Park City Center for Public Policy

January, 2005

SAMHSA, A Vision For Recovery And Prevention
By Charles G. Curie, M.A., A.C.S.W.

Administrator
The Substance Abuse And Mental Health Services Administration

These first years of the 21st century have ushered in an era shaped by overwhelming evidence that treatment for mental and substance use disorders work, that people with mental and substance use disorders can and do recover, and that prevention is not only possible, but incredibly effective. When I accepted President Bush's nomination to serve as the Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), that knowledge guided my vision for the Agency. It is a vision of "a life in the community for everyone." To realize our vision, we have made our mission "building resilience and facilitating recovery." They are simple words that speak volumes about the hopes, desires and abilities of millions with or at risk for mental and substance use disorders.

Initially, I was asked whether SAMHSA would get the support it needed to achieve our mission and vision. The answer is plain: We have. Both President Bush and The Department of Health and Human Services Secretary Tommy Thompson have recognized that it is time that program and policy-and America as a whole-recognize that substance use and mental disorders should be treated with the same concern and urgency as diabetes, obesity, heart disease, stroke and cancer. Thus, this Administration has placed both mental health and substance abuse at the forefront of its public health agenda.

President Bush didn't just say he wanted to help end substance abuse; he put the dollars and program initiatives on the table to help us do just that: he proposed a $1.6 billion increase over five years and the Access to Recovery Initiative. He didn't just establish the New Freedom Commission on Mental Health, receive the report, and say thank you. Rather, he asked SAMHSA to assess the report's recommendations and to delineate the role of the Federal government in the wholesale transformation of mental health care in America. Further, because SAMHSA is working smarter in substance abuse prevention, our Strategic Prevention Framework has become a centerpiece of the Administration's Healthier US health initiative.

Challenging The Statistics With Evidence-based Services
The Administration's support for and confidence in SAMHSA, coupled with our sharpened focus on a few key program areas could not have come at a more important time. In 2003, an estimated 22 million Americans, aged 12 or older needed treatment for an alcohol or drug problem; 19.6 million adults experienced a serious mental illness, according to SAMHSA's National Survey on Drug Use and Health. The survey found that individuals with both mental and substance use disorders continue to be a large underserved population. An estimated four million adults experienced co-occurring serious mental and substance use disorders during the year.

Untreated mental and substance use disorders exact a heavy toll. Drug and alcohol abuse are estimated to cost taxpayers over $275 billion annually in preventable health care costs, extra law enforcement, automobile crashes, crime and lost productivity. The total annual economic cost of mental illness totals more than $148 billion. The human costs of both disorders-measured in lost jobs and educational opportunity, lost families and lost lives-are incalculable.

In 2003, less than half of those individuals with a serious mental illness and 8.5 per cent of individuals with substance use disorders received treatment. Yet, research evidence has shown that mental and substance use disorders are treatable chronic health conditions; people can and do recover. Research also demonstrates the value of effective prevention to prevent or delay the onset of mental illnesses and substance use disorders across the lifespan. SAMHSA recognized that early intervention with state-of-the-art, research-based prevention and treatment, services and supports can reduce the toll of substance abuse and mental illnesses. That is why SAMHSA has been bringing this new science-based knowledge to communities across the nation through its National Registry of Effective Programs and Practices and through its Science-to-Services/Services-to-Science initiative with the National Institutes of Health.

Meeting The Challenge Through National Leadership
With a fiscal year 2005 budget of more than $3.4 billion, SAMHSA administers fund a rich portfolio of grant programs and contracts that support state and community efforts to expand and enhance prevention programs and to improve the quality, availability and range of substance abuse treatment and mental health services where people can be served most effectively-right in their communities. Last year in U.S. MEDICINE, I described the ways in which we wanted to work toward that vision through a mission of building resilience and facilitating recovery. This year, I want to share how far SAMHSA has come in its effort to transform substance abuse and mental health services to achieve our vision and mission.

At the heart of SAMHSA's funding programs is accountability-the need to ensure that the services the Agency supports are outcome oriented and focused on quality improvement. Today, SAMHSA's formula grant programs are changing to focus on performance measurement and management-holding grantees accountable for performance-based outcomes. Driven by a strategy to improve accountability, capacity and effectiveness, or ACE, SAMHSA can ensure that its resources are not only being used effectively and efficiently in state and community programs, but also that these resources are being invested in the best interest of the people SAMHSA serves.

