FY 2005 Government Performance and Results Act (GPRA)

IV. PERFORMANCE PLAN AND REPORT
Mental Health Services

Mental Health programs included in this report are:

1. Child Traumatic Stress Initiative
2. Safe Schools/Healthy Students
3. HIV/AIDS Minority Mental Health Services
4. Comprehensive Community Mental Health Services for Children and Their Families
5. Protection and Advocacy for Individuals with Mental Illness
6. Projects for Assistance in Transition from Homelessness (PATH)
7. Community Mental Health Services Block Grant

Programs of Regional and National Significance (PRNS)

Children's Priority Area
1. Child Traumatic Stress Initiative

Full Cost Table

1. Child Traumatic Stress Initiative Incorporates:	2003	2004	2005
Measure 1.1 (100%)	$32.0	$32.2	$32.1
Measure 1.2
Total Full Cost ($'s in Millions)	$32.0	$32 .2	$32.1

Program Description and Context

Intervention in the aftermath of trauma is perhaps the most significant clinical issue in child and adolescent mental health. Promising interventions for child trauma have been identified, but much needs to be done to provide these services to children and their families. The purpose of the National Child Traumatic Stress Initiative (NCTSI) is to improve treatment and services for all children and adolescents in the United States who have experienced traumatic events. The NCTSI seeks to: 1) improve the quality, effectiveness, and availability of therapeutic services delivered to traumatized children and adolescents, 2) further the understanding of the individual, familial, and community impact of child and adolescent traumatic stress and the methods used to prevent its consequences, and 3) reduce the frequency and consequences of traumatic events on children and adolescents through greater public recognition of the issue, deeper understanding of their sequelae, and improved prevention and treatment services.

As part of NCTSI, the National Center for Child Traumatic Stress (NCCTS) was established to coordinate a national effort to increase services and raise the standard of care for traumatized children. The program has established 54 treatment development and community service centers to treat children who have experienced trauma. Reporting for 2003 shows an average of over 10,000 traumatized children and their families in 18 states directly benefiting from services delivered as a result of the NCTSI. These data provide a baseline of approximately 40,000 children and adolescents served, and have been used to set performance targets for FY 2004 and FY 2005. Many thousands more will benefit from the improvement in treatments, the proliferation of training opportunities, and the many technical, educational and practical information resources that will be made available through the NCTSI Resource Center.

Performance Analysis

Measure 1. Increase the number of children and adolescents reached by improved services

The number of clients who directly and indirectly receive improved services is an important measure of the success of program aimed at children and adolescents who have experienced trauma. Once performance trends are known, targets may be set more aggressively. However, current performance is remarkable in terms of the high numbers of children who have been helped. Further, achieving future targets will result in a significant reduction in trauma related problems in children and adolescents across the Nation. The target of setting a baseline for this measure was achieved in 2003.

Measure 2: Improve Children's Outcomes

This outcome measure is developmental. Targets will be set when baseline data are available.

2. Youth Violence: Safe Schools/Healthy Students
Program Description and Context

Full Cost Table

*This measure and its indicators remain developmental

HIV/AIDS and Hepatitis C Priority Area
3. HIV/AIDS Minority Mental Health Services

Performance Goals (Capacity)	Targets	Actual Performance	Reference
1. Increase the number of clients served (E, O)	FY 05: TBR 6/04 FY 04: TBR 6/04 FY 03: Establish baseline	FY 05: TBR 6/06 FY 04: TBR 6/05 FY 03: TBR 6/04	HHS SP 3.5
Total Funding:	2005: 9,510 2004: 9,454 2003: 9,510

Full Cost Table

3. HIV/AIDS Minority Mental Health Services Incorporates:	2003	2004	2005
3.1 (100%)	$10.2	$10.2	$10.2
3.2
Total Full Cost Funding ($'s in Millions)	$10.2	$10.2	$10.2

Program Description and Context

The HIV/AIDS Minority Mental Health Services Program is a five-year grant program to increase capacity to provide culturally competent mental health treatment services to individuals and communities of color living with HIV/AIDS, within a sustained continuum of services in community-based environments. The program will also identify types and frequency of mental health treatment services utilized by different groups, and pinpoint the types of mental health treatment providers needed in both traditional and non-traditional environments. The program specifically targets African American, Latino/Hispanic, and other racial and ethnic minority populations. The new grantees reflect a diverse range of service providers, including grassroots and indigenous community-based organizations.

