CMHS National Advisory Council
Meeting Minutes
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
National Advisory Council
June 25-26, 2003
Washington, D.C.
Minutes
Open Session
The National Advisory Council of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Mental Health Services (CMHS) met at 8:30 a.m. on September 5, 2002, at the DoubleTree Hotel, Rockville, Maryland, to review grant applications.
Orientation. SAMHSA's William Gualtieri presented an ethics orientation that focused on impartiality and disclosure. Council members' questions should be directed to Ms. Kaufman. Following the presentation, Council members introduced themselves.
Approval of Minutes. Council members unanimously approved the minutes of the CMHS Advisory Council meeting of September 5, 2002.
Closed Session
The Council met in closed session at 9:30 a.m. to review grant applications.
Open Session
The Council reconvened in open session at 10:15 a.m.
Welcome and Opening Remarks. Ms. Hutchings welcomed meeting attendees and referred them to the written CMHS Director's Report for details of activities conducted since the previous Council meeting. She introduced SAMHSA's matrix of priority programs and principles, which underpins all agency decisions regarding investment of resources and staff. She noted that SAMHSA's vision is "a life in the community for everyone," and the mission is "building resilience and facilitating recovery."
Ms. Hutchings stated that the final report of the President's New Freedom Commission on Mental Health would call for transformation of the mental health system. Ms. Hutchings urged Council members to provide feedback on the process, noting that many new relationships must be forged with State and Federal mental health leaders. She announced that Jim Stone will join SAMHSA as Deputy Administrator; Beverly Watts Davis has taken up the reins as Director of the Center for Substance Abuse Prevention; and Kathryn Power will soon become CMHS Director. Ms. Hutchings introduced CMHS staff members, noting several promotions and new Branch Chiefs. She stated that a national recruitment process was conducted for all key positions.
CMHS has focused behind the scenes on personnel issues, budget and process streamlining, and improvements in customer relations. Larry Fricks has been appointed to fill the consumer seat on the Council and will chair the Council's Subcommittee on Consumer/Survivor Issues.
Under the Performance Partnership Grant (PPG) program, States will have more flexibility to spend block grant funds; in turn, they must demonstrate effectiveness in meeting their goals and account for public dollars. Fifty-three States have submitted data under the voluntary Uniform Reporting System that will help in developing good services and evaluating effectiveness. CMHS convened representatives from the data community and the State planning community at the second annual Joint Technical Systems Conference.
Consumers and family members had a strong voice in preparing the Mental Health Commission's recommendations. Through the Eliminating Barriers Initiative, CMHS currently works with eight states to develop and evaluate public education approaches to break down barriers to treatment and community participation for people with psychiatric disabilities. CMHS also is exploring a self-determination initiative to help people with mental illnesses and substance abuse disorders to directly control the services they receive.
Another component of the transformed mental health system is Science to Services, whereby people get the best care as quickly as possible, shortening the unacceptable lag time from research to practice, and implementing the National Registry of Effective Practices (NREP) for Mental Health Treatment Programs. A comprehensive web site lists effective models, which communities will be able to adopt and adapt http://modelprograms.samhsa.gov/pdfs/CSAPScienceReport.pdf
Ms. Hutchings stated that the Emergency Services and Disaster Relief Branch promotes readiness for crisis events. A recent conference featured technical assistance for an all-hazards approach that includes mental health and substance abuse authorities at the planing table. The Homeless Programs Branch is undertaking a $35 million Initiative to End Chronic Homelessness in 10 years that involves HUD, VA, and HHS. One hundred applications have been received for just 10 awards in the program designed to address problem gaps across primary care, housing, and behavioral health services. Preliminary data from the Special Programs Development Branch's Safe Schools/Healthy Students Initiative suggest that fewer incidents of violence and more violence prevention services and counseling have resulted from this program.
Discussion. Ms. Romero encouraged SAMHSA to integrate and implement cultural competence standards and the findings of the Surgeon General's report on disparities in its work to reflect the growing diversity among populations of color. Ms. Hutchings stated that CMHS plans to customize the standards for easier use in the field, that the Disaster Relief Branch staff has developed documentation for cultural competence in times of disaster, and that future work will focus on cultural competence. Ms. Hutchings suggested Council members provide information about their core interests and expertise to facilitate member participation in the process.
