TRANSFORMING MENTAL HEALTH CARE IN AMERICA
The Federal Action Agenda: First Steps
The Federal Mental Health Action Agenda
Fundamentally Altering the Mental Health System
The Federal Mental Health Action Agenda offers an unprecedented opportunity to fundamentally alter the form and function of the mental health service delivery system in this country to one that puts individuals-adults with mental illnesses, children with emotional disturbances, and family members-at its very core. Gone will be a system in which outmoded and contradictory regulations dictate the services an individual receives and the funding that is available. In its place will be a seamless system of care designed to help children, adults, and older adults achieve their maximum potential in all spheres of life and at all points in their development.Transformation of the mental health system will not be easy, nor will it happen overnight. Such wholesale change requires an unparalleled commitment on the part of the Federal government, State governments, communities, public- and private-sector providers, insurers, researchers, consumers, and family members to work together toward a single vision: the day when all adults with serious mental illnesses and all children with serious emotional disturbances live, work, learn, and participate fully in their communities. This Federal Mental Health Action Agenda represents the response of those Federal agencies that have a vital role to play as a catalyst for change at the State and local level.The President's Executive Order 13263 [Appendix A] articulated five principles around which the New Freedom Commission on Mental Health framed its work. These principles embody the vision of transformation that will guide the challenging but necessary work that lies ahead. Each principle is listed below followed by a description of what a transformed mental health system will look like when this principle is applied-the "state of success" over the long term. Specific action steps for each principle represent those immediate activities that Federal agencies will initiate, not to improve on the status quo, but to begin the process of wholesale transformation of the mental health service system called for by the Commission and embraced by the President. Representative current Federal activities that reflect each of the principles are highlighted.
This is not the end of the work that lies ahead; it is, instead, a very exciting and productive beginning of a long-term process that will alter the face of mental health care in this country for generations to come.
Principle A: Focus on the desired outcomes of mental health care, which are to attain each individual's maximum level of employment, self-care, interpersonal relationships, and community participation.
The State of Success
In a transformed mental health system:
Americans seek mental health care when they need it, with the same confidence that they seek treatment for other health problems.
The stigma that surrounds both mental illnesses and seeking care for mental illnesses is reduced or eliminated.
The rate of suicide in the United States is reduced significantly.
Recovery experiences are identified, valued, and promoted as evidence-based practices.
Mental health services are readily available in the most integrated, community-based setting possible. Parents no longer have to relinquish custody of their children to secure needed mental health services.
A telecommunication-based personal health information system enables every American, particularly those in rural areas for whom access to care is problematic, to obtain, maintain, and share reliable information that is crucial to his or her recovery.
Initial Action Steps
Action:Initiate a National Public Education Campaign
The Substance Abuse and Mental Health Services Administration (SAMHSA) in the Department of Health and Human Services (HHS) will convene an interagency, public-private sector workgroup to plan, create, and begin coordinating and evaluating a targeted public education campaign designed to:
- Improve the general understanding of mental illnesses and emotional disturbances;
- Make clear that recovery is possible; and
- Encourage help-seeking behaviors across the age span.
In addition, suicide prevention messages will be part of the awareness campaigns in many States and communities (see action step below). The workgroup will include mental health consumers and family members, and representatives of private- and public-sector groups with experience in developing effective public health education campaigns. Participants will be requested to pool resources to fund a mutually acceptable, comprehensive campaign over 3 years.
The public-private workgroup will develop a plan that will:
- Target educational efforts to specific sectors of America's population, e.g., racial and ethnic minorities, rural communities, education, labor, housing, primary care providers, etc. The group may convene roundtables representative of each sector to solicit recommended approaches to stigma reduction.
- Identify and promulgate research-based public health messages and activities.
- Support local efforts to reduce stigma by using SAMHSA's National Mental Health Information Center as a primary point of contact for information, publications, and service program referrals.
- Develop and initiate a marketing campaign, targeted at public and private employers, that makes a business case for hiring people with psychiatric disabilities.
Action:Launch the National Action Alliance for Suicide Prevention
HHS will launch the National Action Alliance for Suicide Prevention, a public-private partnership that will oversee full implementation of the National Strategy for Suicide Prevention. The Federal agencies that helped develop the National Strategy for Suicide Prevention will contribute expertise and financial resources to support the work of both the public and public-private collaborative efforts. In particular:
- Federal agencies will continue their support for the Suicide Prevention Resource Center (SPRC). The SPRC will provide assistance in planning and program implementation, identification of evidence-based practices, and program evaluation.
- Through the Hotline Evaluation and Linkage Program (HELP) managed by SAMHSA, Federal agencies will:
- Create a mechanism to certify or accredit 200 suicide/crisis hotlines nationwide; linking the hotlines through a centralized, toll-free number; and provide a local mental health resources database for their use.
- Gather evidence to support or refute (1) within-call effectiveness of crisis hotline interventions; (2) use and acceptance of a linked, locally based, toll-free crisis hotline; (3) reduction of self-harming behaviors; and (4) effectiveness of crisis hotline interventions to promote the use of community mental health resources for post-crisis care.
- The National Action Alliance for Suicide Prevention will garner broad stakeholder support, leverage both public and private resources, and coordinate national efforts to prevent suicide.
- SAMHSA will complete the Indicators of Success initiative, through which baseline data will be gathered for each of the National Strategy for Suicide Prevention's 11 goals and 68 objectives.
- The National Institute of Mental Health's (NIMH) Suicide Research Consortium will continue to identify new centers of excellence and manage an aggressive suicide prevention research portfolio.
- The Centers for Disease Control and Prevention (CDC) will initiate and expand several activities to improve the ability to measure and monitor fatal and nonfatal suicidal behavior, among them:
- The National Violent Death Reporting System, which provides objective, high-quality data useful for monitoring the magnitude and characteristics of violent deaths, and for developing and evaluating prevention programs and policies.
- The National Electronic Injury Surveillance System, which will be expanded through a collaboration between CDC and the Consumer Product Safety Commission to collect surveillance data on all types of unintentional and violent injury in a national sample of cases treated at hospital emergency departments.
- A scientific process, overseen by a panel of experts, to develop uniform definitions for self-directed violence.
Action:Educate the public about Men and Depression
NIMH will continue its "Men and Depression" Campaign, a major HHS public information effort to encourage men and their families to recognize depression-the illness that causes the most disability in America-and seek treatment.
Action:Respond to refugees' mental health needs
The Administration on Children and Families' (ACF) Office of Refugee Resettlement (ORR) and the Center for Mental Health Services (CMHS) will continue to develop their intra-agency agreement through which CMHS staff will provide the following services to ORR:
- Technical assistance and consultation on mental health and social adjustment issues to resettlement agencies and community-based organizations.
- Expert consultation on new program initiatives in refugee mental health.
- Education and consultation to public and private mental health clinics and programs about the mental health and social adjustment needs of refugees.
- Regional workgroup meetings, conferences, and symposia on refugee mental health needs and emerging issues that affect refugee groups.
- Response to refugee emergencies or special initiatives.
Action:Develop prototype individualized plans of care that promote resilience and recovery
Individualized plans of care must be developed in full partnership with consumers and family members, must include evidence-based and promising practices in prevention and treatment, and must promote resilience and recovery, including integrated employment that pays above minimum wage, includes benefits, and provides for career advancement. To this end, CMHS will design and initiate a project to:
- Convene a consensus development meeting to discuss the meaning and process of mental health recovery for children, adults, and older adults. Consumers and families will be actively involved in developing knowledge about recovery and in contributing to measurement development activities currently underway.
- Review current best practices in the field for individualized recovery plans that can be customized for children, adults, and older adults. Consensus panels will be used to assess evidence and recommend model plans.
- Design a prototype individualized recovery plan that includes evidence-based and promising practices, and that is flexible enough to change over time.
- Disseminate this prototype model through appropriate technical assistance.
Action:Provide technical assistance on resilience and recovery
CMHS will continue to fund Consumer and Consumer Supporter Technical Assistance Centers. The Centers help improve State and local mental health service systems by providing consumers and their supporters, service providers, and the general public with skills to foster self-help approaches. In addition, CMHS will continue to fund family technical assistance and resource centers to help State and local mental health service systems work collaboratively with families and youth to promote delivery of child- and parent/family-driven care.
Action:Promote the use of customized employment strategies
The Department of Labor (DOL) will work with the Small Business Administration, the Rehabilitation Services Administration, HHS, and the Social Security Administration (SSA) to generalize to the mental health community the customized employment model established by the DOL Office of Disability Employment Policy. This not only includes self-employment, micro-enterprise, and small business development, but also the use of Individual Training Accounts and Individual Development Accounts to focus on training, support, and accommodations for people with psychiatric disabilities. The goals of this effort are to help underemployed and unemployed individuals achieve competitive employment based on individual choice; increase earnings, benefits, and career development opportunities; and use technology to promote employment.
