[Federal Register Volume 69, Number 43 (Thursday, March 4, 2004)]
[Notices]
[Pages 10239-10255]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-4733]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration


Notice of Request for Applications for Access to Recovery (ATR) 
Grants (TI 04-009)

AGENCY: Substance Abuse and Mental Health Services Administration, HHS

ACTION: Notice of request for applications for access to recovery (ATR) 
grants (TI 04-009).

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SUMMARY: The United States Department of Health and Human Services 
(HHS), Substance Abuse and Mental Health Services Administration's 
(SAMHSA) Center for Substance Abuse Treatment (CSAT) is accepting 
applications for

[[Page 10240]]

fiscal year (FY) 2004 grants to implement voucher programs for 
substance abuse clinical treatment and recovery support services 
pursuant to sections 501 (d)(5) and 509 of the Public Health Service 
Act (42 U.S.C. sections 290aa(d)(5) and 290bb-2). This new program, 
called Access to Recovery (ATR), is part of a Presidential initiative 
to provide client choice among substance abuse clinical treatment and 
recovery support service providers, expand access to a comprehensive 
array of clinical treatment and recovery support options (including 
faith-based programmatic options), and increase substance abuse 
treatment capacity. Monitoring outcomes, tracking costs, and preventing 
waste, fraud and abuse to ensure accountability and effectiveness in 
the use of Federal funds are also important elements of the ATR 
program. Through the ATR grants, States, territories, the District of 
Columbia and tribal organizations (hereinafter collectively referred to 
as ``States'') will have flexibility in designing and implementing 
voucher programs to meet the needs of clients in the State. The key to 
successful implementation of the voucher programs supported by the ATR 
grants will be the relationship between the States and clients 
receiving services, to ensure that clients have a genuine, free, and 
independent choice among eligible providers. States are encouraged to 
support any mixture of clinical treatment and recovery support services 
that can be expected to achieve the program's goal of achieving cost-
effective, successful outcomes for the largest number of people.

DATES: Applications are due on June 4, 2004.

FOR FURTHER INFORMATION CONTACT: For questions on program issues, 
contact: Andrea Kopstein, Ph.D., M.P.H., SAMHSA/CSAT, 5600 Fishers 
Lane, Rockwall II, Suite 7-40, Rockville, MD 20857, Phone: (301) 443-
3491, Fax: (301) 443-3543, E-Mail: [email protected].
    For questions on grants management issues, contact: Kathleen 
Sample, Division of Grants Management, Substance Abuse and Mental 
Health Services Administration/OPS, 5600 Fishers Lane, Rockwall II 6th 
Floor, Rockville, MD 20857, Phone: (301) 443-9667, Fax: (301) 443-6468, 
E-mail: [email protected].

SUPPLEMENTARY INFORMATION:
    Date of Issuance: March 2004.

Table of Contents

I. Funding Opportunity Description
II. Award Information
    1. Award Amount
    2. Funding Mechanism
III. Eligibility Information
    1. Eligible Applicants
    2. Cost Sharing
    3. Other
IV. Application and Submission Information
    1. Address To Request Application Package
    2. Content and Form of Application Submission
    3. Submission Dates and Times
    4. Intergovernmental Review
    5. Funding Limitations/Restrictions
    6. Other Submission Requirements
V. Application Review Information
    1. Evaluation Criteria
    2. Review, Selection, and Award Process and Criteria
VI. Award Administration Information
    1. Award Notices
    2. Administrative and National Policy Requirements
    3. Reporting Requirements
VII. Agency Contacts
VIII. Other Information
    1. SAMHSA Confidentiality and Participant Protection 
Requirements and Protection of Human Subjects Regulations
Appendix A: Comprehensive Array of Clinical Treatment and Recovery 
Support Services
Appendix B: Services Included as Administrative Expenses
Appendix C: Standards for the Access to Recovery Program
Appendix D: Screening, Assessment, and Level of Care Determination
Appendix E: Example of How a State Could Implement a Voucher Program
Appendix F: Checklist for Formatting Requirements and Screenout 
Criteria for SAMHSA Grant Applications
Appendix G: Managing on the Basis of Reasonable Costs

    Authority: Sections 501(d)(5) and 509 of the Public Health 
Service Act (42 U.S.C. sections 290aa(d)(5) and 290bb-2).

(Catalogue of Federal Domestic Assistance (CFDA) No.: 93.243.)

I. Funding Opportunity Description

    The United States Department of Health and Human Services (HHS), 
Substance Abuse and Mental Health Services Administration's (SAMHSA) 
Center for Substance Abuse Treatment (CSAT) is accepting applications 
for fiscal year (FY) 2004 grants to implement voucher programs for 
substance abuse clinical treatment and recovery support services 
pursuant to sections 501 (d)(5) and 509 of the Public Health Service 
Act (42 U.S.C. sections 290aa(d)(5) and 290bb-2). This new program, 
called Access to Recovery (ATR), is part of a Presidential initiative 
to provide client choice among substance abuse clinical treatment and 
recovery support service providers, expand access to a comprehensive 
array of clinical treatment and recovery support options (including 
faith-based programmatic options), and increase substance abuse 
treatment capacity. Monitoring outcomes, tracking costs, and preventing 
waste, fraud and abuse to ensure accountability and effectiveness in 
the use of Federal funds are also important elements of the ATR 
program. Through the ATR grants, States, territories, the District of 
Columbia and tribal organizations (hereinafter collectively referred to 
as ``States'') will have flexibility in designing and implementing 
voucher programs to meet the needs of clients in the State. The key to 
successful implementation of the voucher programs supported by the ATR 
grants will be the relationship between the States and clients 
receiving services, to ensure that clients have a genuine, free, and 
independent choice among eligible providers. States are encouraged to 
support any mixture of clinical treatment and recovery support services 
that can be expected to achieve the program's goal of achieving cost-
effective, successful outcomes for the largest number of people.
    In addition, States should propose innovative strategies for their 
ATR projects to accomplish the following:
    [sbull] Ensure genuine, free, and independent client choice for 
substance abuse clinical treatment and recovery support services 
appropriate to the level of care needed by the client. For the purposes 
of this grant program, choice is defined as a client being able to 
choose from among two or more providers qualified to render the 
services needed by the client, among them at least one provider to 
which the client has no religious objection.
    [sbull] Require all substance abuse assessment, clinical treatment, 
and recovery support services under this program be provided pursuant 
to a voucher or vouchers given to a client by a State or its designee. 
No funding shall be given directly to a provider through a grant or 
contract to provide any services under this program, including 
assessment.\1\
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    \1\ Indirect funding means that individual, private choice, 
rather than the Government, determines which substance abuse service 
provider eventually receives the funds. With indirect funding, the 
individual in need of the service is given a voucher, coupon, 
certificate, or other means of free agency, such that he or she has 
the power to select for himself or herself from among eligible 
substance abuse service providers, whereupon the voucher (or other 
method of payment) may be ``redeemed'' for the service rendered. 
Under ``direct'' funding, the Government or an intermediate 
organization with the same duties as a governmental entity purchases 
the needed services directly from the substance abuse service 
provider. Under this scenario, there are no intervening steps in 
which the client's choice comes into play. The government or 
intermediate organization selects the provider from which the client 
will received services.

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[[Page 10241]]

    [sbull] Ensure each client receives an assessment for the 
appropriate level of services and is then provided a genuine, free, and 
independent choice among eligible providers, among them at least one 
provider to which the client has no religious objection.
    [sbull] Use the grant funds to implement a system to provide 
vouchers to eligible clients to pay for assessment and other clinical 
treatment and recovery support services from a broad network of 
eligible providers, including organizations that have not previously 
received public funding. Eligible service providers for the voucher 
program may include the following: public and private, nonprofit, 
proprietary, as well as faith-based and community organizations, as 
approved by the State.
    [sbull] Ensure that faith-based organizations otherwise eligible to 
participate in this program are not discriminated against on the basis 
of their religious character or affiliation.
    [sbull] Maintain accountability by creating an incentive system for 
positive outcomes and taking active steps to prevent waste, fraud and 
abuse. (See Section VI-3 and Appendix C for reporting expectations 
under this program).
    [sbull] Expand clinical treatment and recovery support services by 
leveraging use of all Federal funds, preventing cost shifting, and 
ensuring that these funds are used to supplement and not supplant 
current funding for substance abuse clinical treatment and recovery 
support services in the State.
    SAMHSA is interested in supporting a range of models to implement 
substance abuse voucher programs, including:
    [sbull] Full implementation of the program through a designated 
lead State or sub-State agency.
    [sbull] Implementation of the program through public/private 
partnerships (i.e., a contract between the State and a lead private 
entity to implement all or part of the program).
    States may implement the program statewide or may target geographic 
areas of greatest need, specific populations in need, or areas/
populations with a high degree of readiness to implement a voucher 
program. States may propose alternate models for consideration, as long 
as they conform to the expectations articulated above.
    States are encouraged to minimize the funds used to cover both the 
direct and indirect costs of administration of the program, to develop 
a system to manage the program on the basis of reasonable costs, to 
develop a system to provide incentives to eligible providers with 
superior outcomes, and to include a broad range of stakeholders in 
planning and designing their proposal.
    Appendix E provides a hypothetical example of a program that 
conforms to these expectations. States may wish to consult this 
appendix as a starting point for developing their ATR Grant 
applications.
    Due to the unique nature of this grant program, SAMHSA recognizes 
that applicants may wish to entertain an array of program and 
administrative options. To respond, SAMHSA will make available both 
pre-application and post-award technical assistance to applicants and 
current and future providers of substance abuse clinical treatment and 
recovery support services under this program. Examples of topics for 
which technical assistance may be provided include, but are not limited 
to:
    [sbull] Eligibility determinations for clinical treatment and 
recovery support services providers and for which service in the 
continuum of recovery will be included in the voucher reimbursement 
system.
    [sbull] Eligibility determinations for clients, including 
management of a system for assessment and service determinations.
    [sbull] Identifying and determining eligibility of new clinical 
treatment and recovery support service providers.
    [sbull] Fiscal/cost accounting mechanisms that can track voucher 
implementation.
    [sbull] Management of information systems to track performance and 
outcomes.
    [sbull] Development of quality improvement activities, including 
technical assistance and training to attract, develop, and sustain new 
clinical treatment and recovery support service providers.
    [sbull] Oversight of standards and fraud and abuse.
    [sbull] Outreach to entities unknown to the State.

II. Award Information

1. Award Amount

    It is expected that approximately $100 million will be available in 
fiscal year 2004 to fund up to approximately 15 awards in the Access to 
Recovery (ATR) program. No more than one grant award will be made to 
any State or Tribal Organization. Individual awards are expected to be 
up to $15,000,000 in total costs (direct and indirect) per year. Grants 
will be awarded for a period of 3 years. The actual award amount in any 
one year will depend on the availability of funds. Awards may be 
adjusted based on the number of individuals proposed to be treated 
successfully per year.\2\
    Proposed budgets cannot exceed $15,000,000 in any year of the 
proposed project. Annual continuation awards will depend on the 
availability of funds, grantee progress in meeting project goals and 
objectives, timely submission of required data and reports, and a 
determination that continued funding of the award is in the best 
interest of the Government.
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    \2\ For purposes of this program, successful completion of an 
episode of paid treatment/recovery support is defined, at a minimum, 
as an individual having completed the major goals of his/her 
treatment plan and having submitted a minimum of four consecutive, 
randomly collected samples that are free from illegal drugs and 
alcohol. (This requirement does not apply to brief treatment 
interventions).
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2. Funding Mechanism

    The ATR awards will be made as grants to States that, in turn, must 
distribute funds to clients through vouchers.

III. Eligibility Information

1. Eligible Applicants

    Eligibility for Access to Recovery (ATR) grants is limited to the 
immediate office of the Chief Executive (e.g., Governor) in the States, 
Territories, District of Columbia; or the head of a Tribal 
Organization. (A ``Tribal Organization'' means the recognized governing 
body of any Indian tribe or any legally established organization of 
Indians, including urban Indian health boards, inter-tribal councils, 
or regional Indian health boards, which is controlled, sanctioned, or 
chartered by such governing body or which is democratically elected by 
the adult members of the Indian community to be served by such an 
organization.) The Chief Executive of the State, Territory, or District 
of Columbia, or the head of the Tribal Organization must sign the 
application.
    Eligibility is limited to the immediate office of these Chief 
Executives because only they have the authority to leverage funding 
across the State, implement the necessary policy changes, manage the 
fiscal responsibilities, and coordinate the range of programs necessary 
for successful implementation of the voucher programs to be funded 
through these grants.
    No more than one application from any one Chief Executive or head 
of a Tribal Organization will be funded.