Dr. Beardslee expressed concern that service cuts will preclude uninsured children and parents from receiving adequate services and stated the need to confirm the basic commitment to insurance for all. He also stated that an essential component of a program to end homelessness is adequate subsidized housing. Ms. Hutchings noted the following: Congress will decide on parity; State mental health Commissioners have received technical assistance on managing in times of budget crises; CMHS is working with the Center for Medicare and Medicaid Services (CMS) on program reform; CMHS is examining matching grant mechanisms that may preclude assistance if States cannot afford the match; and requests for waivers will be considered on a case by case basis.
Budget Update. Mr. Searle stated that CMHS funding has doubled over the past 10 years, with major increases in recent years, but the amounts of money are small. Staff numbers have diminished, creating an ongoing management challenge. The Child Mental Health Services budget has risen to $98 million, the Prevention and Advocacy block grant to $34 million, and PATH to $43. The Block Grant is funded at $437 million, half of what CMHS would like to have. Programs of Regional and National Significance (PRNS) are funded at $244 million. From an initial budget in 1999 of $40 million, the School Violence Prevention budget is now $95 million, including the Safe Schools/Healthy Students initiative. The Targeted Capacity Expansion Program is funded at $50 million. Congressional earmarks account for approximately $10 million for 30 individual programs in States. More than 50 percent of available funds in the PRNS account are directed by Congress for specific programs. These include programs such as the Consumer Technical Assistance Centers, Community Action Grants, Jail Diversion, and HIV/AIDS programs. The FY03 budget is $856 million, about $25 million more than in FY02. The proposed FY04 budget was submitted in February 2003 to Congress, and Congressional subcommittees were considering the budget as the Council met. In the absence of a new budget, continuing resolutions allow agencies to pay salaries and run a few important ongoing programs. Ms. Hutchings explained that late budget approvals translate into late grant offerings and reviews. Mr. Searle noted that fewer FTEs are expected in FY04.
Discussion. Members discussed the President's Substance Abuse Initiative to give funding to States through SAMHSA/CSAT. Ms. Hutchings stated that no funds are earmarked for mental health, but the funds would be helpful in dealing with co-occurring disorders. She stated that CSAT, CSAP, and CMHS invest together in the Co-occurring State Incentive Grants (COSIGs). Ms. Romero and Dr. Beardslee concurred that prevention services and interagency collaboration are critical for both mental health and substance abuse. Dr. Beardslee asserted that partnerships that treat children in the context of their parents and bring families together are crucial; funding now goes to individuals. Ms. Hutchings stated that the Children's System of Care program enjoys broad governmental support and that CMHS is evaluating programs to show that the investments work. Ms. Romero urged removing service-delivery barriers that make a distinction between children and adults. Ms. Hutchings stated that HRSA and SAMHSA leadership have met to work on community health and behavioral health and substance abuse issues; most people want and receive services in primary health care settings.
Dr. Perry-White discussed the role of faith-based organizations vis-à-vis SAMHSA's cross-cutting principle of access to recovery. Ms. Hutchings recognized the contributions that religious organizations and other philanthropic and community organizations make in what otherwise might be a service vacuum. SAMHSA has sponsored technical assistance opportunities targeted towards faith- and community-based organizations on how to become successful grant applicants and how to meet accountability requirements.
