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

DIRECTOR'S REPORT
December 1998

Just as humans develop and master new skills over the course of a lifetime, institutions also develop in stages. Now in its sixth year of leading the Federal Government's efforts to support and advance mental health service delivery systems throughout the country, the Center for Mental Health Services (CMHS) has reached a certain maturity. Using Erik Erikson's Eight Stages of Psychosocial Development as an analogy for CMHS's progress, CMHS is in the period of generativity.

This stage of development entails finding ways to satisfy and support the next generation. In fact, CMHS has created a number of programs that will continue to shed light on the best ways to create appropriate, consumer- and family-oriented, community-based systems of mental health care for years to come, even after Federal funding is gone. For example, all seven "graduating" grantees of the Comprehensive Community Mental Health Services Program for Children and Their Families received assurances of State funding to continue. In addition, California, Maine, and Rhode Island have passed legislation codifying systems of care for children with major mental health needs.

The success of many CMHS programs can be attributed, in part, to the strong relationships CMHS has forged with other institutions and organizations over the past five years. Among the institutions and organizations are the Centers for Disease Control and Prevention (CDC), the National Institute of Mental Health (NIMH), the National Association of State Mental Health Program Directors (NASMHPD), and numerous national consumer and family advocacy groups. The collaboration and support of these organizations have been critical to the work CMHS does to help develop mental health service delivery systems that truly meet the wants and needs of people with mental health problems and their families.

Since the National Advisory Council met in September, CMHS has formalized a partnership with the Social Security Administration (SSA) supporting a demonstration program to remove employment barriers for persons with disabilities, has taken the lead in addressing suicide and suicide prevention as public health issues, and has advanced work on the Surgeon General's Report on Mental Health.

In conjunction with other agencies within the Department of Health and Human Services (HHS), CMHS provided expertise to SSA in its decision to award 9 of 12 demonstration grants to States conducting special projects involving people with serious mental illness. These grants to States will address ways of eliminating barriers to competitive employment for persons with disabilities. Each of these nine States is adopting a different approach for removing barriers. For example, Ohio will educate consumers about available services and the use of employer liaisons, Minnesota will address beneficiaries' fears about losing public health insurance and income supports, and Wisconsin will centralize diverse agencies to provide services through multi-disciplinary teams.

In October, CMHS co-sponsored the National Suicide Prevention Conference, the first formal examination of suicide and suicide prevention by Federal agencies and private sector organizations. Surgeon General David Satcher, M.D., and CMHS Director Bernard S. Arons, M.D., addressed the conference, attended by more than 400 leaders in the public health and mental health fields attended. Organized by the Suicide Prevention Advocacy Network, a national grassroots group, this conference produced a National Strategy for Suicide Prevention.

The Surgeon General's Report on Mental Health is currently being written. The HHS Secretary Donna Shalala has designated CMHS as the lead agency in developing the Surgeon General's report. This honor presents an extraordinary opportunity for CMHS to focus public attention on: promoting mental health; ending the stigma associated with mental illness; encouraging early recognition and intervention for mental health problems; and promoting effective, appropriate service delivery systems that enhance mental health treatment for millions of Americans in their own communities.

LEGISLATIVE UPDATE

The 104th Congress did not introduce a bill to reauthorize the Substance Abuse and Mental Health Services Administration (SAMHSA). However, previous roadblocks to reauthorization concerning a formula fix for the distribution of performance partnership block grants to the States have been resolved. In addition, the House Speaker designate has indicated a desire to stop creating task forces to address policy issues and to return to the usual order. As a result, the House Commerce Committee should be able to proceed with authorization of programs under its jurisdiction, including SAMHSA.

SAMHSA seeks reauthorization for the 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 partnership grants. Performance partnership block grants would consolidate the 12 required State plan criteria for community mental health services into five criteria and would reduce the number of mandatory requirements for substance abuse plans.

Other discretionary CMHS grant authorities were proposed for consolidation 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 State and local levels.