2. Cost Sharing

    Cost sharing is not required in this program. However, grantees 
must use these funds to supplement, and not supplant, current funding 
for substance abuse clinical treatment and recovery support services 
within States.

[[Page 10242]]

3. Other

    Applications must comply with the following requirements, or they 
will be screened out and will not be reviewed:
    [sbull] Use of the PHS 5161-1 application;
    [sbull] Application submission requirements in Section IV-3 of this 
document; and
    [sbull] Formatting requirements provided in Section IV-2.4 of this 
document.

IV. Application and Submission Information

(To ensure that all submission requirements are met, a checklist is 
provided in Appendix F of this document.)

1. Address To Request Application Package

    Applicants may request a complete application kit by calling 
SAMHSA's National Clearinghouse for Alcohol and Drug Information 
(NCADI) at 1-800-729-6686.
    Applicants also may download the required documents from the SAMHSA 
Web site at http://www.samhsa.gov. Click on ``grant opportunities.''
    Additional materials available on this Web site include:
    [sbull] A technical assistance manual for potential applicants.
    [sbull] Standard terms and conditions for SAMHSA grants.
    [sbull] Guidelines and policies that relate to SAMHSA grants (e.g., 
guidelines on cultural competence, client and family participation, and 
evaluation).
    [sbull] Enhanced instructions for completing the Public Health 
Service (PHS) 5161-1 application.

2. Content and Form of Application Submission

2.1 Required Documents
    SAMHSA application kits include the following:
    [sbull] PHS 5161-1 (revised July 2000)--Includes the face page, 
budget forms, assurances, certification, and checklist. Applicants must 
use the PHS 5161-1. Applications not submitted on the PHS 5161-1 will 
be screened out and will not be reviewed.
    [sbull] Request for Applications (RFA)--Includes instructions for 
the grant application. This document is the RFA.
    Applicants must use both of the above documents in completing an 
application.
2.2 Required Application Components
    To ensure equitable treatment, applications must be complete. For 
an application to be complete, it must include the required 10 
application components (Face Page, Abstract, Table of Contents, Budget 
Form, Project Narrative and Supporting Documentation, Appendices, 
Assurances, Certifications, Disclosure of Lobbying Activities, and 
Checklist).
    [sbull] Face Page--Use Standard Form (SF) 424, which is part of the 
PHS 5161-1. [Note: Beginning October 1, 2003, applicants must provide a 
Dun and Bradstreet (DUNS) number to apply for a grant or cooperative 
agreement from the Federal Government. SAMHSA applicants are required 
to provide their DUNS number on the face page of the application. 
Obtaining a DUNS number is easy and there is no charge. To obtain a 
DUNS number, access the Dun and Bradstreet Web site at http://www.dunandbradstreet.com or call 1-866-705-5711. To expedite the 
process, Dun and Bradstreet should be informed that the applicant is a 
public/private nonprofit organization preparing to submit a Federal 
grant application.]
    [sbull] Abstract--The total abstract should not be longer than 35 
lines. In the first five lines or less of the abstract, write a summary 
of the project that can be used in publications, reporting to Congress, 
or press releases if the project is funded.
    [sbull] Table of Contents--Include page numbers for each of the 
major sections of the application and for each appendix.
    [sbull] Budget Form--Use SF 424A, which is part of the PHS 5161-1. 
Complete Sections B, C, and E of the SF 424A.
    [sbull] Project Narrative and Supporting Documentation--The Project 
Narrative describes the project. It consists of Sections A through D. 
Sections A through D together may not exceed 35 pages in length. More 
detailed instructions for completing each section of the Project 
Narrative are found in Section 2.3 below.
    The Supporting Documentation provides additional information needed 
for review of the application. This supporting documentation should be 
included immediately following the Project Narrative in Sections E 
through G. There are no page limits for these sections, with the 
exception of Section F (Biographical Sketches/Job Descriptions).
    [sbull] Section E--Budget Justification, Existing Resources, Other 
Support. Applicants must provide a narrative justification of the items 
included in the proposed budget, as well as a description of existing 
resources and other support expected for the proposed project. Proposed 
budgets cannot exceed $15 million per year.
    [sbull] Section F--Biographical Sketches and Job Descriptions.
    [sbull] Include biographical sketches for the Project Director and 
other key positions. Each sketch should be two pages or less. If a key 
staff person has not been hired yet, include a letter of commitment 
from the individual with a current biographical sketch.
    [sbull] Include job descriptions for all key personnel. Each job 
descriptions should be no longer than one page in length.
    [sbull] Sample biographical sketches and job descriptions are 
listed on page 22, Item 6 in the Program Narrative section of the PHS 
5161-1.
    [sbull] Section G--Confidentiality and SAMHSA Participant 
Protection/Human Subjects. Instructions for completing Section G of the 
application are provided in Section VIII-1 of this document.
    [sbull] Appendices 1 through 7--Use only the appendices listed 
below. Do not submit more than 50 pages in total (excluding any data 
collection instruments and interview protocols) for all of the 
appendices combined. Do not use appendices to extend or replace any of 
the sections of the Project Narrative. Reviewers will not consider 
them.
    [sbull] Appendix 1: Letters of Commitment/Support.
    [sbull] Appendix 2: Data Collection Instruments/Interview 
Protocols.
    [sbull] Appendix 3: Sample Consent Forms.
    [sbull] Appendix 4: Non-Supplantation Letter.
    [sbull] Appendix 5: Three-year Capacity Building Plan.
    [sbull] Appendix 6: Three-year Data Collection and Implementation 
Plan.
    [sbull] Appendix 7: Literature Citations.
    [sbull] Assurances--Non-Construction Programs. Use SF 424B found in 
PHS 5161-1. Sign and date the form.
    [sbull] Certifications--Use the ``Certifications'' forms found in 
PHS 5161-1. Sign and date the forms.
    [sbull] Disclosure of Lobbying Activities--Use SF LLL found in the 
PHS 5161-1. Federal law prohibits the use of appropriated funds for 
publicity or propaganda purposes, or for the preparation, distribution, 
or use of information designed to support or defeat legislation pending 
before the Congress, State legislatures, or tribal councils. This 
includes ``grass roots'' lobbying, described as appeals to members of 
the public suggesting they contact their elected representatives to 
express support for or opposition to pending legislation or to urge 
those representatives to vote in a particular way.
2.3. Project Narrative--Sections A Through D
    Sections A through D are the Project Narrative of the application. 
These sections describe the project itself.

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Sections A through D together may not exceed 35 pages in length.
    Use the instructions below that have been tailored to this program 
to develop the project narrative. Do not use the ``Program Narrative'' 
instructions found on page 21 of the PHS 5161.
    Be sure to provide references for any literature cited in the 
application; include those references in Appendix 7 of the application.
[sbull] Section A: Need for Voucher Program
    Describe the current substance abuse clinical treatment and 
recovery support system in the State (or sub-State target area, if 
appropriate), including the number of providers currently funded by the 
State, gaps in service delivery, and barriers to service access.
    Describe the nature and prevalence of substance abuse problems in 
the State (or sub-State target area), and quantify the need for 
services, capacity of the service system to provide services, and the 
difference between the two.
    Describe how a voucher program would help the State (or sub-State 
target area) address the difference between system capacity and service 
need, including how and by how much capacity would be increased for 
each year of the grant. Clearly state the number of clients who would 
be treated under the proposed program in each year of the grant.
    In Appendix 4 of the application, provide a letter certifying the 
State will supplement, and not supplant, current funding for substance 
abuse clinical treatment and recovery support services.
    [sbull] Section B: Proposed Approach
    Describe the approach that will be used to develop or implement 
(depending on applicant level of readiness) the program in the State, 
including the following:
    [sbull] Implementation model (e.g., State, sub-State agency, 
public/private partnership or other model).
    [sbull] Eligibility criteria for clients to receive vouchers for 
clinical treatment and recovery support services.
    [sbull] Procedures/policies for screening, assessment, and level of 
care determinations to identify appropriate clinical treatment and 
recovery support services options and to place clients with the 
eligible provider of their choice. Describe the process to ensure that 
clients receive a comprehensive assessment, using an instrument that 
assesses need for clinical treatment and recovery support services (see 
Appendix A for a discussion of clinical treatment and recovery support 
services, and Appendix D for information on screening, assessment, and 
level of care determination). Describe the process to ensure that 
clients receive vouchers for the most appropriate services and are 
transitioned between services based on established criteria. (See 
Appendices D and E for more information and resources about criteria.) 
Describe steps to ensure that clients successfully enter clinical 
treatment and/or recovery support services following receipt of a 
voucher, regardless of where the client is seen for screening, 
assessment, and referral. Clearly state the number of clients who would 
be successfully treated under the proposed program.
    [sbull] Eligibility criteria for provider organizations, including: 
(1) Standards for all eligible provider organizations and/or processes 
to ensure individuals receive appropriate services in safe settings 
from appropriate individuals, including plans to enforce those 
standards and processes; and (2) reporting requirements. (See Appendix 
C for SAMHSA's expectations regarding standards for States.)
    [sbull] Method/process for designating providers as eligible 
participants in the voucher program and for maintaining an up-to-date, 
client friendly information service to ensure client choice is always 
available and clients are aware of their choices (e.g., a website or 
24-hour staffed help line).
    [sbull] Method/process for measuring client satisfaction in 
management of the voucher program.
    [sbull] Process to enable providers previously unable to compete 
effectively for Federal funds to participate in the Access to Recovery 
program (including some faith-based and community providers). Clearly 
state how many of such providers are expected to be designated under 
this program and the timeframe in which this will occur. Affirm that 
faith-based organizations that otherwise satisfy program requirements 
will not be discriminated against on the basis of religious character 
or affiliation.
    [sbull] Unbundling of services, if the State intends to use this 
strategy to achieve the best outcomes at the lowest cost.
    Describe how the proposed approach will increase capacity over the 
period of the voucher program, particularly capacity for recovery 
support services.
    Provide a three-year plan for increasing capacity in Appendix 5 of 
the application. The plan must include specific milestones with target 
dates for their achievement and must identify the party(ies) 
responsible for achieving milestones.
    Describe how the State will ensure that voucher recipients have 
genuine, free and independent choice among eligible clinical treatment 
and/or recovery service providers.
    [sbull] Section C: Readiness To Implement a Voucher Program
    Describe the timeframe by which the proposed voucher program would 
be fully operational.
    Document which of the following capabilities the State currently 
possesses to implement the voucher program:
    [sbull] Ability to make eligibility determinations for clients and 
providers.
    [sbull] Ability to manage and monitor a voucher program.
    [sbull] Ability to collect and report data (either through an 
existing or planned system).
    [sbull] Ability to implement quality improvement activities 
including technical assistance and training.
    [sbull] Ability to establish and implement standards for clinical 
treatment and/or recovery support service providers.
    [sbull] Capability to conduct screening and assessment and issue 
vouchers for clinical treatment and recovery support services based on 
established criteria.
    [sbull] Capability to provide a list of eligible providers for 
anyone to whom a voucher is issued.
    Describe other organizations/entities partnering in the project, 
including their roles in implementing the voucher program. In Appendix 
1 of the application, provide letters of commitment showing that 
identified partner organizations are ready and able to fulfill their 
roles.
    Describe anticipated potential operational problems, if any, and 
propose feasible solutions to them. Examples include:
    [sbull] Ensuring clients genuine, free, and independent choice of 
clinical treatment and/or recovery support providers in situations in 
which the range and number of providers are limited.
    [sbull] Handling significant numbers of clients eligible for 
vouchers who may exceed the State's ability to fund vouchers, and 
ensuring that resources are appropriately allocated during the course 
of the year.
    [sbull] Preventing potential conflict-of-interest among those 
conducting screening, assessment, level of care determination, and 
service provision.
Section D: Management, Staffing and Controlling Costs
    Describe how the lead agency will manage the voucher program, 
including steps the State will take to ensure quality of care; prevent 
waste, fraud and abuse; and prevent supplantation of funds. Document 
how resources will be appropriately allocated throughout the project 
period to ensure against funding shortfalls.
    Describe how the State will address provider performance issues 
through