Action:Promote the transition of youth with serious emotional disturbances from school to post-secondary opportunities and/or employment
The Department of Education's (ED's) Office of Special Education and Rehabilitation Services will work with DOL, SAMHSA, and SSA on this issue. Activities will include researching, demonstrating, and disseminating successful strategies to transition youth and young adults with mental disorders into employment and developing policy, regulatory, and systemic change to ensure that strategies are implemented. These activities will be coordinated with SAMHSA's Partnerships for Youth Transition Grants Program (see Principle E).
Action:Develop an employer initiative to increase the recruitment, employment, advancement, and retention of people with psychiatric disabilities
DOL will increase the participation of people with psychiatric disabilities in high-growth industries and expanding sectors of the economy by marketing to employers the business case for hiring these individuals. Employer focus groups will be used to identify barriers to hiring people with psychiatric disabilities. The initiative will involve local business leadership networks, Chambers of Commerce, and various trade associations. This initiative also will include working with the Federal government to increase the hiring of people with psychiatric disabilities.
Action:Assist youth with serious emotional distubances who are involved with the juvenile justice system to transition into employment
DOL will work with the Department of Justice (DOJ) and SAMHSA to identify youth with serious emotional disturbances who are involved with the juvenile justice system. Once these potential workforce development customers are identified, DOL, through its One-Stop Centers, will support their efforts to find employment in the community.
Action:Promote employment of people with psychiatric disabilities who are chronically homeless
DOL and the Department of Housing and Urban Development (HUD) will jointly fund five chronically homeless employment 5-year demonstration grants. These grants are system-change grants. DOL will fund a Technical Assistance Initiative to support these projects, along with identifying and disseminating information on effective practices. SAMHSA's PATH program and its other homeless initiatives will be linked with these grants and the workforce development system.
Action:Establish a DOL Work Group to promote quality employment of adults whith serious mental illnesses and youth with serious emotional disturbances
Under the auspices of its Office of Disability Policy, DOL will convene an intra-Department workgroup to develop a multi-pronged strategy, including policy research and demonstration grants, to promote quality employment outcomes for adults with serious mental illnesses and youth with serious emotional disturbances. A uniform data collection system will be developed to provide a clear picture of the impact of DOL's programs, including discretionary grants, Workforce Investment Act-mandated programs, and other programs not mandated by the Workforce Investment Act. Based upon this information, a research agenda will be developed.
Action:Provide treatment and vocational rehabilitation that support employment for people with mental disabilities
The SSA's Mental Health Treatment Study will determine the effect of treatment funding on the health, health care, and job-seeking behaviors of disability beneficiaries for whom a mental disorder is the primary diagnosis. The study will pay for outpatient mental health treatments (pharmaceutical and psychotherapeutic) and/or vocational rehabilitation services that are not covered by other insurance.
Action:Conduct outreach to homeless individuals with mental disorders
Congress appropriated $8 million for SSA to conduct outreach to homeless individuals, including those with serious mental illnesses, and other underserved populations. SSA awarded cooperative agreements with medical and social service providers currently doing outreach to homeless people to help connect these individuals to benefits for which they are eligible.
Action:Initiate a national effort focused on meeting the mental health needs of young children as part of overall health care
A Task Force of the Federal Executive Steering Committee (described below under Principle B) will focus on the mental health needs of young children. The Task Force will do the following:
- Develop a national public education plan for parents, providers, and policy makers about the importance of the first years of life in developing a healthy foundation for social, emotional, and cognitive development.
- Propose a comprehensive approach at the Federal and State levels for the appropriate intervention for children identified to be at risk for mental disorders in early childhood settings; educating and training professionals and families in effective treatment approaches and supports for young children identified to be at risk and their parents; and eliminating disincentives and barriers, particularly in financing systems, to serving this population.
The national effort will build on and coordinate Federal and State programs that are intended to address the needs of at risk young children and their parents, such as:
- Head Start;
- Parts B and C of the Individuals with Disabilities Education Act (IDEA);
- ACF's Child Care Development Fund;
- Early and Periodic Screening, Diagnosis, and Treatment (EPSDT);
- The Health Resources and Services Administration's (HRSA's) State Maternal and Child Health Early Childhood Comprehensive Systems Grants and federally funded health centers; and
- DOJ's Safe Start program.
For this and all other proposed actions related to children and adolescents, the Federal Mental Health Action Agenda clearly recognize that parents are the decision-makers in the care for their children and if any services, including screening, appear to be an appropriate action, parental consent must be obtained before it occurs. Parents or guardians should always be included in the process of making choices and decisions for minor children. This same support and guidance can also include family members for individuals older than 18 years of age.
Action:Create a comprehensive action agenda to implement throughout the Veterans Health Administration all relevant recommendations of the President's New Freedom Commission on Mental Health
As the largest provider of comprehensive health services in America, the Veterans Health Administration has created an action agenda for implementing all relevant recommendations in the Final Report of the President's New Freedom Commission on Mental Health. An internal Steering Committee, along with participants from various Federal partners, already has embarked upon this challenging undertaking. The action agenda will drive a sustained effort over time to orient the Veterans Health Administration toward the expectation of recovery and veteran-centered care with a commitment to the provision of evidence-based services.
Action:Launch a user-friendly, consumer-oriented web site
Personal health information systems can help consumers manage their own care while gaining computer literacy skills. To this end, CMHS will explore investing in the development of a user-friendly, consumer-oriented web site-such as the San Diego Network of Care for Mental Health-in 25 geographically diverse locations around the country. The San Diego web site was featured as a model program in the Final Report of the President's New Freedom Commission. It provides information on mental illnesses and community resources, and gives individuals and family members the ability to create personal health records on a secure server. Consumers can control personal health records, and the privacy of such records is protected according to the regulations of the Health Insurance Portability and Accountability Act (HIPAA). The Federal funding will serve as seed money to the local jurisdictions, which will fund ongoing development and support of this vital resource to place mental health information and services as close as the nearest Internet connection. Information technology accessibility for all individuals with disabilities is mandated by Section 508 of the Rehabilitation Act and is a cornerstone of the President's New Freedom Initiative.
Action:Promote ADA compliance, support and work to eliminate unnecessary institutionalization, and help eliminate discrimination
The Office of Civil Rights (OCR) in the HHS Office of the Secretary, together with the SAMHSA/CMHS New Freedom Initiative technical assistance center, will continue Olmstead voluntary compliance initiatives, including providing technical assistance to States, disseminating information about Olmstead compliance, and promoting Americans with Disabilities Act (ADA) compliance and community care. In keeping with its compliance responsibilities, OCR also will continue to investigate complaints and conduct compliance reviews to protect and enhance the rights of people with mental illnesses under Section 504 of the Rehabilitation Act and the ADA, with particular emphasis on Title II ADA most integrated setting complaints (i.e., Olmstead complaints) and will protect the rights of people with mental illnesses under the HIPAA Privacy Rule to prevent inappropriate disclosures of mental health information to employers.
Selected Current Federal Activities in Support of This Goal
ACTIVITY National Mental Health Information Center
SAMHSA's National Mental Health Information Center serves as a focal point for mental health information and referral to services. This service includes a toll-free call center staffed by English- and Spanish-speaking specialists trained to respond to inquiries about mental health issues and treatments, and to refer callers to appropriate State and local mental health organizations and resources. The Information Center also operates a web site that offers materials targeted to consumers, families, and professionals. See www.mentalhealth.samhsa.gov.
ACTIVITY National Runaway Switchboard and Clearinghouse on Families and Youth
ACF operates the National Runaway Switchboard, providing 24-hours-a-day, 7-days-a-week counseling and referral to youth in crisis, runaway youth, and homeless youth, many of whom are at risk for suicide and other mental health issues. ACF also funds the National Clearinghouse on Families and Youth to provide information and referrals for youth at risk.
ACTIVITY Depression Health Disparities Collaborative
The Depression Health Disparities Collaborative, funded by HRSA, facilitates development of learning opportunities for treating depression as a chronic disease. HRSA will use the infrastructure of the Health Disparities Collaboratives to ensure appropriate treatment protocols for primary health care practices in selected Community Health Centers.
ACTIVITY Collaborative Care Models for People Who Are Chronically Homeless
The HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE) is contributing to the evaluation of 12 SAMHSA- and HRSA-funded service delivery grants to improve access to both behavioral and primary care services for individuals who are chronically homeless. The evaluation is examining clinical outcomes for the collaborative models.
ACTIVITY Initiative for Ending Chronic Homelessness
Through Employment and Housing DOL and HUD jointly fund the Initiative for Ending Chronic Homelessness Through Employment and Housing. The agencies awarded five cooperative agreements to evaluate whether partnerships between employment and permanent housing services result in a higher employment rate for people with disabilities, including people with mental disorders.