Performance Analysis

Measure 1: Increase the number of clients served

This is an important outcome measure for the program consistent with the program goal. Grantees will be monitored to ensure that appropriate performance is achieved. The target of establishing a baseline was not met. Given circumstances beyond CMHS control through the closing of the MHHSC Coordinating Center responsible for collecting client data, FY 2003 client data are not yet available. However, a new Coordinating Center award was made in August 2003, and either through retrieval of already collected data or through resubmissions of data by the sites, FY 2003 data will be available by FY 2004 to develop an accurate baseline number for this program.

Children's Priority Area
4. Comprehensive Community Mental Health Services for Children and Their Families

Performance Goals (Capacity)	Targets	Actual Performance	Reference
1. Increase in number of children receiving services (E)	FY 05: 9,120 FY 04: 8,000 FY 03: Establish baseline	FY05: TBR 10/05 FY04: TBR10/04 FY03: 7,032	HHS SP 3.5 HP 18-07 18-10
2. Improve children's outcomes: (O) (a) Increase in the percentage of children attending school 75% or more of time after 12 months (b) Increase percentage of children with no law enforcement contacts at 6 months (c) Decrease utilization of inpatient facilities at 12 months (E,O) (d) Decrease inpatient costs	FY 05: 80% FY 04: 80% FY 03: 82.6% FY 02: 82.6% FY 05: 53% FY 04: 50% FY 03: 47% FY 02: Establish new baseline FY 05: -3.65 days FY 04: -3.65 days FY 03: -3.00 days FY 02: Establish new baseline FY 05: -$6,326,097 FY 04: -$6,326,097 FY 03: Establish new baseline	FY 05: TBR 10/05 FY 04: TBR 10/04 FY 03: 75% FY 02: 76.7% FY 05: TBR 10/05 FY 04: TBR 10/04 FY 03: 50.5% FY 05: TBR 10/05 FY 04: TBR 10/04 FY 03: -3.48 FY 02: -2.95 FY 05 TBR 10/05 FY 04: TBR 10/04 FY 03: -$6,024,855	HHS SP 3.5 HP18-07 18-10
Long-Term Measures 3. Improve children's outcomes (60% of grantees will exceed a 30% improvement in outcomes)	FY 10: 30% FY 04: Estab. baseline	FY 10: TBR 10/11 FY 04: TBR 4/04
4. Increase percent of systems of care sustained post Federal funding (80% of systems of care will be sustained post-funding)	FY 10: 80% FY 04: Estab. baseline	FY 10: TBR 10/11 FY 04: TBR 4/04
5. Percentage of grantees that decrease inpatient care costs (25% of systems of care will exceed a 10% decrease in inpatient care)	FY 10: 25% FY 04: Estab. baseline	FY 10: TBR 10/11 FY 04: TBR 4/04
Total Funding	2005 $106,013 2004 $102,353 2003 $98,053

Full Cost Table

4. Comprehensive Community Mental Health Services for Children & Their Families Incorporates: ($'s in Millions)	2003	2004	2005
4.1 (60%)	$60.3	$62.9	$65.0
4.2 (20%)	$20.0	$20.9	$21.7
4.3 (20%) (a) (b)	$20.0	$20.9	$21.7
4.4
4.5
4.6
Total Full Cost Funding ($'s in Millions)	$100.3	$104.7	$108.4

Program Description and Context

The Children's Mental Health Services Program supports the development of systems of care for children who have a serious emotional disturbance or diagnosable mental disorder. It is estimated that nationally, two-thirds of children with these disorders do not receive mental health services. At least one-third of children ages 12-21 who are served through the CMHS-funded systems of care appear to have dual mental and substance use problems. Findings from the National Evaluation suggest that the Program's unique approach especially benefits dually diagnosed children.