Appropriations

The Omnibus Appropriations Act provided $514 million for CMHS in fiscal year 1999. This is a $62.5 million increase or a 14-percent increase over fiscal year 1998. The KDA received an increase of $40 million for a Violence Prevention Initiative, the Children's Mental Health Services program received an increase of $5 million, Protection and Advocacy programs got a $1 million boost, PATH received an increase of $3 million, and the Mental Health Performance Partnership Block Grants Program received an increase of $13.4 million, which means no state will receive less than its fiscal year 1998 allotment.

Center for Mental Health Services Proposed FY 1999 Budget

CMHS Director Bernard S. Arons, M.D., delivered a number of speeches at mental health conferences throughout the country. Presentations included a keynote speech at the National Briefing on Managed Health Care for Foundations Grant Makers Meeting in Dallas/Fort Worth, Texas and remarks on school violence and suicide at the 126th Annual Meeting of the American Public Health Association in Washington, DC.

Dr. Arons moderated a panel on "New Trends in Integrated Community Service" during the 40th anniversary celebration of Woodley House Programs in Washington, D.C. Dr. Arons also participated in a discussion on women and depression with talk show host Jack Shapiro on "MediPolitics," a syndicated radio show that airs on 40 stations nationwide.

PROGRAM ACTIVITIES AND INITIATIVES

Thomas H. Bornemann, Ed.D., CMHS Deputy Director; and his colleagues, Brian Flynn, Ed.D., Director, Division of Program Development, Special Populations, and Projects; and Robert DeMartino, M.D., of the same Division, received Public Health Commissioned Corps Honor Awards. They received these awards for contributing to increased international understanding of disasters and emergency mental health. In February 1997, the Russian Minister of Health and the U.S. Secretary of the Department of Health and Human Services (HHS) identified disaster and emergency mental health issues as a new area of potential collaboration under the Gore-Primakov Commission Health Committee. Since that time, a number of activities between the two Nations have established this area as one of true international collaboration.

The Russian minister and HHS Secretary participated in a series of discussions and symposia at three sites in the Russian Federation this Fall. This third in a series of bilateral visits solidified areas of potential collaboration, which include: developing a glossary of mental health terms and common language; reviewing training curricula to determine its common applicability; developing evidence-based "fear containment" messages for distribution to the media and others at the time of a disaster; examining data analysis and evaluation opportunities; exploring opportunities to use telemedicine; and creating a database of disaster/terrorism institutions and specialists with the potential of establishing an international society.

Associate Director for Medical Affairs

Two new programs were recently funded for this fiscal year: (1) the HIV/AIDS Treatment Adherence, Health Outcomes, and Cost Study; and (2) the Mental Health Care Provider Education II Program. The first study will determine the specific costs of providing integrated HIV, mental health, and substance abuse services for people living with HIV/AIDS. This 5-year study is being funded by several agencies and will be conducted by eight universities, research institutions, hospitals, and a coordinating center.

Findings from the HIV/AIDS Mental Health Services Demonstration Program about the mental health needs of people living with or affected by HIV/AIDS continue to be disseminated. This knowledge is expected to shed new light on approaches to providing integrated care to persons with HIV/AIDS. Policy makers, health care providers, and others who serve this population will have the opportunity to learn from the experiences of the 11 grantees involved in the program and to replicate the most promising approaches in their communities.

Office of Managed Care

CMHS and the Center for Substance Abuse Treatment (CSAT) released the results of a major study of national expenditures for mental health, alcohol, and other drug abuse treatment on September 15, 1998. This study, the first major update of spending estimates since those published by Rice et al., in 1990, is the result of a collaborative effort between the managed care offices in the two centers. Estimates will be presented by payer and type of provider for 1996, and trends since 1986 will be identified. The study will also provide estimates that allow for a direct comparison with those published by the the Centers for Medicare and Medicaid Services for all health care.

Major findings from the study were published in the September/October issue of Health Affairs. A full report is available from CSAT and CMHS. Unlike previous studies, CMHS and CSAT will update these estimates annually to maintain current information on national spending for MH/SA services.

Office of External Liaison

The Office of External Liaison (OEL), in conjunction with the public affairs office of the Center for Substance Abuse Treatment, conducted a press conference on September 15, 1998, to unveil the findings of the "National Expenditures for Mental Health, Alcohol and Other Drug Abuse Treatment, 1996" study (see Office of Managed Care section for details). The press conference drew reporters from 17 trade publications and generated 20 newsletter articles.

