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CMHS National Advisory Council
Meeting Minutes
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
National Advisory Council
June 16-17, 2004
Rockville, Maryland
Minutes
Open Session
The National Advisory Council of the Substance Abuse and Mental Health Services
Administration’s (SAMHSA) Center for Mental Health Services (CMHS) convened
in open session on June 16, 2003, at 9:00 a.m. at the Hotel Washington, Washington,
D.C. CMHS Director A. Kathryn Power, M.Ed., presided. Council members present
included
Abdul Basit, Ph.D., William R. Beardslee, M.D., Larry Fricks, Timothy A. Kelly,
Ph.D.,
Sally L. Satel, M.D., Cheryll Bowers-Stephens, M.D., M.B.A., Michael J. Vergare,
M.D., and Stephanie White-Perry, M.D. Also present were ex officio members William
W. Van Stone, M.D., and David Shore, M.D., CMHS Deputy Director Ted Searle,
M.B.A., and Council Executive Secretary Dale Kaufman.
Welcome and Opening Remarks
Ms. Power welcomed attendees, noting that the meeting’s agenda would focus on
transformation of the mental health system, and encouraged Council members’
input.
Approval of Minutes. Council members unanimously approved
the minutes of the CMHS Advisory Council meeting of September 4-5, 2003.
CMHS Director’s Report and Remarks. Ms. Power referred attendees
to the written CMHS Director’s Report, which describes the prodigious work ongoing
at CMHS. Ms. Power stated that SAMHSA’s fiscal 2005 budget request is $3.5 billion,
of which $912.5 million is budgeted for CMHS. Ms. Power chairs the Matrix Workgroup
for Seclusion and Restraint, with Paolo del Vecchio as lead staff; chairs the
Mental Health Systems Transformation Workgroup; and co-chairs the Co-occurring
Matrix Workgroup with CSAP Director Dr. Westley Clark. Ms. Power introduced
Diane Abbate, new director of the Office of Program Analysis and Coordination,
and members of the Council and audience introduced themselves.
Ms. Power highlighted the responsibilities of selected CMHS offices and introduced
lead staff. The Office of Program Analysis and Coordination oversees funding
announcements and GPRA activities. Associate Director for Medical Affairs Mel
Haas has responsibility for HIV/AIDS treatment adherence and health outcome
studies. Associate Director for Organization and Financing Jeff Buck’s staff
produce materials on mental health statistics and demographics. Paolo del Vecchio
is Associate Administrator, Office of Consumer Affairs, which addresses consumer
concerns and issues. Anne Mathews-Younes directs the Division of Prevention,
Traumatic Stress, and Special Programs, which conducts prevention activities
targeting issues from school violence to disaster preparedness. Neal Brown serves
as Acting Director of the Division of Service and Systems Improvement, which
is working to strengthen systems for delivering mental health services. This
division includes Child and Adolescent and Family Services Branch and Homeless
Branch. Joyce Berry directs the Division of State and Community Systems Development,
which works with the State mental health block grant program, technical assistance,
and surveys and analysis.
Discussion. Dr. Kelly requested that CMHS send a
copy of the briefing book to Council members a week before the meetings.
Update on Mental Health Transformation and the National Advisory Council’s
Role.
Ms. Power briefed Council members on how transformation fits with SAMHSA’s other
initiatives. The Center for Substance Abuse Treatment’s (CSAT) Access to Recovery
(ATR) program, a FY 04-05 voucher initiative ($100 million in FY04), offers
up to $15 million for States to expand their substance abuse treatment capacity.
This program is a “redwood,” (that is, a major program) according to SAMHSA
Administrator Charles Curie, and a majority of States have applied for funds.
The Strategic Prevention Framework (SPF), a redwood for the Center for Substance
Abuse Prevention (CSAP), encourages States to combine and leverage their prevention
activities according to best prevention theory. SPF promotes viewing mental
health promotion as part of wellness and mental illness prevention. CMHS will
work with CSAP on SPF to ensure that mental health prevention is an important
component. Together, CSAT and CMHS continue to develop capacity within systems
to strengthen and integrate treatment for co-occurring disorders with grant
programs, contracts, policy academies, and the technical assistance Center of
Excellence for Co-occurring Disorders. For FY04 and FY05, budget priorities
will reflect these initiatives. In addition, seclusion and restraint, consumer
network, Systems of Care, and other grant programs will continue to support
SAMHSA/CMHS matrix priority areas.
Mental health systems transformation, CMHS’s top priority, focuses CMHS’s work
to ensure that mental health services and supports actively facilitate recovery
and build resilience to face life’s challenges. Based on the New Freedom Commission’s
recommendations, a literature review, and focused conversations, CMHS is developing
a structure for transformation. Transformation relates to new values, attitudes,
and beliefs, and how they are expressed in the behavior of people and institutions.
Readiness to change and willingness to risk are important to the pace, scope,
and character of transformation; it is important at all levels of governments
to overcome natural aversion to change. Ms. Power acknowledged the threat and
uncertainty associated with change.
Ms. Power described the steps in her framework for transformation: creating
a broad inventory of activities, capabilities, and resources; conducting strategic
assessments to determine whether activities are aligned with the vision; making
investments of people, resources, and political capital, and engaging constituencies
in change; beginning the transformation, while at the same time recording it;
and modeling transformation to encourage implementation elsewhere.
CMHS is building a vocabulary and facilitation skills to be helpful as States
and other entities begin the process of transformation.