Dr. Vergare supported the CMHS focus on early intervention, interplay between substance abuse and mental illnesses, and need for stable living environments to support services provided. He questioned what services are provided for elderly Americans. Ms. Hutchings noted that a $5 million annual grant program focuses on the mental health needs of older Americans and interfaces with primary care and that the SAMHSA working group on aging has developed an action plan. Ms. Romero supported the need to holistically address the needs of elderly individuals, many of whom are caregivers for their grandchildren or other family members. Ms. Hutchings noted that the CMHS Youth-in-Transition grant program links children's systems of care to the adult system. Dr. Bowers-Stephens recommended a focus on youth with developmental disabilities, who may be at risk of behavioral problems and contact with the criminal justice system, and who are not typically the target of evidence-based practices. Ms. Hutchings acknowledged that CMHS recognizes co-occurring issues and has funded the NASMHPD dialogue with State mental disability directors. Ms. Edelman raised the issue of stigma, and Ms. Hutchings asserted that the President's New Freedom Commission on Mental Health report would present new opportunities to raise the issue with the American public. Dr. Basit mentioned that CMHS has awarded $1 million to the University of Chicago to find ways to eliminate stigma. Ms. Hutchings noted that the Institute of Medicine (IOM) has published a study on health-related public information campaigns, and CMHS will investigate how to use that work vis-à-vis stigma and mental health.
Update on Report to Congress on Co-occurring Disorders and Council Discussion
Larry Rickards, Ph.D. Public Health Advisor, Homeless Programs Branch, Division of Service and Systems Improvement, SAMHSA, CMHS, stated that the Congressionally mandated report addresses specific questions about how treatment is delivered currently, gaps in services, and data on incidence of co-occurring disorders; how block grants are used in prevention efforts; and the status of evidence-based practices. The report defines co-occurring disorders as individuals who have at least one mental disorder, as well as an alcohol and/or drug disorder.
A matrix defines the locus of the services provided in relation to the severity of the problem. Separate groups receive services for substance abuse and for mental health. Others receive services from primary care, State hospitals, jails/prisons, and emergency rooms. Some do not receive services at all. Most individuals with co-occurring disorders receive treatment for one disorder, but rarely for both. Barriers to treatment include policy, funding, program, clinical, consumer, and family barriers.
Regarding the impact of Federal block grants, the report finds that States and communities are engaged in many positive activities. Regulatory and statutory requirements limit how block grant funds can be used, so "braided," instead of blended, funding often is used. The study offers descriptions of SAMHSA's prevention programs for children and youth and a discussion of evidence-based practices. SAMHSA's leadership in evidence-based practices related to co-occurring disorders includes activities such as NREP and the NASMHPD/NASADAD Joint Task Force on Co-occurring Disorders.
SAMHSA's 5-year blueprint for action calls for strategic planning with other Federal agencies to change the service systems. The goals of the process include accountability (ensuring that best practices, infrastructure, and direct service capacity are accompanied by useful and practical performance measures), capacity (continuing to identify and disseminate successful strategies for use of block grant funds to treat co-occurring disorders; using discretionary grants to help States develop, enhance, and phase in evidence-based practices; closing the gap between research and practice; developing the workforce; using prevention strategies), and effectiveness (planning a national summit).
SAMHSA submitted the report to Congress in November 2002 and continues to work on setting objectives and action steps and developing leadership. Current initiatives include COSIGs, a national cross-training and technical assistance contract to help States (and others) improve infrastructure and capacity, NREP, plans for a national summit on co-occurring disorders, and a Treatment Improvement Protocol and resource kits.
Discussion. Dr. Rickards stated that 38 states have applied for COSIGs; approximately 10 awards will be made. Ms. Hutchings explained that the designation of evidence-based practices is balanced with recognizing creativity sparked in the field. The National Institute of Mental Health (NIMH) has identified a number of evidence-based interventions (not programs), including integrated treatment, illness self-management, family psycho-education, medication treatment algorithms, and assertive community treatment; CMHS will produce toolkits on these interventions. Dr. Rickards noted that evidence-based practices must be transferable to communities. Ms. Romero urged CMHS to balance its focus on evidence-based practice with recognition and evaluation of "practice-based evidence," particularly in communities that have not been studied rigorously. Ms. Hutchings acknowledged this need.
Public Comment
Kathy Muscari, Consumer Organization Network and Technical Assistance Center, stated her hope for continued funding of consumer initiatives and commended the CMHS emphasis on evidence-based practices and practice-based evidence. She highlighted the problem of stigma and discrimination among mental health professionals and urged attention to the issue.