ACTIVITY Reducing Transportation Barriers
The HHS' Office of Disability (OD), the Federal Transportation Administration, ED, and DOL are addressing transportation barriers by supporting coordinated State planning efforts that result in action plans to help people with disabilities, including those with serious mental illnesses, have access to available transportation that promotes full community integration.
ACTIVITY Strategic Prevention Framework
SAMHSA's Strategic Prevention Framework is an approach to prevention and early intervention based on the public health model that promotes resilience and facilitates recovery by addressing risk and protective factors. The Strategic Prevention Framework undergirds and aligns all of SAMHSA's prevention and early intervention activities.
ACTIVITY Prevention and Early Intervention Grant Program
SAMHSA's Prevention and Early Intervention Grant Program is a Targeted Capacity Expansion (TCE) grant designed to develop mental health promotion and early intervention services targeted to infants, toddlers, preschool, and school-aged children, and/or to adolescents in mental health care settings and other programs that serve children and adolescents.
ACTIVITY HIPAA Education Card
SAMHSA is developing a HIPAA Education Card to help consumers understand their privacy rights as they relate to HIPAA.
ACTIVITY Application of HIPAA Privacy Rule to Mental Health Issues
The HHS OCR has met with mental health groups to discuss the Privacy Rule under HIPAA and its application to mental health issues and has provided guidance on protecting the privacy of mental health information.
ACTIVITY Resolution of Olmstead Cases
HHS' OCR has resolved more than 100 Olmstead compliance cases to prevent unnecessary institutionalization and help individuals return to their communities; has collaborated with DOJ to develop and implement an alternative dispute resolution program for Olmstead complaints filed with OCR; and has provided technical assistance to approximately 40 States on Olmstead planning.
Principle B: Focus on community-level models of care that effectively coordinate the multiple health and human service providers and public and private payers involved in mental health treatment and delivery of services.
The State of Success
In a transformed mental health system:
- A diagnosis of a serious mental illness or a serious emotional disturbance sets in motion a well-planned, coordinated array of treatments and support services that may involve multiple agencies in a single plan of care. These plans of care give consumers, parents of children with serious emotional disturbances, clinicians, and other providers a genuine opportunity to construct and maintain meaningful, productive, and healing partnerships. Consumers and family members participate directly in planning, delivering, and evaluating community-based treatment and support services and formulating policies that direct these activities.
- Mental health services are accessible to all and responsive to the cultural differences of racial and ethnic minority groups, including their languages, histories, traditions, beliefs, and values.
- The mental health workforce provides evidence-based practices; is ethnically, culturally, and linguistically competent; and reflects the diversity of the individuals it serves.
- Faith-based organizations and leaders are knowledgeable about the effectiveness of mental health services and encourage individuals and families to seek help from mental health service providers where needed. They continue to provide direct services, such as pastoral counseling that helps engage individuals who might otherwise not seek help.
- Rural mental health and public health professionals collaborate to provide evidence-based care.
- Individuals of all ages who are at risk for mental disorders are (with their or their parents'/guardian's consent) appropriately screened for the presence of mental illnesses, emotional disturbances, and substance use disorders in primary care settings; in specialty mental health and substance abuse treatment settings; and in settings where individuals are at high risk for co-occurring disorders, such as the juvenile and criminal justice systems, the child welfare system, and the homeless service system. Mental health services and substance abuse treatment are coordinated or integrated within a program or across a network of services.
Initial Action Steps
Action:Include issues critical to mental health services in health care reform
To help integrate discussions of mental health and physical health concerns, the HHS Office of the Secretary, together with agencies across the Department, will ensure that issues critical to mental health services are considered as a part of any dialogue on health care reform.
Action:Launch the Federal Executive Steering Committee on Mental Health
The Federal government must take a leadership role to promote and model the type of collaborative efforts required for system transformation at the State and local levels. To this end, HHS will lead an intra- and inter-agency Federal Executive Steering Committee to guide the work of mental health system transformation. The Department will:
Action:Build on and expand criminal and juvenile justice and mental health collaborations
Building on the excellent collaboration between SAMHSA, DOL, and DOJ's Office of Justice Programs (OJP) to date, a new initiative will encompass a DOJ/HHS Cooperative Agenda that includes:
- The Serious and Violent Offender Re-entry Program;
- The Mentally Ill Offender Treatment and Crime Reduction Act of 2004;
- Efforts to address the mental health needs of victims of crime, including victims of mass violence and terrorism, and utilization of community-based grief centers; and
- Increased use of evidence-based practices.
OJP and SAMHSA will also continue to develop and support a range of successful criminal justice diversion programs, including crisis intervention teams for police; jail-based diversion; court-based diversion programs such as mental health courts and juvenile justice diversion; and reintegration practices for youth.
Action:Suppoort the Interagency Autism Coordinating Committee
The Interagency Autism Coordinating Committee was created within HHS to coordinate autism research, education, and services efforts. Under the leadership of NIMH, the Committee's primary mission is to facilitate the efficient and effective exchange of information on autism activities among the member agencies and to coordinate autism-related programs and initiatives. NIH, SAMHSA, other HHS agencies, and ED are committee members. Public members of the committee help bring to HHS the concerns and interests of members of the autism community.
Action:Review standards and set guidelines for culturally competent care
HHS will convene a group of representative behavioral health accrediting, licensing, training, and provider organizations and payers to review and adopt standards, and to develop guidelines and strategies to implement culturally competent care.
- At minimum, this interagency, public-private sector workgroup will include:
- Consumers of behavioral health care services, and
- Accrediting bodies for services and workforce training.
- The public-private workgroup will develop a plan to:
- Review existing standards, practice, and research to ascertain the hallmarks of culturally
- Propose additional research to identify key indicators of care that improve quality, access,
utilization, effectiveness, and consumer satisfaction for racial and ethnic minorities.
- Create an operational set of standards, benchmarks, and performance measures for
culturally competent services, and disseminate this information to accrediting agencies,
providers, trainers, and payers.
- Encourage all parties to adopt and implement such expectations in their standards for
services and training.
Action:Create a national Strategic Workforce Development Plan to reduce mental health disparities
A Task Force of the Federal Executive Steering Committee will oversee creation of a national strategic plan to develop a mental health workforce better able to deliver culturally competent, evidence-based, 21st century health care. The creation of a significantly more competent, capable workforce that includes mental health consumers and family members is fundamental to transformation of the mental health service delivery system and is particularly critical to address and eliminate the disparities in mental health care experienced by racial and ethnic minorities in this country.The goal of this effort will be to expand and improve the capacity of the mental health workforce to meet the needs of racial and ethnic minority consumers, children, and families; to address the concerns of rural mental health consumers and family members; to make consistent and appropriate use of evidence-based mental health prevention and service interventions; and to work at the interface of primary care and behavioral health care settings.
The Task Force will convene selected leaders in both public and private behavioral health care to create and manage a national strategic planning process. At minimum, these leaders will represent:
- HHS (SAMHSA, HRSA, ACF, ASPE, OCR, and OD), ED, DOJ, and DOL;
- Graduate and undergraduate training programs;
- Behavioral health care providers;
- National ethnic minority mental health organizations;
- Rural mental health organizations;
- Families; and
- The faith community.
This leadership group will review all relevant existing studies to understand the capacity of the current mental health workforce to provide high-quality, culturally competent services to racial and ethnic minority consumers; to meet the needs of rural consumers and family members; to understand and use evidence-based practices; and to work at the interface of primary care and behavioral health care settings. The results of this review will inform development of the strategic plan to expand and improve the Nation's mental health services workforce.
Action:Initiate a project to examine cultural competence in behavioral health care education and training programs
The President's Commission recommended that all federally funded health and mental health training programs explicitly include cultural competence in their curricula and training experiences. To this end, SAMHSA will initiate a project to examine all current behavioral health care education and training programs that receive Federal funds to help determine the extent to which they:
- Recruit and retain racial and ethnic minority and bilingual trainees.
- Ensure that diversity of the community is reflected among trainees and in the training experience.
- Emphasize the development of cultural and linguistic competence in clinical practice.
- Prepare trainees to work in rural, frontier, and underserved areas.
- Develop and include curricula that address the impact of culture, race, ethnicity, and geography on mental health, mental illnesses, and emotional disturbances; on help-seeking behaviors; and on service use.
- Encourage training and research on multicultural populations and the needs of rural consumers.
- Engage minority consumers and families in workforce development and training.
- Educate trainees about evidence-based mental health interventions.
- Prepare trainees to work in multidisciplinary, integrated treatment settings and systems, particularly at the interface of primary care and behavioral health care treatment.