SAMHSA’s transformation workgroup reviewed reports of the Commission and its
subcommittees, as well as the report of the 1975 Carter Commission on mental
health, as the starting point to define activities necessary to initiate mental
health transformation. SAMHSA invited agencies mentioned in the New Freedom
Commission report to form a Federal Partners Group; 18 agencies compiled inventories
of their activities related to each goal. These inventories were consolidated
into a Federal Action Agenda, which is being finalized. CMHS has initiated a
strategic plan to build its own transformation agenda. SAMHSA’s FY05 budget
includes $44 million for transformation efforts, including State mental health
transformation grants.
The Federal Partners have agreed on the importance of mental health, as reflected
in the Federal Action Agenda and based on the conviction that mental illnesses
are treatable and recovery should be the expectation. The Agenda identifies
first practical steps at the Federal level and sets out realistic priorities
for the first year of a five-year arc of transformation. Mr. Curie is inviting
high-level officials to join a Federal Executive Steering Committee to embrace
the work of the Federal Action Agenda and to monitor progress through FY05.
Discussion. Dr. Kelly suggested constituting a subcommittee
on transformation that can help assess and evaluate CMHS/SAMHSA actions and
allocating more time for Council discussions.
Federal Partners and Mental Health Transformation. Representatives
of several of SAMHSA’s Federal partner agencies in mental health transformation
described their activities.
National Institute of Mental Health. Junius Gonzales, M.D., Chief,
Services Research and Clinical Epidemiology Branch, National Institutes of Health,
Department of Health and Human Services (DHHS), presented an overview
of NIMH’s transformation activities from a services research perspective. Services
implementation includes evidence-based interventions, as well as the interaction
between evidence-based practices and the environment, which involves issues
of access, engagement, organization, financing, and stigma.
Although NIMH and CMHS share goals, they have different specific charges. One
NIMH mission is to achieve scientific rigor and relevance in real time, a difficult
challenge when scientists partner with real-world settings. Scientific issues
of interest include ecological rationality and validity, and balancing innovation
with scientific rigor. NIMH’s two integrative scientific directions are dissemination
and implementation research, and disablement and community reintegration. NIMH
has undertaken to improve its capacity to conduct dissemination and implementation
research with mechanisms to develop research infrastructure in the real world.
The Institute has also implemented a time-sensitive opportunities mechanism
and is building capacity in the States with a series of regional dialogues on
creating science and service networks, sponsored by CMHS and the National Association
of State Mental Health Program Directors (NASHMPD).
Examples of NIMH’s partnership activities for transformation include a program
announcement with CMHS that incorporates Systems of Care sites. In March 2004
a technical assistance workshop hosted multi-stakeholders, including researchers,
community leaders, consumers, providers, and family members. NIMH and CMHS also
have provided grants to nine States to help them enhance their science-to-service
capacity by creating a sustainable planning process. A follow-up RFA aims to
provide planning grants to a second cohort of States and to provide research
funds for developmental work for States ready to move to that level.
Administration for Children and Families. Martin Dannenfelser,
Deputy Assistant Secretary for Policy and External Affairs, Administration for
Children and Families (ACF), Department of Health and Human Services (DHHS).
The two major programs within ACF’s $47 billion budget are Temporary Assistance
to Needy Families (TANF) and Head Start. Most ACF programs provide grants to
States. Because mental health is seen as essential to overall health, mental
health permeates the agency’s programs. TANF’s caseload has dropped nearly 60
percent, leaving mostly people unable to leave welfare to go to work. Many of
these people have mental health or other disabilities or substance abuse problems.
ACF works with States to engage people individually and to develop personalized
treatment plans.
Beyond its focus on early literacy, Head Start deals with families’ overall
health and well-being, engaging in outreach and providing mental health services.
The Administration for Developmental Disabilities works with advocacy groups
at the State level and with colleges and universities, providing grants to help
individuals and families. Within the Refugee Resettlement Office, mental health
is an important focus, for example in the Unaccompanied Minors and Trafficking
in Human Persons Programs, and ACF has mounted an intensive public awareness
campaign to alert the public on how to identify victims. The President has requested
increased funds for the Safe and Stable Families Program for States designed
to help heal families broken by substance abuse or mental health problems and
to promote family reunification. Together with State representatives, ACF conducts
rigorous follow-up on child welfare services and works with States to improve
their performance, and conducts a broad array of youth programs. Many ACF services
overlap with SAMHSA, a key partner in designing program evaluations.
Department of Veterans Affairs. Mark Shelhorse, M.D., Acting Chief
Consultant, Mental Health Strategic Health Care Group, Veterans Health Administration
(VHA), Department of Veterans Affairs (VA), stated that VHA has
taken a proactive approach to implement the New Freedom Commission’s goals.
VHA has created a Mental Health Action Agenda Steering Committee and a Mental
Health Strategic Planning Group. Because the VA provides diverse services at
its many locations, individualized plans must be developed. VA will need to
coordinate with governors in developing their State mental health plans and
to determine how to partner with the States and the private sector to use resources
best. VHA is looking for best practices, reviewing the literature, and talking
with veterans on a recovery orientation. The goal is to have veteran- and family-centered
care programs at all VA medical centers by FY05’s end.
The VA recognizes the need to involve families more. Dr. Shelhorse stated that
the VA endorses collaborative care; no matter where a person enters care, a
mental health assessment should be part of the work-up. About 20-30 percent
of veterans have mental health problems that need to be identified and treated.
The VA wants to develop a knowledge management system that identifies best practices
and produces changes in provider practices. A training program on cultural competence,
stigma, and the nature of mental illnesses will be incorporated into a workforce
development plan. The VA must develop a mental health research strategic plan.
The department plans to participate in the Federal Action Agenda. Ms. Power
noted that the VA has asked CMHS to join its strategic planning committee.
