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Center for Mental Health Services
National Advisory Council
Washington, D.C.

CMHS Director's Report
to the Advisory Council-May 1998

Halfway through its fifth year of leading the nation’s efforts to improve mental health services delivery systems, the Center for Mental Health Services (CMHS) reports numerous achievements and looks forward to an equally productive remainder of the year. Among its most recent accomplishments are: (1) the May 2 "Walk the Walk: For Lives Touched by Mental Illness," (2) a new study that examines full parity for mental health and substance abuse services in private health insurance plans, and (3) ongoing work on the Surgeon General’s Report on Mental Health.

Because the lives of all Americans are or will likely be affected in some way by mental illness, CMHS sponsored a 1-mile walk in Washington, D.C., on Saturday, May 2, 1998, to help reach the public with important information about mental health and mental illness. The "Walk" was an important step in dispelling negative preconceptions about people with mental illness. Its purpose was to educate the public, gain equal treatment for people with mental illness, and celebrate mental health.

The honorary co-chairs for the "Walk" were Donna Shalala, Secretary of the Department of Health and Human Services; Tipper Gore, Mental Health Advisor to the President; and Rosalynn Carter, former First Lady. The special project directors were Patricia Kempthorne, a member of the Congressional/ Cabinet Spouses Forum on Mental Health, and Ellen Pena, wife of the Secretary of Energy. Numerous mental health professional guilds and advocacy groups worked with CMHS to make the "Walk" a success.

CMHS released a new study, the "Costs and Effects of Parity for Mental Health and Substance Abuse Insurance Benefits," that provides essential, research-based information on the effects of parity on insurance premiums. The study estimates that full parity for mental health and substance abuse services in private health insurance plans would increase family insurance premiums an average of 3.6 percent. Parity, limited to substance abuse treatment benefits alone, would raise premiums only 0.2 percent. The projected premium increase is less than one percent for mental health and substance abuse benefits in health plans that tightly manage care. The study provides a literature review on mental health and substance abuse parity, discusses State parity laws, includes case study reports from five States with parity laws, and estimates premium increases for full and partial parity options.

The appointment of David Satcher, M.D., as the new Assistant Secretary for Health and Surgeon General gives new impetus to the forthcoming Surgeon General’s Report on Mental Health. The high-profile nature of the Surgeon General’s reports presents CMHS with an excellent opportunity to focus public attention on promoting mental health, ending the stigma associated with mental illness, encouraging early recognition and intervention for mental illnesses, and promoting innovative service delivery systems that enhance mental health treatment for millions of Americans in their own communities.

Dr. Satcher previously was the Director of the Centers for Disease control and Administrator of the Agency for Toxic Substances and Disease Registry. During his tenure, these agencies made enormous strides in preventing the spread of infectious diseases, immunizing the nation’s children, ensuring food safety, expanding access to vital preventive services and activities, and improving the environment.

Legislative Update

Reauthorization

There is a great deal of dialogue on reauthorization among the Senate Committee on Labor and Human Resources, Subcommittee on Public Health and Safety; SAMHSA; and its constituents. Compromise is being sought on the block grant formulas. Committee Chairman Senator Bill First’s staff has developed draft legislation reauthorizing SAMHSA, expected to be introduced during this legislative year.

SAMHSA seeks reauthorization for the four formula grant programs, including the CMHS Projects for Assistance in Transition from Homelessness (PATH) program, the Comprehensive Community Mental Health Block Grant, and the Protection and Advocacy (P&A) program.

These programs include provisions for a smooth transition of the CMHS Block Grant programs into performance partnerships. Performance partnership block grants would consolidate 12 required State plan criteria for community mental health services into five and would reduce the number of mandatory requirements for substance abuse plans. It was proposed that other discretionary CMHS grant authorities be consolidated into one Knowledge Development and Application (KDA) program for mental health.