During Mental Illness Awareness Week (October 4-10), OEL issued a series of press releases to inform the public about CMHS' 15 new grant programs totaling $45 million. As a result, The Washington Post quoted Melvyn R. Haas, M.D., Associate Director for Medical Affairs, regarding the CMHS "Cooperative Agreements for the Mental Health Care Provider Education in HIV/AIDS Program II" and its relevance to this year's 12th annual "AIDS Walk Washington."

OEL media efforts for Mental Illness Awareness Week also resulted in the placement of an Op-ed crafted by CMHS Director Bernard S. Arons, M.D., in the Sunday, October 4 edition of the Chicago Sun Times (circulation of 501,115) and the Thursday, October 15 edition of the Charleston Gazette (circulation of 104,647).

OEL arranged for a CMHS exhibit at "4 Your Health and Fitness Expo," sponsored by WRC-TV, the NBC affiliate in Washington, DC. The event is expected to attract more than 70,000 individuals to the Washington, D.C. Convention Center in January.

OEL Consumer Affairs Office staff chaired a Mental Health Section town hall meeting on Public Health Citizen Involvement attended by approximately 100 participants of the American Public Health Association (APHA) conference. Staff also organized a meeting for more than 40 consumers and family members on increasing consumer involvement in APHA.

Staff continue to manage and participate in the SAMHSA-wide Consumer Bill of Rights Workgroup that is implementing a plan for promoting adherence to the President's Advisory Commission Consumer Bill of Rights and Responsibilities.

CMHS is currently forming a Planning Group of representatives from national consumer organizations to assist in the development of a Consumer Subcommittee to the CMHS National Advisory Council. This group will meet via teleconference and in-person.

Consumer Affairs staff are managing the production of a consumer training video. The video, which will focus on first-person consumer accounts, will be used to raise awareness and knowledge on service delivery issues among residents of psychiatry programs

On September 15, 1998, the Consumer Affairs Office sponsored the Northwest Regional Consumer Meeting in Seattle, WA, attended by more than 50 representatives from Washington, Oregon, Alaska, and Idaho. State participants discussed their most pressing needs and developed a list of priorities: (1) funding and expansion of consumer self-help and peer support efforts; (2) meaningful consumer participation in mental health systems; (3) housing; (4) employment; (5) insurance parity; and (6) holistic approaches and treatment alternatives

On October 8, 1998, staff addressed a United Nations event focusing on human rights and mental health issues to commemorate 1998 World Mental Health Day.

On November 9 and 10, 1998, the Consumer Affairs Office convened the National People of Color Consumer/Survivor Summit. The event brought together more than 40 participants form across the nation to examine the impact of health care reform on people of color and to develop strategies to improve consumers' lives.

Consumer Affairs staff provided consultation to the Center for Substance Abuse Treatment's "Recovery Community Support Grant Program," a new effort focusing on development of consumer initiatives in the substance abuse/addictions response systems.

Consumer Affairs staff also conducted several training sessions including: (1) In-service training on mental health issues for more than 50 managers of equal employment offices at the U.S. Department of Transportation; (2) In-service training on the changing trends associated with integrating consumerism with holistic and alternative health care approaches; and (3) An orientation about community mental health support services to consumers and staff of the National Institute of Health's Clinical Center.

SAMHSA's National Mental Health Information Center recently received a national Key Resource award for the outstanding quality and accessibility of its Web site. The Information Center Web site continues to grow. On average, more than 30 new links, many of them reciprocal, are added each month. The number of Information Center Web site users is also increasing. On its single most active day, the Information Center was contacted 15,268 times.

Office of Policy, Planning, and Administration

CMHS is involved in a project to examine the issues and obstacles facing vulnerable families affected by welfare reform. Vulnerable families are defined as families with young children in which mental illness, substance abuse, or domestic violence are present. To carry out this project, CMHS awarded a professional services contract to the National Center for Children in Poverty, Columbia University School of Public Health. The purpose of the contract is to assess state-of-the-art practices designed to enhance the lives of the most vulnerable of these young children and families. On October 29, 1998, researchers, early interventionists, mental health and substance abuse administrators, and welfare and child welfare administrators met to create an Issue Brief and a Resource Guide focusing on this topic.