Department of Labor. Michael Reardon, Employment Supports Policy Team, Office
of Disability Employment Policy (ODEP), Department of Labor, stated that approximately
35 percent of people with disabilities are employed full-time (or close), but
the percentage of persons with psychiatric disability is much lower. Despite
passage of the Americans with Disabilities Act in 1990, the percentages of employed/disabled
persons have not risen greatly. Labor seeks to address this problem by accessing
generic employment and related services, such as personal assistance and assistive
technology services. The Department of Labor has 3,000 local workforce investment
boards and one-stop local offices, for which the department is trying to eliminate
disincentives and other barriers to serving people with disabilities, including
psychiatric disabilities.
An ODEP workgroup represents six agencies and 15 offices. Its active subcommittees
focus on youth, incarcerated persons, data collection, and promising practices.
The group’s action plan, to be finalized in July 2004, includes developing an
employer initiative to increase recruitment, employment, and retention of persons
with psychiatric disabilities (series of focus groups of employers); developing
and disseminating a fact sheet on workplace accommodations for persons with
psychiatric disabilities (awaiting clearance); compiling and analyzing Labor’s
existing grant data on employment of persons with psychiatric disabilities;
tracking employment status of people with psychiatric disabilities; promoting
transition from school to post-secondary opportunities for youth with severe
emotional disturbances, on a person-by-person basis; promoting the use of customized
employment strategies for persons with psychiatric disabilities (e.g., self-employment,
microenterprise, entrepreneurship); and exploring opportunities in the workforce
development system to better assist ex-offenders with psychiatric disabilities
to obtain employment and reintegrate into communities. Employment is a viable
treatment option for people with psychiatric disabilities.
Discussion. Dr. Basit stated that a SAMHSA-sponsored
grant found that the most common problems of Asian youth in the U.S. were intergenerational
conflict and depression and anxiety; least common were drug addiction and violence,
a ranking that is largely reversed for mainstream youth. Mr. Dannenfelser responded
that ACF funds some prevention grants that use a positive youth development
model to promote connection to families, schools, and communities. Other strategies
include stressing avoiding risky behaviors and incentives for States to place
older children in adoptive homes. Dr. Basit volunteered to participate in a
cultural competence program. Dr. Shelhorse suggested collaboration in developing
a single cultural competence program and sharing information among agencies.
Dr. Vergare expressed concern that insurers are deflecting care, hoping that
symptoms will abate or that the delay will force people back into public agencies.
He questioned how Institutes might help to bring forward evidence-based practices
to force more deliberate and faster transformation towards ensuring that people
access the right kind of care at the right time before they develop “metastases”
of their problems. Dr. Gonzales responded that NIMH is focusing on prevention,
emphasizing community mobilization and encouraging participatory models of research.
Increased community demand for services will influence decision makers at the
purchasing or insuring levels. He noted that Ken Wells has revamped UCLA’s research
center’s mechanism to encourage senior researchers to develop a network to link
research to more stakeholders.
Dr. Shelhorse stated that the VA is working on the challenge of how to make
time in a patient visit for primary care providers to do generic assessments
of mental health.
Dr. Satel questioned how NIMH’s agenda differs from CMHS’s agenda; Dr. Gonzales
explained that SAMHSA does not do research, but by contributing resources it
becomes easier to take advantage of economies of scale, learning, and knowledge.
Dr. Satel urged rigor in the research. She suggested articulating a goal of
optimal functioning, rather than recovery, and commented that disability policy
is rife with disincentives for people to go to work. Dr. Shelhorse concurred,
noting that data collection is a first step in prompting legislative change.
Mr. Fricks expressed his appreciation of the Commission’s view on recovery.
He noted that the Carter Commission report called for transformation; yet little
has changed in the intervening 25 years. The difference today is that the New
Freedom Commission recognized the need to focus on recovery. Mr. Fricks stated
that in Georgia, the consumer movement votes employment as a top priority. Eight-five
percent of people with mental illnesses are unemployed, the largest group of
people with a disability who are unemployed. Considerable material on this subject
exists. Mr. Reardon stated that the Department of Labor foresees holding listening
sessions with consumers. Consumers currently access one-stops for resume consultation
and job search, but one-stops also can finance potential microenterprise ventures
through training funds and intensive services. Typically, however, one-stops
focus on easy cases in order to boost their success rate; Labor has been working
on exemptions for people with more complex issues. Ms. Randee Chafkin suggested
contacting Doug Crandall, executive director of the customized employment grant,
which is focusing on microenterprise for people with significant disabilities.
Labor plans to work more intensively with the Small Business Administration
on this issue. Labor and HUD have funded five grants focused on employment for
people with psychiatric disabilities and who are chronically homeless. Mr. Dannenfelser
explained that DHHS’s Assets for Independence grant program provides up to $1
million to nonprofits to help individuals establish individual development accounts.
United Way typically participates, and programs exist for prisoners anticipating
release into the community. Applications on behalf of people with mental illnesses
or other disabilities would be welcomed.
Dr. Perry expressed excitement about the commitment to recovery and queried
the role of co-occurring disorders in transformation. Dr. Gonzales stated that
co-occurring disorders is a priority at NIMH, National Institute of Alcohol
Abuse and Alcoholism (NIAAA), National Institute of Drug Abuse (NIDA), and SAMHSA.
An upcoming services research conference, with record-breaking pre-registration,
will cover substance abuse and mental and physical health; the three Institutes
will issue a program announcement on co-occurring disorders; and the Science
to Services Workgroup is considering options. Dr. Shelhorse asserted that co-occurring
mental health disorders is a big issue at the VA. Education is important to
ensure that providers address medical and mental health issues as a spectrum
of care. The VA is debating the issue of how and where to treat geriatric patients
with mental health issues.