[[Page 10244]]

both the process of determining provider eligibility and monitoring/
oversight.
    Describe how the lead agency will work with other agencies with 
roles and responsibilities related to implementing and administering 
the voucher program.
    Describe the State's and other participating entities' experience 
managing other voucher-type programs (e.g., Temporary Assistance for 
Needy Families (TANF), HUD/housing, daycare), if any, and discuss how 
these experiences will be applied to the proposed voucher program.
    Describe qualifications of the key staff to effectively implement 
and manage the voucher program.
    Document the ability or present a plan for developing the ability 
of the State to collect and report all necessary data on costs and 
outcomes to SAMHSA (see Appendix C for more information about data 
collection and reporting to monitor costs and outcomes).
    Provide a detailed three-year data collection and implementation 
plan identifying key tasks/milestones, target dates, role and 
responsibilities, in Appendix 6 of the application.
    Describe the process the State will use to regularly monitor 
implementation of the voucher program (including costs and outcomes) 
and make adjustments to the program (including the introduction of 
evidence-based practices) in order to achieve the intended outcomes in 
the most cost-effective manner. Specify how the State will create 
incentives for positive outcomes (e.g., adjusting provider eligibility 
reimbursement based on such outcomes). The extent to which evidence 
supports abstinence from substance use is of the utmost importance in 
assessing provider performance.
    Describe how the State will maintain direct and indirect costs of 
administration of the program to as low of a percentage of total 
expenditures as possible, preferably no more than 15% of total 
expenditures. Include a specific percentage of the total grant award 
that is intended to cover administrative costs, as defined in Appendix 
B.
    Describe how the State will manage the program on the basis of 
reasonable costs. Include a justification if the applicant proposes to 
deviate from the cost ranges outlined in Appendix G.
2.4. Application Formatting Requirements
    Applicants also must comply with the following basic application 
requirements. Applications that do not comply with these requirements 
will be screened out and will not be reviewed.
    [sbull] Information provided must be sufficient for review.
    [sbull] Text must be legible.
    [sbull] Type size in the Project Narrative cannot exceed an average 
of 15 characters per inch, as measured on the physical page. (Type size 
in charts, tables, graphs, and footnotes will not be considered in 
determining compliance.)
    [sbull] Text in the Project Narrative cannot exceed six (6) lines 
per vertical inch.
    [sbull] Paper must be white paper, 8.5 by 11.0 inches in size.
    [sbull] To ensure equity among applications, the amount of space 
allowed for the Project Narrative (Sections A-D) cannot be exceeded.
    [sbull] Applications would meet this requirement by using all 
margins (left, right, top, bottom) of at least one inch each, and by 
adhering to the page limit of 35 pages for the Project Narrative 
(Sections A-D).
    [sbull] Should an application not conform to these margin or page 
limits, SAMHSA will use the following method to determine compliance: 
The total area of the Project Narrative (excluding margins, but 
including charts, tables, graphs, and footnotes) cannot exceed 58.5 
square inches, multiplied by the page limit of 35 pages. This number 
represents the full page, less margins, multiplied by the total number 
of allowable pages.
    [sbull] Space will be measured on the physical page. In determining 
compliance, space left blank within the Project Narrative (excluding 
margins) is considered part of the Project Narrative.
    [sbull] The page limit for Appendices 1 through 7 cannot exceed 50 
total pages (excluding data collection instruments and interview 
protocols).
    To facilitate review of your application, follow these additional 
guidelines. Failure to adhere to the following guidelines will not, in 
itself, result in your application being screened out and returned 
without review. However, following these guidelines will help reviewers 
to consider your application.
    [sbull] Pages should be typed single-spaced with one column per 
page.
    [sbull] Pages should not be printed on both sides.
    [sbull] Please use black ink and number pages consecutively from 
beginning to end so that information can be located easily during 
review of the application. The cover page should be page 1, the 
abstract page should be page 2, and the table of contents page should 
be page 3. Appendices should be labeled and separated from the Project 
Narrative and budget section, and the pages should be numbered to 
continue the sequence.
    [sbull] Send the original application and two copies to the mailing 
address in the funding announcement. Please do not use staples, paper 
clips, and fasteners. Nothing should be attached, stapled, folded, or 
pasted. Do not use heavy or lightweight paper or any material that 
cannot be copied using automatic copying machines. Odd-sized and 
oversized attachments such as posters will not be copied or sent to 
reviewers. Do not include videotapes, audiotapes, or CD-ROMs.

3. Submission Dates and Times

    The application must be received by June 4, 2004. Applications 
received after this date must have a proof-of-mailing date from the 
carrier dated at least one (1) week prior to the due date. Private 
metered postmarks are not acceptable as proof of timely mailing.
    Applicants will be notified by postal mail that the application has 
been received.
    Applications not received by the application deadline or postmarked 
by a week prior to the application deadline will be screened out and 
will not be reviewed.

4. Intergovernmental Review

    Because eligibility for the ATR Grants is limited to the Chief 
Executive of the States, applicants for the ATR Grants Program are not 
required to comply with the requirements of Executive Order (EO) 12372.

5. Funding Limitations/Restrictions

    Cost principles describing allowable and unallowable expenditures 
for Federal grantees, including SAMHSA grantees, are provided in the 
following documents:
    [sbull] Institutions of Higher Education: Office of Management and 
Budget (OMB) Circular A-21.
    [sbull] State, Local Governments and Indian Tribal Governments: OMB 
Circular A-87.
    [sbull] Nonprofit Organizations: OMB Circular A-122.
    [sbull] Appendix E Hospitals: 45 Code of Federal Regulations (CFR) 
Part 74.

6. Other Submission Requirements

6.1 Where To Send Applications
    Send applications to the following address: Office of Program 
Services, Review Branch, Substance Abuse and Mental Health Services 
Administration,U.S. Department of Health and Human Services, 5600 
Fishers Lane, Room 17-89, Rockville, Maryland, 20857.
    Be sure to include the title of this program (Access to Recovery--
Grants) and funding announcement number (TI 04-009) on the face page of 
the

[[Page 10245]]

application. If a phone number is needed for delivery, use (301) 443-
4266.
6.2 How To Send Applications
    Mail an original application and two copies (including appendices) 
to the mailing address provided above. The original and copies must not 
be bound. Do not use staples, paper clips, or fasteners. Nothing should 
be attached, stapled, folded, or pasted.
    Use a recognized commercial or governmental carrier. Hand-carried 
applications will not be accepted. Fax or e-mail applications will not 
be accepted.

V. Application Review Information

1. Evaluation Criteria

    Applications will be reviewed and scored using specific evaluation 
criteria.
    The Project Narrative (Sections A-D), Supporting Documentation 
(Sections E-G), and Appendices 1-7 will be considered by reviewers in 
assessing the application.
    A Peer Review Committee will assign a point value to the 
application for each evaluation criterion.
    The number following each heading in the listing of evaluation 
criteria is the maximum number of points a review committee may assign 
to that section of the Project Narrative. Statements within each 
criterion are provided to invite the attention of applicants and 
reviewers to important areas within the criterion and are not 
individually scored.
    Reviewers also will look for evidence of cultural competence in 
each section of the Project Narrative. The score received for each 
evaluation criterion will be based in part on how well cultural 
competence is addressed in the relevant sections of the Project 
Narrative.
    The following evaluation criteria will be used by the Peer Review 
Committee:
    [sbull] Evaluation Criterion 1: Extent to Which Proposed Project 
Meets ATR Goals (30 points).
    Has the applicant provided feasible and timely plans to:
    [sbull] Ensure voucher recipients have a genuine, free and 
independent choice among eligible clinical treatment and recovery 
support service options?
    [sbull] Enable providers previously unable to compete effectively 
for Federal funds to participate in the Access to Recovery program 
(including some faith-based and community providers) and ensuring that 
faith-based organizations otherwise eligible to participate in the 
program are not discriminated against on the basis of religious 
character or affiliation?
    [sbull] Increase capacity over the period of the voucher program, 
particularly for recovery support services?
    [sbull] Monitor the operation and the effectiveness of the voucher 
program in their jurisdiction through the timely reporting of data?
    [sbull] Evaluation Criterion 2: Proposed Approach (20 points).
    [sbull] Has the applicant proposed a feasible, effective approach 
to developing a substance abuse voucher program that meets all Federal 
requirements described in Section 1 and addresses all instructions 
provided for completing the Project Narrative?
    [sbull] Evaluation Criterion 3: Management, Staffing and 
Controlling Costs (25 points).
    [sbull] Has the applicant proposed effective plans to manage the 
voucher program?
    [sbull] Has the applicant proposed a method for managing provider 
performance through both its process of determining provider 
eligibility and its monitoring/oversight process?
    [sbull] Have key staff been designated? Do they have the necessary 
skills, qualifications and experience to administer and manage the 
program?
    [sbull] Has the applicant proposed a feasible, effective plan that 
minimizes the amount of funds used to cover both direct and indirect 
costs of administering the program?
    [sbull] Has the applicant proposed a feasible, effective plan for 
managing the program on the basis of reasonable costs?
    [sbull] Has the applicant proposed a feasible, effective plan for 
providing incentives to eligible providers with superior outcomes, 
particularly abstinence?
    [sbull] Has the applicant proposed an effective strategy to adjust 
the program to achieve intended outcomes?
    [sbull] Has the applicant proposed abstinence from substance use as 
the critically most important outcome to assess provider performance?
    [sbull] Has the applicant demonstrated that resources will be 
appropriately allocated throughout the year and that the State will 
take effective steps to ensure quality of care; prevent waste, fraud 
and abuse; and prevent supplantation of funds?
    [sbull] Evaluation Criterion 4: Readiness To Implement Voucher 
Program (15 points).
    [sbull] Has the applicant demonstrated that the proposed voucher 
program can be fully operational in an appropriate timeframe?
    [sbull] Are all participating organizations at the administrative 
and services levels ready and/or able to fulfill their roles in this 
program?
    [sbull] Has the applicant adequately anticipated potential 
operational problems and proposed feasible solutions to them?
    [sbull] Has the applicant demonstrated that an operational 
information management system is in place?
    [sbull] Is the information management system capable of tracking 
outcomes and costs as described in Appendices C and G?
    [sbull] Evaluation Criterion 5: Need for a Voucher Program (10 
points).
    [sbull] Has the applicant clearly documented the need for a voucher 
program and described the current substance clinical treatment and 
recovery support services system, using the instructions provided for 
Section A of the Project Narrative?

    Note: Although the budget for the proposed project is not a 
review criterion, the Peer Review Committee will be asked to comment 
on the appropriateness of the budget after the merits of the 
application have been considered.

2. Review, Selection, and Award Process and Criteria

    SAMHSA applications for this program are peer-reviewed according to 
the review criteria listed above. For those programs with an individual 
award of over $100,000, the Center for Substance Abuse Treatment 
National Advisory Council also must review applications.
    Decisions to fund a grant are based on:
    [sbull] Strengths and weaknesses of the application as identified 
by the Peer Review Committee and approved by the Center for Substance 
Abuse Treatment National Advisory Council.
    [sbull] Availability of funds.
    [sbull] Balance among the geographic regions of the United States, 
different models for implementing the voucher programs (see Program 
Requirements, in Section I.), and the use of effective approaches to 
address those with special needs (e.g., homeless populations, people 
with co-occurring disorders, people living in rural areas, etc.).
    [sbull] Evidence that funds will be distributed through a voucher 
mechanism that guarantees clients genuine, free, and independent choice 
among eligible clinical treatment and recovery support providers, among 
them at least one provider to which the client has no religious 
objection.
    [sbull] Evidence that the applicant has addressed the standards for 
grantees outlined in Appendix C.
    [sbull] Evidence the applicant will increase capacity for recovery 
support services.
    In the event of a tie among applicant scores, the following method 
will be

[[Page 10246]]

used to break the tie: Scores on the criterion with the highest 
possible point value will be compared (Extent to Which Proposed Project 
Meets ATR Goals--30 points). Should a tie still exist, the evaluation 
criterion with the next highest possible point value will be compared, 
continuing sequentially to the evaluation criterion with the lowest 
possible point value, should that be necessary to break all ties. If an 
evaluation criterion to be used for this purpose has the same number of 
possible points as another evaluation criterion, the criterion listed 
first in Section V-1 will be used first.