Jon Brock, Member, Subcommittee on Consumer/Survivor Issues, acknowledged Ms. Hutchings' support for the subcommittee and urged continuing Council support. He applauded the appointment of Larry Fricks to the Council. Mr. Brock noted that evidence-based practices are a way to reform psychiatric medicine from the top down and suggested partnerships with consumers, who work to reform the system at the grassroots level. He also urged attention to the development of consumer providers.
Update on President's New Freedom Commission on Mental Health and Council Discussion. Gail Hutchings, M.P.A, stated that, since President Jimmy Carter convened his Mental Health Commission 25 years ago, a legal framework and some protections have been established, but major issues have endured. President George W. Bush established the New Freedom Commission on Mental Health to study the Nation's mental health system and to recommend improvements. Ms. Hutchings described the diverse membership of the Commission and its consultants and how the Commission conducted its information gathering from experts and the public. (Web site: www.mentalhealthcommission.gov)
The Commission found the system to be opaque and in disarray, particularly with regard to services for children. Adults with severe mental illnesses have unacceptably high unemployment rates, in part, because disability benefits present disincentives for returning to work. Older adults with mental illnesses are not receiving care, and stigma issues abound. Although mental health services are meant to be comprehensive, in reality, many silos with overlapping connections exist, as do differences among States and between the State and local levels. The working conclusion is that quick-fix approaches no longer will work and that a fundamental transformation of the mental health system is needed. The Commission's vision embraces recovery and resilience, prevention of mental health disorders, and improved investment in the research for cures. The report describes six goals: (1) establish mental health as essential to overall health (an approach to replace the two-tiered system of physical and behavioral health); (2) provide consumer and family-driven care; (3) eliminate disparities and discrimination based on race and location in mental health care; (4) provide early mental health screening and treatment across the life span; (5) provide the best care science can discover (based on eliminating gaps between science and services and investing in research); and (6) capitalize on communications and information technology (such as electronic personal health records and increased telemedicine, with proper attention to privacy concerns).
The Commission report was in its final stages. The White House may charge one or more agencies with developing a Federal plan to address mental health. SAMHSA/CMHS will assume the leading role, in collaboration with other agencies. Subcommittee reports will be published as part of the record. CMHS will map its resources and activities to the six goals. Although prevention is not a priority of the Commission, CMHS will continue its prevention investments. Other activities that do not map with the goals will be examined closely for the purpose of reassigning resources.
Discussion. In response to Council member questions, Ms. Hutchings noted the following: the report discusses private-sector roles and responsibilities; prevention will reduce the numbers of people affected by mental illnesses; prevention also relates to the goal of early assessment and intervention; and the report will identify the multiple Federal agencies charged with mental health policy. At the September meeting, members will advise CMHS about its future course.
Council Charter. Members discussed provisions of the National Advisory Council's charter. The Council is charged with providing counsel and recommendations to the director of CMHS. Members are selected on the basis of specific, diverse backgrounds. Two meetings per year are held, and public participation is encouraged. Four primary functions of the Council are to: (1) advise, consult, and make policy recommendations; (2) review applications and recommend approvals; (3) collect and disseminate information; and (4) appoint subcommittees and convene workshops and conferences. The first and second functions are mandated. Dr. Kelly suggested holding a future discussion on a mutual vision for the Council.
Dr. Beardslee discussed the advantages of the Joint SAMHSA Council meetings, including learning about and discussing critical matters of interest to both mental health and substance abuse. He noted that the questions people addressed in substance abuse are almost identical to those addressed in mental health and that knowing what other people are doing is important. Ms. Romero suggested there is value in considering together how to make systems more useful to the customer. She encouraged the holding of at least one joint meeting annually to make the Commission on Mental Health recommendations operational. Dr. White-Perry noted the benefits of networking among the members of the six SAMHSA councils. Dr. Basit pointed out that the meeting serves to reduce fragmentation. Dr. Beardslee suggested that members have an informal meal together.