Dr. Beardslee pointed out that it takes between 7 and 15 years for physicians
to adapt evidence-based practices widely into their practices after the evidence
is established. He concurred that work is crucial to recovery; studies show
that for adolescents, the capacity to get work done is the single best predictor
of success in adulthood. A focus on supporting parents and getting treatment
for their depression can make them more effective parents, and parenting has
multigenerational impacts. Head Start’s data show that half of mothers of children
aged zero to three are depressed on entering the program. Dr. Beardslee urged
consideration of families as well as individuals.
Dr. Kelly concurred that jobs and meaningful employment are the
single best measures for treatment programs, and noted the increasing importance
of clinical outcome measures.
Dr. Gonzales explained that NIMH recommends use of standardized outcome and
assessment measures. He encouraged stakeholders to work on a template for mental
health, and urged attention to the relative lack of use of technology in both
public and private mental health care.
Dr. Bowers-Stephens stated that in Louisiana, access to services is a barrier
to recovery and resilience. A TANF exclusion, ineligibility for Medicaid, and
State focus on severe mental illness make access to mental health services unavailable
to mothers who are depressed. She asserted that parity for individuals with
mental health problems in access to services is key to a transformed mental
health system. Mr. Dannenfelser responded that a legislative fix would be required,
an unlikely occurrence this year. Ms. Power stated that she would bring the
issue to the Centers for Medicare and Medicaid Services (CMS) through the Federal
Partners Workgroup. Mr. Reardon noted that opening up the existing workforce
development system is largely a civil rights issue that has not yet been addressed
at Labor. Dr. Vergare stated the need for incentives to bring young people into
training in behavioral health who will implement programs in the future. Ms.
Power noted that workforce development is a priority area in CMHS’s Federal
Action Agenda.
Public Comment. Although time was set aside for public comment, no one wished
to speak.
SAMHSA Administrator’s Report. Deputy Administrator James Stone, M.S.W., stated
that the President and Secretary Tommy Thompson gave SAMHSA a vote of confidence
by moving the New Freedom Commission’s report from a recommendation to an agenda
for action, to be released in July 2004. SAMHSA’s matrix of priority programs
and cross-cutting principles fosters a focus on programs and dollars, as well
as management responsibilities and principles. SAMHSA’s budget reflects support
from the President, who approved a 6 percent increase over the previous year.
The budget calls for $44 million in transformation, including grants to help
States plan for comprehensive State mental health care and $15 million for State
Incentive Grants for co-occurring disorders. House action is expected in July,
with Senate action to follow.
SAMHSA focuses on national outcomes and outcome measures of whether people
are better off than they were when they began to receive services. SAMHSA programs
will emphasize indicators of real outcomes, including abstinence from drug and
alcohol use or decreased mental illness symptomatology, increased or retained
employment and school enrollment, decreased involvement with the criminal justice
system, increased stability in family and living conditions, increased access
to services, increased retention and services for substance abuse treatment
or decreased utilization of psychiatric inpatient beds for mental health treatment,
and increased social connectedness to family, friends, coworkers, and classmates.
In science to services, SAMHSA works toward rapid implementation of evidence-based
mental health and substance abuse interventions into routine clinical practice,
and strengthened feedback from the field. SAMHSA has partnered with NIMH, NIDA,
and NIAAA, and has appointed Dr. Kevin Hennessey to lead the science-to-services
agenda. SAMHSA’s budget includes SIGs for co-occurring disorders that will help
to achieve the action steps in SAMHSA’s 2002 report to Congress. Aligned with
the President and Secretary’s Healthier U.S. Initiative, the Strategic Prevention
Framework aims to improve overall public health by engaging in prevention. The
process includes promoting youth development, reducing risk-taking behaviors,
building on assets, and preventing problem behaviors in all areas of a young
person’s life, at home, in school, and in the community.
Other continuing program areas include diversion and prevention of recidivism
with the Justice Department, older adults, co-occurring HIV/AIDS and hepatitis,
minorities, seclusion and restraint, disaster readiness, and the impending move
to a new building.
Discussion. Dr. Kelly expressed interest and approval
of the focus on national outcome measures. Mr. Stone stated that the measures
are under development amid controversy, and SAMHSA plans to work with State
mental health directors. Use of commercial standards is to be negotiated. Mr.
Stone suggested that Council members can help accomplish this mission by “promoting
the winds of change.” Dr. Vergare raised the issue of sustaining transformation
in light of potential for change in political priorities. Mr. Stone asserted
that interagency collaborative work and the crossover nature of the Council
will promote sustainability, as will staff. Mr. Stone considers publication
of the report of the Federal Action Agenda to be an example of a good outcome
of transformation.
Mental Health Transformation in the States and Mental Health State Incentive
Grants. Ms. Power described her view of a transformed mental health
system: individualized plans of care for everyone with a severe mental illness
and every State engaged in comprehensive mental health planning. Authority for
transformation ultimately rests with States, and the following three panelists
explained each of their States’ transformation process.
New Mexico: Interagency Behavioral Health Purchasing Collaborative/Redesigning
the Mental Health System. Pamela Martin, Ph.D., Director, Behavioral Health
Services Division, Department of Health, highlighted New Mexico’s
transformation context: a prevention SIG, 5-year plan, evidence-based interventions
provided by State-certified preventionists, block grant as a significant part
of this frontier State’s budget; and a vision consistent with Federal goals.