VI. Award Administration Information

1. Award Notices

    After the application has been reviewed, applicants will receive a 
letter from SAMHSA through the postal mail that describes the general 
results of the review, including the score the application received.
    If approved for funding, an applicant will receive an additional 
notice, the Notice of Grant Award, signed by SAMHSA's Grants Management 
Officer. The Notice of Grant Award is the sole obligating document that 
allows the grantee to receive Federal funding for work on the grant 
project. It is sent by postal mail and is addressed to the contact 
person listed on the face page of the application.
    If not funded, applicants may re-apply if there is another receipt 
date for the program.

2. Administrative and National Policy Requirements

    [sbull] Applicants must comply with all terms and conditions of the 
grant award. SAMHSA's standard terms and conditions are available on 
the SAMHSA Web site. For the SAMHSA web page, please use the following: 
http://www.samhsa.gov/grants/2004/useful_info.aps.
    [sbull] Depending on the nature of the specific funding opportunity 
and/or the review of the proposed project itself, additional terms and 
conditions may be negotiated with the grantee prior to grant award. 
These may include, for example:
    [sbull] Actions required to be in compliance with human subjects 
requirements;
    [sbull] Requirements relating to participation in a cross-site 
evaluation; or
    [sbull] Requirements to address problems identified in review of 
the application.
    [sbull] Applicants will be held accountable for the information 
provided in the application relating to the capacity expansion proposed 
in the application. SAMHSA program officials will consider progress in 
meeting goals and objectives, as well as failures and strategies for 
overcoming them, when making an annual recommendation to continue the 
grant and the amount of any continuation award. Failure to meet stated 
goals and objectives may result in suspension or termination of the 
grant award, or in reduction or withholding of continuation awards.

3. Reporting Requirements

3.1 Progress and Financial Reports
    On a quarterly basis, ATR Grantees must report financial and 
outcome data to SAMHSA. Financial data will monitor costs and ensure 
that funds are being used for appropriate and intended purposes. 
Outcome data will measure the success of clinical treatment and 
recovery support services and ultimately measure the success of the 
voucher program. SAMHSA will obtain OMB approval for the various 
reporting requirements and final requirements will be available only 
upon receipt of OMB approval.
    By design, outcome data are consistent with performance domains 
that SAMHSA will implement to assess the accountability and performance 
of its discretionary and formula grant programs. In addition, these 
same will be used by SAMHSA to meet the reporting requirements of the 
Government Performance and Results Act (GPRA).
    GPRA mandates accountability and performance-based management by 
Federal agencies, focusing on results or outcomes in evaluating the 
effectiveness of Federal activities and on measuring progress toward 
achieving national goals and objectives. All SAMHSA grantees must 
comply with GPRA data collection and reporting requirements.
    ATR Grantees will be required to report data in seven specific 
domains, as follows:
    [sbull] Abstinence from Drug/Alcohol Use.
    [sbull] Employment/Education.
    [sbull] Crime and Criminal Justice.
    [sbull] Family and Living Conditions.
    [sbull] Social Support.
    [sbull] Service Access/Capacity.
    [sbull] Retention in Clinical Treatment and/or Recover Support 
Services.
    Data expectations for each domain are provided in Appendix C. The 
grantee's ability to demonstrate improvement in the domains listed 
above, particularly abstinence, will be a factor in determining grantee 
funding levels in years occurring after year one of the grant.
    Applicants should be aware that SAMHSA may conduct a cross-site 
evaluation of the ATR program. If SAMHSA does conduct a cross-site 
evaluation, grantees will be required to provide performance data to 
the evaluator as well as to SAMHSA. In addition, it is possible the 
evaluation design may necessitate changes in the required data elements 
and/or timing of data collection or reporting. Grantees will be 
required to comply with any changes in data collection requirements.
3.2 Publications
    If funded under this program, an applicant is required to notify 
the Government Project Officer (GPO) and SAMHSA's Publications 
Clearance Officer (301-443-8596) of any materials based on the SAMHSA-
funded grant project that are accepted for publication.
    In addition, SAMHSA requests that grantees:
    [sbull] Provide the GPO and SAMHSA Publications Clearance Officer 
with advance copies of publications.
    [sbull] Include acknowledgment of the SAMHSA grant program as the 
source of funding for the project.
    [sbull] Include a disclaimer stating the views and opinions 
contained in the publication do not necessarily reflect those of SAMHSA 
or the U.S. Department of Health and Human Services, and should not be 
construed as such.
    SAMHSA reserves the right to issue a press release about any 
publication deemed by SAMHSA to contain information of program or 
policy significance to the substance abuse treatment/substance abuse 
prevention/mental health services community.

VII. Agency Contacts

    For questions on program issues, contact: Andrea Kopstein, Ph.D., 
M.P.H., SAMHSA/CSAT, 5600 Fishers Lane, Rockwall II, Suite 7-40, 
Rockville, MD 20857, Phone: (301) 443-3491, Fax: (301) 443-3543,E-Mail: 
[email protected].
    For questions on grants management issues, contact: Kathleen 
Sample, Division of Grants Management, Substance Abuse and Mental 
Health Services Administration/OPS, 5600 Fishers Lane, Rockwall II 6th 
Floor, Rockville, MD 20857, Phone: (301) 443-9667, Fax: (301) 443-
6468,E-mail: [email protected].

VIII. Other Information

1. SAMHSA Confidentiality and Participant Protection Requirements and 
Protection of Human Subjects Regulations

    Applicants must describe their procedures relating to 
Confidentiality,

[[Page 10247]]

Participant Protection and the Protection of Human Subjects Regulations 
in Section H of the application, using the guidelines provided below. 
Problems with confidentiality, participant protection, and protection 
of human subjects identified during peer review of the application may 
result in the delay of funding.
    Confidentiality and Participant Protection:
    All applicants must address each of the following elements relating 
to confidentiality and participant protection. The application must 
document how these requirements will be addressed or why they are not 
applicable.
Protect Clients and Staff From Potential Risks
    [sbull] Identify and describe any foreseeable physical, medical, 
psychological, social, legal, or other risks or adverse affects.
    [sbull] Discuss risks that are due either to participation in the 
project itself or to the evaluation activities.
    [sbull] Describe the procedures that will be followed to minimize 
or protect participants against potential risks, including risks to 
confidentiality.
    [sbull] Identify plans to provide help if there are adverse effects 
to participants.
    [sbull] Where appropriate, describe alternative treatments and 
procedures that may be beneficial to the participants. If other, 
alternative beneficial treatments will not be used, provide the reasons 
for not using them.
Fair Selection of Participants
    [sbull] Describe the target population(s) for the proposed project. 
Include age, gender, and racial/ethnic background and note if the 
population includes homeless youth, foster children, children of 
substance abusers, pregnant women, or other groups.
    [sbull] Explain the reasons for including groups of pregnant women, 
children, people with mental disabilities, people in institutions, 
prisoners, or others who are likely to be vulnerable to HIV/AIDS.
    [sbull] Explain the reasons for including or excluding 
participants.
    [sbull] Explain how participants will be recruited and selected. 
Identify who will select participants.
Absence of Coercion
    [sbull] Explain if client participation in the project is voluntary 
or required. Identify possible reasons why it may be required, for 
example, if court orders may require people to participate in this 
program.
    [sbull] If the project plans to pay clients, state how clients will 
be awarded money or gifts.
    [sbull] State how volunteer participants will be told that they may 
receive services even if they do not participate in the project.
    [sbull] Explain how the project will ensure that a client receives 
a genuine and independent choice among eligible clinical treatment and 
recovery support services providers, even if required to participate in 
the program, for example, through a court order.
    [sbull] Explain how the project will ensure that a client will be 
guaranteed the choice of an alternative service provider to which the 
client has no religious objection.
Data Collection
    [sbull] Identify from whom data will be collected (e.g., from 
participants themselves, family members, teachers, others). Describe 
the data collection procedures and specify the sources for obtaining 
data (e.g., school records, interviews, psychological assessments, 
questionnaires, observation, or other sources). Where data are to be 
collected through observational techniques, questionnaires, interviews, 
or other direct means, describe the data collection setting.
    [sbull] Identify what type of specimens (e.g., urine, blood) will 
be used, if any. State if the material will be used just for evaluation 
or if other use(s) will be made. Also, if needed, describe how the 
material will be monitored to ensure the safety of participants.
    [sbull] Provide in Appendix 2, ``Data Collection Instruments/
Interview Protocols,'' copies of all available data collection 
instruments and interview protocols that the project plans to use.
Privacy and Confidentiality:
    [sbull] Explain how privacy and confidentiality will be ensured. 
Include who will collect data and how it will be collected.
    [sbull] Describe:
    [sbull] How data collection instruments will be used.
    [sbull] Where data will be stored.
    [sbull] Who will or will not have access to information.
    [sbull] How the identity of participants will be kept private, for 
example, through the use of a coding system on data records, limiting 
access to records, or storing identifiers separately from data.

    Note: If applicable, grantees must agree to maintain the 
confidentiality of alcohol and drug abuse client records according 
to the provisions of Title 42 of the Code of Federal Regulations, 
Part II.

Adequate Consent Procedures:
    [sbull] List what information will be given to clients who 
participate in the project, particularly information regarding the 
genuine and independent choice clients have among eligible providers. 
Include the type and purpose of their participation. Notice given to 
clients must, at a minimum, include:
    [sbull] The client's right to a genuine, free, and independent 
choice among eligible providers, that includes the client's right to an 
alternative provider to which the client has no religious objection.
    [sbull] A description of the data to be collected, how the data 
will be used, and how the data will be kept private.
    [sbull] The client's right to leave the project at any time.
    [sbull] Possible risks from participation in the project.
    [sbull] Plans to protect clients from these risks.
    [sbull] Explain how, if the client's participation in the voucher 
program is not voluntary (e.g., is by court order), the client will 
still be provided genuine, free, and independent choice among eligible 
providers.
    [sbull] Explain how consent will be elicited for youth, the 
elderly, people with limited reading skills, and people who do not use 
English as their first language.

    Note: If the project poses potential physical, medical, 
psychological, legal, social or other risks, written informed 
consent is necessary.

    [sbull] Indicate if informed consent will be requested from 
participants or, in the case of minor children, from their parents or 
legal guardians. Describe how the consent will be documented. For 
example: Will consent forms be read? Will prospective participants be 
questioned to be sure they understand the forms? Will they be given 
copies of what they sign?
    [sbull] Include sample consent forms in Appendix 3, ``Sample 
Consent Forms.'' If needed, give English translations.

    Note: Never imply that the participant waives or appears to 
waive any legal rights, may not end involvement with the project, or 
releases the project or its agents from liability for negligence.

    [sbull] Describe if separate consents will be obtained for 
different stages or parts of the project. For example, will they be 
needed for both participant protection in treatment intervention and 
for the collection and use of data.
    [sbull] Additionally, if other consents will be used in the project 
(e.g., consents to release information to others or gather information 
from others), provide a description of these consents. Will individuals 
who do not consent to

[[Page 10248]]

having individually identifiable data collected for evaluation purposes 
be allowed to participate in the project?
    Risk/Benefit Discussion:
    Discuss why the risks are reasonable compared to expected benefits 
and importance of the knowledge from the project.
Protection of Human Subjects Regulations
    Applicants for the ATR Grants are not required to address 
Protection of Human Subjects Regulations (45 CFR Part 46). However, 
SAMHSA may choose in the future to conduct a cross-site evaluation of 
the ATR Grants. Such an evaluation could require grantees to comply 
with the Protection of Human Subjects Regulations, depending on the 
evaluation design. If SAMHSA does conduct a study that requires grantee 
compliance with the Protection of Human Subjects Regulations, SAMHSA 
will assist grantees in obtaining Institutional Review Board (IRB) 
approval for their projects.
    Additional information about Protection of Human Subjects 
Regulations can be obtained on the web at http://ohrp.osophs.dhhs.gov. 
Applicants may also contact OHRP by e-mail ([email protected]) or by 
phone (301-496-7005).