Veteran Council members offered their observations of the Council's workings. Dr. Beardslee sees the Council's role as supporting CMHS staff in doing their jobs. He views CMHS's civil servants as an extraordinary resource. He encouraged members to use their expertise to contribute to highly successful, measurable public programs and public policy; to advocate for people with mental illnesses and for consumer/survivor groups; and to be mindful of disparities around race, class, and ethnicity. Ms. Romero concurred, adding that she sees the role of the Council as enabling SAMHSA staff to do the best job possible for all impacted communities. Linking SAMHSA with communities gives them access to resources and information without having to develop them. She sees members as ambassadors in communities, disseminating knowledge and literature. She stated that benefits accrue from member views of different communities and asserted the importance of sharing news of SAMHSA's work. Dr. White-Perry agreed, noting the importance of listening to individual testimonies and of networking within and outside the mental health community. Dr. Basit expressed the value of the diversity of backgrounds among Council members.
New members discussed their particular interests. Dr. Bowers-Stephens hopes to help bridge the gap between local governments and national policy. Dr. Vergare hopes to help develop programs within SAMHSA. Dr. Kelly suggested that each member tackle a specific aspect of the Commission's report. Ms. Hutchings discussed the need for balance and selectivity among activities.
Update on Subcommittee on Consumer/Survivor Issues. Paolo del Vecchio, Associate Director for Consumer Affairs, CMHS, discussed the Subcommittee's organization and work. In 1998, the Council adopted a resolution to establish the Subcommittee. A planning group, comprised of national consumer and family organizations, helped to design the overall mission, purpose, structure, and potential activities. The Subcommittee convened for the first time in September 2000 to inform the Council on specific needs, issues, and concerns from the perspective of mental health consumers. Membership of the Subcommittee is geographically, culturally, racially, and ethnically diverse. Mr. del Vecchio stated that Council members would be asked for guidance to fill several vacancies in the near term.
Subcommittee meetings precede Council meetings, and recommendations are reported out to Council for consideration. To date, the Subcommittee has issued 25 to 30 recommendations, and virtually all were passed by the Council. Among them were "people first" terminology, inclusion of "discrimination" when discussing stigma-related issues, consumer involvement in research development activities, improved data collection on civil commitment, and continued grant support for self-help technical assistance centers. Other recommendations included appointment of a consumer to the President's New Freedom Commission on Mental Health and Subcommittee involvement in the selection process for the CMHS director.
Jon Brock, Member, Subcommittee on Consumer/Survivor Issues, acknowledged the contributions of Mr. del Vecchio, the first Federal consumer advocate to be hired by CMHS. He asserted that the consumer/survivor movement offers much to public mental health in terms of system reform and expressed the Subcommittee's anticipation for working with the Council. Mr. Brock summarized the proceedings of the most recent Subcommittee meeting. Members discussed the use of language in discussions on discrimination and stigma, the importance of SAMHSA/CMHS exploring models of self-determination, the expanded use of consumer providers/peer specialists, and the ways that CMHS is addressing State budget cuts. The Subcommittee linked its agenda for the coming year with the six Commission goals. Dan Fisher, M.D., a consumer/survivor participant on the Commission, reported on the Commission's work. The Subcommittee learned about the CMHS work to inform consumers about HIPAA and reviewed the needs of consumers with co-occurring physical disorders. Members developed a proposal related to cross-disability issues and discussed the CMHS action plan on seclusion and restraint. Capt. John Tuskan reported on the Faith-based and Community Initiative and on the dialogue between consumers and members of faith-based and community organizations.
The Council unanimously passed, as amended, the following subcommittee recommendation: "In recognition of the importance of meaningfully involving Americans with various disabilities and to promote cross-disability (physical, developmental, emotional, and psychological) collaboration and attention to cross-disability issues, SAMHSA/CMHS is encouraged to conduct outreach to such individuals and include their appointment to the SAMHSA/CMHS National Advisory Council." Future members Drs. Vergare and Bowers-Stephens stated they would have voted in support of the recommendation.