Action:Advance efforts to integrate mental health and primary care services for racial and ethnic minorities
HRSA and SAMHSA will collaborate to improve access to mental health assessment and treatment for individuals with limited English proficiency and for individuals living in remote, rural, or hard-to-access areas in urban communities. The Agencies will urge State and local agencies to co-locate and integrate behavioral health services within other key systems, such as primary care or faith-based service organizations.SAMHSA will convene a conference on the interface of mental health care and primary care for diverse populations. SAMHSA, HRSA, AHRQ, and the OPHS Office of Minority Health will collaborate to develop a national action agenda that includes leadership development and financing models to advance the integration of mental health services and primary health care for underserved populations, with an emphasis on racial and ethnic minorities.
Action:Participate in the HHS "Close the Gap Intitiative"
A Task Force of the Federal Executive Steering Committee will work closely with the HHS Secretary's Health Disparities Council to ensure that eliminating disparities in mental health services is part of the Department's overall "Close the Gap Initiative" and is a priority for the Health Disparities Council as it shapes and coordinates Department-wide activities.
Action:Develop a National Rural Mental Health Plan
A Task Force of the Federal Executive Steering Committee will work with the HHS Secretary's Rural Task Force to identify and convene key leaders in both the public and private behavioral health care sectors, and will provide leadership and logistical support to develop a national rural mental health plan. At minimum, leaders will include representatives of HHS (SAMHSA and HRSA), the U.S. Department of Agriculture, and rural providers, consumers, and family members. This leadership group will contract with a qualified provider to:
- Circulate the report of the HHS Rural Task Force.
- Develop a plan for action by both the public and private sectors involved in the delivery of behavioral health care services.
- Publish a report of the workgroup's findings and recommendations that address:
- The type and degree of integration of mental health and physical health care;
- Alternative insurance mechanisms, e.g., pool purchasing;
- The impact of non-Federal match requirements for grants;
- Workforce enhancement programs to address the unique requirements of rural and remote geographical areas; and
- The effectiveness of mental health services delivered by distant providers using telehealth technologies.
Action:Promote strategies to apropriately serve children at-risk for mental health problems in high risk service systems
The Federal Action Agenda does not recommend mandatory nor universal screening of children for mental health problems. Parents are the decision-makers in the care for their children and if screening appears to be an appropriate action, parental consent must be obtained before it occurs. For these children, early detection through screening may help parents identify emotional or behavioral problems and assist them in getting appropriate services and supports before problems worsen and have longer-term consequences. Therefore, HHS agencies-including SAMHSA, ACF and its Administration on Developmental Disabilities, AHRQ, OD, and HRSA-together with ED and DOJ will gather and review current screening instruments to determine which are the most developmentally, culturally, and environmentally appropriate for children. Mental health consumers, parents, family members, and youth will participate in this review.
Serious emotional disturbance in childhood can be an important precursor to the development of serious mental illnesses as an adult. Supporting the mental health of children and adolescents with serious emotional disturbance and their parents/guardians is seen as a strategic investment that will create long-term benefits for individuals, systems, and society. Children at risk for development of mental disorders and serious emotional disturbances are seen in numerous service systems, including schools, primary health care clinics, child care programs, the child welfare system, and the juvenile justice system.
This Federal review group will make a commitment to assess the feasibility of implementing one or a combination of these instruments in specific service systems where children identified to be at risk for mental disorders present for care and where providers can work with parents to link children to appropriate services and interventions, as needed. The goal is to recognize emotional and behavioral problems at an early stage so preventive interventions can help forestall future disease and disability and reduce the need for extensive treatment.
Action:Develop a demonstration project for children in foster care
ACF, SAMHSA, and NIMH will collaborate to develop and test approaches to target and meet the mental health needs of very young children who enter the foster care system, a high-risk population with documented poor outcomes. Service and research demonstration grants for foster care early intervention approaches will be developed to support States and communities in implementing and testing effective screening, assessment, and intervention approaches for young children in foster care and their families.
Action:Foster joint responsibility and implementation strategies for children, youth, adults, and older adults with co-occurring disorders
Federal agencies will clarify roles, policies, and funding to fully implement action steps detailed in SAMHSA's Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders. This includes identifying, disseminating, and providing technical assistance on:
- Effective assessment tools and best practices to identify children/adolescents and their parents in the child welfare and juvenile justice systems who have, or are at risk for, emotional disturbances, mental illnesses, or co-occurring mental and substance use disorders.
- Effective approaches, strategies, and best practice examples of service integration models and juvenile justice diversion models.
Further, Federal agencies will identify, disseminate, and provide technical assistance on:
- Effective screening and assessment tools and best practices to identify adults and older adults who have mental illnesses or co-occurring mental and substance use disorders, in both primary care and specialty care settings, and in the criminal justice system.
- Effective approaches, strategies, and best practice examples of service integration models.
Action:Focus on children in the juvenile justice and child welfare systems
SAMHSA will encourage applicants for the Comprehensive Community Mental Health Services Program for Children and Their Families to focus on youth in the juvenile justice and child welfare systems, and to increase the application of evidence-based practices and promising community-based approaches for these youth by designating them as a priority population in the Request for Applications (RFA). These strategies will be shared with the DOJ Office of Juvenile Justice and Delinquency Prevention and ACF for development of future joint funding initiatives.
Action:Include mental health in Community Health Center Consumer Assessments
Based on findings of the U.S. Preventive Services Task Force and the Institute of Medicine Report From Neurons to Neighborhoods: The Science of Early Childhood Development (2000), SAMHSA, HRSA, and the CDC will collaborate to facilitate serving adults and older adults identified to be at risk for depression and, with prior parental consent, children and adolescents identified to be at risk for mental, emotional, and behavioral problems in federally funded Community Health Centers and to coordinate followup treatment with community mental health agencies or other appropriate providers.
Selected Current Federal Activities in Support of This Goal
ACTIVITY Family Voices
HRSA's Maternal and Child Health Bureau and HHS' CDC support Family Voices, a national grassroots network of families and friends who advocates for health care services that are family-centered, community-based, comprehensive, coordinated, and culturally competent for all children and youth with special health care needs.
ACTIVITY Circles of Care
The SAMHSA-funded Circles of Care Grant Program provides technical assistance to tribal governments and urban Indian programs to plan and assess the feasibility of implementing a culturally appropriate behavioral health care system for American Indian and Alaska Native children. Intra-agency agreements with the IHS and NIMH in HHS support technical assistance for program development and a cross-site evaluation.
ACTIVITY National Center for Cultural Competence
HRSA, SAMHSA, and ACF provide funding support to a National Center for Cultural Competence at Georgetown University that helps programs assess, plan, implement, and evaluate culturally competent approaches to health and mental health, particularly for children and their families.
ACTIVITY Rural Workforce Shortages Study
The Western Interstate Commission on Higher Education (WICHE) and the HRSA Office of Rural Health Policy support a contract to study the existing workforce shortages specific to rural communities and to make recommendations that address the findings.
ACTIVITY Tribal Youth Program Mental Health Initiative
Under the DOJ Tribal Youth Program Mental Health Initiative, American Indian and Alaska Native tribal communities receive grants to provide diagnosis and treatment for tribal youth with mental and substance use problems.
ACTIVITY Rural Access to Care for Bureau of Primary Health Care (BPHC) Grantees
A memorandum of understanding between SAMHSA and the HRSA BPHC funds training and technical assistance to improve access to mental health and substance abuse care in rural areas served by BPHC grantees.
ACTIVITY Rural Outreach Grants
The Rural Health Care Services Outreach Grant Program, funded by the HRSA Office of Rural Health Policy, includes 29 projects that deliver mental health or substance abuse services. Many of these projects integrate mental health services with primary care.
ACTIVITY Safe Start
DOJ's Safe Start initiative seeks to prevent and reduce the impact of family and community violence on young children (birth to age 6) by creating more comprehensive service delivery systems. Program sites must demonstrate collaborative partnerships among health, mental health and substance abuse, education, social services, and law enforcement agencies.
ACTIVITY Mental Health in Schools
Mental Health in Schools is a project funded by the HRSA Maternal and Child Health Bureau and SAMHSA's CMHS to support two national training and technical assistance centers. These centers, at the University of California, Los Angeles, and the University of Maryland School of Medicine, help school systems and providers strengthen their ability to address psychosocial and mental health problems in schools. As stated throughout this document, any steps to screen or assess children may only be done with the informed consent of parents/guardians.
ACTIVITY Safe Schools/Healthy Students
ED, DOJ, and HHS established the Safe Schools/Healthy Students Interdepartmental Grant Program. Local Education Agencies that receive grants establish formal partnerships with mental health service systems and law enforcement agencies to promote the healthy development of children and youth and to reduce school violence. These grants do not call for mandatory nor universal screening of school children.
Principle C: Focus on those policies that maximize the utility of existing resources by increasing cost-effectiveness and reducing unnecessary and burdensome regulatory barriers.
The State of Success
In a transformed mental health system:
- The mental health service system relies on multiple sources of financing with the flexibility to pay for effective mental health treatments and services.
