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CMHS National Advisory Council
Meeting Minutes
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
National Advisory Council Meeting Minutes
May 1998
Arlington, Virginia
Closed Session
Members of the National Advisory Council of the Center for Mental Health Services (CMHS) met in closed session on May 5, 1998, at the Washington National Airport Hilton. CMHS Director Bernard S. Arons, M.D., presided.
Open Session
Dr. Arons convened the open meeting later that morning. Attendees included Thomas Bornemann, Ed.D., Frank D. Burgmann, Marshall Forstein, M.D., Eric J. Getka, Ph.D., Ruby J. Martinez, R.N., Ph.D., Donna Mayeux, Andres Pumariega, M.D., Ian Shaffer, M.D., Steven P. Shon, M.D., David Shore, M.D., William Van Stone, M.D., David K. Yamakawa, Jr., J.D., and Anne Mathews-Younes, Ed.D., Executive Secretary. New Council members Betty E. King, Ruby Martinez, Donna Mayeux, and Andres Pumariega, were introduced and welcomed by the Council.
CMHS Director's Report. Dr. Arons discussed the following highlights of CMHS's activities: (1) In its efforts to raise public awareness, the successful Walk the Walk: For Lives Touched by Mental Illness took place in Washington, D.C. A post mortem was to be conducted. (2) CMHS has begun collaboration in planning the forthcoming Surgeon General's Report on Mental Health; the report will focus on promoting mental health, ending stigma, encouraging early recognition and intervention for mental health problems; and advancing innovative, community-based service-delivery systems. (3) CMHS completed the research-based report, Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits, which estimates that full parity in private health insurance plans would increase family insurance premiums an average 3.6 percent; parity in substance abuse treatment benefits alone, 0.2 percent; projected premium increase, less than 1 percent for mental health and substance abuse benefits in health plans that closely manage care. (4) The Child, Adolescent, and Family Branch received Vice President Gore's Hammer Award as an outstanding example of governmenal collaboration, and the Branch's Caring for Every Child's Mental Health: Communities Together Campaign received a bronze Mercury Award from the International Academy of Communications Arts and Sciences for its video Voices of Strength: An Inside Look at Children's Mental Health. (5) The Child, Adolescent, and Family Branch is launching the Circles of Care initiative involving technical assistance and a grant program to support Native American tribes in developing and implementing systems of care for their children. (6) Two major HIV/AIDS initiatives are soon to be launched, as will a grant program to support conferences that focus on knowledge synthesis and dissemination. (7) Funds are to be made available for cooperative agreements to Evaluate Consumer-Operated Human Service Programs for Persons with Serious Mental Illness, particularly programs designed to improve rehabilitation and recovery of individuals with serious mental illness, and to assess costs. (8) Grants for the Women and Violence Study will support the first of a two-phase study on women, alcohol, drug, and mental disorders, and violence. (9) Community Action Grants for Service Systems Change will support the adoption of exemplary service delivery practices for children and adults, with a priority initiative for Hispanic communities. (10) State Reform Grants will provide technical assistance to states in their efforts to integrate, analyze, synthesize, and use information for planning and management efforts.
CMHS Initiatives
Homeless Programs Branch: ACCESS grantees met to discuss evaluation findings and other issues. Housing Initiatives grantees met to resolve issues of instrumentation and measurement, among others; a consumer advisory panel was included. An expert focus group discussed issues of homeless families with custody of their children and in which one or more parent has a psychiatric and/or co-occurring substance abuse disorder.
Protection and Advocacy Branch was instrumental in convening the Involuntary Interventions and Coercive Practices meeting (an executive summary is available through SAMHSA's National Mental Health Information Center. Two major training sessions were held.
Survey and Analysis Branch: The branch continues to focus on quality development activities.
Consumer-Directed Initiatives: A series of regional consumer meetings began in Atlanta, Alternatives Conference in February.
Construction Grant Monitoring Program monitored more than 200 grantees and 900 recipients of National Institute of Mental Health (NIMH)/CMHS clinical training stipends.
Emergency Services and Disaster Relief Branch: Services are provided in almost every state and territory in the wake of El Nino; President Clinton acknowledged on national television the importance of providing mental health support services in such circumstances.