The KDA program redirects the focus of SAMHSA discretionary grant programs from supplementing and building services to a targeted approach of developing and applying knowledge in service systems at the State and local levels.

Appropriations

SAMHSA Administrator Nelba Chavez, Ph.D., Dr. Arons, and the other Center Directors testified before the House Appropriations Subcommittee on Labor/HHS/Education in March on the Administration’s proposed 1999 budget for SAMHSA. The Administration requests level funding for SAMHSA during the 1999 fiscal year which begins October 1, 1998.

Center for Mental Health Services Proposed FY 1999 Budget

(Dollars in Millions)

Final Rule: Protection and Advocacy for Mentally Ill Individuals Act of 1991

The final regulations for the Protection and Advocacy for Individuals with Mental Illness (PAIMI) Act of 1991 appeared in the Federal Register dated October 15, 1997 (Vol. 62, No. 199, pp. 53548-53471).

These regulations govern activities carried out by P&A systems under the PAIMI Act. The regulations include: definitions; basic requirements to determine eligibility for and use of allotments; grant administration; eligibility for protection and advocacy services; annual and financial status reports; requirements regarding program facilities; and records and confidentiality.

Key provisions of the Final Rule include:

• Defines terms related to P&A programs--such as care or treatment, facilities, and legal guardian.
• Stipulates that P&A staff shall have access to the records and documents they need to carry out their duties.
• Determines that P&A staff shall have access to facilities and residents to investigate alleged incidents of abuse or neglect when such an incident is reported, when there is probable cause to believe such an incident occurred, or when there is imminent danger of serious abuse or neglect.
• Limits tenure on the P&A governing board and PAIMI Advisory Council to no more than four years and restricts reappointment for a two-year period.
• Requires the PAIMI Advisory Council to include at least one family member who is the primary caregiver for a minor child or youth who receives or has received mental health services.

The PAIMI Rule included a request for comments on a proposal that requires at least 25 percent of the governing board to be made up of individuals with mental illness and family members of those with mental illness. CMHS received comments from 35 organizations and individuals. Most respondents were from P&A programs. The Administration on Developmental Disabilities, The National Alliance on Mental Illness, the National Association of P&A Systems, and eight other national and State disability groups also commented. As a result of these comments, CMHS will not take any action on the proposal.

Center Director’s Meetings

As in the past, Dr. Arons spoke at several meetings over the winter and is scheduled to address many diverse groups in the coming months. His speaking engagements included the National Association of State Mental Health Program Directors’ "Winter Commissioners Meeting" in December. Also in December, Dr. Arons gave the introductory remarks at the CMHS "Involuntary Intervention Meeting" and the "Federal/National Partnership for Children’s Mental Health," both in Washington, D.C. Attendees at the "Involuntary Intervention Meeting" included health care professionals, consumers, and representatives of State and constituency organizations. The "Federal/National Partnership for Children’s Mental Health" is co-sponsored by the Child, Adolescent, and Family Branch of CMHS and the Children’s Bureau of the Administration on Children, Youth, and Families.

In January, Dr. Arons gave the keynote speech at the Annual Winter Meeting of the American Association of Community Psychiatrists. This year’s theme was "Transformation of Public Mental Health Systems: A National Forum in a State of Transition." The conference objectives were to provide a national context for public mental health systems reform, to highlight Maryland’s efforts to change the public mental health system, and to identify the contribution of Federal, State, and local policies on reform. The meeting was sponsored by the Department of Psychiatry and the Program of Continuing Education, University of Maryland; SAMHSA/CMHS; the Alliance for the Mentally Ill of Maryland; Black Mental Health Alliance of Maryland; Johns Hopkins University; Maryland Association of Psychiatric Support Services; Maryland Council of Community Mental Health Programs; Maryland Psychiatric Society; Maryland State Black Psychiatrists’ Association; Mental Health Association of Maryland; and On Our Own of Maryland. Also in January, Dr. Arons spoke before The National Alliance on Mental Illness Legislative Conference.