Demonstrating leadership at the top, Governor Richardson initiated a new Behavioral
Health Purchasing Collaborative, a single delivery system across multiple agencies
with braided resources. Seventeen State agencies participate in the Purchasing
Collaborative, and have agreed to equal votes, irrespective of the amount of
resources they contribute. By statute, the Collaborative will consider problems,
regional differences, border issues, and special populations. The State inventoried
advisory committees and created one Behavioral Health Council, with many subcommittees,
that reports to the Behavioral Health Purchasing Collaborative and the Governor.
Foundations of transformation for New Mexico include top-down commitment from
the Governor’s office and Cabinet, guiding legislation for sustainability, continuous
stakeholder inputs, and a Statewide analysis of needs and gaps. Dr. Martin stated
that while some efficiencies may be achieved in its transformation efforts,
New Mexico will need more mental health funds to transform the system. Among
many items, a SIG grant would help New Mexico shore up its infrastructure to
staff workgroups and committees, provide travel funding and per diem for consumers
and families to participate in meetings, and staff communications development.
Dr. Martin stated that every State should receive some transformation funding,
based on the degree of readiness and where the State is with respect to readiness.
CMHS could consider three stages related to transformation: One would be system
evaluation; a second would be foundation development, including working with
legislators and stakeholders, holding town meetings, and writing papers; and
the third would be where New Mexico is now, transformation in process.
Connecticut: Toward Mental Health Transformation. Thomas A. Kirk,
Jr., Ph.D., Commissioner, Department of Mental Health and Addiction Services,
explained that the department’s goal is a value-driven, recovery-oriented health
care system that provides highest-quality services at the most reasonable price.
Recovery means that people should be helped to learn how to manage their illness
and to regain the highest quality of life possible.
Connecticut would use a mental health transformation SIG to provide impetus
to move to the next level of transformation. New Freedom Commission Chair Mike
Hogan briefed diverse Connecticut stakeholders on the work of the Commission
and participated in a discussion of the Connecticut system. Dr. Hogan later
provided feedback to the State on how to move forward with transformation. Following
release of the Surgeon General’s Report on Mental Health, the governor established
a broad Blue Ribbon Commission on Mental Health. Acting on the Commission’s
recommendations, the governor created a Mental Health Policy Council to implement
the other recommendations, and the legislature appropriated considerable funding
for mental health. Dr. Kirk urged sustained technical assistance support for
systems change. He noted that Connecticut has a collaborative contracting arrangement
and aggressively seeks foundation and Federal grants. In an analysis of results
of funded projects, researchers compiled a set of principles to guide the system.
In Connecticut, mental health must be a part of the agenda for every issue.
Dr. Kirk asserted that things that do not work are “projects du jour,” executive
and legislature out of synch, and a highly conceptual, instead of product-driven,
approach.
Connecticut has tied its activities to the goals of New Freedom Commission
through such State programs as: Goal 2 (consumer and family driven) its Person-Centered
Planning Initiative; Goal 3 (eliminate disparities) its Behavioral Health Disparities
Initiative; Goal 4 (early screening and referral), Partnership Resources and
Infrastructure Support Monies Initiative; Goal 5 (research to services) its
Bridging Prevention and Recovery Initiative; and Goal 6 (technology) its Connecticut
Clearinghouse.
Based on Connecticut’s experience, Dr. Kirk suggested a flexible, two-tier
SIG grant process that includes both planning and action strategies in order
to address differences in approaches and progress among States. He said that
a culture change is taking place in Connecticut, in which a focus on outcomes
drives the system. He said that States need to develop an “action strategy,”
not just a planning strategy. He urged that Federal funding levels be tied to
States’ commitment to transformation. There should be a single point of accountability
for transformation in the State. He recommended strong Federal strategic partnership
agreements, flexibility regarding waivers, Medicaid buy-in to recovery plans,
and sustained technical assistance.
Oklahoma: Addressing Mental Health as a Public Health Issue with
the State Department of Health. Terry Cline, Ph.D., Commissioner,
Department of Mental Health and Substance Abuse Services, described his State’s
transformation efforts: State Mental Health Planning Council meetings on transformation
goals; technical assistance on the block grant for consistency with New Freedom
Commission goals; development of a support group network and peer-to-peer support
services at community mental health centers; education with other State agencies;
broad stakeholder understanding that behavioral health is integral to overall
health; and mobilization of leadership and stakeholders who disseminate this
concept of mental health.
Oklahoma will develop a new recovery-oriented behavioral health service system
in partnership with Medicaid, has initiated a Children’s Behavioral Health Partnership
with Policy Academy guidance to develop an interagency strategic plan, and has
created a high-level task force on mental illness, substance abuse, and domestic
violence to look at their costs. Dr. Cline believes that transformation impacts
every sector; good data and evidence-based outcomes promote support; and the
block grant is an important part of Oklahoma’s funding. The State needs supportive,
flexible reimbursement policies from CMS to promote recovery-based initiatives;
workforce development; organizational change technology to support organizational
change; performance improvement and outcomes monitoring; buy-in by all stakeholders;
early demonstration of more effective services and systems (otherwise no reason
for change); and improved data infrastructure. Barriers include a lack of commitment
by top Federal and State leadership to evidence-based initiatives, lack of staff
training and workforce development, lack of confidence and involvement of consumers
and families, lack of performance outcomes assessment and quality improvement
functions at all levels of State and local entities, and lack of cultural change
to value recovery.
Oklahoma needs support for infrastructure development to align the strategic
plan with the New Freedom Commission goals. Dr. Cline expressed support for
a tiered grant system based on readiness; suggested value in cross-walking relationships
among the mental health block grant criteria, SAMSHSA matrix, and New Freedom
Commission goals; and encouraged diminishing fragmentation. Helpful SIG requirements
include interagency and interdisciplinary collaboration, consumer involvement,
standardized data collection and reporting, and workforce development plans.