- Regulations and funding guidelines relevant to people with mental illnesses and emotional disturbances for housing, vocational rehabilitation, criminal and juvenile justice, disability payments, and education are clarified and coordinated to improve access and accountability for effective services. The burden of coordinating care rests with the system, not with individuals or families.
- Emerging technologies-including computers and video cameras, e-mail, and telephone consultations-overcome geographical and sociocultural distances to provide comprehensive care for individuals in underserved, rural, and remote communities.
- Reimbursement policies of both public and private payers are flexible enough to allow coordination of both traditional clinical care and e-health visits, and to ensure that services delivered through new technologies are suggested and sustained.
- Secure and private electronic medical records enhance communication between informed consumers and health care professionals and improve their discussions about treatment options.
Implementation Action Steps
Action:Educate employers and benefits managers on the practicability of paying for mental health services
A multidisciplinary group of mental health consumers, corporate benefit managers, health care consultants, pharmacy benefit managers, and Employee Assistance professionals will be invited to form an Employer Toolkit Workgroup to review the recommendations of the New Freedom Commission on Mental Health and to suggest a comprehensive approach for employers in selecting and purchasing mental health services. A toolkit for employers to use will contain several items, including a Solution Brief outlining the issues, guidelines for selecting a mental health vendor, recommendations for evaluating performance of mental health vendors, disability programs, and pharmacy vendors. The toolkit will provide guidance for the structure and operations of these various programs, including sample policies and procedures.
Action:Evaluate and report the impact of mental health parity
SAMHSA will continue to study and report on the experiences of California, Vermont, and other States that implement mental health parity legislation.
Action:Initiate Medicaid Demonstration Projects
Medicaid is the largest single funder of public mental health services in this country, with Medicare a significant payer, as well. As such, CMS is a critical player in the Federal response to mental health system transformation. Current Medicaid policies may act as disincentives to the development of community-based services for children, adults, and older adults with mental disorders. Thus, if authorized and funded by Congress, CMS is committed to supporting demonstration projects that will test the feasibility of alternative approaches. These include the following:
- Supported employment. To help individuals with mental illnesses gain and maintain employment, which can be critical to their recovery, CMS is exploring creation of a supported employment demonstration project. Supported employment is considered a mental health evidence-based practice.
- Respite Care Services. If authorized by Congress, CMS will support a demonstration of respite care services for caregivers of adults with disabilities or long-term illnesses, including psychiatric disabilities, and respite care for caregivers of children with substantial disabilities. Respite services that provide temporary relief for caregivers can help individuals with disabilities remain in their homes and communities.
- Community-Based Alternatives for Children. If authorized by Congress, CMS will support States in the Demonstration of Community-Based Alternatives to Psychiatric Residential Treatment Facilities for Children. The demonstration will allow CMS to determine the effectiveness and efficiency of extending home- and community-based services waivers as an alternative to residential treatment for children, thereby allowing them to receive treatment in their own homes, surrounded and supported by their families.
- Self-Determination. CMS and SAMHSA will develop a strategic action plan and consider supporting one or more demonstration projects to further efforts to promote self-determination and consumer direction in mental health service systems. These efforts-including such approaches as person-centered planning, vouchers, and consumer-operated services-have been found to be effective for people with physical disabilities and developmental disabilities, as well as for older adults. In 2004, SAMHSA collaborated with CMS to convene a Consumer Direction Initiative Summit to identify the specific needs of mental health consumers, identify potential barriers, develop a vision, and recommend next steps toward a self-directed behavioral health care system.
- Money Follows the Individual. If authorized by Congress, CMS will support a demonstration project to create a system of flexible financing for long-term services and supports that enables available funds to move with the individual to the most appropriate and preferred service setting as the individual's needs and preferences change. To the participant, the movement of funds will be seamless.
Action:Convene Directors of Stat Mental Health, Stat Medicaid, and Regional Medicare Programs
SAMHSA and CMS recognize that it is essential their agencies work together on behalf of children, adults, and older adults with psychiatric disabilities. To model this commitment, they will continue to convene meetings of the Directors of State Mental Health, State Medicaid, and Regional Medicare programs, as well as groups of other key stakeholders (e.g., employers, benefits managers, and other public and private purchasers), to discuss how to fund and deliver evidence-based practices and community-based care to adults with serious mental illnesses and children with serious emotional disturbances. Meeting summaries will be developed and provided as guidance to the field on the use of current steps and/or new, creative methods of financing that can be used to meet the need for full community integration of individuals with mental disorders.
Action:Help parents avoid relinquishing custody and obtain mental health services for their children
HHS will lead an effort among Federal agencies to initiate a multifaceted approach across systems with the goals of ending this tragic practice and increasing families' access to home- and community-based services and systems of care for their children with serious emotional disturbances. At a minimum, this effort will include the provision of technical assistance and dissemination of information to families and States on the State Children's Health Insurance Program (SCHIP) and on Medicaid options, such as the provision of home- and community-based services for children with mental or physical disabilities as authorized by the Tax Equity and Fiscal Responsibility Act (TEFRA); the Home and Community-Based Services Waiver; the Rehabilitation Option; and proposed Medicaid demonstration projects, including respite services for caregivers and alternatives to psychiatric residential treatment for children with serious emotional disturbances. In addition, HHS and its ACF will clarify Federal law, Title IV-E, and develop model legislation clarifying the responsibility of State Child Welfare Agencies and prohibiting custody relinquishment to access mental health services.
Action:Support the Ticket to Work program
As part of its overall support for the Ticket to Work and Work Incentives Improvement Act of 1999, CMS will release a solicitation to provide health care and other support services to individuals, including those with serious mental illnesses, who may be at risk of losing employment and independence. This solicitation will be for the Demonstration to Maintain Independence and Employment.
Additionally, under the Ticket to Work and Work Incentives Improvement Act, CMS will provide assistance to States through a Medicaid Infrastructure Grant Program. The Ticket to Work Act addresses many of the work disincentives faced by people receiving Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), such as loss of cash benefits and medical coverage. The Medicaid Infrastructure Grant program for 2004 includes a provision that will allow States to propose the use of funding to lessen or remove the primary barriers to employment for adults with disabilities through a comprehensive, coordinated approach between Medicaid and non-Medicaid programs.
The major objectives of this program, called Comprehensive Employment Opportunities Infrastructure Development, are (1) protection of health care coverage, (2) availability of key supportive services, and (3) increased coordination of programs and policies. While the proposals submitted by States will vary, CMS expects that States participating in this program will use the funds to remove barriers to work for people with disabilities, including people with mental disorders, by creating health systems change through the Medicaid program or by bridging Medicaid and other programs to further remove barriers.
Action:Address reimbursement in primary care
HHS will convene a high level forum of key Federal agencies (including CMS, HRSA, and SAMHSA), primary care providers, managed care organizations, mental health consumers, family members, and insurers to develop and implement an action agenda that will (1) address the barriers to providing coverage for screening, linkage, consultation, and management of mental health services in the primary health care sector, and (2) develop model benefits design and strategies for reimbursement.
Action:Develop a strategy to implement innovative technology in the mental health field
SAMHSA will convene a consensus development workgroup, including HHS Office of the National Coordinator for Health Information Technology (ONCHIT), HRSA's Office for the Advancement of Telehealth, public mental health and private-sector experts, consumers, and family members, to:
- Review the current status of telemedicine, information technology, Internet technology, and electronic decision support tools in health care;
- Examine the current status of implementation of these tools in mental health; and
- Prepare key recommendations for immediate next steps in technology support for mental health services.
Action:Explore creation of a Capital Investment Fund for Technology
SAMHSA will explore the creation of a Capital Investment Fund for Technology. The Capital Investment Fund will be used to work with States to design and implement an electronic health record and information system consistent with the Institute of Medicine Report, Patient Safety: Achieving a New Standard of Care (2004), and with successful models of person-centered, comprehensive electronic health record systems, such as the U.S. Department of Veterans Affairs health record system, highlighted in the Commission's Final Report.
The electronic health record and information system will incorporate an individualized plan of care and will be consistent with proposed Comprehensive State Mental Health Plans. The system will include state-of-the-art treatment guidelines and clinical reminders that enhance using standardized, evidence-based, and promising practices to foster recovery and resiliency for children, adults, and older adults with mental disorders. System administrators will incorporate these innovations into the electronic medical records systems that providers use in clinics, offices, hospitals, and acute care and long-term care settings.
Consumers and family members can use the system to evaluate the quality of care provided; participate in online support groups; evaluate best practices; learn about the most recent treatment breakthroughs; interface with a wide range of services and programs, including appointment scheduling and reminders and medication refills; and determine how to best use resources they manage. Consumers and families must be assured that their privacy and the confidentiality of their health information are well protected.