Appendix A: Comprehensive Array of Clinical Treatment and Recovery 
Support Services

Overview

    Research has established that there are many paths to recovery 
from alcohol and drug problems. Indeed, many resolve their alcohol 
and drug problems naturally, without any outside intervention. 
Others recover with the support of self-help groups such as 
Alcoholics Anonymous, and/or the faith community. Still others have 
found recovery through formal clinical treatment interventions. A 
variety of factors can influence which of these paths is taken 
successfully. For example, individuals with moderate problems and 
social support/stability are more apt to recover naturally or with 
minimal interventions. In contrast, people who seek treatment tend 
to have more serious problems.
    To achieve the best outcomes at the lowest cost, SAMHSA 
encourages States to provide access to a comprehensive array of 
clinical treatment and recovery support services as described below. 
Both components--clinical treatment services and recovery support 
services--are appropriate for many, if not all, individuals who meet 
the DSM-IV diagnostic criteria for substance dependence. However, 
not all services and/or interventions are needed by every individual 
in treatment for or in recovery from substance dependence. Those who 
meet the diagnostic criteria for substance abuse may require a less 
comprehensive range of services. In addition, the array of services 
described below need not be provided by a single entity but can be 
provided by a consortium of addiction treatment, health, and human 
service providers.
    This array is not specific to any particular philosophy of 
clinical treatment and recovery, modality, or setting. It is a 
generic framework within which potential applicants can 
conceptualize service arrays, service capabilities, and appropriate 
managerial and administrative processes, including evaluation.
    Methods of implementing the components of this array, the staff 
who deliver each service, the manner and setting in which different 
services are delivered, etc., should be based on individual 
assessment and level of care determination that considers (1) the 
needs of the individual; (2) the extent to which there are clinical 
treatment services, recovery support services, health, human 
services, housing, criminal justice supervision, and labor training 
alternatives in the jurisdiction of authority; and (3) the extent of 
available resources and agencies linked through coordinated case 
management.
    In many cases, it will be desirable to provide various 
components of the array simultaneously, with the emphasis changing 
throughout the clinical treatment and recovery process. For example, 
in the earlier, acute phase of clinical treatment, heavier emphasis 
may be placed on clinical treatment services; the emphasis may 
switch toward recovery support as individuals move through 
rehabilitation and enter a maintenance phase of clinical treatment 
and recovery. In some cases, recovery support services alone will 
suffice.

Examples of Clinical Treatment and Recovery Support Services

    Clinical treatment services are provided by individuals who are 
licensed, certified, or otherwise credentialed to provide clinical 
treatment services in the State, often in settings that address 
specific treatment needs.
    Recovery support services are typically provided by paid staff 
or volunteers familiar with how their communities can support people 
seeking to live free of alcohol and drugs, and are often peers of 
those seeking recovery.
    Such services can include:
    [sbull] Screening/assessment
    [sbull] Brief intervention
    [sbull] Treatment planning
    [sbull] Detoxification
    [sbull] Medical care
    [sbull] Substance abuse education
    [sbull] Individual counseling
    [sbull] Group counseling
    [sbull] Residential services
    [sbull] Pharmacological interventions
    [sbull] Co-occurring treatment services
    [sbull] Family/marital counseling
    [sbull] Family services, including marriage education, and 
parenting and child development services
    [sbull] Pre-employment counseling
    [sbull] Case management
    [sbull] Relapse prevention
    [sbull] Continuing care (including face-to-face and telephone-
based continuing care counseling)
    [sbull] Alcohol/drug testing
    [sbull] Outreach
    [sbull] Individual services coordination, providing linkages 
with other services (legal services, TANF, social services, food 
stamps, etc.)
    [sbull] Recovery coaching (including stage-appropriate recovery 
education, assistance in recovery management, telephone monitoring, 
etc.)
    [sbull] Family support and child care
    [sbull] Transportation to and from treatment, recovery support 
activities, employment, etc.
    [sbull] Supportive transitional drug-free housing services
    [sbull] Self-help and support groups, such as 12-step groups, 
SMART Recovery, Women for Sobriety, etc.
    [sbull] Spiritual support
    [sbull] Employment coaching

Appendix B: Services Included as Administrative Expenses

    [sbull] Eligibility determinations for clinical treatment and 
recovery services providers and for which services in the 
comprehensive array of clinical treatment and recovery support 
services will be included in the voucher reimbursement system.
    [sbull] Management of a system for client eligibility 
determination and assessment for appropriate level of care.
    [sbull] Identifying, screening, and determining eligibility for 
clinical treatment and recovery support services providers.
    [sbull] Fiscal/cost accounting mechanisms that can track voucher 
implementation.
    [sbull] Management of information systems for tracking outcomes 
and costs, including the costs of data collection and reporting.
    [sbull] Development of quality improvement activities, including 
technical assistance and training to attract, develop, and sustain 
new clinical treatment and recovery support providers.
    [sbull] Marketing of vouchers to client and provider 
organizations.
    [sbull] Oversight of standards and fraud and abuse issues.

Appendix C: Standards for the Access to Recovery Program

    States will be expected to administer the Access to Recovery 
(ATR) program in a manner consistent with good management practices. 
States will have flexibility in establishing standards appropriate 
and feasible for their service delivery system and target 
population. However, once States and Tribes have established 
standards for participating provider organizations, they are 
expected to enforce such standards.
    In its application, the State should demonstrate how it intends 
to:
    1. Ensure that clients receive a genuine, free, and independent 
choice among assessment, placement, clinical treatment, and recovery 
support services.
    a. For purposes of this program, choice is defined as a client 
being able to select among at least two providers which are 
qualified to provide the services needed by the client, among them 
at least one provider to which the client has no religious 
objection.
    2. Ensure that clients receive a clinical assessment and a level 
of care determination

[[Page 10249]]

from a qualified person and/or provider organization.
    a. States should describe the qualifications they require of 
individuals and/or providers that perform assessments and level of 
care determinations.
    b. States should describe steps they will take to prevent 
potential conflicts of interest among practitioners and/or provider 
organizations conducting screening, assessment and referral to 
clinical treatment and/or recovery support services.
    3. Ensure that clients receive appropriate services from 
clinical treatment and recovery support programs.
    a. To be eligible for voucher reimbursement, clinical treatment 
and recovery support programs should meet standards that are 
required by the State for other providers that provide the same type 
of services (e.g. residential, outpatient, family support services, 
etc.).
    b. Each State should document the eligibility requirements and 
program standards the State intends to use for each of the services 
proposed to be reimbursed under the voucher program. Eligibility 
requirements and standards should be documented for services across 
the entire array of recovery, as described in Appendix A, including 
eligibility requirements and standards for clinical treatment 
services and recovery support services. (For example, the State 
should document its eligibility requirements and standards for 
specific types of providers such as residential, outpatient, 
methadone, recovery support services, etc.) In the case of services 
for which no standards currently exist, the State must describe the 
process to be used to ensure that individuals receive appropriate 
services in safe settings from appropriate individuals. States must 
also describe how they intend to monitor compliance with these 
standards and/or processes.
    4. Expand the range of clinical treatment and recovery support 
services providers that meet appropriate standards.
    a. States should describe how they intend to provide technical 
assistance and training to providers of clinical treatment and 
recovery services as described in Appendix A in order for them to 
meet State standards.
    5. Ensure that outcome and financial data is reported in a 
timely manner.
    a. States should describe how they intend to ensure that outcome 
data are reported in the following seven domains:

1. Abstinence From Drug and Alcohol Use

    1.1 During the past 30 days, how many days has the client used 
the following:

------------------------------------------------------------------------
                                                      Number  of days
------------------------------------------------------------------------
a..................  Any alcohol                  ......................
b1.................  Alcohol to intoxication (5+  ......................
                      drinks in one setting)
b2.................  Alcohol to intoxication (4   ......................
                      or fewer drinks and felt
                      high)
c..................  Illegal drugs                ......................
------------------------------------------------------------------------

    1.2 During the past 30 days, how many days has the client used 
any of the following:

------------------------------------------------------------------------
                                                      Number  of days
------------------------------------------------------------------------
a..................  Cocaine/crack                ......................
b..................  Marijuana/Hashish            ......................
c..................  Heroin or other opiates      ......................
d..................  Hallucinogens/psychedelics   ......................
e..................  Methamphetamine or other     ......................
                      amphetamines
f..................  Benzodiazepines              ......................
g..................  Barbiturates                 ......................
h..................  Ecstasy and other club       ......................
                      drugs
i..................  Ketamine                     ......................
j..................  Inhalents                    ......................
------------------------------------------------------------------------

2. Employment/Education

    2.1 Is the client currently employed?
    [sbull] Full time--Working 35 hours or more each week; includes 
members of the uniformed services
    [sbull] Part time--Working fewer than 35 hours each week
    [sbull] Unemployed, looking for work during the past 30 days, or 
on lay off from a job
    [sbull] Not in labor force--Not looking for work during the past 
30 days or a homemaker, student, disables, retired, or an inmate of 
an institution
    2.2 For those not in the labor force, what is their status?
    [sbull] Student enrolled in a school or job training program
    [sbull] Homemaker
    [sbull] Retired
    [sbull] Disabled
    [sbull] Inmate of an institution that restrains a person, 
otherwise able, from the workforce
    2.3 Is the client currently enrolled in school or a job training 
program?
    [sbull] Not enrolled
    [sbull] Enrolled, full time
    [sbull] Enrolled, part time
    [sbull] Other (specify) ----------

3. Crime and Criminal Justice

    3.1 In the past 30 days, how many times has the client been 
arrested?

If no arrests, go to item 4
--------times

    3.2 In the past 30 days, how many times has the client been 
arrested for alcohol or illicit drug offenses?

--------times

3.3 In the past 30 days, how many nights has the client spent in 
jail/prison?

----------times

4. Family and Living Conditions

    4.1 In the past 30 days, where has the client been living most 
of the time?
    [cir] Homeless--No fixed address; includes shelters
    [cir] Dependent living--Dependent children and adults living in 
a supervised setting such as a halfway house or group home
    [cir] Independent living (including on own, self-supported, and 
non-supervised group homes)
    4.2 Does the client have children?

[cir] No (go to section 5) [cir] Yes

    2.a How many children does the client have? --------
    2.b Are the client's children living with someone else due to a 
child protection court order?

[cir] No (go to section 5) [cir] Yes

    2.c If yes, how many of the client's children are living with 
someone else due to a child protection court order? --------
    2.d For how many children has the client lost parental rights?

(The client's parental rights were terminated.)

 --------

5. Social Support of Recovery

    5.1 In the past 30 days, did the client attend any voluntary 
self-help groups?

(i.e., did the client participate in a non-professional, peer-
operated organization devoted to helping individuals who have 
addiction related problems such as: Alcoholics Anonymous, Narcotics 
Anonymous, Oxford House, Secular Organization for Sobriety, Women 
for Sobriety, etc.)

[cir] No [cir] Yes

    5.2 In the past 30 days, did the client attend any religious/
faith affiliated recovery or self-help groups?

[cir] No [cir] Yes

    5.3 In the past 30 days, did the client attend meetings of 
organizations that support recovery other than the organizations 
described above?

[cir] No [cir] Yes

    5.4 In the past 30 days, did the client have interaction with 
family and/or friends that are supportive of recovery?

[cir] No [cir] Yes

6. Access/Capacity

    6.1 How many people received vouchers for clinical treatment and 
recovery support services?

-----------------------------------------------------------------------

    6.2 What is the total number of vouchers issued for clinical 
treatment and recovery support services?

-----------------------------------------------------------------------

    6.3 How many providers of clinical treatment and recovery 
support service providers were designated as participating providers 
in the ATR program?