In November, CMHS and the National Cancer Institute co-sponsored a meeting about the effects of serious parental illnesses such as cancer, multiple sclerosis, HIV/AIDS, or depression on children. This joint meeting convened researchers, policy makers, service providers, advocates, and youth and adult consumers to discuss the extraordinary challenges faced by children who have a parent with a serious illness. The primary goals for the meeting were to define service delivery needs for these families, identify gaps in the literature base, address research priorities and promising interventions, and explore innovative public and private partnerships. Representatives from the Health Resources and Services Administration, the National Institute of Mental Health, and the Department of Education attended and will conduct a follow-up meeting to discuss relevant projects and future collaborations.

Division of Knowledge Development and Systems Change

The omnibus spending agreement for fiscal year 1999 allocates an additional $40 million to the KDA program to improve mental health services for children with emotional and behavioral disorders who are at risk of violent behavior. This initiative will assist schools in identifying and addressing the mental health needs of children and in preventing aggressive behaviors. CMHS intends to work with the Department of Education and other Federal partners to develop a coordinated approach to violence prevention in the schools.

Discussions with the the Centers for Medicare and Medicaid Services (CMS) may foster use of evidence-based assertive community treatment (ACT) in States that have not already adopted the practice. As a result, the Medicaid Bureau Director may encourage all States to promote and fund ACT. In addition, CMS may distribute descriptions of ACT minimum practice standards and models of appropriate Medicaid funding mechanisms.

Findings on emerging exemplary mental health practices generated by CMHS and other agencies will be translated into easy-to-read pamphlets for members of State planning and advisory councils. Developed by the National Association of Mental Health Planning and Advisory Councils, these pamphlets will further the development of State mental health service plans mandated by the block grant statute.

CMHS and the National Institute of Corrections are collaborating on improving the partnerships between mental health and corrections agencies that provide services to adults or juveniles with mental illness who are either incarcerated or part of a community corrections system.

Child, Adolescent, and Family Branch

Fifty key professional and family members involved in Comprehensive Community Mental Health Services Program for Children and their Families grants participated in a 5-day Leadership Academy. The training was based on the model developed by Ronald Heifetz, author of Leadership Without Easy Answers. The second half of the Services grantees will receive the training in January. Eventually, all Family Network and Circles of Care grantees will also receive the training.

A poster featuring Native American Children has been created for use within the Services Program, Circles of Care, and the general public.

To ease start-up issues for the 14 new grantees, the Branch has developed a 2-day training conference. In addition, seven grant applications for the CARING FOR EVERY CHILD'S MENTAL HEALTH: Communities Together campaign are in the peer review process.

Community Support Programs Branch

Eleven Hispanic organizations across the Nation were awarded a total of $1.5 million in 1-year community action grants. These grants will enable Hispanic communities to implement best practices for persons with mental health and/or substance abuse problems. The grantees were selected because they presented established, evidence-based models demonstrating effective outcomes.

Fifteen programs in 10 States were awarded a total of $8.5 million in grants to develop effective integrated systems for treatment and care of women with co-occurring mental health and substance abuse disorders who are victims of violence. This two-phase "Women and Violence Study" is expected to generate valuable knowledge on the confluence of violence and co-occurring mental health and substance abuse disorders affecting women and their children. Research has shown that existing health care systems are inadequately designed and are unprepared to address either the problems of co-occurring disorders in women and the associated violence or the effects on their children.

Homeless Programs Branch

Findings from the Access to Community Care and Effective Services and Support (ACCESS) Program were published in the November 1998, American Journal of Public Health. The findings were based on data obtained on baseline client characteristics, use of services, and outcomes at 30 and 12-month intervals. Complete follow-up data were obtained from 1,340 clients, or 73 percent. The study concluded that service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.

The Homeless Programs Branch and other Federal agencies sponsored a joint symposium to review nearly two decades of research on solutions to homelessness. The meeting participants reviewed 11 commissioned papers that summarized work in epidemiology, housing, and health services. The papers are being revised based on input from the symposium, and a joint report from the Departments of Health and Human Services and Housing and Urban Development will be issued in Spring 1999.