The Council passed (with one abstention) the following Subcommittee recommendation: "In accordance with the current Self-Help Technical Assistance Center Request for Applications (RFA), SAMHSA/CMHS is strongly encouraged to continue-past the RFA's 1-year commitment-to fund and support the national mental health consumer technical assistance conference entitled, "Alternatives," and to retain its respected, time-honored name, and to maintain that the event is consumer planned and managed." In discussion, Ms. Hutchings reaffirmed the CMHS commitment to hold a national Alternatives conference in 2004.
Budget Update (cont.). Mr. Searle reported on updated FY04 preliminary House budget figures.
Public Comment
Yvonne Smith, Recovery 2000, Board of NAMI DC, and Member, National Mental Health Association, commented on the importance of the Alternatives conference and of retaining its name. She discussed the effects of stigma and the importance of looking holistically at linkages among HIV, substance abuse, mental illness, and some physical illnesses.
Jon Brock asserted that the key problem in mental health policy is a lack of the means for ongoing, effective reform. He submitted a paper to the Council on the subject. Ms. Hutchings noted that Larry Fricks has initiated a program for peer specialists in Georgia that has achieved Medicaid reimbursement status. CMHS will explore with him the possibility of providing technical assistance to other localities.
Discussion. Mr. Brock explained that traditional major mental health reforms typically have revolved around informed, passionate individuals who then pass from the scene. He asserted that one way to sustain ongoing minor reform is to develop a cadre of mental health providers who provide niche services and programs-providers who have experienced traditional mental health treatment and who have recovered. Ms. Romero spoke from her perspective as a family member, urging Council members to remember that consumers who offer public comment speak for others whose voices are not typically heard.
The meeting recessed at 4:15 p.m. and reconvened at 8:30 a.m. the following day.
Budget Update (cont.). Mr. Searle reported that the House and Senate committees would meet in conference, where differences between the bills will be reconciled.
Administrator's Update. Frank Sullivan, Ph.D., Director of Organizational Effectiveness, SAMHSA, acknowledged Ms. Hutchings' contributions as Acting Director and presented an overview of SAMHSA's management activities. SAMHSA's performance system is organized around purpose and accountability, reengineering work processes with an emphasis on the discretionary grant portfolio, and attention to future leadership and the management cadre-all based on SAMHSA's vision and mission. Each executive and agency head in the department has a specific, measurable performance contract that is central to performance appraisals. Among others, Administrator Charles Curie's management objectives relate to improving SAMHSA's publications development, approval, and clearance processes and to reducing the time it takes to develop and clear RFAs. Multifunctional SAMHSA teams are working on elements and activities to resolve both issues. Standardized language and one-page announcements of funding availability will foster a common understanding of SAMHSA's purchasing goals. The documents are expected to yield savings in staff time and energy and to improve the clarity of communication with the field, the public, Congress, and the department.
SAMHSA also is redesigning its grant review process; an outside firm would work under the direction of SAMHSA contract managers to handle large volumes of applications. To preserve the integrity of the peer review system, the contractor will work for a Federal contract manager with experience in the area; SAMHSA staff members will be present at every meeting or conference call; government project officers will approve all reviewers; and SAMHSA will recommend reviewers. Dr. Beardslee emphasized that the integrity of the review and SAMHSA control of the process are important. Dr. Sullivan said SAMHSA believes that clearer announcements will mean better communication with applicants. In turn, better-informed applicants will write better applications. More careful and detailed review also will produce better applications. This shift will free staff time to focus more on the award, assistance to grantees as they encounter problems, and the synthesis of findings and outcomes. The experiences of the Departments of Justice and Education are informing this shift.
Dr. Sullivan stated that SAMHSA is starting to work on the redesign and to put it in place in high-volume situations, such as using telephone conference calls. SAMHSA already has extensive logistics contract support for the review effort but is looking toward a think-tank, program-knowledge-based organization. Dr. Vergare suggested that an unclear announcement process might produce excessive applications. Dr. Sullivan responded by saying that the number of applications is not always out of balance but that it is necessary to find the right balance and to have a flexible personnel plan in place to handle the volume of applications submitted. Standing announcements will serve to ease logjams. Dr. Basit noted the need for providing guidance to reviewers and for matching reviewer skills and knowledge to the application pool. Dr. Sullivan stated that a structured reviewer comment protocol is being pilot tested.