Selected Current Federal Activities in Support of This Goal
ACTIVITY Evaluation of Parity in the Federal Employees Health Benefits Program
HHS, led by ASPE, has partnered with the U.S. Office of Personnel Management (OPM) to evaluate the impact of providing parity for mental health and substance abuse services to the approximately 8.5 million beneficiaries enrolled in the Federal Employees Health Benefits Program. HHS and OPM evaluated the impact of parity on benefit design and management; access to and use of mental health and substance abuse services; beneficiary, plan, and OPM costs; quality of mental health and substance abuse services; and provider awareness.
ACTIVITY Guidance on Meeting Title VI English Proficiency Requirement
The HHS OCR has published guidance for recipients of HHS funds about how to meet their obligations under Title VI of the Civil Rights Act to provide meaningful access to people with limited English proficiency, including those who are trying to gain access to mental health services.
ACTIVITY Effectiveness of Telepsychiatry
AHRQ in HHS is testing the effectiveness of mental health service delivery using videoconferencing equipment (telepsychiatry) versus "same-room" (traditional) treatment for veterans with post-traumatic stress syndrome (PTSD). Clinical and process outcomes will be assessed.
ACTIVITY Development of Core Data Standards and Information Infrastructure
The SAMHSA/CMHS Evolution of Healthcare Reform Models Phase II project will complete Decision Support 2000+ work on core data standards and will develop an Internet-based IT system to collect and process data. Decision Support 2000+ is an integrated set of mental health data standards and an information infrastructure designed to help all stakeholders answer key questions and make critical decisions that will improve the quality of care.
ACTIVITY National Health Information Infrastructure
In support of the HHS Secretary's National Health Information Infrastructure (NHII) policy priority, ASPE has begun to accelerate the development and adoption of technology and national standards necessary for the NHII, including Electronic Health Record Systems and their use by the health care and public health systems. ASPE is coordinating its work across HHS and with other Federal agencies.
Principle D: Consider how mental health research findings can be used most effectively to influence the delivery of services.
The State of Success
In a transformed mental health system:
- Research is used to develop new evidence-based practices to prevent and treat mental illnesses; these discoveries are put into practice at the earliest opportunity. New findings on recovery and resilience help individuals with mental disorders live, work, learn, and participate fully in their communities.
- Evidence-based practices are identified, disseminated, and applied routinely in mental health care. Reimbursement policies of both public- and private-sector payers support broad implementation of evidence-based practices.
- Research findings help eliminate disparities in access to quality care among racial and ethnic groups; educate consumers about the efficacy, effectiveness, and limitations of psychotropic medications; enhance the evidence base on the impact of trauma on specific populations; and promote the delivery of acute care and crisis intervention services.
Initial Action Steps
Action:Accelerate research to reduce the burden of mental illnesses
Building on the discoveries rapidly emerging from the decoding of the human genome and from new, more powerful imaging techniques, NIMH will reorganize and streamline research to produce new interventions. The ultimate goal will be to prevent or cure mental illnesses.
Action:Foster a research partnership
SAMHSA will foster a public-private partnership to review the major mental health intervention research of the past 5 years. The review will:
- Identify areas that show particular promise for promoting recovery and resilience under field conditions;
- Outline specific projects and initiatives to further develop these key areas; and
- Engage in ongoing dialogue with major research institutes, academic centers, and practitioners.
Action:Expand the Science-to-Services Agenda
SAMHSA and NIH have begun a formal "Science-to-Services" agenda to further develop and expand evidence-based practices in the field. This is an ongoing, reciprocal relationship in which science informs services, and the experiences of service providers identify priority areas for further research. CMHS and NIMH are spearheading this effort in the area of mental health. To expand these efforts, a Task Force of the Federal Executive Steering Committee will work with SAMHSA, NIH, AHRQ, and CMS to identify evidence-based and promising practices that warrant further research, those ready for field implementation, and those that can and should be funded at the State and local levels. The Task Force will consider all three legs of the research-to-practice stool-science, services, and funding-and will establish guidance to the field about the practical application of research findings.
Action:Conduct research to understand co-occurring disorders
The high rate of comorbidity of mental and substance use disorders warrants further exploration. NIDA and NIMH at NIH will support basic and clinical research to further clarify mechanisms of comorbidity, including research on genetic and environmental mechanisms. This information will lead to more informed prevention and treatment measures.
Action:Harness research to improve care
NIDA will join with several agencies-including NIMH, the National Institute on Alcohol Abuse and Alcoholism (NIAAA), AHRQ, HRSA, and SAMHSA-to support a conference to help develop a health services research agenda to improve care for mental illnesses, substance use disorders, and physical disorders. This initiative will help ensure that evidence-based practices for co-occurring disorders are adopted and implemented in real-world settings in a timely manner. It will also address issues such as the organization, management, and economics of service delivery for co-occurring disorders across the lifespan in a variety of populations and settings.
Action:Support research to develop new medications
NIDA and NIMH will support research designed to develop new medications to treat common neurobiological and behavioral substrates of co-occurring mental and substance use disorders. This could include medications targeting compulsive behavior patterns, stress reduction, and co-morbid psychosis and tobacco addiction.
Action:Expand the National Registry of Evidence-based Programs and Practices to include mental health
SAMHSA's CMHS will expand and improve its National Registry of Evidence-based Programs and Practices (NREPP) to:
- Identify a procedure through which the status of evidence-based practices can be reviewed and summarized for the public and private mental health fields.
- Summarize action steps currently being taken in parallel fields, such as primary care, to implement evidence-based practices.
- Review the activities of the Practice Guideline Coalition and NREPP and make recommendations for how they might be integrated and implemented in the mental health field.
- Recommend a procedure through which consensus might be developed across key mental health groups, consumers, and family members regarding implementation of evidence-based practices.
Action:Develop new toolkits on specific evidence-based mental health practices
SAMHSA will expand its National Evidence-Based Practices Project with the addition of new toolkits. Toolkit topics may include:
- Children's services,
- Supportive housing,
- Older adults,
- Trauma and violence,
- Collaborative models in primary care,
- Consumer-operated service approaches, and
- Supported education.
The toolkits will include materials for administrators, clinicians, consumers, and family members on the implementation of evidence-based practices and will be tested in pilot States and developed in collaboration with private partners.
Action:Develop the knowledge base in understudied areas
Within HHS, NIMH, AHRQ, CMHS, HRSA, CDC, and the OCR will:
- Synthesize available knowledge about clinical and rehabilitation practice in each of four understudied areas, including information on:
- The gap that exists in the quality of and access to mental health care for racial and
- The long-term positive and negative effects of psychotropic medications for
maintenance treatment of mental disorders, particularly for children with serious
- The impact of trauma and violence on the mental health of specific populations such
as women, children, and victims of violent crime-including terrorism.
- The availability and effectiveness of acute inpatient and other short-term, 24-hour
services, especially for those in crisis who need the safety and intensive treatment of
- Convene workgroups in each of the areas to identify the next intervention projects that should be undertaken.
- Develop detailed specifications for the proposed studies.
- Seek funding for the proposed projects from appropriate Federal and private sources.
Action:Conduct research to reduce mental health disparities
NIMH is expanding its support for programs that conduct research to reduce health disparities by issuing a new program announcement (2004) for the development of Advanced Centers for Mental Health Disparities Research. The purpose of this initiative is to promote the enhancement of established research core infrastructures and investigator-initiated research to understand and ameliorate mental health disparities. Research projects may include, but are not limited to, studies of mental health disparities among American Indians/Alaska Natives, Asian Americans, African Americans, Hispanics, and Native Hawaiians and Pacific Islanders. Studies of ethnic subpopulations within these broad categories also are encouraged. The Institute will also continue its support for the Disparities in Mental Health Services Research Program, the Socio-Cultural Research Program, the Office of Special Populations, and the Office of Rural Mental Health.
Action:Review the literature and develop new studies on mental illness/general health
To gain a better understanding of the impact of mental illnesses and emotional disturbances on general health and, conversely, the impact of physical illnesses on a person's mental health, AHRQ, CDC, and NIH will:
- Evaluate current surveillance systems for the co-existence of mental and physical health and illness metrics and make recommendations regarding appropriate measures to be included in these systems to enhance the ability to monitor the co-occurrence of physical and mental illness on an ongoing basis.
- Conduct a comprehensive review of the scientific literature to determine what is known about the relationship between mental and physical health.
- Review the literature regarding strategies to promote general health in people with mental illnesses through improved nutrition, physical activity, and tobacco cessation.
- Design a portfolio of new studies to examine the impact of mental health and illnesses on physical health and illnesses and, conversely, to examine the impact of physical health and illnesses on mental health and illnesses. These studies will take into account developmental issues across the lifespan.
Action:Conduct mental health services research in diverse populations and settings
NIMH will conduct an extensive range of mental health services research aimed at improving services in settings and populations that represent real, diverse clinical populations in real, diverse settings. NIMH will work with CMHS to obtain feedback on such evidence-based service innovations.