Detrimental requirements would include ignoring State and organizational differences,
nonstandard grant formats and requirements, and denying flexibility in agency
responsibility for the SIG. SIGs should require collaboration with Native American
tribes to diminish the silo effect. Transformation with a focus on recovery
requires collaboration at and among all governmental levels, consumers knowing
that the system will support them in meeting their needs, and support, technical
assistance, and strong leadership.
Discussion. Ms. Power commented on the importance
of energetic, committed, passionate leadership. Drs. Bowers-Stephens and Kelly
stated that they would like to see Council becoming more involved and discussing
SIGs plans with States, even if it requires adding more Council meetings.
Dr. Vergare pointed out that because 65 percent of behavioral health services
are funded through Medicaid/Medicare, the Center for Medicare and Medicaid Services
(CMS) must be at the transformation table. Dr. Cline stated that more flexibility
is needed in funding recovery-promoting services. Noting that his State’s Medicaid
requirements have become more restrictive, Dr. Kirk concurred that flexibility
to achieve good clinical management will help limit the rate of growth of Medicaid
dollars and stop reinforcement of high-cost acute care. Dr. Cline reported that
State Medicaid Commissioners present at a recent NASMHPD meeting expressed frustration
with the tightened regulations.
Mr. Fricks stated that preliminary data on Georgia’s certified peer specialists
programs show significant improvement in client outcomes as well as reduced
costs. Dr. Kirk responded that, as an alternative to outpatient commitment,
peer engagement specialists might focus on outreach to people resistant to staying
within system. Yale research shows that although inpatient days did not decrease,
peers brought consumers into the care system. Peers trained in emergency department
work have helped engage clients in treatment. Emergency room staff have agreed
to have peers as part of their teams. Dr. Kirk stated that although no control
group is present in the emergency room peer program, measures are built in to
assess the efficacy of the approach. The program, however, may not meet rigorous
scientific standards of an evidence-based study.
Dr. Kelly asserted that measuring clinical outcomes is critical to transformation.
Dr. Kirk noted that stakeholders’ views of desirable outcome measures differ
widely, and that cultural change must occur to look beyond the numbers. Dr.
Kirk added that input from outside leadership makes a difference in readiness
to change. Dr. Van Stone noted the unprecedented expectation of length of hospital
stay measured in hours instead of days. He stated that the VA now is committed
to participating in State mental health plans. For the past 10 years, the VA
has focused on outcomes. Dr. Martin found no bridge to the VA in New Mexico,
but she knew about resources for homeless veterans. The VA has not reached toward
the State level, but she welcomed the connection. Dr. Beardslee suggested considering
outcomes measurement as an outcome of partnerships, noting that standard measurements
now do not exist. He asserted that true transformation will depend on insurance
coverage for everyone for both physical and mental health.
State Incentive Grants. Mike Lowther, Director, Division of State and Community
Systems Development, Center for Substance Abuse Prevention (CSAP). Mr. Lowther
explained that experience with previous SIGs has shown that three years is not
long enough to sustain and secure programs to their communities. The new SPF
SIGs will cover five years, in recognition that change takes time. Important
elements include convening a strong SIG advisory council to serve as a force
for change, leadership and top-down support, project staff committed to the
process, technical assistance consultation, strong planning processes before
distributing funds into communities for services, attention to sustainability
from the inception of the program, creating a balance between planning and action,
and making prevention a public health, public education, public safety, and
behavioral health issue.
Discussion. Ms. Power pointed out that many States
have started thinking about how they would design programs funded through transformation
SIGs. She explained that transformation SIGs aim toward infrastructure development.
Dr. Bowers-Stephens observed that the new State initiatives issued during the
past year feel fragmented, and she urged integration at the Federal and State
levels to ensure that entities work together sensibly. Ms. Power suggested that
SAMHSA should make clear how its initiatives link to transformation, and that
evidence of integration is required in grant applications. She explained that
the lists of States’ transformation activities provided to Council members represent
voluntary reports. Mr. Lowther explained that SIGs focus on how to change States’
infrastructures to see the world in a different way.
Ms. Power stated that SIGs for mental health transformation are new and that
SAMHSA is gathering input on what these grants should look like to facilitate
transformation. To Dr. Kelly’s question about what differentiates upcoming SIGs
from earlier initiatives, Ms. Power replied that many States are ready for mental
health transformation and are moving forward on their own, and Federal dollars
will offer new incentives.
Dr. Vergare observed that connecting transformation to funding for services
is key. Ms. Power reiterated CMS’s partnership in the Federal Action Agenda,
but noted that Glenn Stanton, an important ally, has left government service,
making it necessary to reestablish links. On the commercial side, CMHS is working
to open dialogues with employers, health plans, and third-party payers other
than the Federal government. The National Business Group on Health will work
with CMHS to develop an employer packet for the top 5,000 companies with the
message that mental and behavioral health—essential to overall health—affect
productivity. Ms. Power suggested that Council members can be helpful in building
the credibility of that message, and Dr. Vergare volunteered his efforts.
Dr. Satel questioned whether SAMHSA could allocate transformation funds to
States based on accountability, outcome measurement, streamlining, and flexible
Medicaid funding—but no Medicaid-like strings. Ms. Power stated that the reality
is that States will need to show outcomes and accountability of State leadership.
Dr. Kirk cautioned that without tight controls, State political forces might
divert transformation funds to solve tangential State problems. Dr. Kirk recognized
the need for attention to longer-term outcome measures in five-year prevention
grants to reflect time lags in meaningful outcomes. Dr. Kelly concurred with
the necessity of tight fiscal controls.
