant is ineligible for cash assistance but remains in the Work First Family Assistance case. This means that the individual continues to receive Medicaid, the time clock continues, and is still required to participate in the employment program. The Work First payment must be made to a protective payee.
If an appropriate drug or alcohol treatment program is not available, the individual is not considered to have failed to comply with a treatment plan. The QPSA determines if appropriate treatment is available.
Once the individual complies with the individual treatment plan, their needs are added back into the need standard of the family effective the month following the month the individual complied with his treatment plan.
If a former Work First applicant/recipient who has in the past failed to comply with either a referral to a QPSA or QPSA treatment recommendation applies for Work First, the applicant is referred back to the QPSA using the Substance Abuse Behavioral Checklist II screening tool. The QPSA will either assess the applicant if no prior assessment has been completed; or, if an assessment has been completed and a substance abuse diagnosis determined within the last 30 days, the QPSA will refer the applicant back to a treatment provider for treatment. If the assessment and diagnosis is not current, i.e., within the last 30 days, the QPSA will reassess. If the applicant is non-compliant with treatment recommendations, the Work First caseworker will initiate the steps to reduce the family’s need standard and put in place a protective payee.

28. North Carolina DSS Food and Nutrition Policy 290
Class H or I Controlled Substance Felons
All applicants identified by the FNS staff as having a Class H or I Controlled Substance Felony, who are eligible to apply, are referred to the QPSA for a substance abuse assessment.
Applicants are referred to the QPSA even if they state they are currently engaged in treatment.
If treatment is indicated, the applicant must engage in treatment as a condition for receiving FNS benefits.
To review eligibility may be established if it has been six months after release from custody, if no additional controlled substance felony offense has been committed during that period & successful completion of or continuous active participation in a required substance abuse treatment program determined appropriate by the area mental health authority; Or if an individual has not been committed to custody, then six months after the date of conviction, if no additional controlled substance felony offense has been committed during that period, and successful completion of or continuous active participation in a required substance abuse treatment program determined appropriate by the LME or their contracted provider.

29. Referral from Food and Nutrition Services to QPSA
Food and Nutrition Services Application
Eligible Class H or I Controlled Substance Felon?
NO YES
The referral to the QPSA from FNS is fairly straight forward if the individual is an eligible Class H or I Controlled Substance Felon as demonstrated in this chart.
Qualified Professional in Substance Abuse

30. North Carolina DSS Food and Nutrition Policy 290 Compliance
Applicant is disqualified when Food and Nutrition Services is notified that the individual has failed to follow through with the required assessment and/or treatment.
Compliance with a substance abuse treatment program is waived for individuals who reside in counties whose QPSA require an assessment fee.
Food and Nutrition Services staff verify an assessment fee is required prior to waiving the individual’s requirement to comply with a substance abuse treatment program.

31. Expansion of the Initiative
Child Welfare Cases 2001
QPSA services expanded to serve substantiated cases of child abuse, neglect and/or dependency that involve substance abuse or cases found ‘in need of services’ that involve substance abuse.
The QPSA provides assessment and case support for families with substance abuse or dependency diagnoses.
The expansion of the Initiative to include certain CPS cases occurred in 2001 and was communicated in a letter to the county Department of Social Services Directors, with 3 attachments, covering release of information, Memorandum of Agreement and protocol for referrals.

32. DSS Child Protective Services
Substantiation or finding of services needed based on SA being part of substantiation.
Work First and H or I Controlled Substance Felons have legislative priority.
CPS may have limited access.
If QPSA is not available, CPS will refer to outside provider for assessment.
The QPSA may serve families who are out of the investigation stage and whose case has been, in CPS language ‘substantiated’ or ‘in need of services’ based on substance abuse as a contributing factor. In these situations it would be appropriate when time permits, for the QPSA to perform a substance abuse assessment. However, due to the legislative priorities of this Initiative, the QPSA must serve the other two populations first. Many county DSS’s have contracts with providers to perform all the substance abuse assessments needed for their families or utilize the screening, triage and referrals services of the Local Management Entities, to meet this goal. To be clear the intention of the Initiative is to provide additional support, when possible, in serving the families in need of substance abuse assessments.

33. Referral from CPS to QPSA
CPS assessment results in substantiation or a finding that the family is in need of services and substance abuse was identified as one of the factors
Currently in Substance Abuse Treatment?
Yes (verified) No
Family continue in Substance Abuse Treatment
Qualified Professional in Substance Abuse QPSA
This flow chart demonstrates how a CPS involved family may be referred to the QPSA.
QPSA able to provide assessment
QPSA not available to assess due to priority WF and FNS referrals
CPS worker refers to LME or assessment agency used by county CPS SA assessment

34. Test yourself ?
All WF applicants must have a mental health screening. True or False?
The QPSA provides substance abuse assessments on all involved with CPS. True or False?