Program funds are available through competitive cooperative agreements to States, political subdivisions of States, Territories, and Indian Tribes or tribal organizations. Funds build on the existing services infrastructure so that the array of services required to meet the needs of the target population is available and accessible. Grants are limited to a total of 6 years, with an increasing non-Federal matching requirement over the term of the award to promote sustainability of the local systems of care beyond the grant period. It is estimated that over 18 of the first 22 (82%) grant communities initially funded in fiscal years 1993 and 1994 have continued to be sustained as service delivery systems since the federal program funds ended in fiscal years 1999 and 2000.

From 1993-2003, CMHS has funded grants in 46 States and 2 territories, and provided services to approximately 59,850 children. The program has served children in 274 of the 3,142 counties (9%) in the United States.

Performance Analysis

The Children's Mental Health program was reviewed by OMB through the PART process in 2002 for the FY 2004 budget, and received a "moderately effective" score. During this process, the program developed several long-term goals addressing clinical outcomes, sustainability, and cost-efficiency. These measures have been added to the table of measures.

Measure 1: Increase number of children receiving services (Measure modified in FY 2003)

This measure now reflects the total number of children served across sites, rather than the average number of children served per grantee.

A new numerical target of 8,000 has been set for fiscal year 2004. This target takes into consideration that from FY 2002 to FY 2003, 25 new cooperative agreements were funded representing over 40% of all sites funded during FY 2003. The newly funded grant sites are not expected to generate large numbers of children served until they are well into their third or fourth years of funding when the sites have had significant time to develop their new systems and services.

Measure 2: Improve children's outcomes:

(a) Increase percentage of children attending school 75% or more of the time after 12 months

The target was not met. The percentage of children achieving school attendance of 75% or more or the time has declined over the past several fiscal years. Because funding for some grantees funded in earlier cycles ended and new grantees were funded during these years, the mix of communities and types of children served has changed based on the program focus of each community. It is speculated that observed declines in this measure are related to changes in the specific characteristics of children served across the varying cohorts of communities represented in each fiscal year. Additional analytic work is needed to identify the specific child characteristics that may be related to school attendance, such as the level of mental health need.

(b) Increase percentage of children with no law enforcement contacts at 12 months

Target exceeded.

(c) Decrease utilization of inpatient facilities at 12 months

Target exceeded; FY 2004 target was increased by 5 percent.

(d) Decrease inpatient costs

Indicator (d) was added as a new indicator for FY 2003. The baseline was established with FY 2003 data. The FY 2004 and FY 2005 targets were established based on a 5% increase in savings due to a projected decrease in inpatient hospitalization utilization days from FY 2003 to FY 2004.

Long Term Measures

Measure 3: Increase the percentage of children with improved behavioral and emotional symptoms

80% of grantees will exceed a 30% improvement in behavioral and emotional symptoms among children receiving services. Data to be reported in 2011.

Measure 4: Increase percent of systems of care sustained post Federal funding

80% of systems of care will be sustained 5 years post funding. Data to be reported in 2011.

Measure 5: Percentage of grantees that decrease inpatient care costs

30% of systems of care will exceed a 10% decrease in overall inpatient care costs. Data to be reported in 2011.

Mental Health Systems Transformation Priority Area
5. Protection and Advocacy for Individuals with Mental Illness

Performance Goals (Capacity)	Targets	Actual Performance	Reference
1. Increase the number of persons served (O, E)	FY05: 22,000 FY04: 21,000 FY 03: 20,000 FY 02: 19,000 FY 01: Baseline	FY 05: TBR 7/06 FY 04: TBR 7/05 FY 03: TBR 7/04 FY 02: 18,566 FY 01: 17, 620	HHS SP 3.5
2. Increase the percentage of substantiated incidents reported to State P&A systems that are favorably resolved (O)	FY 05: 84% FY 04: 82% FY 03: 80% FY 02: 77% FY 01: 76% FY 00: 75%	FY 05: TBR 7/06 FY 04: TBR 7/05 FY 03: TBR 7/04 FY 02: 86% FY 01: 88% FY 00: 84% FY 99: Baseline: 75%
Total Funding:	2005: $34,620 2004: $34,620 2003: $33,779