Making The Hope Of Recovery A Reality
SAMHSA's matrix of priority programs identifies 11 areas to ensure that the Agency's work is focused. Most recently, SAMHSA has honed in on three of them, each with the strong support of the Administration. These program initiatives have been integrated-as all SAMHSA programs are-with our emphasis on performance measurement and management, outcomes that are meaningful to the people we serve, measures of recovery, of employment and education, of family and home, and a life in the community.

Substance Abuse Treatment Capacity And Access To Recovery
It is abundantly clear that many of our most pressing public health, public safety and human services needs have a direct link to substance use disorders. This obvious link is why the Administration places such a great importance on increasing the nation's substance abuse treatment capacity.

At SAMHSA, we support and maintain state substance abuse treatment systems through the Substance Abuse Prevention and Treatment Block Grant. Our Targeted Capacity Expansion grant program continues to help us identify and address new and emerging trends in substance abuse treatment needs. And, now, we also have Access to Recovery (ATR). It provides us a third complementary grant mechanism to expand clinical treatment and recovery support service options to people in need.

In his 2003 State of the Union address, President Bush resolved to help people with a drug problem who sought treatment but could not find it. He proposed ATR, a new consumer-driven approach for obtaining treatment and sustaining recovery. The President proposed to provide grants for a state-run voucher program for substance abuse clinical treatment and recovery support services. It was designed to accomplish three main objectives:

Expand capacity by increasing the number and types of providers who deliver clinical treatment and/or recovery support services;
Allow recovery to be pursued through many different and personal pathways;
Require grantees to manage performance, based on outcomes that demonstrate patient successes.

The new initiative recognizes that the process of recovery is a personal one that can take many pathways including physical, mental, emotional and/or spiritual needs. Under the Access to Recovery program, people in need of addiction treatment and recovery support choose the programs and providers that will help them most.

President Bush proposed $200 million in FY 2004 for SAMHSA to set in place the first year of the Access to Recovery grant program. Congress ultimately appropriated approximately $100 million to SAMHSA to undertake Access to Recovery. The President again requested $200 million for Access to Recovery in FY 2005 to expand the program. Again, Congress only appropriated $100 million, eliminating any opportunity for expansion.

To initiate the program, SAMHSA announced in March 2004 it was seeking applications for ATR grant funds. The application deadline was June 2, 2004. During that timeframe, SAMHSA maintained a grant application help-line, convened five pre-application technical assistance workshops around the country and conducted a national teleconference to help potential applicants.

The first 15 ATR grantees, 14 states and one tribal organization, were selected through a competitive grant review process that included 66 applications submitted by 44 states and 22 tribes and territories. The three-year grants were awarded to California, Connecticut, Florida, Idaho, Illinois, Louisiana, Missouri, New Jersey, New Mexico, Tennessee, Texas, Washington, Wisconsin, Wyoming and the California Rural Indian Health Board.

Overall, the grant application provided broad discretion. Applicants had to design and implement a voucher program to pay for a broad range of effective, community-based substance abuse clinical treatment and recovery support services. They could choose to implement the program through a state or sub-state agency, or implement some or all of the program in partnership with a private entity. Applicants could target the program to areas of greatest need, to areas with a high degree of readiness to implement such an effort, or to specific populations, including adolescents.

For example, in Louisiana the ATR grant will assist the state in closing identified gaps in treatment services for eligible Louisiana citizens with special emphasis on women, women with dependent children and adolescents.

In Connecticut, the ATR grant will expand clinical substance abuse treatment services, including brief treatment interventions; intensive outpatient; ambulatory; detoxification; and methadone maintenance to those in the criminal justice system. Recovery support services will also be expanded, including case management; housing; vocational/educational programs; child care; transportation; and other recovery support, such as peer- and faith-based ancillary support services.

In New Mexico, the ATR project will enhance the City of Albuquerque's existing voucher system. Individuals will receive eligibility for voucher-funded services through a centralized intake, assessment and eligibility process and will gain entry into a greatly expanded continuum of treatment and recovery services.