Action:test new treatments for co-occurring disorders in community settings
Through the National Institute on Drug Abuse's (NIDA's) National Drug Abuse Treatment Clinical Trials Network, new treatment protocols will be tested in community settings that address people who have co-occurring mental and substance use disorders.
Action:Disseminate findings of the Juvenile Justice and Mental Health Project
SAMHSA's Juvenile Justice and Mental Health Project will examine existing juvenile justice diversion and reintegration practices for youth with serious emotional disturbances and co-occurring substance use disorders in various jurisdictions across the Nation. SAMHSA will support dissemination of the Project's findings through Policy Academies that share findings with States and local jurisdictions, and explore the feasibility of implementing effective program models for youth in their regions.
Selected Current Federal Activities in Support of This Goal
ACTIVITY Developing Science-Based Interventions for Major Mental Disorders
NIMH maintains large research portfolios focused on the development of new and better science-based interventions for major mental disorders, including new pharmacological and psychosocial interventions; interventions for children, adolescents, adults, and older adults; and services research. For example, NIH sponsors large, multi-site clinical trials on bipolar disorder, schizophrenia, Alzheimer's disease, and treatment-resistant depression, as well as research on trauma/post-traumatic stress disorder.
ACTIVITY National Evidence-Based Practices Project
The National Evidence-Based Practices Project is a collaborative effort being undertaken by SAMHSA, the Robert Wood Johnson Foundation, National Alliance for the Mentally Ill (NAMI), and State and local mental health organizations in eight States. These States are evaluating toolkits developed in six mental health evidence-based practices: medications, illness self-management, Assertive Community Treatment, family psychoeducation, supported employment, and integrated treatment for co-occurring mental and substance use disorders.
ACTIVITY Rural Mental Health Research
The NIMH Office of Rural Mental Health directs, plans, coordinates, and supports research on the delivery of mental health services in rural areas.
ACTIVITY Outreach Partnership Program
The NIH/NIMH Outreach Partnership Program (formerly the Constituency Outreach and Education Program) develops partnerships with nonprofit organizations and the individuals and families they serve in all 50 States and the District of Columbia to help close the gap between mental health research and practice, and to help reduce the stigma of mental illness.
ACTIVITY Anti-Stigma Research and Strategies
NIMH is developing a program of research aimed at better understanding stigma and designing science-based interventions to reduce the stigma of mental illness. NIMH also is working with SAMHSA to develop research on the role of the media to reduce the stigma of mental illness. CMHS is pilot testing anti-stigma messages and strategies in partnership with eight States. The findings from this evaluation will be available to inform further program development and research needs.
ACTIVITY Complexities of Co-Occurring Conditions Meeting
NIMH, NIAAA, NIDA, HRSA, AHRQ, and SAMHSA sponsored a major meeting to speed modern evidence-based treatment knowledge to clinicians and service organizations. The meeting was called "Complexities of Co-occurring Conditions: Harnessing Services Research to Improve Care for Mental, Substance Use, and Medical/Physical Disorders."
ACTIVITY National Child Traumatic Stress Initiative
The National Child Traumatic Stress Initiative, funded by SAMHSA, is providing Federal support for a national effort to improve treatment and services for child trauma, to expand availability and accessibility of effective community services, and to promote better understanding of clinical and research issues relevant to providing effective interventions for children and adolescents exposed to traumatic events.
ACTIVITY Women, Co-occurring Disorders, and Violence Study
SAMHSA's Women, Co-occurring Disorders, and Violence Study was designed to develop, implement, and evaluate integrated systems of care for women with mental illnesses and co-occurring substance use disorders who have experienced violence and their children. Nine sites are evaluating the effectiveness of comprehensive, integrated service models for women who have co-occurring disorders and histories of physical and/or sexual abuse; four sites are evaluating trauma-informed services for their children.
ACTIVITY National Comorbidity Study
NIMH is supporting a 10-year followup of the National Comorbidity Survey, a representative national sampling of 6,000 people ages 15-54 designed to estimate the prevalence and correlates of mental and substance use disorders. The current survey focuses on the relationship between mental disorders and the subsequent onset and course of substance use disorders. As such, it may suggest modifiable risk factors that could be targets for preventive interventions.
ACTIVITY Preparing Preschool Children for Success
HHS and ED have launched a 5-year research effort to find the best ways to prepare preschool children for later success in school. In the initiative's first year, eight institutions across the country will receive $7.4 million in research grants to test preschool curricula, Internet-based teacher training, and the importance of parental involvement for improving children's readiness to enter school.
ACTIVITY Mental Health Response to Mass Violence and Terrorism Victims
DOJ and SAMHSA have developed a training manual and field guide to address the mental health response to mass violence and terrorism victims.
ACTIVITY Model of Behavioral Response to Uncertain and Stressful Situations
CDC is applying a public health framework to model the impact of social factors, mental health, and how people appraise risk and safety regarding terrorism and disasters on behavioral response to uncertain and stressful situations (e.g., compliance with public health recommendations).
ACTIVITY Mental Health Risk Factors Associated with Violence
CDC collects data and supports research to better understand the mental health risk factors associated with violence.
Principle E: Follow the principles of Federalism, and ensure that [the Commission's] recommendations promote innovation, flexibility, and accountability at all levels of government and respect the constitutional role of the States and Indian tribes.
The State of Success
In a transformed mental health system:
- Each State's Comprehensive State Mental Health Plan is constructed with the active involvement of all State and regional entities responsible for housing, health, transportation, employment, education, justice, and entitlements, and addresses the full range of the treatment and support services that mental health consumers and family members want and need.
- States are held accountable for improved outcomes and, in turn, are granted greater flexibility in combining resources to develop innovative and efficient services.
- States receive the technical assistance and training they need to implement innovative strategies designed to promote full community integration for children with serious emotional disturbances and adults with serious mental illnesses.
- Elimination of seclusion and restraint becomes a policy and practice directive.
Initial Action Steps
Action:Award State Mental Health Transformation Grants
Much of the work of system transformation will take place at the State and local levels. This is why the Commission has vested in States one of the most critical elements of system transformation: creation of state-specific Comprehensive State Mental Health Plans. As outlined by the Commission, each State plan should:
- Increase the flexibility of resource use at the State and local levels, encouraging innovative uses of Federal funding and flexibility in setting eligibility requirements.
- Hold State and local levels of government accountable for results, not just to Federal funding agencies, but also to consumers and families.
- Expand the options and the array of mental health services and supports along a continuum, and ensure their integration into a seamless system of care in which "any door is the right door" to get help.
- Leverage additional resources from systems that also interact with children and their parents, adults, and older adults who have mental disorders, such as housing, health, transportation, employment, education, entitlements, substance abuse treatment, child welfare, and corrections.
President Bush's Fiscal Year 2005 proposed budget contained $44 million and Congress appropriated $20 million to help States develop comprehensive plans. SAMHSA's CMHS will design, implement, and evaluate a 3-year State Mental Health Transformation Grant program to support State efforts to develop a Comprehensive Mental Health Plan. These grants are expected to support State mental health services infrastructures and to promote implementation of science-based mental health interventions. SAMHSA will help grantees identify prototype State plans and provide technical assistance to customize these plans for specific State needs.
In the first year, States will be required to conduct statewide planning and infrastructure development efforts across multiple service systems to better meet the complex needs of adults with serious mental illnesses and children with serious emotional disturbances and their families. Consumers and family members will be actively involved in these statewide planning efforts. Specific infrastructure development activities include policy development to support best practices, organizational development to support integrated service delivery, financial planning and leveraging of resources, workforce training and development, quality assurance mechanisms, and management information systems and data infrastructure development.
With an optimally effective State infrastructure and plan in place, Federal, State, and local resources can be used and leveraged in the most effective ways to eliminate fragmentation and improve mental health services. Over time, the goal would be to award a grant to each State. A coordinating center will be funded to provide technical assistance and other resources to help States accomplish the objectives of this program.
Action:Provide technical assistance to help States develop Comprehensive State Mental Health Plans
CMHS will be contracting with a number of national mental health organizations to provide technical assistance to States in the development of activities and plans to implement the New Freedom Commission recommendations. Written analysis of onsite training and technical assistance will be delivered on a range of policy issues that impact the development of a comprehensive State mental health system.
Action:Award Child and Adolescent State Infrastructure Grants
SAMHSA will continue to support Child and Adolescent State Infrastructure Grants to help States increase their system infrastructure to support mental health and/or substance abuse services and programs for children, adolescents, and youth in transition, who have serious emotional disturbances, substance use disorders, and/or co-occurring disorders, and their families. A comparable amount of annual funding is projected for subsequent years. These 5-year grants will focus on strengthening State capacity to transform the service delivery system to meet the needs of this population of youth and their parents and other family members, including cross-system coordination and collaboration, financing, increased access to services, workforce development, data management and accountability, implementation of evidence-based interventions, individualized care planning, service integration, family and youth involvement, and sustainability of system reforms. These grants will complement and help prepare States for SAMHSA's State Mental Health Transformation Grants and the development of their Comprehensive State Mental Health Plans, which include cross-system planning for children who have serious emotional disturbances.