-----------------------------------------------------------------------

7. Retention

    7.1 Identify the number of service sessions/days provided to 
each client during the past 30 days.

------------------------------------------------------------------------
                                                              Sessions/
                           Field                                 days
------------------------------------------------------------------------
Clinical Treatment and Recovery Support Services:
    7.1.1. Screening/assessment
    7.1.2. Brief Intervention
    7.1.3. Treatment planning
    7.1.4. Detoxification
    7.1.5. Medical care
    7.1.6. Substance abuse education

[[Page 10250]]

 
    7.1.7. Individual counseling
    7.1.8. Group counseling
    7.1.9. Family/marriage counseling
    7.1.10. Pharmacological interventions
    7.1.11. Co-occurring treatment services
    7.1.12. Family services, including marriage education,
     and parenting and child development services
    7.1.13. Pre-employment counseling
    7.1.14. Case management
    7.1.15. Relapse prevention
    7.1.16. Continuing care (including face-to-face and
     telephone-based continuing care counseling)
    7.1.17. Alcohol/Drug testing
    7.1.18. Outreach
    7.1.19. Individual services coordination, providing
     linkages with other services (legal services, TANF,
     social services, food stamps, etc.)
    7.1.20. Recovery coaching (including stage-appropriate
     recovery education, assistance in recovery management,
     telephone monitoring, etc.)
    7.1.21. Family support and childcare
    7.1.22. Transportation to and from clinical treatment,
     recovery support activities, employment, etc.
    7.1.23. Supportive transitional drug-free housing
     services
    7.1.24. Self-help and support groups, such as 12-step
     groups, SMART Recovery, Women for Sobriety, etc.
    7.1.25. Spiritual support
    7.1.26. Employment coaching
    7.1.27. Other
------------------------------------------------------------------------

    7.2 Length of stay (described by date of first individual or 
group addiction counseling service to date of last contact for 
addiction service)
    2.a What is the date (month, day, and year) that the client last 
received clinical treatment or paid recovery support services?
    2.b What is the date of discharge? (Specify the month, day, and 
year the client was formally discharged from the treatment provider, 
service, or program. This date may be the same as the date of last 
contact.)
    2.c What is the reason for discharge?
    [cir] Treatment completed.
    [cir] Transferred to another provider.
    [cir] Administrative discharge.
    [cir] Incarcerated.
    [cir] Death.
    [cir] Lost contact (dropped out).
    Notes regarding outcome data in the 7 domains:
    (1) Data on drug/alcohol use, employment/education, crime and 
criminal justice involvement, family and living conditions, and 
social support shall be collected at the time of entry to, exit 
from, and at least every two months during an episode of care. This 
data will be collected by the providers and given to the States. In 
the case of brief interventions, only drug/alcohol use should be 
reported. Please note that the substance use domain is framed in 
terms of rates of frequency of use; however, the primary outcome 
measure for this program is abstinence from substance use, and 
successful completion of an episode of care should be established by 
randomly collected samples that are free of these substances.
    (2) It will be necessary for States to uniquely identify clients 
through the course of a clinical treatment/recovery support episode 
of care and provide basic demographic information. Client IDs should 
be client specific and should also allow for clients to be tracked 
through multiple episodes of care.
    (3) For the purposes of the voucher program, an episode of care 
means the period of time from entry to exit from a paid service, 
whether it be a clinical treatment service or a recovery support 
service.
    (4) Providers will collect data on access/capacity and retention 
at entry to, exit from, and at least every two months during an 
episode of care. This data will be given to the States. The 
retention domain does not apply in the case of brief interventions; 
however, for brief interventions the client should report 
completion.
    (5) The grantee's ability to demonstrate improvement in the 
above domains will be a factor in determining funding levels in 
years after year 1 of the grant.
    (6) States should propose a plan for collecting 6-month post-
exit data from a paid service on a sample basis by the third year of 
the grant.
    b. States should describe how they intend to ensure financial 
data is reported as follows:
    1. Information should be provided on the type of service, date 
of service, and the days, partial days, or hour(s) of service 
provided.
    2. Each State should submit data on reimbursement rate per 
service (clinical treatment or recovery support service) per day, 
partial day, or hour (s) for the voucher program.
    c. States should describe how they intend to ensure data is 
reported to SAMHSA within the following time frames:
    1. Outcome measures and financial data will be reported to 
SAMHSA quarterly, within 30 days from the end of the quarter.
    2. States will take action necessary to ensure that data are 
valid and reliable, and are submitted in a timely manner.

Appendix D: Screening, Assessment, and Level of Care Determination

Screening

    The purpose of screening is to quickly and cost-effectively rule 
out people without substance abuse problems and to identify the need 
for specialized substance abuse treatment.
    The basic questions asked in the screening process are: (1) Is a 
substance abuse problem present; and (2) does it require specialized 
care. Although we often think individuals seeking clinical treatment 
have been previously screened, some individuals seek specialized 
treatment directly.
    If screening suggests an individual probably has a problem 
likely to require specialized treatment, the next step in the 
sequence may be thought of as the problem assessment.

Assessment

    Assessment is the systematic process of interaction with an 
individual to observe, elicit, and subsequently assemble the 
relevant information required to manage his or her problems, both 
immediately and for the foreseeable future. An assessment gauges 
which of the available clinical treatment and recovery services 
options are likely to be most appropriate for the individual being 
assessed. Hence, assessment must occur prior to any referral of the 
individual to a particular kind of clinical treatment and/or 
recovery support service. When the same general approach is applied 
to all or most clients, assessment may have little impact.

Purpose of Assessment

    [sbull] To characterize a problem--
    Substance abuse problems differ from person to person, often 
both in degree and in kind. What should emerge from an assessment is 
a detailed picture of the particular kind of substance abuse problem 
manifested by a particular individual at a particular point in time.
    In the absence of a clear, unambiguous picture at initial 
contact, appropriate decisions regarding care for the present and 
future may be difficult.
    [sbull] To characterize an individual--
    Substance abuse problems do not occur in a vacuum. Individuals 
who manifest them are at least as different from one another as they 
are from people without substance use disorders. Some of these 
problems may be the result of abuse of drugs or alcohol; some may 
result in using drugs or alcohol; others may be independent 
problems. All are important in themselves, requiring assessment, 
(and often attention), in clinical treatment and/or recovery support 
programs. Individual characteristics may affect a person's 
acceptance (and, in consequence, the eventual outcome) of various 
forms of clinical treatment and/or recovery support services. Thus, 
detailed knowledge of individual characteristics can help provide 
the client with a list of appropriate clinical treatment and/or 
recovery support service options.
    [sbull] To identify appropriate clinical treatment and/or 
recovery support service options--

[[Page 10251]]

    Assessment prior to clinical treatment and/or recovery support 
forms the basis on which individuals are provided a list of clinical 
treatment and/or recovery support options appropriate to their 
needs.
    Additional information on the individual will need to be 
gathered by program staff following the selection of a clinical 
treatment and/or recovery support program to plan the individual's 
ongoing course of care.

Level of Care Determination

    Level of care determination is achieved through the client's 
selection of clinical treatment and recovery support alternatives 
that are both available and most likely to facilitate a positive 
outcome in a particular individual. Level of Care Determination:
    [sbull] Focuses on matching clinical treatment and/or recovery 
support services to individual needs within the framework of client 
choice
    [sbull] Defines expectations for each stage of care:
    [sbull] Acute intervention, including detoxification.
    [sbull] Rehabilitation.
    [sbull] Maintenance and relapse prevention.
    While choice among the various clinical treatment and/or 
recovery support services options resides with the individual, the 
assessor is responsible to ensure that the individual is fully 
conversant with all of the therapeutic alternatives available from 
eligible providers.

The Level of Care Determination Process

    Level of Care determination is a complex matter, requiring 
consideration of individuals and their substance abuse problems, and 
knowledge of available clinical treatment and recovery support 
services by both the assessor and the client.
    The following general descriptors of clinical treatment and 
recovery support services represent the kinds of information most 
useful to help identify appropriate levels of care and clinical 
treatment and/or recovery support service options for individuals 
with substance abuse problems. When presented to clients in every-
day language, the following information can assist clients in making 
an informed choice of the clinical treatment and/or recovery support 
service option(s) that may meet their needs:
    [sbull] Philosophy and orientation of the program (e.g., medical 
model, social model, spiritual model, etc.);
    [sbull] Stage of substance abuse problem or recovery at which 
the clinical treatment and/or recovery support service is directed 
(e.g., detoxification, rehabilitation, maintenance);
    [sbull] Setting of the program (e.g., inpatient, outpatient, 
residential) and staffing; and
    [sbull] Therapeutic approach/type of intervention.

Additional Resources for Screening, Assessment, and Level of Care 
Determination

I. Resources To Implement Screening

    In health care, screening is a process to identify people who 
have, or are at risk for, an illness or disorder. The purpose of 
screening is to target persons for clinical treatment and/or 
recovery support services, thus reducing the long-term morbidity and 
mortality related to the condition. In addition, by intervening 
early and raising the individual's level of concern about risk 
factors and substance-related problems, screening for drug and 
alcohol problems in community settings can reduce subsequent use.
    Two types of screening procedures are typically used. The first 
includes self-report questionnaires and structured interviews; the 
second, clinical laboratory tests that can detect biochemical 
changes associated with excessive alcohol consumption or illicit 
drug use.
    A variety of screening instruments are available. The majority 
of studies and implementation efforts have focused on screening for 
alcohol problems. The CAGE and AUDIT are the most commonly used 
screening tools. The DAST has also been used in conjunction with the 
AUDIT in several projects, where there has been an effort to 
implement this approach for persons with or at risk for a substance 
use disorder. Several new instruments have been developed, but not 
yet rigorously tested, to assess harmful use of either alcohol or 
drugs (e.g., the CAGE-D, the ASSIST, the TCUDS, the GAIN-QS, the 
PDES).

Brown, RL and Rounds LA. 1995. Conjoint screening questionnaires for 
alcohol and other drug abuse: criterion validity in a primary care 
practice. Wisconsin Medical Journal, 94, 135-140.
Brown R, Leonard T, Saunders LA, et al. (1997). A two-item screening 
test for alcohol and other drug problems. Journal of Family 
Practice, 44, 151-160.

    A bibliography with descriptions and evaluations of various 
interview, questionnaire, and laboratory test screening approaches 
is available from Project Cork.

    Project Cork. 2002. CORK Bibliography: Screening Tests. 2001-
2002, 58 Citations. http://www.projectcork.org/bibliographies/data/Bibliography_Screening_Tests.html

    Screening instruments have been developed or modified for use 
with different target populations, notably adolescents, offenders 
within the criminal justice system, welfare recipients, women, and 
the elderly. Several have been translated into other languages and 
have been evaluated for cultural sensitivity. Again, SAMHSA is not 
requiring a specific instrument or protocol, but choice of 
instruments or laboratory tests must be justified.
    It is well recognized that screening instruments used with 
adolescents must be developmentally appropriate, valid and reliable, 
and practical for use in busy medical settings. One example of a 
brief substance abuse screening instrument recently developed 
specifically for use with adolescents is the CRAFFT test.

Knight JR, Sherritt L, Shrier LA, Harris SK, Chang G. 2002. Validity 
of the CRAFFT substance abuse screening test among adolescent clinic 
patients. Arch Pediatr Adolesc Med. 156(6): 607-14.

    Additional screening tests and procedures targeted at 
adolescents, including the PDES and the GAIN-QS, are described in 
these publications:

Winters KC. 1992. Development of an adolescent alcohol and other 
drug abuse screening scale: Personal Experience Screening 
Questionnaire. Addict Behav. 17(5): 479-90.
Winters KC. 1999. Screening and Assessing Adolescents For Substance 
Use Disorders. Treatment Improvement Protocol (TIP) Series 31 DHHS 
Publication No. (SMA) 99-3282.
Winters KC. 1999. Treatment of Adolescents With Substance Use 
Disorders. Treatment Improvement Protocol (TIP) Series 32. DHHS 
Publication No. (SMA) 99-3283.
Winters KC. 2001. Assessing adolescent substance use problems and 
other areas of functioning: State of the art. In: PM Monti, SM. 
Colby, and TA. O'Leary (eds). Adolescents, Alcohol, and Substance 
Abuse: Reaching Teens Through Brief Interventions. New York, 
Guilford Publications, Inc., pp. 80-108.
Dennis ML 1998. Global Appraisal of Individual Needs (GAIN) manual: 
Administration, Scoring and Interpretation, (Prepared with funds 
from CSAT TI 11320). Bloomington IL: Lighthouse Publications. http://www.chestnut.org/LI/GAIN/GAIN_QS/index.html
Martino S, Grilo CM, and Fehon DC 2000. Development of the drug 
abuse screening test for adolescents (DAST-A). Addictive Behaviors 
25(1): 57-70.