In February, Dr. Arons addressed the Women’s Institute on Sports and Education at the 1998 National Girls and Women in Sports Symposium. He also spoke on the "Audacious Imagination: Redefining Children’s Mental Health" at the Yale Child Study Center.

In April, Dr. Arons addressed the Harvard Mental Health Research Seminar and participated in a panel presentation at the Orthopsychiatric Association’s Annual Meeting.

Program Activities and Initiatives

SAMHSA

SAMHSA honored the work of Max Schneier, a pioneer in the mental health field, by establishing an annual award for employees who demonstrate dedication to serving people with mental and substance abuse disorders, courage to take on difficult issues, knowledge about best practices, and tenacity in fighting for the mental health cause. Veronica M. Friel, Ph.D., of SAMHSA’s Center for Substance Abuse Prevention, was the first recipient of this award. Dr. Friel was selected for her dedication in organizing and leading a year-round nonperishable food collection program in SAMHSA and other HHS agencies to help the needy in the Montgomery County, Maryland, area.

Karol L. Kumpfer, Ph.D., was named as the Director of the Center for Substance Abuse Prevention. Dr. Kumpfer is a well-known and highly respected leader in the substance abuse prevention field. Since 1989 she served as an associate professor, Department of Health Education, University of Utah. Before joining the university staff, Dr. Kumpfer served as the Deputy Director of the Utah State Division of Substance Abuse. Dr. Kumpfer has published extensively and has held many professional leadership roles, including her current appointment as President, Society for Prevention Research.

CMHS Office of the Director

Thomas Bornemann, Ed.D., CMHS Deputy Director; Judith Katz-Leavy, M.Ed., Senior Policy Analyst; and Patricia Rye, Special Assistant to the Director, participated in a meeting of the Health Committee of the Mental Health Liaison Group. They addressed the Surgeon General’s Report on Mental Health and ways for CMHS to track State action on the child health insurance program.

In addition, Dr. Bornemann and other CMHS staff accompanied Russian officials on visits to emergency preparedness sites in Oklahoma City, OK, and Little Rock, AR.

Associate Director for Medical Affairs

Melvyn Haas, M.D., was interviewed for an article on Abraham Lincoln, depression, and bipolar disorder for the Scripps Howard newspaper.

The HIV/AIDS Program launched two initiatives: Cooperative Agreements for the Mental Health Care Provider Education and another for an HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study. The Mental Health Care Provider Education grant will disseminate state-of-the-art knowledge about how to identify and treat the psychological and neuropsychiatric sequela of HIV/AIDS and develop ways to effectively disseminate this knowledge. The latter includes an assessment, through a multi-site evaluation, of both the use and usefulness of this knowledge for providers of HIV/AIDS-specific mental health care services. The HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study will determine the effectiveness of treatment adherence models, health outcomes, and costs associated with providing integrated mental health, substance abuse, and HIV/AIDS primary care services for individuals, 14 years and older, living with HIV/AIDS who have both a mental and substance abuse disorder. Another goal is to advance scientific knowledge about the effectiveness of typical mental health, substance abuse, and HIV/AIDS primary care treatment for individuals with HIV/AIDS by analyzing a wide range of relevant scientific and policy questions.

Office of Managed Care

In collaboration with its sister center, the Center for Substance Abuse Treatment, CMHS contracted with Mathematica Policy Research for cost estimates to provide expanded insurance coverage for mental health and substance abuse services. The report will look at the effects on utilization and costs of mental health and substance abuse services in States with laws requiring equivalence between mental health and substance abuse benefits and those for general health care, including employer health plans with comprehensive mental health and substance abuse coverage.