In her view of a three-tier system, Dr. Martin explained that the first two
phases would have definable products—for example, evaluation plan, concept papers,
reorganizational chart—cross-walked to major State initiatives and health disparities.
Flexibility is necessary because of States’ varying demographic and epidemiological
sets of needs. In the third phase, the set of needs is more individualized and
requires a larger workforce for implementation and sustainability planning.
More funding would be needed in the third phase than the first two. In the context
of a SIG for every State recommended by Dr. Martin, Ms. Abbate asked whether
it would be more prudent to fund fewer, selected states that demonstrate greater
readiness for transformation, rather than funding every State with less money.
Dr. Martin responded that all States should and will engage in transformation
using whatever funding is available.
Dr. Bowers-Stephens suggested looking at the reform of the children’s program
as a model. She questioned what might be done with block grants to promote transformation,
for example, offer discretionary SIG grants but require certain actions in the
block grants as an incentive.
Ms. Power concurred with the concept of looking at all mechanisms to promote
transformation. Dr. Kirk suggested offering incentives for early adaptors of
change, for example, among providers. He does not advocate a SIG for every State,
but every State should have an opportunity, based on a tiered approach. Dr.
Vergare asserted the need to address workforce issues in behavioral health and
across all health care. Thought should be given about how to introduce new concepts
beyond behavioral health and how to use incentives in professional schools.
Ms. Power noted that CMHS will build on the related workforce development promoted
by the Annapolis Coalition. Dr. Kelly recommended generously funding fewer States
instead of minimally funding many.
Public Comment
Cynthia Folcarelli, Executive Vice President, National Mental Health
Association, expressed enthusiasm for moving transformation using
multiple approaches. NMHA is a founding member of the Campaign for Mental Health
Reform, a coalition of national organizations. Ms. Folcarelli urged incorporation
of meaningful consumer and family involvement in every aspect of State planning
efforts, especially in light of varying States’ understanding of “meaningful.”
She asserted that transformation is not possible without that input and involvement,
noting that sustainability is based in part on how well the system serves individuals’
needs. While consumers, families, and advocates are optimistic about transformation,
reform without appropriate resources amounts to cutting services or reducing
choice; real improvement in quality of services requires resources for services
and parity. NMHA advocates that, in addition to adults with severe mental illness
and children with severe emotional disturbance, State mental health plans must
cover the needs of TANF mothers and children in foster care, child welfare,
and the juvenile justice system, for example, who without support may develop
serious problems. This preventive approach is prudent from humanitarian and
economic perspectives.
Kathy Muscari, Director, Consumer Organization Networking Technical
Assistance Center (CONTAC), stated that over six years CONTAC
has provided support to consumers in 26 States. She urged consumer involvement
in transformation activities, noted that block grant funding supported a peer-clinician
training program for West Virginia’s largest behavioral health center on what
is recovery, trained 20 peer specialists, and secured a grant to provide supports
to peer specialists. Ms. Muscari highlighted the importance of consumers’ life
experiences in the peer-support process and urged attention to Medicaid issues.
The meeting recessed at 4:55 p.m. until the following day.
Closed Session
Ms. Power reconvened the Council meeting on June 17, 2004, at 9:00 a.m. in
closed session. Diane Sondheimer, M.S.N., M.P.H., C.P.N.P., Deputy
Chief, Child, Adolescent, and Family Branch, Division of Service and System
Improvement, CMHS, led a secondary review of grants. Dawn Colbert,
Division of Management Systems, SAMHSA, presented training on accessing summary
statements via the Internet.
Open Session
Subcommittee on Consumer/Survivor Issues Report. Subcommittee
chair Larry Fricks described the agenda of the subcommittee’s June meeting.
At that meeting, Mr. del Vecchio and Deanna Troust described the Eliminating
Barriers Initiative (EBI); Ingrid Goldstrom presented survey findings of more
than 4,500 mental health mutual support, self-help, or consumer-run organizations
in the United States; and subcommittee members J. Rock Johnson and Jon Brock
described how self-determination can help people with mental illnesses.
The subcommittee considered two goals of the New Freedom Commission, eliminating
disparities in mental health services and accelerating research. NIMH Advisory
Council member Sergio Aguilar-Gaxiola described his research findings on the
mental health of Mexican Americans and barriers to access to service, and subcommittee
member Maria Maceira-Lessley pointed out the disproportionately low percentage
of Hispanic-Latino consumers seeking services and of becoming consumer leaders.
Crystal Blyler described CMHS’s research portfolio and evidence-based practices.
Consumer researcher Jean Campbell discussed rollout in October of findings from
the eight grants in the State Consumer Operated Services Program, an initiative
to determine the value of consumer-operated services; urged improvement in measuring
recovery; and described the process of the Consumer Issues Subcommittee of the
New Freedom Commission. Ms. Power remarked that a series of CMHS’s toolkits
will be issued soon, and Mr. Fricks requested copies of the New Freedom Commission’s
consumer subcommittee report. Mr. Fricks stated that both Mr. Curie and Ms.
Power have great credibility with the consumer/survivor movement because of
their issue positions and actions.
Mr. Fricks submitted the following recommendations to the Council:
- A condition of the proposed State Incentive Grants for Mental Health Transformation
should require that States fund the application of recovery-based research
findings, including peer-operated services and crisis alternatives.
- Focus groups should be conducted composed of representatives of racial/ethnic/cultural
groups to identify:
a. Their specific needs and preferences for mental health services
b. The unique factors that foster resiliency within these groups
c. Strategies for mental health leadership development among these populations.
The subcommittee emphasized its prior recommendation that the Council advise
CMHS to increase support for jobs, including the employment of consumers as
service providers. In addition, the subcommittee asked that the Council and
CMHS consider how to encourage states to use recovery-oriented individualized
service plans as agents for change.