    Screening tests and procedures targeted at the elderly are 
described in these publications:

Blow, F.C. Consensus Panel Chair. 1998. Substance Abuse Among Older 
Adults. Treatment Improvement Protocol (TIP) Series 26. DHHS 
Publication No. (SMA) 98-3179.
Blow FC and Barry KL. 1999-2000. Advances in alcohol screening and 
brief intervention with older adults. Advances in Medical 
Psychotherapy. 10:107-124.
    Screening tests and procedures targeted at persons in the 
criminal justice system are described in these publications:

Inciardi JA Consensus Panel Chair 1994. Screening and Assessment for 
Alcohol and Other Drug Abuse Among Adults in the Criminal Justice 
System. Treatment Improvement Protocol (TIP) Series 7. DHHS 
Publication No. (SMA) 94B2076.
Peters, RH, Greenbaum, PE, Steinberg, ML, Carter, CR, Ortiz, MM, 
Fry, BC, Valle, SK. 2000. Effectiveness of screening instruments in 
detecting substance use disorders among prisoners. Journal Substance 
Abuse Treatment: 18(4): 349-58.
Simpson DD. 2001. Core set of TCU forms. Fort Worth: Texas Christian 
University, Institute of Behavioral Research. http://www.ibr.tcu.edu.

    Efforts are ongoing to develop methods to better screen people 
with co-occurring substance use and mental disorders.

II. Assessment Instruments

    Substance abuse assessment instruments are designed to determine 
the precise nature and severity of an individual's problems.

[[Page 10252]]

Some instruments are also designed to help pinpoint specific 
diagnoses. While the results of assessment instruments do not 
necessarily specify the service needs of clients, the data collected 
from these instruments can help determine a client's level of care 
need and, thus, the options of eligible service providers.

[sbull] Adult Assessment Instruments

Addiction Severity Index (ASI)

    ASI is a 30- to 40-minute, interviewer-administered instrument 
that assesses severity of alcohol and drug problems across several 
domains. The ASI has been tested extensively and used widely for 
initial client assessments and to measure client progress and 
outcomes. The ASI should be administered by trained clinicians.

McLellan, A.T.; Luborsky, L.; O'Brien, C.P.; Woody, G.E. An improved 
diagnostic instrument for substance abuse patients: The Addiction 
Severity Index. J Nerv Ment Dis 168:26-33, 1980.
and/or
McLellan, A.T.; Kushner, H.; Metzger, D.; Peters F.; et al. The 
fifth edition of the Addiction Severity Index. J Subst Abuse Treat 
9:199-213, 1992.

Substance Use Disorders Diagnostic Schedule (SUDDS-IV)

    ``The SUDDS-IV is a comprehensive diagnostic assessment 
interview providing definitive documentation for substance-specific 
abuse or dependence diagnoses based on DSM-IV-TR criteria. It also 
screens for depression and anxiety disorders. In addition to 
diagnostic documentation, the SUDDS-IV provides valuable information 
for treatment planning and patient placement.'' (Source: http://www.evinceassessment.com)

Harrison, P. & Hoffman, N. (1987). Substance Use Disorders 
Diagnostic Schedule (SUDDS). St. Paul, MN: Norman G. Hoffman.

Minnesota Multiphasic Personality Inventory (MMPI)

    ``The Minnesota Multiphasic Personality Inventory (MMPI) is an 
objective verbal inventory designed as a personality test for the 
assessment of psychopathology consisting of 550 statements, 16 of 
which are repeated. The replicated statements were originally 
included to facilitate the first attempt at scanner scoring. Though 
they are no longer needed for this purpose, they persist in the 
inventory.'' (Source: http://www.cps.nova.edu/ [sim]cpphelp/MMPI-
2.html)

Hathaway, S. & McKinley, J. Manual for the Minnesota Multiphasic 
Personality Inventory. New York: Psychological Corporation; 1951, 
1967, 1983.
and/or;
Hathaway, S.; McKinley, J.; Butcher, J.; Dahlstrom, W.; Graham, J.; 
Tellegen, A.; et al.
Minnesota Multiphasic Personality Inventory-2: manual for 
administration. Minneapolis: University of Minnesota Press; 1989.

The Recovery Attitude and Treatment Evaluator (RAATE)

    ``The RAATE-CE and QI instruments were designed to assist in 
placing patients into the appropriate level of care at admission, in 
making continued stay or transfer decisions during treatment 
(utilization review), and documenting appropriateness of discharge. 
Both instruments demonstrate good face and rational-expert content 
validity.'' (Source: NIAAA)

Mee-Lee, D. An instrument for treatment progress and matching: The 
Recovery Attitude and Treatment Evaluator (RAATE). J Subst Abuse 
Treat 5:183-186, 1988.
and/or
Mee-Lee, D.; Hoffmann, N.G.; and Smith, M.B. The Recovery Attitude 
And Treatment Evaluator Manual. St. Paul, Minnesota: New Standards, 
Inc., 1992.

[sbull] Adolescent Assessment Instruments

Comprehensive Adolescent Severity Inventory (CASI)

    CASI measures education, substance use, use of free time, 
leisure activities, peer relationships, family history and 
intrafamilial substance use, psychiatric status, and legal history. 
The CASI also incorporates results from urine drug screens and 
observations form the assessor. Psychometric studies on the CASI 
support the instrument's reliability and validity.

Meyers, Kathleen. Comprehensive Adolescent Severity Inventory 
(CASI). Philadelphia, PA : Penn/VA Center for Studies of Addiction, 
1996. c. 176 p. [RJ 503.7 M4 1996].

Global Assessment of Individual Needs (GAIN)

Dennis, ML 1998. Global Appraisal of Individual Needs (GAIN) manual: 
Administration, Scoring and Interpretation, (Prepared with funds 
from CSAT TI 11320). Bloomington IL: Lighthouse Publications. http://www.chestnut.org/LI/GAIN/GAIN_QS/index.html.
Winters, KC. 1999. Screening and Assessing Adolescents For Substance 
Use Disorders. Treatment Improvement Protocol (TIP) Series 31 DHHS 
Publication No. (SMA) 99-3282.

III. Diagnostic Criteria

Diagnostic and Statistical Manual of Mental Disorders-Fourth 
Edition (DSM-IV)

    DSM-IV includes the most widely accepted criteria for diagnosing 
substance abuse and mental disorders. Based on data collected during 
an assessment, the DSM criteria for substance use disorders can be 
used to determine if someone has a ``substance abuse'' or 
``substance dependence'' diagnosis. DSM-IV was first published in 
1994 by the American Psychiatric Association, Washington, DC.

IV. Level of Care Determination, Continued Stay, and Discharge Criteria

Patient Placement Criteria for the Treatment of Substance-Related 
Disorders

    The American Society of Addiction Medicine (ASAM) published the 
second edition of its Patient Placement Criteria for the Treatment 
of Substance-Related Disorders (ASAM PPC-2) in 1996. ASAM's PPC-2R 
presents the criteria for determining which level of services best 
fits a client's needs. The PPC-2R now has both adult and adolescent 
criteria and the appropriate criteria should be used for each of 
these groups.

RAATE

    ``The RAATE-CE and QI instruments were designed to assist in 
placing patients into the appropriate level of care at admission, in 
making continued stay or transfer decisions during treatment 
(utilization review), and documenting appropriateness of discharge. 
Both instruments demonstrate good face and rational-expert content 
validity.'' (Source: NIAAA)

Mee-Lee, D. An instrument for treatment progress and matching: The 
Recovery Attitude and Treatment Evaluator (RAATE). J Subst Abuse 
Treat 5:183-186, 1988.
and/or
Mee-Lee, D.; Hoffmann, N.G.; and Smith, M.B. The Recovery Attitude 
And Treatment Evaluator Manual. St. Paul, Minnesota: New Standards, 
Inc., 1992.

Appendix E: Example of How a State Could Implement a Voucher Program

    The following is an example of how a State (hypothetically named 
``PIB'') could use vouchers for assessment and level of care 
determination as well as for substance use clinical treatment and 
recovery support services.
    Please note that technical assistance is available to all 
applicants to assist them in the development and implementation 
processes. We encourage all applicants to seek such assistance.

1. Outreach and Client Choice

    Prior to launching its voucher program, PIB conducted outreach 
to a wide range of substance abuse service providers--both those 
involved in clinical treatment and those involved in other recovery 
support services. PIB explained to the providers that the State's 
new voucher program would differ from traditional treatment 
services. Instead of the State choosing a particular treatment for 
an individual, clients would receive vouchers to redeem at the 
providers of their choice. PIB encouraged providers to become 
eligible providers, explaining that the program would be most 
successful if clients have access to a variety of treatment and 
recovery service choices.
    Before implementation, PIB also conducted significant outreach 
to clients, prior to implementing its voucher system, to ensure 
individual clients were aware of how the program would operate, and 
that the program would give individuals a choice among various 
eligible service providers. PIB also established a 24-hour, seven-
day-a-week telephone line in place (800-FOR-HELP). This number made 
available a list of eligible assessment, treatment, and recovery 
service providers (throughout the State) for the voucher treatment 
system. PIB was committed to providing an administrative process to 
be used to ensure individuals received appropriate services in safe 
settings and services delivered by appropriate individuals.

[[Page 10253]]

2. Standards, Eligible Providers, Voucher Process, and Incentives

    PIB recognized it had to set a minimum level of eligibility 
criteria and standards for each provider within the clinical 
treatment and recovery support services network to provide quality 
treatment services to its citizens. Therefore, in accordance with 
State administrative procedures, PIB published eligibility criteria 
and standards and, based on provider response to the standards, 
created a list of eligible entities to provide assessment and level 
of care determination as well as treatment and recovery services. 
Two major eligibility conditions were required of providers: (1) 
Meeting standards required by PIB for other providers that provide 
the same type of clinical treatment and recovery support services 
within the State and (2) agreeing to provide the relevant outcomes 
and financial data. The list of eligible entities included 10 new 
providers who had never been funded by the State before, four of 
which were faith-based providers, three of which were proprietary 
providers, and three of which were community-based, recovery support 
organizations.
    At the outset of the voucher initiative, PIB developed an 
eligibility application process and incentives to improve outcomes. 
As part of the application process, providers agreed to receive 90% 
of the reimbursement rate for their services; 10% was withheld and 
set aside to be used to reimburse and incentivize positive client 
outcomes.

3. The Role of PIB's Information System

    A critical component of PIB's voucher program was its electronic 
information system (EIS). As clients submitted a request for 
services from the State of PIB, they entered an electronic voucher 
system. A first task was to establish a client's identity and 
ascertain whether she or he previously had participated in the 
voucher program. If a client was new to the voucher system, they 
received a unique client number and an initial client record was 
created. Initial contact information included, at a minimum, name, 
social security number, birth date, and--where possible--substance 
abuse problem information. The client was then given a voucher for 
an assessment and a list of various assessment sites. The client was 
also provided with notice of the right to genuine and independent 
choice among eligible providers, including the right to an 
alternative provider to whom the client had no religious objection. 
After the client redeemed the assessment voucher, the client 
received a full assessment, involving the administration of an 
assessment instrument, resulting in the creation of a new case 
number, a sequence number that essentially counted the client's 
assessments (if they were re-assessed following an initial 
assessment) within the voucher system. This allowed level of care 
determination and subsequent client activity to be associated with 
particular assessment events.
    The entire assessment packet, for use in the development of an 
interim treatment and recovery plan, was then sent to the 
provider(s) chosen by the client. When the level of care 
determination was entered into the EIS system, a summary of the 
assessment and disposition were made available electronically to the 
chosen provider. PIB provided detailed requirements for data 
reporting, including data definitions to be used.