Dr. Beardslee asserted that one reason for the large number of applications is desperation in the face of service funding cuts, highlighting the need to advocate for adequate support for high-quality programs. In the CMHS focus on innovative and high-quality practices, the body of expertise resides in multiple places, which must be reflected in the review process by rewarding creativity, the capacity to take programs to scale, and cultural competence. It is important to supply feedback to applicants, so they can reapply based on comments of reviewers. Dr. Sullivan expects opportunities to link with existing technical assistance resources. Ms. Hutchings explained that the outsourcing mechanism would be a SAMHSA contract.
Led by Mr. Searle, a SAMHSA work group has been examining the development of better agency managers. Plans are underway to provide managerial assessment and training in FY04. The President's management agenda includes strategic management of human capital; improved financial performance, financial systems, and timeliness and accuracy of data, including expanded access to electronic government (grants.gov is one source of information on HHS funds); budget and performance integration (matching what we ask for with demonstration of program effectiveness); and competitive sourcing (regarding the review process at SAMHSA, as well as information technology activities in FY03, and, perhaps in FY04, changes to methodology used for studies). Competitive sourcing will pose challenges for SAMHSA.
Discussion. Dr. Kelly observed that SAMHSA is transforming itself. Dr. Sullivan stated that the agency is refocusing on its core issues, noting that Council members can contribute by raising questions about these issues. Ms. Romero questioned the extent to which staff morale is considered in the midst of change. Dr. Sullivan responded that the approach rests on clear communication about managing the mission. He acknowledged that outsourcing threatens the notion of having a government job as long as one wants. The Secretary's commitment is for everyone in the department to have a job, but people are concerned about the future.
Dr. Beardslee urged obtaining data on what gets better and what gets worse in the transformation, suggesting that the ability to attract talent for long-term government service may be jeopardized. He commented on the growing incidence of mental health problems, particularly anxiety, depression, and PTSD, and the mental health field's transformation in terms of good (broadly defined) evidence-based treatment. He urged support for CMHS to ensure that staff can get the work done. Dr. Vergare suggested that there is a need to compile emerging patterns in populations and to apply them to government agencies, some of which may need to grow. Dr. Perry-White applauded CMHS/SAMHSA strategic planning efforts. Dr. Kelly suggested that Council members identify their natural constituencies to help with specific issues.
Science to Services Initiative Overview. Kevin Hennessy, Ph.D., Public Health Advisor, SAMHSA, stated that most people wait 17 years to access science's most helpful substance abuse and mental health interventions. The Science to Services Initiative is a systematic effort to accelerate the process of identifying and translating effective or evidence-based mental health and substance abuse treatment and preventive interventions into widespread practice, and, in turn, for practical experience to inform the research. The IOM defines evidence-based practice as the integration of research evidence with clinical expertise and patient values. The initiative involves collaboration with the National Institutes of Health, the Agency for Healthcare Research and Quality, and the private sector. It is based on the IOM's "Crossing the Quality Chasm;" the Surgeon General's mental health report; the NIMH reports, "Bridging Science and Services" and "Translating Behavioral Science into Action;" and the forthcoming report of the President's New Freedom Commission on Mental Health.
Science to Services is a quality-improvement initiative that has three phases: research and development (R&D), translation and dissemination, and implementation and monitoring. R&D activities include identifying research gaps (e.g., at information-gathering meetings), setting the research agenda (e.g., RFAs submitted by applicants, program announcements that identify priority research areas), and conducting research (e.g., NIMH-funded research at CMHS-funded sites). Translation and dissemination activities include SAMHSA-wide expansion of NREP (to include all priority programs on the management matrix), solicitation of NREP candidates from NIH, and NREP involvement in disseminating current practices, identifying gaps, and conducting the research to fill in the gaps. Ms. Hutchings added that a core set of review criteria and descriptors will be applied to mental health treatment within months (see www.modelprograms.samhsa.gov). Dr. Hennessy stated that NREP identifies programs targeted at specific populations. A number of substance abuse prevention programs are mental health treatment programs as well.