The tribal organization recipient, the California Rural Indian Health Board, will implement an approach for ATR that upholds the integrity of Indian self-determination by providing treatment opportunities through existing community-based programs. The program will allow patients to select among Indian and non-Indian providers of services; traditional native spiritual and mainstream faith-based services; restrictive or non-restrictive environments; and discrete or wrap-around services.

While all applicants had the opportunity to expand treatment options for different target population groups and utilize different treatment approaches, they all had to meet some specific common requirements. The first was to ensure genuine, free and independent client choice of eligible providers. Second, they had to establish how clients will be assessed, given a voucher for identified services, and provided with a list of appropriate service providers from which to choose. Third, applicants were required to supplement, not supplant, current funding, thus expanding both capacity and available services. And finally, they will all report on common performance measures to illustrate effectiveness. In both program design and implementation, applicants delineated a process to monitor outcomes. These performance measures will be used to measure treatment success and the ultimate success of the voucher program itself.

Mental Health System Transformation
The President's New Freedom Commission on Mental Health report, issued in July 2003, called for profound change and transformation of the current system, recommending new service delivery patterns and incentives to ensure that every American with mental illness has easy access to the most current treatments and best support services.

SAMHSA was tasked by HHS Secretary Thompson to review the Commission's report and to lead the development of an Action Agenda for that transformation to create a more recovery-focused mental health services delivery system. Of necessity, it also may reshape the roles of the federal government, the States and other partners in that service system. An executive team at SAMHSA-along with senior staff from six federal departments and the Social Security Administration are working collaboratively to conduct a thorough review and assessment of the report.

As expected, developing the Action Agenda has proven to be a tremendous undertaking. The result, however, has been commitment for a true Federal Action Agenda that is informed by the final report of the New Freedom Commission and aligned with the President and Secretary's priorities. A hallmark of the Action Agenda is the unprecedented collaboration and partnership across the federal government to work together and make every effort to keep consumers and families at the center of care.

While the release of the Federal Action Agenda is anticipated in the near future, SAMHSA has not waited to take action. In the recently completed fiscal year 2004, SAMHSA invested more than $517 million in transformation efforts through its discretionary grant programs. SAMHSA's mental health Programs of Regional and National Significance promote service capacity expansion and foster service effectiveness through the adoption, adaptation and evaluation of proven evidence-based approaches at the state and community levels. A new $43.8 million State Incentive Grants for Transformation program to implement the Commission's findings was proposed as part of SAMHSA's fiscal year 2005 Programs of Regional and National Significance funding request. Congress appropriated $20 million.

Strategic Prevention Framework
This Administration is working to marshal America's resources to realize the vision of a Healthier US-an America in which our citizens can use the power of prevention to help lead longer, healthier lives. Unfortunately, individuals, communities, or state and federal agencies do not always translate what is known about prevention into action. Thus, for example, while the latest data on substance abuse show some promising findings, much remains to be done to reduce illegal drug use and alcohol abuse in America.

Fortunately, over the years, we have shown prevention programs can and do produce results. Currently, 60 model programs are listed in SAMHSA's National Registry of Effective Programs and Practices. These programs yield on average a 25 per cent reduction in substance use, and impact a broad range of behavioral issues, from violence and delinquency to emotional problems. Word about what works in prevention is getting out, but much work remains in substance abuse prevention-and in the relatively new and emerging area of mental health promotion and mental illness prevention.

To provide a structured approach to substance abuse prevention, mental health promotion and mental illness prevention that is based on the best that science has to offer, Thompson launched SAMHSA's Strategic Prevention Framework during the National Healthier US Prevention Summit in Baltimore on April 29, 2004.

The Framework is based on the risk and protective factor approach to prevention that operates at the levels of the individual, family, school, community and broader environment. For example, family conflict, low school readiness and poor social skills are risk factors that conduct disorders and depression, which in turn increase the risk for adolescent substance abuse, delinquency, and violence. In contrast, protective factors, such as strong family bonds, social skills, opportunities for school success and involvement in community activities, can foster resilience and mitigate the influence of risk factors. The Strategic Prevention Framework brings together multiple funding streams from multiple sources to implement a comprehensive approach to prevention that cuts across existing programs and systems.