The Information Center: For more information, call 1-800-789-CMHS, or access the website at mentalhealth.samhsa.gov.
Discussion:
- Council members urged the allocation of funds to enhance the impact of dissemination conferences, particularly those related to the Knowledge Dissemination and Application (KD&A) program. Acknowledging that conferences/information alone do not change behaviors in practice, post-conference technical assistance activities would help move attendees toward sustained action to implement the information imparted.
- Council members urged CMHS staff to plan some Council meetings in locations outside Washington, D.C.
- Council members will be invited to contribute to the Surgeon General's Report on Mental Health on several levels: suggest authors and contributors, supply comments, and review processes.
Update from the American Psychiatric Association. Medical Director Steven Mirin, M.D., identified ways in which his organization supports the mutual goals of CMHS and the APA. These include the following efforts:
- Work with CMHS on AIDS education, outreach, and support. Since 1986, the education project has trained more than 12,000 psychiatrists on clinical and neuropsychiatric and psychosocial aspects of AIDS/HIV. The APA has developed AIDS training curricula and educational resources, and conducted regional training conferences and train-the-trainer programs. Established a network of psychiatrists who provide training and clinical support in the AIDS arena. Created a database to link psychiatrists and other mental health professionals to HIV resources, clinical information, and educational opportunities.
- CMHS helps support the APA's Practice Research Network (PRN), a national network of 600+ psychiatrists that serves as a laboratory for studying patterns of psychiatric care and clinical outcomes for patients in a wide array of practice settings. The PRN, which provides information on the interplay between patient variables, treatment variables, system factors, and clinical outcomes, fosters understanding of the nature of clinical decision making and the effect of those clinical decisions on outcomes.
- CMHS funds the State University Collaboration Project, which provides consultation and clinical assistance to states and universities in identifying human resource needs in mental health service systems. It also provides interdisciplinary and culturally competent care training for mental health caregivers.
- CMHS has contracted with the APA to examine the use of psychotropic medications in children and adolescents with ADHD, and to study the regional differences and patient characteristics of individuals who receive electroconvulsive therapy.
- The APA was a co-sponsor of Walk the Walk and expects to work on the Surgeon General's Report.
- The APA supports full parity and works to increase public support for existing mental health programs.
- The APA will increase its patient advocacy focus.
Shaping the Future of Mental Health Service Systems Improvement. Panel members: Michael English, Esq., CMHS, Division of Knowledge Development and Systems Change; Jane Steinberg, Ph.D., NIMH, Executive Director of the National Advisory Mental Health Council (NAMHC); Kathryn Magruder,Ph.D., NIMH, Chief of the Services Research and Clinical Epidemiology Branch; Michael Hogan, Ph.D., Director of the Ohio Department of Mental Health; David Shore, M.D., Associate Director for Clinical Research, NIMH, and liaison to the CMHS Advisory Council; moderator, Steven Shon.
Panel and Council members discussed the potential benefits and challenges inherent in collaboration related to CMHS's KD&A program and NIMH's services research activities. Chief among the benefits of collaboration are (1) the potential for broader and more effective and efficient dissemination and implementation of existing and developing scientific knowledge, and (2) the advantages of moving on a continuum from merit-based research to the real world. Among the major challenges are those inherent in (1) melding the cultures, business/management styles, and expectations of two separate entities with different missions and histories, and (2) the complexity of selecting, designing, and developing project(s) that meet those disparate missions, styles, and expectations in a meaningful way for both entities. Representatives of both NIMH and CMHS concurred that the time is right to continue the active pursuit of collaboration. Multiphase, multifaceted collaborative efforts may be indicated. Major details of this discussion follow:
- Dr. Shon set the context for the discussion: NIMH develops and disseminates new scientific knowledge for mental health services in communities. In areas of overlapping interest between CMHS and NIMH, appropriate collaborations may prove fruitful. The discussion, it was hoped, would identify boundaries and changes necessary to proceed to this end.