The office continues its work in a number of areas, such as contracting with the George Washington University Center for Health Policy, for ongoing analyses that include: preparing annual reports on all Medicaid managed care contracts; developing technical assistance guides that address contract negotiation for providers, public purchaser, and consumers; supporting a project to produce a series of legal briefs over the next two years on procurement, contracting, and contract execution; and producing a series of in-depth specialty reports on contracting issues.

Division of Knowledge Development and Systems Change

Grants are available to support up to 75 percent (at a maximum of $50,000) of the total direct costs of domestic conferences for the purpose of knowledge synthesis and dissemination. The goal of SAMHSA’s knowledge synthesis and dissemination activities is to improve the quality of the Nation’s substance abuse and mental health treatment and prevention services and systems. Conferences supported will coordinate, exchange, and disseminate knowledge. These conferences are intended to improve effective treatment, recovery, early intervention, and prevention services for individuals who have, or are at risk of, mental illness and/or substance abuse.

Child, Adolescent, and Family Branch

The Comprehensive Community Mental Health Services Program for Children and their Families offered grants to implement a broad array of community-based and family-focused services for children with serious emotional disturbances and their families. These services include individualized case planning, as well as coordination and assistance to communities in integrating child- and family-serving agencies into a comprehensive system of care. The programs will be evaluated and include longitudinal studies of the outcomes provided by such systems.

This program also received the prestigious Hammer Award from Vice President Albert Gore. The interagency team of Federal and private sector officials was formed to consolidate training and technical assistance to grantees from several Federal agencies into a single, comprehensive program that provides coordinated, non-duplicative services and project direction. The team’s efforts have yielded better relations with grantees, increased technical capacity, and reduced duplication and conflicting guidance.

The CARING FOR EVERY CHILD’S MENTAL HEALTH: Communities Together Campaign received a bronze Mercury Award from the International Academy of Communications Arts and Sciences for the video "Voices of Strength: An Inside Look at Children’s Mental Health." The video highlights the stories of young people who have experienced a mental health problem. The stories reveal how the young people and their families found community resources and supports, built upon their individual and family strengths, and developed new skills to help them succeed. Considered the ‘Oscars’ of the worldwide communications industry by the award sponsors, the Mercury Awards recognize outstanding achievement in public relations. A panel of 75 judges reviewed approximately 1,000 entries in a variety of print and broadcast media. Corporations, associations, government agencies, public relations agencies, designers, and other suppliers from 16 countries competed for these awards.

A new initiative, "Circles of Care," will plan, design, and assess the feasibility of implementing a culturally appropriate mental health service model for American Indian/Alaska Native children with serious emotional disturbances and their families. The purpose of the program is to support the development of mental health service delivery models that are designed by American Indian/Alaska Native communities for their own children.

Community Support Program

Funding for cooperative agreements to "Evaluate Consumer-Operated Human Service Programs for Persons with Serious Mental Illness" will assess the extent to which consumer-operated services are effective in improving rehabilitation and recovery of individuals with serious mental illness. The program also seeks to determine how participation in such services affects cost.

In cooperation with the CMHS Consumer Affairs Office, the Branch sponsored a meeting to assess the technical assistance needs of local and State consumer self-help programs.

Homeless Programs Branch

Grantees of the Access to Community Care and Effective Services Support (ACCESS) met in January to discuss the latest evaluation findings and other issues that affect homeless persons with serious mental illnesses. Approximately 150 people from nine States and 18 projects attended.

Also in January, Housing Initiatives grantees met to finalize an instrument for defining the housing models that are being evaluated in this knowledge development program and to resolve questions on the cross-site study and instrumentation that will be used to measure outcomes. This meeting included the first consumer advisory panel to guide decisions regarding this program. The consumers are supported by the individual grantees and the coordinating center for these cooperative agreements, the Vanderbilt Institute for Public Policy Studies.

In February, the Branch convened a focus group of experts to address issues of homeless families who have custody of their children, especially where the parent/s have psychiatric and, often, co-occurring substance abuse disorders. The resulting comments and recommendations will be used to develop a funding announcement for documenting and evaluating promising interventions for the target population, including the needs of both parents and children.