Full Cost Table

5. Protection & Advocacy for Individuals w/ Mental Illness Incorporates:	2003	2004	2005
5.1 (50%)	$17.1	$17.5	$17.5
5.2 (50%)	$17.1	$17.5	$17.5
Total Full Cost Funding ($'s in Millions)	$34.2	$35.0	$35.0

Program Description and Context

Protection and Advocacy for Individuals with Mental Illness (PAIMI) provides formula grant awards to support protection and advocacy (P&A) systems designated by the governor of each State, the Territories, and the Mayor of the District of Columbia. P&A systems investigate complaints of abuse, neglect and civil rights violations of PAIMI-eligible individuals with severe mental illness and severe emotional disturbance who reside in hospital or residential care settings. P&A Systems have the authority to investigate complaints at both public and private residential care and treatment facilities as well as non-medical community-based facilities for children and youth to ensure the enforcement of the U.S. Constitution and Federal and State laws. The program supports SAMHSA's Capacity goal by expanding the availability of protection and advocacy services. The program served 18,566 people in FY 2002.

Performance Analysis

Measure 1: Increase the number of persons served

The number served in 2002 narrowly missed the target. The expanded facility reporting required by the Children's Health Act of 2000 resulted in more P&A systems having to utilize legal remedies to gain access to clients, facilities and records, as they attempt to investigate incidents of seclusion, restraint and related deaths which slows investigations thus reducing the number served. The Healthcare Insurance Portability and Accountability Act (HIPAA) also puts constraints on the ability of P&A systems to investigate complaints which also slows investigations.

Measure 2: Increase the percentage of substantiated incidents of abuse, neglect, or rights violations reported to State P&A systems that are favorably resolved

The program substantially exceeded its FY 2002 target. Accordingly, targets for future years have been raised.

Homeless Priority Area
6. Projects for Assistance in Transition from Homelessness (PATH)

Performance Goals (Capacity)	Targets	Actual Performance	Reference
1. Increase number of persons contacted (E,O)	FY 05: 154,500 FY 04: 147,000 FY 03: 137,000 FY 02: 132,500 FY 01: 124,000 FY 00: 117,000 FY 99: 102,000	FY 05: TBR 7/07 FY 04: TBR 7/06 FY 03: TBR 7/05 FY 02: TBR 7/04 FY 01: 125,730 FY 00: 109,000 FY 99: 123,000 FY 98: 115,000 FY 97: 105,000 FY 96: Baseline 105,000	HHS SP 3.5
2. Increase percentage of persons contacted who become enrolled in services (O)	FY 05: 47% FY 04: 46% FY 03: 45% FY 02: 44% FY 01: 35% FY 00: 33% FY 99: 30%	FY 05: TBR 7/07 FY 04: TBR 7/06 FY 03: TBR 7/05 FY 02: TBR 7/04 FY 01: 43% FY 00: 42% FY 99: 36% FY 98: 37% FY97: 41% FY96: Baseline 41%	HP-18-3
3. Long term: Increase the percentage of enrolled homeless persons with serious mental illnesses who receive case management services.	FY 05: 73%	FY 05: TBR 7/07 FY 00 Baseline: 68%
· 4. Long term: Increase the percentage of enrolled homeless persons with serious mental illnesses who receive community mental health services.	FY 05: 65%	FY 05: TBR 7/07 FY 00 Baseline: 44%
5. Long term: Maintain cost of enrolling a person in services. (E)	FY 05: $668.00	FY 05: TBR 12/07 FY 03 Baseline: $668.00
Total Funding:	2005: $55,251 2004: $49,760 2003: $43,073

Full Cost Table

6. Projects for Assistance in Transition from Homelessness (PATH) Incorporates:	2003	2004	2005
6.1	22.0	25.3	28.1
6.2	22.0	25.3	28.1
6.3
6.4
6.5
Total Full Cost Funding ($'s in Millions)	$44.0	$50.7	$56.2

Program Description and Context

The Projects for Assistance in Transition from Homelessness (PATH) formula grant program, established in 1991, primarily supports SAMHSA's Capacity goal by expanding the availability of services to homeless individuals with serious mental illnesses. The program distributes Federal funds to each State, the District of Columbia, and certain US territories to support a broad array of individualized services to this vulnerable population. The program directly supports the Secretary's Initiative as well as SAMHSA's Homelessness priority area.