Dr. Hennessy explained that tensions exist between researcher and practitioner communities about levels of evidence but that NREP walks that fine line well. Pathways to NREP include literature in various areas based on outcomes in scientific studies and also program data submissions for NREP review. More than 40 programs have model or effective status (plus a group of promising practices), and scientific rigor is "fairly high."
Dr. Hennessy asserted that the NREP process is building the next generation of evidence-based practices. His vision is for SAMHSA to provide guidance to programs that submit their credentials to enable them to achieve higher levels of effectiveness. Ms. Romero suggested that links be made now with the academic community. Mr. Hennessy noted that much work remains for providers to implement evidence-based programs; a good part of the work is a matter of communication, and the Federal government has a key role. Dr. Vergare urged consideration of how to provide incentives to professional educational programs to incorporate evidence-based practice. Ms. Romero suggested enlisting accreditation bodies in the process. Dr. Kelly suggested targeting professional training organizations and making presentations at their annual meetings.
Returning to his presentation, Dr. Hennessy stated that other translation and dissemination activities include developing materials and transfer strategies (e.g., joint NIMH/CMHS services/ research statements) and promoting dissemination systems (e.g., Centers for Application of Prevention Technology and technical assistance centers). In the implementation and monitoring phase, activities include supporting State/community infrastructure development, promoting performance monitoring systems (e.g., Performance Partnership Grants, Mental Health Statistics Improvement Program [MHSIP]), and assessing the impacts of fidelity and adaptation on outcomes (e.g., local best practice support grants, training and technical assistance).
It will be important to engage other partners in the cycle, including Federal partners, States, and communities, to advance model programs. Also important are the goals to enhance involvement of consumers and providers in helping to identify research gaps and programs in which to invest, and to train providers in the application of evidence-based programs.
Discussion. Dr. Hennessy stated that he would communicate with Ron Manderscheid about possible synergies between NREP and MHSIP in State reporting. Ms. Hutchings cautioned against mandating such reporting because of the potential for misuse of the data. CMHS will take the approach of offering technical assistance and then asking for data. Dr. Hennessy remarked that the "carrot" in science to services is incentives.
Dr. Beardslee noted the importance of recognizing the level of resource commitment necessary to bring about meaningful change to evidence-based practices. Dr. Hennessy stated that constrained budgets make evidence-based practices more germane to States that want to invest in what is most effective. Dr. Beardslee observed that States vary greatly, citing Medicaid guidelines as an example, and stated that it would be helpful to know about success stories and real costs of leadership and training. Ms. Hutchings responded, saying that CMHS has developed several resources to capture that information. Dr. Beardslee noted that Vermont and Ohio might have interesting results to report. Dr. Vergare remarked that mental health care is moving increasingly beyond the traditional public arena and into the private arena. Interventions are occurring earlier, and less will be under the control of Commissioners and more will fall under broader health care delivery. It is necessary to address the systems where people go for their care. Ms. Romero pointed out that enlisting ethnic communities in the process requires a one-on-one approach. She noted the importance of identifying community-based organizations that are doing the work with no direction or science and suggested it would be better if they were to do it with knowledge and expertise.
Public Comment
Anika Keens Douglas, Contractor for the NIMH Consistency Outreach and Education Program, questioned whether consideration has been given to cross-reporting mechanisms, given that the reporting burden diminishes available resources. A cross-reporting mechanism would build on what programs are doing and would fulfill reporting requirements, resulting in better tracking, continuous improvement, and sustainability.
Next Council Meeting: September 4-5, 2003. Possible agenda items include: the new Director's vision for CMHS vis-à-vis the Commission on Mental Health report, data and outcome measures, the post-grant review process, discussion of the CMHS National Advisory Council vision, older persons projects, a report on the Annapolis project on the workforce, faith-based initiatives, RFA structure, a detailed budget overview, the MHSIP relationship with NREP, and a shared meal among Council members.
Adjournment. The meeting adjourned at 11:25 a.m.
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