Branch staff made several presentations at the APHA conference held in Washington, D.C. in November. Findings from several Branch grant programs were part of the agenda including ACCESS, the prevention of homelessness, and the study of housing alternatives.

Data from the Projects for Assistance in Transition from Homelessness (PATH) Program for grantee performance for fiscal years 1995 and 1996 have been edited and formatted fore the release of a final report in late November. Data for FY97 will be ready in early 1999.

The Branch and the American Psychiatric Association sponsored a joint one-day seminar at the Psychiatric Services meeting in Los Angeles in October. The event, held annually, is directed at encouraging psychiatric residents to devote a portion of their work to homeless individuals with serious mental illnesses.

Branch staff provided technical assistance to the ACCESS grantee in Kansas City, MO, for developing a strategy to integrate its services system as the ACCESS grant terminates. The site, a comparison city, provided services in a non-integrated environment for the past 5 years and wanted to be poised to reform its system beginning in 1999.

DIVISION OF PROGRAM DEVELOPMENT, SPECIAL POPULATIONS, AND PROJECTS

The Program in Trauma and Terrorism, directed by Robert DeMartino, M.D., has been actively raising awareness about the serious potential costs of behavioral and psychological damage in the wake of a bioterrorist event. Dr. DeMartino helped prepare the Department of Justice's Five-Year Inter-Agency Counter-Terrorism and Technology Crime Plan and will serve on the 10-member HHS Anti-Bioterrorism Strategic Planning Committee. Dr. DeMartino has also participated in briefings on bioterrorism for the Surgeon General and the Assistant Secretaries of Planning and Evaluation at HHS and the Department of Defense.

CMHS has taken the SAMHSA lead in mounting a department-wide effort focused on suicide and suicide prevention. A collaborative effort with CDC, NIMH, and community and national organizations such as SPAN (Suicide Prevention Advocacy Network) culminated in the co-sponsorship of a National Suicide Prevention Conference, held October 15-18, 1998, in Reno, Nevada.

Emergency Services and Disaster Relief Branch

This Branch works with the Federal Emergency Management Agency (FEMA) to help States provide effective mental health services in response to disasters. So far this calendar year, 23 crisis counseling programs, serving victims in 35 States and territories, have been initiated. Over $8.5 million has been directed to these programs.

An inter-departmental work-group for responding to youth violence in schools is underway with the Departments of Justice and Education. In addition, the new training video "Hope and Remembrance" was developed which focuses on the effects of a disaster's anniversary on its victims/survivors and shows how mental health services can help victims/survivors at this time.

Special Programs Development Branch

Cultural Competence Standards in Managed Care for Underserved/Underrepresented Racial/Ethnic Groups, a consensus document, is now available on both the CMHS and the Information Center web sites. The document synthesizes the findings of four work groups who developed cultural competence standards and guidelines for people of African descent, Asian and Pacific Islanders, and Latinos and American Indians, and Native Alaskans and Native Hawaiians. Many of the guidelines and standards have been adopted by associations and organizations around the country.

Elzbieta Gozdziak, Ph.D., Public Health Advisor, and John Tuskan, R.N., were instrumental in planning the November 9-11 annual conference of the Office of Refugee Resettlement in Washington, D.C. Dr. Gozdziak and Mr. Tuskan also organized, facilitated, and presented at several sessions on aggression and violence, torture victims, victims of domestic violence, spirituality and mental health, and women's and intergenerational issues. The conference had more than 800 participants from nonprofit organizations, government agencies, community-based agencies, and the United Nations High Commissioner for Refugees.

CMHS has contracted with the Georgetown University Child Development Center to develop a monograph for helping administrators of early childhood programs with the task of hiring mental health consultants. Staff who work in early childhood settings increasingly deal with children who have behavioral problems, who are at risk for mental disorders, and whose parents feel great stress due to a number of difficulties. The monograph will be a practical document with guiding principles and explicit examples of how a mental health consultant can help a particular staff member or program.

"Healthy People 2010," a public/private initiative, will define the Nation's agenda to promote health and prevent disease. As with "Healthy People 2000," the new version will contain a section dedicated to mental health. A draft of "Healthy People 2010" was released on September 15, 1998, for public comment. A summary of the main points are posted on the "Healthy People" Web site at http://web.health.gov/healthypeople. CMHS welcomes comments from both the Advisory Council and the public. Following review, comments will be incorporated into the final document for release to the public in January 2000.