In fiscal year 2004, SAMHSA took a major step toward building its Strategic Prevention Framework. It announced the availability of and awarded $45 million through a competitive grant process to selected states and territories to implement the Strategic Prevention Framework. Grantees will use the funds to implement a five-step process at the community level known to promote youth development, reduce risk-taking behaviors, build on assets and prevent problem behaviors. The five steps are: (1) conduct needs assessments; (2) build state and local capacity; (3) develop a comprehensive strategic plan; (4) implement evidence-based prevention policies, programs and practices; and (5) monitor and evaluate program effectiveness, sustaining what has worked well.

The success of the Strategic Prevention Framework will be measured by specific national outcomes, among them: abstinence from drug use and alcohol abuse, reduction in substance abuse-related crime, attainment of employment or enrollment in school, increased stability in family and living conditions, increased access to services, and increased social connectedness. The challenge in the coming fiscal year for SAMHSA is to continue to build a national commitment to the community-based risk and protective factor approach to prevention supported by the Strategic Prevention Framework.

From Talk To Action: Measuring And Managing Performance
To help SAMHSA present consistent and reliable information, we have been developing and implementing a data strategy. The strategy is simple: The tighter our measurements become, the more we can prove our effectiveness. The greater our effectiveness, the greater the number of people served, the greater the chances for a life in the community for everyone. Developing a data strategy is a task that has been hanging around for years. Now, we have gotten real about doing it.

Our SAMHSA data strategy is a critical building block to achieve true accountability in a performance environment by transforming the way we do business. We are looking at what data we are collecting. We are asking why we are collecting it. And, we are asking how we are using it to manage and measure performance. If we don't use it, we need to lose it.

We have learned that a limited number of key outcomes measured in structured ways can help all of us know how well SAMHSA and its grant programs are building resilience and facilitating recovery. Our emphasis on a limited number of national outcomes and related national outcome measures is built on a history of extensive dialogue with our colleagues in state mental health and substance abuse service agencies and the people we serve.

While the discussions with states focused specifically on SAMHSA's block grant programs, the application of national outcomes and national outcome measures extends across all SAMHSA grant programs. All of our programs are about achieving our vision of a life in the community for everyone and our mission building resilience and facilitating recovery. So it only makes sense that SAMHSA uses the same outcomes across all of our programs.

The National Outcomes we have identified are:

Abstinence from alcohol abuse or drug use or decreased symptoms of mental illness;
Increased or retained employment and school enrollment;
Decreased involvement with the criminal justice system;
Increased stability in family and living conditions;
Increased access to services;
Increased retention in services (substance abuse) or decreased utilization of psychiatric inpatient beds (mental health); and
Increased social connectedness.

Already, SAMHSA is implementing these National Outcomes, including them in the grant announcements for its Access To Recovery Program (ATR), and its Strategic Prevention Framework (SPF). States have voluntarily been collecting and reporting performance information on a variety of measures for SAMHSA's Block Grants and we have required reporting on many of these measures in our discretionary programs.

Focusing on this handful of National Outcomes will minimize the reporting burden on the states and other grantees, and will promote more effective monitoring of client outcomes and system improvements. Ultimately, they show that people are achieving a life in the community-a home, a job and meaningful personal relationships.

The Future
Achieving the vision of a life in the community for everyone will require collaborative efforts from all individuals, organizations and levels of government that deliver these services and supports. Every segment of society-federal, state and local agencies; public and private organizations; faith-based and community-based groups; health practitioners and providers; policymakers; individuals with mental and substance use disorders as well as those in recovery and their families and friends-must join forces and take action now to respond to the challenge.

Although barriers exist, they are being overcome. As HHS Secretary Thompson recently told SAMHSA staff at the dedication of our new building, "You don't have to share a man's faith to save his life. You don't have to speak a woman's language to cure her illness. You don't need to grow up in a town to heal its people. But you do have to understand your place in the world and your responsibility to love your neighbors, whether they live down the street or across the country." Together with our many partners, SAMHSA will continue to bring the message of hope, courage and recovery and the promise of a life in the community to every individual it touches through its work, both down the street and across America.

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