Division of Program Development, Special Populations, and Projects

Brian Flynn, Ed. D., Division Director, was interviewed by National Public Radio in reference to an article on increased suicide following disasters that appeared in the New England Journal of Medicine.

Emergency Services and Disaster Relief Branch

Susan Flanigan, Public Health Advisor, participated on a Federal panel at the Children’s Emergencies in Disaster: A National Emergency Medical Services for Children Workshop in Orlando, FL.

Special Projects Development Branch

Grants for the "Women and Violence Study" will support the first of a two-phase study on women; alcohol, drug, and mental disorders; and violence. Phase one will develop an integrated system of care with services intervention models, implement a qualitative evaluation, and develop evaluation protocols for phase two. Phase two will be full-scale implementation of integrated strategies, services intervention models, and outcome evaluation. Up to 12 sites and a coordinating center will be funded.

"Community Action Grants for Service Systems Change" will support the adoption of exemplary service delivery practices related to the delivery and/or organization of services or supports for children with serious emotional disturbances and adults with serious mental illness. The adult population may also have co-occurring disorders. Funds will also be available for a priority initiative for Hispanic communities to support exemplary practices for Hispanic adults and adolescents with mental health and/or substance abuse problems.

Division of State and Community Systems Development

The Division sponsored a meeting for the Prevention Enhancement Protocol Systems (PEPS) group to review PEPS field experience regarding the development, production, distribution, and current dissemination plans. Attendees also discussed alternatives, systematic evaluation of PEPS guidelines, and new topics.

Protection and Advocacy Branch

CMHS convened the "Involuntary Interventions and Coercive Practices" meeting to further its mission of fostering independence and protecting the legal rights of people with mental illness. Involuntary interventions and coercive practices interfere with basic freedom and liberty. CMHS is committed to reducing the need for these practices in the delivery of mental health care nationwide. An executive summary of the meeting is available through SAMHSA's National Mental Health Information Center.

The most recent CMHS report on topics of concern to the mental health field and the American public is a background paper on electroconvulsive therapy (ECT). This report summarized the current state of knowledge regarding ECT, consumer and public views, relevant laws and regulations, and priority research tasks.

Two major trainings were held for the P&A programs: "Solving the Management Puzzle" held in Austin, TX, in January and the "New Director’s Training and the CEO Training" held in Albuquerque, NM, in April.

State Planning and Systems Development Branch

Performance outcomes were the main topic of a workshop in early May that included a day of regional breakout sessions for attendees.

Survey and Analysis Branch

"State Reform Grants" will facilitate the integration, analysis, synthesis, and use of information for State mental health planning efforts and will manage State mental health care reform efforts. The major objective of this technical assistance to State mental health agencies is to ensure that appropriate information is available for key decision making.

The Consumer Survey Component of the Consumer-Oriented Report Card was accepted by the National Committee on Quality Assurance for inclusion in the HEDIS Test Data set for behavioral health care. The Consumer Survey consists of 21 items that have been refined through the methodological findings from the 20 Mental Health Statistics Improvement Program (MHSIP) State Reform grants initiated in FY96.

Branch Chief Ronald Manderscheid, Ph.D., convened and attended several conferences and meetings. Among them were: a technical work group to finalize the document "Methodological Standards for Outcomes Systems;" a plenary address on "The Quality Crisis in Behavioral Health Care;" a joint meeting with the American Public Health Association to bring together major disability groups and discuss potential collaborative projects; a joint effort with the National Association of Psychiatric Health Systems to develop key measures for the industry; and a meeting of major psychiatric nursing groups to discuss "Models of Psychiatric Nursing Care."

Marilyn Henderson, M.P.A., convened a meeting in January of the Policy Coordinating Group for a new project entitled "Analyses for Improved Information in Managed Care."