CMHC Construction Grant Monitoring Branch

In FY99, the Branch will collaborate with the Special Programs Development Branch to identify best practices and to develop community-based consultation and education models for rural areas.

DIVISION OF STATE AND COMMUNITY SYSTEMS DEVELOPMENT

The State Planning and Systems Development Branch (SPSDB) has recently reviewed the State mental health block grant plans/applications for FY99. Consultative reviews were held in Portland, Maine; Albuquerque, New Mexico; St. Paul, Minnesota; Portland, Oregon; and Tampa Florida in October and November. Each review panel was comprised of consumers, State mental health officials, family members of both adults and children, advocates, and community-based providers of mental health services. All States now have approved plans. States will submit their FY98 Implementation Reports on December 1, 1998.

The Branch is drafting regulations for State Block Grant programs. A number of issues are being addressed through these regulations including simplifying the format for the State plan and providing a more appropriate degree of Federal oversight while decreasing burdensome requirements for States and Territories.

The Block Grant Program held a focus group during October to help with organizing the annual national meeting of State planners and mental health planning councils to be held in the Washington area in the spring.

The Block Grant Program has been receiving funding at the $275 to $288 million dollar level for the past 10 years. A modest increase of $13 million was received due to the formula adjustment for FY 1999 and FY 2000. HHS Secretary has requested an increase to the $375 million dollar level.

The Block Grant Program has been an active participant in the SAMHSA-wide planning group that sponsored four training meetings, in conjunction with the the Centers for Medicare and Medicaid Services, on managed care contracting throughout the country. The two-day training sessions were held during September and October in San Diego, California; Alexandria, Virginia; Atlanta, Georgia; Portland, Oregon; and Washington, D.C. Each State was invited to send a delegation of six individuals representing mental health, substance abuse, and Medicaid agencies; consumers and family members; and local government officials.

The Branch is collaborating with the Survey and Analysis Branch on the 16 State Performance Indicator Pilot Project. A kick-off meeting of the 16 States was held in Washington, D.C. in November. This project will help States uniformly report on a number of performance indicators with a focus on outcome indicators and measures. It is a follow-up to the 5 State Feasibility Study of performance indicators that concluded earlier this year. Both projects have helped to build a bridge between the data and planning components of federal and state mental health programs.

The cooperative agreement with the National Technical Assistance Center (NTAC) has entered a new funding cycle. NTAC will assist in providing technical assistance to the States. NTAC has provided valuable assistance in developing a national needs assessment of State mental health agencies. The Division is exploring a number of new initiatives, including providing technical assistance to States based on need and requests received from the States. Discussions are also underway to involve historically Black colleges and universities and higher educational institutions with large numbers of Hispanic students as a resource for training mental health professionals who serve African American and Hispanic populations.

Survey and Analysis Branch

One focus within CMHS on quality measurement is the accurate assessment of client outcomes. Outcomes are particularly important as they play a growing role in payment systems. State and local agencies increasingly are using managed care approaches and performance-based contracting for child mental health and child welfare services. However, these agencies do not have outcome measurement systems to support these approaches.

To help such agencies develop outcome-based accountability systems, the CMHS Outcomes Roundtable has produced a monograph, "Fitting the Pieces Together: Building Outcome Accountability in Child Mental Health and Child Welfare Systems." This monograph reflects an interdisciplinary and parental perspective on children's mental health, substance abuse treatment, child welfare, and other social services.

CMHS staff assisted the Mental Health Section of the American Public Health Association (APHA) in hosting a town hall meeting. This meeting was open to the public and focused on the new role citizens are playing to promote health and prevent health problems in their communities. Representatives from many groups such as churches, labor unions, disability organizations, and mental health consumer associations attended. An ad hoc steering committee was created to organize interested parties and to formulate an initial budget for submission to the APHA. In addition, for the first time, free screenings for depression, diabetes, and high blood pressure were provided to APHA registrants. More than 250 people were screened for depression, and an additional 250 people visited the depression booth to request screening forms.

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