The goal of the PATH program is to provide services that will enable homeless persons with serious mental illnesses to be placed in appropriate housing and to receive formal mental health treatment and other resources to improve their mental health functioning. The statute specifies the range of services that may be supported by States under the program: outreach; screening and diagnostic services; habilitation and rehabilitation; community mental health services; alcohol or drug treatment (for those with co-occurring disorders); staff training; case management; supportive and supervisory services in residential settings; and referrals for primary health care, job training, and education. Some housing services may be provided as well. States have considerable flexibility in designing programs, and are required to match funds with one dollar for every three dollars received in Federal funds. In recent years, State and local support has been more than three times the amount required by the match.

Performance Analysis

Measure 1: Number of persons contacted.

The target was exceeded for 2001. As data reporting methods improve, the reported number of persons contacted has become more accurate. The program is taking several steps to improve the accuracy of reported data, including improvements in software, strengthened verification of questionable numbers, and increased training of State and local PATH-funded staff.

Measure 2: Increase percentage of persons contacted who become enrolled in services

The percentage of persons contacted who actually enrolled in services rose from 36% in FY 1999 to 42% in FY 2000, and to 43% in FY 2001. This increase considerably exceeded the target of 35% (targets for future years have been revised upward). Targets may appear conservative, however, the focus of this measure is the chronic homeless population, who are very difficult to reach. During OMB PART review in 2002, the long-term target of 47% was acknowledged as realistic given the enormous difficulties of serving this often intractable population.

Data Note: Most States award their annual PATH funds late in the fiscal year. Accordingly, there is an unavoidable data lag as States collect and compile data prior to submitting the data to SAMHSA. It is also important to note that this data lag also delays the apparent impact of any budget increase or decrease on performance data.

Long Term Measures

Measure 3: Increase the percentage of enrolled homeless persons with serious mental illnesses who receive case management services.

Baseline and targets set.

Measure 4: Increase the percentage of enrolled homeless persons with serious mental illnesses who receive community mental health services.

Baseline and targets set.

Measure 5: Maintain cost of enrolling a person in services.

Baseline and targets set.

Mental Health Systems Transformation Priority Area 7. Community Mental Health Services Block Grant

4. Increase the number of (a) SAMHSA-identified evidence-based practices (EPBs) in each state and (b) the percentage of service population coverage for each EPB. (E) (Developmental) Long term target:	FY 05: TBR 4/04 FY 04: TBR 4/04 FY03: Establish baseline FY 08: TBR 4/04 FY 04: Estab. Baseline	FY 05: TBR 4/06 FY 04: TBR 4/05 FY 03: TBR 4/04 FY 08: 12/08 FY 04: 4/04
Total funding:	2005: $436,070 2004: $434,690 2003: $437,140

Full Cost Table

7. Community Mental Health Services Block Grant Incorporates:	2003	2004	2005
7.1 (60%)	$265.6	$264.2	$265.3
7.2 (20%)	$88.6	$88.3	$88.5
7.3 (20%)	$88.6	$88.3	$88.5
7.4
Total Full Cost Funding ($'s in Millions)	$442.8	$440.7	$442.2

Program Description and Context

The Community Mental Health Services Block Grant addresses SAMHSA's goal of increasing capacity as well as the goal of promoting effective services. The Program assists the 59 eligible and participating States and Territories in moving care for adults with serious mental illness (SMI) and children with serious emotional disturbance (SED) from costly and restrictive inpatient hospital care to the community. States have considerable latitude in determining how they will use funds. The program also provides strong support to the Effectiveness goal through the implementation of best practices. The Block Grant program supports multiple SAMHSA priority areas, including co-occurring disorders; children and families; and Mental Health Systems Transformation.