- Mr. English highlighted CMHS efforts, particularly in knowledge development and dissemination. CMHS has taken on the role to identify and then eliminate gaps in knowledge about mental health services delivery, and has developed a strong services-oriented portfolio of activities.
CMHS's major challenge is its insufficient capacity to be an effective change agent, but nevertheless must implement a consistent strategy to market the knowledge available to be used. Dissemination alone does not cause change, and a multifaceted approach is necessary.
Among CMHS's knowledge synthesis efforts have been expanding Community Action Grants to overcome implementation barriers and engaging membership organizations (such as the National Association of State Alcohol and Drug Abuse Directors [NASADAD]) to take proactive steps to promote change among their members. Teleconferences, conferences, technical assistance networks, consumers, and families are all change agents. The Surgeon General's Report could be an important change agent, but it has not yet been determined how to use it to best advantage.
- Dr. Steinberg expressed the desire of NIMH Director Steven Hyman and the NAMHC for renewed NIMH emphasis on producing research that matters to people with mental disorders, clinicians, policy makers, and family members. NIMH's recent reorganization mingles clinical research and basic science to provide rapid translation from the bench to treatment development activities.
The NAMHC's Clinical Treatment and Services Research Workgroup, constituted to review NIMH efforts to support research to improve treatment and systems of care, is charged to develop an action plan to enhance the usefulness of NIMH research.
The workgroup will establish an ongoing, public process for setting NIMH priorities; take on a synthesis role through new informatics, meta-analysis, and continuous development; create stronger bonds between clinical trials and service research; foster various types of research that will aid patients, clinicians, policy makers, and payers in decision making; stimulate the next generation of methodological refinements; build collaborations with business, MCOs, and CMHS. Dr. Steinberg noted that NAMHC is looking for ideas to input into NIMH.
- Dr. Magruder outlined NIMH's organizational structure. The Services and Research and Clinical Epidemiology Branch administers the following programs: Methodological Research, which, for example, investigates new outcome or quality-of-life instruments; Managed Care and Systems Research, which looks at structural aspects of services and the extent to which clinical practice, outcomes, etc., relate to the structures; Outcomes and Quality of Care Research, which examines the content of care and how that relates to clinical outcomes; Socio-Cultural, which focuses on social, ethnic, and cultural influences on delivery of care; Child and Adolescent Services Research; Cost and Financing Research Program; Primary Care Research; Clinical Epidemiology; Diagnosis and Disability Assessment; Dissemination Research; and Research Training and Fellowships.
Among the goals set for 1998-99 are the following: continue to improve the Clinical Services Research Program with the help of the work group; focus on dissemination, managed care, and primary care research; look at aging populations; continue child and adolescent work; and establish a work site program.
Dr. Magruder noted that the culture of NIMH is mainly to award investigator-initiated grants, although occasionally set-aside funds are available. The institute is working to streamline its review cycle. NIMH would like to examine recovery and maintenance issues.
- Dr. Hogan reiterated the dominant fact of NIMH life: investigator-initiated research. In contrast, however, he noted the activist approach of NIMH's director to address the disconnect between science and the lives that people lead and the quality of care they receive.
- Council Discussion
The Council discussed change. This complex process occurs at many levels, but does not occur without follow-up action and a perception that change is better than stasis. New to the equation of policy change is the presence at the table of consumers and advocates, involved in both care and research.
Participants discussed an actual (TMAT Project) collaboration between the two agencies, a future collaboration (Mr. English will speak at an NIMH fall conference), and some potential projects (effectiveness studies involving interventions for children, a program for rural areas, the Surgeon General's Report).
Problems of linkage between CMHS and NIMH websites were identified by consumer advocate Joe Rogers, National Mental Health Association, along with the need for general coordination in dissemination. NIMH is currently examining its communications efforts.
The advantages were described of following a knowledge-dissemination conference with related grant or contract funding cycles.
The participants observed that collaboration on projects can be achieved by the two agencies without compromising their broad missions or processes. Dialogue can be triangular)among clinicians, researchers, and consumer)to design a collaborative project. Skill building and technical assistance may play a role in surmounting organizational cultural barriers to deriving mutually desirable design characteristics and a possible Request for Proposal. Defining the process is an important component, along with content, of defining a project.