Discussion. Ms. Power noted that SAMHSA and CMHS
have taken initial steps to work toward focus groups with minorities to help
guide transformation to meet their needs. Dr. Vergare suggested examining successes
in the developmental disability community to determine their usefulness in mental
health. Mr. Fricks stated that some independent living centers welcome people
with mental illnesses. Ms. Power noted that NASHMPD and CMHS cosponsored a joint
meeting of mental health and developmental disability leaders that produced
profound learnings about language, services, funding, and building self-directed
lives and natural supports with new emerging technologies. She stated that Rhode
Island’s developmental disability system conducted personal capacity inventories;
the area is ripe for exploitation and conversation with developmental disability
and other disability communities. Dr. Satel volunteered to examine the social
anthropology literature about resilience and low usage of mental health services
in Hispanic communities.
Referring to an EBI publication list of reasons why people do not come to care,
Dr. Satel stated that she would add the fact that some small numbers of people
do not know they are sick. She recommended that SIGs address whether States
provide assisted outpatient treatment. Acknowledging her controversial view,
she noted that stigma regarding severe mental illness may be addressed by early
coercive care that then migrates into other, less coercive systems. She asserted
that some people need intrusive, highly paternalistic, life-saving care. Dr.
Kelly suggested as an agenda item a presentation on the status of States on
outpatient commitment.
Regarding the subcommittee’s first recommendation, Ms. Power noted that although
SIG grants are not services grants, RFA language may present principles and
directions. Dr. Beardslee suggested that States should consider the application
of research-based findings, including peer-operated services and crisis alternatives,
in their care plans or array of services. Mr. Fricks noted that the recommendations
need language to tie them to their respective New Freedom Commission goals.
Mr. Fricks also explained that the aim of the subcommittee’s first recommendation
is to constitute homogenous, culture-specific groups, not groups with a spectrum
of people of color.
Dr. Vergare suggested that the subcommittee consider ways that peer interactions
can influence people who reject care, for example, consumers in emergency rooms—funded
through a mental health association—offering housing and medication support.
Mr. Fricks noted the importance of helping persons develop their readiness status
and cited several examples of this approach. Mr. del Vecchio stated that a decade
ago SAMHSA funded a series of crisis alternative demonstrations whose findings
might offer important information.
Ms. Power stated that Council members will receive copies of materials from
presentations to the subcommittee and to the Council. On behalf of the Council,
Ms. Power accepted the subcommittee’s recommendations and accompanying discussion.
Council Roundtable: Role of the Council. Ms. Power noted that
CMHS has engaged the National Advisory Council to provide guidance on the transformation
process, specifically on SIG grants. Other Councils’ roles are to provide advice
and consent, serve as agents (e.g., of transformation), and act as ambassadors.
Council members may have innovative ideas about their roles, and some already
have identified ways they can serve as transformation agents.
Dr. Kelly urged allocating more time during Council meetings for discussion,
Council involvement in setting the agenda, providing the briefing book in advance
of meetings, and holding annual joint Council meetings. In addition, he suggested
a focus on standardized outcome measures and other particular interests of Council
members, and increased Council input on upcoming grant programs.
Dr. Beardslee acknowledged the tension of balancing personal convictions and
CMHS’s legislative, organizational, and other pressures. He stated that exercising
the Council’s ambassadorial role might help to bolster support for resources
to bring about transformation. He highlighted the importance of looking for
measures that lead to transformation in the mental health care system; competitions
that required data have produced better data on services and outcomes. He pointed
out that maternal depression impacts on many areas of health and behavior, and
called for a required focus on parental conditions in programs for children.
Dr. Vergare questioned what role SAMHSA might play in compiling knowledge
from services grants and integrating it broadly into practice and systems of
payment, perhaps using competition as a carrot. This issue should be raised
to SAMHSA’s Advisory Council and NIMH, and beyond mental health as an overall
health issue. Dr. Beardslee suggested focusing on the rate of the disorder/illness,
use of evidence-based practices, and unmet need. Ms. Power asserted that EBI
will teach social marketing lessons on mental health as part of overall health
and asked for guidance on how to move that effort forward. Mr. Fricks pointed
out that the Annapolis Coalition has done some related work. The Medical College
of Georgia’s School of Psychiatry will work with residents on recovery and the
role of trained peers. Dr. Vergare suggested contacting the American Association
of Medical Colleges.
Drs. Bowers-Stephens and Beardslee asserted that access, parity, and equity
must be addressed. Dr. Kelly raised the issue of Council participation in funding
directions within SAMHSA.
Dr. Kelly asserted that the role of spirituality and religion in mental health
warrants attention in transformation. Ms. Power noted that the New Freedom Commission
addressed this issue and suggested that individualized plans of care may be
the mechanism to translate that role programmatically. Dr. Beardslee observed
that faith is a protective factor against depression. He stated that access
to major funding of Medicare/Medicaid and TANF is important to initiate evidence-based
care, empower flexibility in use of funds, distribute some funds to innovative
strategies, and devote some resources to prevention. Other platforms for transformation
include regulatory, inspirational, and congressional interventions.
Dr. Beardslee suggested reviving the tradition of Council breakfasts on the
second day of meetings. Dr. Bowers-Stephens recommended adding as an agenda
item strategies to use the mental health block grant as a transformation vehicle.
Dr. Satel offered to provide contacts for a discussion on involuntary care.
Dr. Vergare raised the issue of people with mental illnesses in the criminal
justice system, which Ms. Power noted is part of a broad ongoing conversation.
Adjournment. Ms. Power adjourned the meeting at 12:10 p.m.
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