States vary widely in their ability to report mental health data depending upon data infrastructure and reporting capacity. Since its inception, CMHS has worked with States to improve data collection and reporting. Efforts have included working to develop performance measures, participant counts, and other program data. Some of these measures were piloted in the 16-State Project, which was designed to develop uniform data and unduplicated counts of people served by the State Mental Health Authority. Core measures for the Block Grant program were implemented on a voluntary basis in an effort to capture the data available at that time. Despite efforts to establish standard data definitions, these were not available through FY 2001. Consequently, the data reported were not meaningful when aggregated or comparable across States or across time. These data issues have led to difficulty in quantitatively demonstrating the efficiency and effectiveness of the Block Grant program. In FY 2002, the Block Grant application contained a set of OMB-approved performance measures with more precise definitions, in an effort to obtain more uniform data.

The Children's Health Act of 2000 included a requirement to provide $6 million in PRNS funding for the enhancement of the States' and Territories' data infrastructure. Forty-seven States have now received grants to improve their ability to develop data standards for uniform, comparable, high-quality statistics on mental health services administered with Block Grant funds. Preliminary data that are the result of these grants are now being reported for GPRA measure 1,2 and 3.

The Children's Health Act further requires the Secretary, in conjunction with the States and other interested groups, to develop plans for creating more flexibility and accountability for States in the use of mental health and substance abuse block grant funds based on outcome and other performance measures.

In responding to this mandate, CMHS has worked with the States to develop three goals for performance measurement that describe the State Mental Health Authority (SMHA) Public Mental Health System, develop continued quality improvement (CQI) benchmarks for the SMHA Public Mental Health System, and improve the performance of the SMHA Public Mental Health System. Some of the measures will be replaced by Performance Partnership Measures in 2005. It is expected that all of these efforts will improve States' ability to report data on mental health services and recipients.

Performance Analysis

Measure 1 : Number of people served.

Preliminary data representing the actual number of people served by State mental health systems are now available. The baseline of 4,275,826 is now set with FY 2003 data and the FY 2004 target is set for 4,318,584. Previously, the number of persons served by the MHBG funds was estimated. CMHS continues to derive the estimate based on the average dollars spent by Medicaid clients for outpatient care. According to the estimate, 220,000 persons will be served by the block grant in FY 2005.

Measure 2: Reduce rate of readmissions to State psychiatric hospitals

Both targets for this measure have been exceeded. Data reported is preliminary. For the indicator tracking adults, 36 States have reported. For the measure tracking children and adolescents, 28 States have reported. Success in community placement from inpatient settings and decreased need for inpatient care indicates that systems of care are working to support patients in the community.

Utilization of inpatient/residential treatment at 12 months is now computed differently. Prior to FY 2002, years, this measure included only children who already had a history of inpatient or residential care (only 5% of the children served by the program). The measure was re-defined to document in service use among the entire population of children served across the program's system-of-care communities. The sample of children for this measure no longer is a cumulative sample across grant years, but represents the sample of children for whom the CMHS evaluation contractor had received information on 12-month assessments conducted during a one-year period from 7/1/01 to 6/30/02. Accordingly, a new baseline has been established and future year targets have been revised. Note that because all children are included, most of whom will have no inpatient treatment, the baseline targets represent a much smaller average number of days.

Measure 3: Increase rate of consumers/family members reporting positively about outcomes

The targets for adults and children were exceeded, however, this is preliminary data and more complete data is needed before targets can be appropriately raised. The graphs below show consumer assessment of care as positive for both adults and children. This data represents 36 States reporting for adults and 28 States reporting for children.

Measure 4: Increase the number of (a) SAMHSA-identified evidence-based practices (EPBs) in each state and (b) the percentage of service population coverage for each EPB.

This long-term measure was developed as part of the OMB PART process. In order to operationalize this measure, a pilot study will be conducted in FY04 on the relationship between Evidence Based Practices and cost for baseline data.