- At the close of the discussion, Dr. Arons proposed a multifaceted course of action by which to pursue collaboration: (1) Provide support for continuing opportunities for regional exchanges, staff exchanges at meetings, and review of materials. (2) Convene a group of communications staff from both agencies to address enhancing interaction between websites and transfer between toll-free numbers, and also to explore the longer-term advisability and feasibility of either continuing discrete dissemination activities or combining them. (3) Work together on the Surgeon General's Report. (4) Explore the possibility of convening a joint NIMH-CMHS conference)a learning community conference)on a state-of-the-science topic of interest to both organizations, attended at minimum by policy makes, innovators, and implementers. The timing of the conference could be coordinated with a grant announcement. Possible topics are suicide prevention, youth transition to adulthood, and sexual predator treatment. (5) Investigate the design of a new nationwide activity as a successor to CSP or CRI. With a major new investment, it might be possible to effect the nationwide application of research.
- Mr. English raised methodological issues related to the definition of good science vis-a-vis replication problems. He identified the inevitability of the collaboration between CMHS and NIMH to be evolutionary. Synthesis of the available knowledge in such a way as can be used effectively by the clinician is an important element of the equation.
The passing of consumer advocate Clint Rossander was acknowledged by CMHS Consumer Affairs Specialist Paolo del Vecchio.
Proposal for a Consumer Subcommittee to the CMHS National Advisory Council. Following a presentation by Paolo del Vecchio and expressions of support by members of the Council and the public, the Council resolved unanimously to constitute a consumer subcommittee. This subcommittee will facilitate inclusion of the consumer voice in the mental health debate and will advise the CMHS National Advisory Council on consumer perspectives and priorities. Mr. Rogers suggested that the committee's ex-officio membership include representatives from the national mental health associations and the two technical assistance centers, and also that teleconferencing and the use of other interactive electronic media may elicit broader consumer input. The establishment of this subcommittee complies with an executive order to promote ongoing consumer involvement. A planning group, which plans to report back to the Council at its next meeting, will require about a year to complete the establishment of the subcommittee. CMHS staff will seek legal advice on language in the draft concept paper related to restrictions on grassroots lobbying.
Minutes. Members of the Council approved the minutes of the December 1977 meeting with minor corrections.
Recent Developments in CMHS Quality Initiatives. Ronald W. Mandersheid, Ph.D., Chief, Survey and Analysis Branch, CMHS. Dr. Mandersheid updated the Council on the quality development activities underway at CMHS. These activities relate to practice guidelines, outcome measurement, and report cards. The future of these activities)with a trend toward global, distal outcomes/person-centered outcomes)involves more consumer-driven data and less centralized Federal data; payment for (measurable) outcomes; population-based, not just service-based, measurements, which will be critical for early intervention; and virtual information systems with distributed information.
In the outcome area, the methodological standards paper will be finalized by the beginning of summer. The content standards group for children will look at population risk adjustments, interval adjustments, outcome principles, and outcome domains; the paper will be available in draft for comment around June 1. In the adult group, a survey of 1,800 community facilities has been completed; findings indicate that only 20 percent of the facilities have nationally based outcome systems for adults and children. This group is also working on a paper on person-centered outcomes. Groups will be organized to look at the outcome management standards. By the end of Fiscal Year 1998, grants in 41 states are to be funded to test features of the consumer-oriented report card. The preliminary results appear replicable. The state feasibility assessment has been completed, and an executive summary is available. The study found it feasible to develop comparable state indicators)sometimes with different populations, but on the same set of facilities. A technical assistance event was held on grantsmanship for the pilot stage that will involve 10 states.
The implications of the branch's ongoing work include the need to focus more on quality activities, especially a special initiative on the development and implementation of quality tools; the need for additional work on comparability, whereby work undertaken for report cards is not just service based but population based; and, with increased reliance on technology in therapy, standards of quality must be addressed. Members of the Council requested that they be provided with a diagram of the statistical process, and that they be updated on these issues on a regular basis.
Public Comment and Adjournment. Time was allocated for public comment; there being none, the meeting was adjourned.
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