Office of External Liaison

"Taking Charge Together" was the theme of February’s Alternatives ’98 Conference in Long Beach, CA. This annual gathering sponsored by CMHS provides an opportunity for mental health consumers to exchange ideas, hear about national issues, and learn new skills. Representatives form CMHS participated in a caucus to brief conferees on current CMHS activities and to solicit conferees’ feedback. Over 650 people attended.

The first of several regional consumer meetings was convened in Atlanta, GA, to assess the pressing needs of consumers in southeastern States and to inform CMHS how it can best respond to these needs.

Organizational/Personnel Updates

Community Support Program hails the addition of Susan Salasin (formerly with the Special Programs Development Branch). She has worked with CSP on the Criminal Justice Diversion Study, a collaboration between CMHS and the Center for Substance Abuse Treatment (CSAT). Ms. Salasin also is working on the Violence and Women program, a new joint effort between CMHS and CSAT.

Emergency Services and Disaster Relief Branch has two new Project Officers: James Blair and Charles Cook. Mr. Blair joins the Branch from the Center for Substance Abuse Prevention and has a special background in international disasters. Mr. Cook, a private sector disaster mental health expert, has worked closely with the crisis counseling program as a consultant, trainer, and stress manager since the Midwest floods of 1993.

Office of External Liaison announces the arrival of Shelly L. Burgess, Public Affairs Specialist, to oversee publications clearance operations and help SAMHSA's National Mental Health Information Center's Project Officer with graphics projects. Ms. Burgess joins OEL from HRSA’s Office of Maternal and Child Health Bureau where she responded to press inquiries, coordinated interviews with senior-level program officials and the media, and wrote articles and press releases on HRSA, as well as educational materials for the general public.

Carol Schauer, Public Health Advisor, also joins OEL from the CMHS Protection and Advocacy Branch. Ms. Schauer will be working with SAMHSA's National Mental Health Information Center to review responses to controlled correspondence and to assist with activities through the consumer affairs wing.

Office of Policy, Planning, and Administration welcomes Eileen Elias, M.Ed. She offers a wealth of experience in public and private behavioral health care service delivery systems. Most recently, she was the Acting Commissioner of Mental Health with the District of Columbia. Ms. Elias also has been a behavioral health managed care consultant with the Health Care Finance Administration and the Commissioner of Mental Health in Massachusetts. Ms. Elias has been a guest lecturer at Harvard University’s Kennedy School of Government and Massachusetts Institute of Technology. She also has published numerous articles on behavioral health care systems, managed care, and mental health. Ms. Elias received her master’s degree in education from Temple University.

Special Programs Development Branch has two new staff members in refugee mental health programming: Elzbieta Gozdziak, Ph.D., and John Tuskan, R.N., M.S.N. Dr. Gozdziak brings more than a decade of experience in program management, research, and policy analysis in the areas of international migration, ethnic diasporas, ethnic conflict, ethnic minorities, and gender and age issues. She also has provided technical assistance to many social service programs for refugees, immigrants, and undocumented migrants in the U.S. and Europe. Her most recent position was as a graduate faculty member at Howard University School of Social Work. Dr. Gozdziak received her doctorate in cultural anthropology from Adam Mickiewicz University in Poznan, Poland.

Mr. Tuskan has expertise in designing, administering, and delivering mental health services to special populations. He has a background in providing mental health-related disaster assistance services and mental health services for refugees. For example, during Operation Desert Storm, he worked in Kuwait to set up health and mental health services for Iraqis and Kuwaitis. Prior to CMHS, Mr. Tuskan trained oncology nurses in mental health issues and provided direct mental health care in oncology wards for the National Cancer Institute.

Recent and Forthcoming Publications

"CMHS/CSAT Collaborative Demonstration Program for Homeless Individuals," Journal of Social Distress and the Homeless, 1997, 6(4), 261-274.

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