Action:Track State mental health system transformation activities
CMHS will maintain an information database on transformation activities in the States. An annual database on State transformation activities will be created and the results will be posted on the National Association of State Mental Health Program Director's web site. CMHS will also use results from a demonstration data collection to measure resources expended by other State agencies on people with mental illness. Descriptive results will be reported, and trends will be monitored to examine changes over time. As comprehensive State mental health transformation plans are implemented, CMHS will expand the scope of the Decision Support 2000+ System and the Uniform Reporting System to incorporate performance measures that extend beyond the State mental health agencies.
Action:Establish a foundation for the Samaritan Initiative
Based on experience with the $35 million Collaborative Initiative to Help End Chronic Homelessness, the President proposed the Samaritan Initiative at $200 million in his Fiscal Year 2005 budget. This initiative would provide funding for permanent supportive housing for people who experience chronic homelessness.
Action:Establish the Reentry Initiative for ex-prisoners with psychiatric disabilities
HUD's 2006 budget request includes $25 million as a part of a prevention initiative for prisoners returning to the community, many of whom are struggling with serious mental illnesses. HUD will collaborate with DOL and DOJ in this effort. In addition, DOL will compile data on people served and types of services provided to people with psychiatric disabilities who are incarcerated. Information will be solicited from SAMHSA and DOJ's Bureau of Prisons, National Bureau of Corrections, and relevant foundations and associations. DOL's Employment and Training Administration, VETS, and the Faith-Based Office will support One-Stop Centers to identify resources and effective practices. Policy recommendations will be developed to address service gaps systematically and strategically.
Action:Award Seclusion and Restraint State Incentive Grants
SAMHSA will continue to support grants designed to enhance State capacity to provide staff training to implement alternatives to seclusion and restraint in mental health care settings. This program also supports a Resource Center, which acts as a central repository on effective practices to reduce and eliminate seclusion and restraint and provides technical assistance to the grantees.
Action:Develop statewide systems of care for children with mental disorders
HRSA's State Maternal and Child Health Early Childhood Comprehensive Systems Grants will bring in other Federal partners to plan for and develop statewide systems of care to support the healthy social and emotional development of children. These grants enable States to plan, develop, and implement comprehensive, collaborative systems to improve childhood outcomes. In particular, grants support the development of a State plan that addresses access to health insurance and regular primary care services, mental health and social-emotional development interventions, early child care and educational supports, and parent education and family support. These are 2-year planning grants followed by multi-year implementation grants.
Action:Provide technical assistance to States on systems of care for children and their families
Through its technical assistance contracts and/or grants, SAMHSA, in collaboration with HRSA, will provide technical assistance to support State efforts to plan, finance, and implement a coordinated approach to providing mental health screening, early intervention, services, and supports to young children identified to be at risk for mental disorders and their parents/guardians. Technical assistance will include training and materials on development of a collaborative State plan, as well as examples of successful State and community approaches and evidence-based interventions. SAMHSA and HRSA will collaborate with other Federal technical assistance and training efforts.
Action:Convene State leadership to develop Statewide plans to serve children with serious emotional disturbances
ED and HHS will convene representatives of State education, public health, and mental health leadership to set the stage for the inclusion of children's services in the Comprehensive State Mental Health Plan; to develop a prototype State education, public health, and mental health collaborative plan; and to establish support for State-level infrastructures for school-based mental health. These plans will address the need for informed parental consent for screening children for mental health issues.
Action:Expand the Partnerships for Youth Transition Grant Program
SAMHSA will collaborate with ED, ACF, and other relevant Federal agencies and departments, including DOL, to expand its Partnerships for Youth Transition Grants Program aimed at developing effective models for youth with serious emotional disturbances who are transitioning from the child to the adult systems. Through this grant program, States develop, implement, stabilize, and document models of comprehensive programs to support transition to adulthood and independent living for youth with serious emotional disturbances. Funding and partnerships from other Federal agencies will expand the number of States and communities to be funded, strengthen the cross-system linkages necessary for successful independent living and transition to adult system supports, and address systems barriers to serving this vulnerable population.
Action:Provide technical assistance on Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
SAMHSA, CMS, and HRSA will conduct a technical assistance forum for State Medicaid Directors, State Mental Health Directors, and Community Health Centers on implementation of the EPSDT program. Assistance will be available on model screening instruments, strategies for creating partnerships across child-serving agencies to ensure access to appropriate care, and mechanisms for managing costs and State Medicaid match.
Action:Facilitate linkages among DOL/SSA's Joint Disability Program Navigator Initiative, SAMHSA, and related State and local mental health systems
DOL's Employment Training Administration will incorporate information on the employment of people with psychiatric disabilities, resources, effective practices, information on SAMHSA's programs and resources, and State and local mental health systems' programs into its training for more than 100 Disability Program Navigator staff hired in pilot States. Linkages will be developed between local One-Stop Centers and State and local mental health systems.
Action:Disseminate information on mental health issues through DOL grant initiatives and programs
DOL will disseminate mental health information through its many grants and programs including: Work Incentive Grants, Customized Employment Grants, Homeless Veterans' Reintegration Program, Veterans' Workforce Investment Program, Incarcerated Veterans' Transition Program, Youth Offender Demonstration Program, Serious and Violent Re-entry Initiative, Ready4Work Grants, High School/High Tech Grants, and Chronically Homeless Grants.
Selected Current Federal Activities in Support of This Goal
ACTIVITY New Freedom Initiative Technical Assistance Center
The SAMHSA/CMHS New Freedom Initiative technical assistance center supports State collaborative efforts to develop community integration plans for individuals with mental illnesses and emotional disturbances residing in, or at risk for, placement in State facilities.
ACTIVITY Technical Assistance Center to Improve State and Local Systems
SAMHSA/CMHS-funded Technical Assistance Centers help improve State and local mental health systems by providing information, publications, and referrals to consumers, family members, service providers, administrators, researchers, advocates, and the general public.
ACTIVITY Comprehensive Community Mental Health Services Program for Children and Their Families
The CMHS Comprehensive Community Mental Health Services Program for Children and Their Families provides cooperative agreements to States, tribes, and territories to develop systems of care for children with serious emotional disturbances and their families. Ninety-two communities in 47 States and 2 territories have received funding to develop these comprehensive systems of care. Individualized plans of care that integrate services across child-serving systems are a key goal of this program. ACF, HRSA, ED, and the Office of Juvenile Justice are partners with SAMHSA in this program.
ACTIVITY Intergovernmental Young Adult State Planning Initiative
The HHS Office on Disability's Intergovernmental Young Adult State Planning Initiative, co-sponsored with other HHS agencies and Federal departments (Education, Labor, Transportation, and SSA), helps States develop and implement infrastructure-based coordinated action plans to address the health, human services, employment, education, housing, and transportation needs of young adults (ages 16 to 30) with disabilities, including those with mental illnesses and comorbid disabilities.
ACTIVITY Collaboration to End Chronic Homelessness for People with Mental and Substance Use Disorders
HRSA, HUD, VA, the Interagency Council on Homelessness, and SAMHSA jointly fund a $35 million collaborative initiative to end chronic homelessness among people with mental and substance use disorders.
ACTIVITY Toolkit on Interagency Management Information Systems
CMHS is developing a toolkit for States and communities on interagency management information systems to better track services for children and families across agencies, to reduce duplication of information gathering, to increase access to services, and to provide accountability.
ACTIVITY Protection and Advocacy for Individuals with Mental Illness (PAIMI) Program
CMHS will continue to support and improve the PAIMI program. To facilitate continuous quality improvement, CMHS will conduct an Evaluability Assessment of the PAIMI program, which will form the foundation of a plan for the full, independent evaluation of the PAIMI program.
ACTIVITY Restraint and Seclusion Demonstration Grant
The CMHS-funded Restraint and Seclusion Demonstration Grant is a 3-year program to develop best practice models to reduce staff use of seclusion and restraint procedures in facilities for children and youth.
ACTIVITY Children's Justice Act Grants
Children's Justice Act Grants funded by ACF provide funds to help States develop, establish, and operate programs designed to improve (1) the handling of child abuse and neglect cases, (2) the handling of suspected child abuse or neglect-related fatalities, and (3) the investigation and prosecution of child abuse and neglect cases.
ACTIVITY Co-occurring State Incentive Grant Program
The SAMHSA-funded Co-occurring State Incentive Grant (COSIG) program provides funds to States to increase their capacity to provide effective treatment and services for people with co-occurring mental and substance use disorders. The emphasis is on building or enhancing service system infrastructures to offer integrated treatment.