35. Test yourself ?
All WF applicants must have a mental health screening. False, verbal mental health screening is voluntary on the part of the applicant.
The QPSA provides substance abuse assessments on all involved with CPS. False, the QPSA only provides assessments for families whose cases have been found ‘in need of services’ or substantiated, with indication of substance abuse, time permitting.

36. Work First/CPS SA Initiative: Role of the Qualified Professional
Arrange for appointment for assessment of consumer.
Provide assessment of Substance Abuse for Work First (WF) and Food and Nutrition Services (FNS) applicants and consumers as needed.
Provide assessment of Mental Health for WF consumers as applicable.
Provide assessment of Child Protective Services (CPS) referrals as applicable.
Refer for treatment when assessment indicates.
Provide case support services for consumer.
Track the provision of consumer services relevant to WF/FNS/CPS participation.
Provide treatment compliance reports to DSS staff. .
The QPSA plays a vital role in initially providing the professional substance abuse assessment service to individuals who are compelled to have the assessment as a result of their need for the public services. They provide an opportunity for the consumers to access treatment services for both substance abuse and mental health issues. Their key functions include the tracking of services, care coordination and case support so that the consumer may be eligible to receive the DSS services vis a vis the Substance Abuse or Mental Health issues.

37. Work First/CPS SA Initiative: Role of the Qualified Professional
QPSA role continued
Follow up with treatment providers regarding participation in treatment with signed consent.
Liaison between treatment providers and DSS.
Report to county DSS information that relates to the Mutual Responsibility Agreement (MRA) with signed consent.
Participate in interagency staffing with DSS.
Provide case consultation with DSS staff.
Provide SA and MH training to DSS staff.
Provide orientation to the WF/SA Initiative for WF clients.
Data collection: WF/CPS SA Initiative Quarterly Project Report, submitted by the LME.

38. Work First/CPS SA Initiative: Screening & Assessment Tools
The AUDIT and DAST-10 are used to screen all Work First applicants and recipients.
The Substance Abuse Behavioral Indicator Checklist II is used by Work First DSS workers to identify consumers at risk who may not be identified by the AUDIT or DAST-10 screening tools.
The Substance Abuse Disorders Diagnostic Schedule (SUDDS- IV) or other DMH/DD/SAS approved standardized assessment tools, are used by QPSAs as a part of a comprehensive clinical assessment with all referrals.
The individuals with H or I controlled substance felonies go directly to the QPSA for assessments, they are not screened.
The LME may submit a request to DMH/DD/SAS to utilize an alternative standardized tool to the SUDDS, for the assessment process.

39. Work First/CPS SA Initiative Accountability
State Level Monitoring-Annual Audits
Audit Tools (Individual and Program)
Plan of Correction
Local Level Monitoring-LME
Quarterly Reports
Review of report
On going accountability activities occur through state level monitoring and local level monitoring. Additionally, the submission and review of quarterly project reports provide monitoring and technical assistance opportunities.

40. Billing Medicaid and State Comprehensive Clinical Assessment Codes
State Integrated Payment and Reimbursement System Target (IPRS) Populations
If the individual is Medicaid eligible the comprehensive clinical assessment may be billed to Medicaid. If the consumer is not Medicaid eligible, billing for the comprehensive clinical assessment is based on the contractual agreement between the LME and the QPSA provider agency. It may include IPRS Target Population ‘Adult Substance Abuse DSS Involved’.

41. Funding
Non-Unit Cost Reimbursement (Non-UCR) SAPTBG funds are allocated to the LME.
IPRS Target Population, Adult SA DSS involved
Medicaid
Non UCR federal substance abuse prevention and treatment block grant funds are allocated to each LME to support the activities of the QPSA that are not Medicaid or IPRS billable.

42. Work First/CPS SA Initiative
Collaborative Trainings and Technical Assistance
Regional/Statewide Meetings
Cross training for LMEs, QPSA’s and DSS
Technical assistance (e.g. phone, onsite, etc)
Questions? contact: or
Collaborative training and technical assistance is available and ongoing. This concludes the orientation to the Work First/CPS Substance Abuse Initiative.
Melissa Godwin of Behavioral Healthcare Resource Program at UNC School of Social Work or Starleen Scott Robbins of DMH/DD/SAS may be contacted with questions about this Initiative.