4. How Vouchers Are Issued

    In the State of PIB, clients who were determined to be 
financially eligible for subsidies had 30-day vouchers for an 
assessment created for them by the State. Once an assessment 
occurred, the assessor created a treatment/recovery services voucher 
with an active life of one-year (365 days). PIB specified that 
creation of a treatment voucher was not a guarantee of payment for 
services up to the full voucher value. It represented a commitment 
on the part of the State of PIB to pay for services up to that 
maximum while funding was available and the client remained 
eligible. If at any point in the fiscal year funds for that year 
were exhausted, all subsidies ended for that year, without regard to 
the existence of vouchers that still retained value. When the next 
fiscal period began and new money was allocated to the funding pool, 
vouchers that had not expired and were not fully expended remained 
chargeable for services, but only for those services rendered after 
the beginning of the new fiscal period.
    Vouchers were created and information about them was forwarded 
to participating providers as follows:
    (1) The staff responsible for the client's assessment determined 
eligibility and created a computer record of the treatment and/or 
recovery voucher based on the determined level of need, including 
client identification, voucher type and value, and effective and 
expiration dates for the voucher. The vouchers were not available to 
be charged against until written or electronic notification of 
client admission to a participating provider's program was received 
at PIB's State Substance Abuse Authority.
    (2) Assessment staff provided the client with a recommendation 
regarding level of care and a list of the various eligible 
providers. The client selected a provider and assessment staff 
determined whether the provider had an opening. If an appropriate 
opening existed, an appointment was made with the provider. The 
client was given the date and time of the appointment and directions 
to the provider, and a voucher packet was sent to the provider. If 
the client was not prepared to make a provider selection at 
assessment, the client was given a voucher packet, which included a 
list of eligible providers and information regarding the client's 
time-limited voucher eligibility.
    (3) Printed notification of the client's voucher eligibility was 
included in the voucher packet sent to the provider, as part of the 
`Voucher Letter'. Another document included in the packet, the 
``Voucher Completion Form,'' was provided so the treatment or 
recovery agency could record the outcome of the placement, including 
the date the client was admitted, if appropriate. This admission 
date had to be communicated to the State agency administering the 
program--either via electronic submission through the PIB Voucher 
Client System, or by filling out the ``Voucher Completion Form''--
before services could be entered against the corresponding treatment 
voucher. PIB specified that the information returned by the provider 
must include both verification of client admission and date of 
admission.
    (4) Upon receipt of verification of client admission from the 
provider, the computerized voucher record became available for use 
by the provider.

5. Invoicing and Payment for Services

    PIB specified that payments to providers be calculated on a 
service-by-service basis, using a standardized rate schedule. PIB 
specified that 90% of the rate be invoiced when services were 
delivered, and that the additional 10% be generated following 
outcomes reporting. In the State of PIB, the services allowable were 
determined by the particular type of voucher that was issued for the 
client and by the services offered by the submitting provider. 
Individual services were restricted to clearly defined minimum and 
maximum time limits. PIB provided a detailed account of the voucher 
and service types, rate schedule, incentive payment conditions, and 
restrictions that were in effect for the voucher program in the 
State of PIB.
    Charges for payment available to providers could be submitted in 
one of two ways: electronic submission on-line from the provider's 
facility, or submission at PIB's administrative agency. Invoices for 
voucher services were generated once a month at the PIB's 
administrative agency and submitted to PIB for payment. PIB 
specified that providers could not generate their own invoices; only 
administrative agency staff could do so. Services performed on or 
after the start day for the invoice period were not invoiced until 
the next invoice period.

6. Voucher Closure/Expiration and Subsidy Shortfalls

    PIB specified that a voucher was in effect for 365 days from the 
date of assessment, when client eligibility was determined. If at 
the end of this period all subsidy funds had not been expended and 
the client was still in treatment or recovery, a client might--on a 
case-by-case basis--receive a time extension on the voucher's 
expiration date. If the client sought another assessment subsequent 
to the expiration of a previous voucher, voucher eligibility also 
might be reconsidered on a case-by-case basis. This process, 
however, required review of the client's circumstances by a 
designated PIB Utilization Review person/board.
    PIB specified that only two circumstances could necessitate the 
closure of a voucher prior to its 365-day life: (1) Change in the 
client's residence beyond the State of PIB; and (2) death of the 
client.
    Providers were responsible for notifying the PIB administrative 
agency when either of the above situations occurred. In addition, 
providers were required, as part of their eligibility to participate 
in the PIB voucher program, to communicate discharge/separation 
information to the PIB administrative agency via the ``Treatment/
Recovery Services Discharge Summary'' form, or through the automated 
Voucher Client System. This information included

[[Page 10254]]

outcome information on each client, such as achieving abstinence 
from substance use. In addition, outcome information became an 
important part of ``report cards'' issued in the second year of the 
program.
    PIB monitored provider reporting of outcomes information on a 
monthly basis. At the end of the first six months of the first year, 
PIB recognized that six providers needed technical assistance to 
accurately report outcomes information. PIB provided such technical 
assistance in a timely manner. At the end of the first year, 
however, four of the six providers were still unable to provide the 
outcomes information in each of the seven domains. As a result, PIB 
declared these four providers ineligible for the voucher program for 
the next year.
    Clients could not receive subsidies for the same type of 
clinical treatment or recovery support service from more than one 
provider at a time, so separation information was necessary if a 
client was being re-placed and the new provider was expecting the 
client to be subsidized with a voucher.
    Because the voucher program operated with limited money, PIB 
told providers it was unlikely that each year's subsidy fund will 
cover all services provided to all qualified clients. In order to 
reduce the impact of funding shortfalls to providers, PIB agreed to 
allocate subsidy funds on a quarterly basis during the fiscal year 
(July 1 to June 30), one-fourth being made available July 1st, one-
fourth added in on October 1st, and so on. If the quarterly 
allotment was exhausted prior to the end of the quarter service 
subsidies stopped until the new quarter began and a new allotment 
was added. At that point services rendered after the beginning of 
the new quarter could be entered and subsidized. PIB felt that, 
while this approach to fund allocation might produce a brief period 
of non-payment at the end of each quarter, it would guarantee that 
funding was available in all four quarters, and avoid any long, 
disruptive interruption of subsidies in the last months of the 
fiscal year.
    PIB frequently reviewed its program to ensure clients had 
genuine, free and independent choice of clinical treatment and/or 
recovery support providers. It committed to recruiting a broad array 
of eligible providers, contacting traditional providers, faith-based 
providers, proprietary providers, and other community organizations. 
PIB ensured that clients were notified of their right to choose 
among eligible providers, and it educated assessment staff on the 
importance of allowing clients to make this choice. PIB also 
maintained an up-to-date, client friendly information service in 
order to ensure client choice was always available (e.g. a Web site 
or 24-hour manned help line) with a list of provider organizations 
and an associated list of available services from the continuum of 
treatment and recovery. The lists developed by PIB were constantly 
evolving to incorporate the most accurate information. The list of 
provider organizations was searchable by category of available 
services and by location.

Appendix F--Checklist for Formatting Requirements and Screenout 
Criteria for SAMHSA Grant Applications

    SAMHSA's goal is to review all applications submitted for grant 
funding. However, this goal must be balanced against SAMHSA's 
obligation to ensure equitable treatment of applications. For this 
reason, SAMHSA has established certain formatting requirements for 
its applications. If you do not adhere to these requirements, your 
application will be screened out and returned to you without review. 
In addition to these formatting requirements, programmatic 
requirements (e.g., relating to eligibility) may be stated in the 
specific funding announcement. Please check the entire funding 
announcement before preparing your application.
    [squ] Use the PHS 5161-1 application.
    [squ] Applications must be received by the application deadline. 
Applications received after this date must have a proof of mailing 
date from the carrier dated at least 1 week prior to the due date. 
Private metered postmarks are not acceptable as proof of timely 
mailing. Applications not received by the application deadline or 
not postmarked at least 1 week prior to the application deadline 
will not be reviewed.
    [squ] Information provided must be sufficient for review.
    [squ] Text must be legible.
    [sbull] Type size in the Project Narrative cannot exceed an 
average of 15 characters per inch, as measured on the physical page. 
(Type size in charts, tables, graphs, and footnotes will not be 
considered in determining compliance.)
    [sbull] Text in the Project Narrative cannot exceed 6 lines per 
vertical inch.
    [ballot] Paper must be white paper and 8.5 inches by 11.0 inches 
in size.
    [ballot] To ensure equity among applications, the amount of 
space allowed for the Project Narrative cannot be exceeded.
    [sbull] Applications would meet this requirement by using all 
margins (left, right, top, bottom) of at least one inch each, and 
adhering to the page limit for the Project Narrative stated in the 
specific funding announcement.
    [sbull] Should an application not conform to these margin or 
page limits, SAMHSA will use the following method to determine 
compliance: The total area of the Project Narrative (excluding 
margins, but including charts, tables, graphs and footnotes) cannot 
exceed 58.5 square inches multiplied by the total number of allowed 
pages. This number represents the full page less margins, multiplied 
by the total number of allowed pages.
    [sbull] Space will be measured on the physical page. Space left 
blank within the Project Narrative (excluding margins) is considered 
part of the Project Narrative, in determining compliance.
    [ballot] The page limit for Appendices stated in the specific 
funding announcement cannot be exceeded.
    To facilitate review of your application, follow these 
additional guidelines. Failure to adhere to the following guidelines 
will not, in itself, result in your application being screened out 
and returned without review. However, the information provided in 
the application must be sufficient for review. Following these 
guidelines will help ensure your application is complete, and will 
help reviewers to consider your application.
    [ballot] The 10 application components required for SAMHSA 
applications should be included. These are:
    [sbull] Face Page (Standard Form 424, which is in PHS 5161-1).
    [sbull] Abstract.
    [sbull] Table of Contents.
    [sbull] Budget Form (Standard Form 424A, which is in PHS 5161-
1).
    [sbull] Project Narrative and Supporting Documentation.
    [sbull] Appendices.
    [sbull] Assurances (Standard Form 424B, which is in PHS 5161-1).
    [sbull] Certifications (a form within PHS 5161-1).
    [sbull] Disclosure of Lobbying Activities (Standard Form LLL, 
which is in PHS 5161-1).
    [sbull] Checklist (a form in PHS 5161-1).
    [ballot] Applications should comply with the following 
requirements:
    [sbull] Provisions relating to confidentiality, participant 
protection and the protection of human subjects stated in the 
specific funding announcement.
    [sbull] Budgetary limitations as specified in Sections I, II, 
and IV-5 of the specific funding announcement.
    [sbull] Documentation of nonprofit status as required in the PHS 
5161-1.
    [ballot] Pages should be typed single-spaced with one column per 
page.
    [ballot] Pages should not have printing on both sides.
    [ballot] Please use black ink and number pages consecutively 
from beginning to end so that information can be located easily 
during review of the application. The cover page should be page 1, 
the abstract page should be page 2, and the table of contents page 
should be page 3. Appendices should be labeled and separated from 
the Project Narrative and budget section, and the pages should be 
numbered to continue the sequence.
    [ballot] Send the original application and two copies to the 
mailing address in the funding announcement. Please do not use 
staples, paper clips, and fasteners. Nothing should be attached, 
stapled, folded, or pasted. Do not use heavy or lightweight paper or 
any material that cannot be copied using automatic copying machines. 
Odd-sized and oversized attachments such as posters will not be 
copied or sent to reviewers. Do not include videotapes, audiotapes, 
or CD-ROMs.

Appendix G: Managing on the Basis of Reasonable Costs

    States are encouraged to manage the program on the basis of 
reasonable costs. Proposed per person costs for treatment and 
recovery support services to be provided under this initiative 
should be included in the application. In cases where it is not 
possible to include costs that are based on prior experience, the 
application should include an estimate of the cost of the service, 
as well as a plan and timeline for developing cost data based on 
experience.

[[Page 10255]]

    The following are considered reasonable ranges by treatment or 
modality:
    [sbull] Screening/Brief Intervention/Brief Treatment/Outreach/
Pretreatment Services--$200 to $1,200.
    [sbull] Outpatient (Non-Methadone)--$1,000 to $5,000.
    [sbull] Outpatient (Methadone)--$1,500 to $8,000.
    [sbull] Residential--$3,000 to $10,000.
    If the State deviates from these costs, it should provide a 
justification for doing so, in order for SAMHSA to determine 
reasonableness of costs. Reasonable cost is based on actual cost of 
providing such services, including direct and indirect cost of 
providers and excluding any costs that are unnecessary in the 
efficient delivery of services covered by the program (Center for 
Medicare and Medicaid Services, 2003). While cost ranges for 
recovery support services are not specified above, due to the great 
variations that exist, applicants are expected to provide costs for 
recovery support services that they intend to provide. Per person 
costs for each modality should be computed by dividing the number of 
persons served in each modality by the amount of the project budget 
used to fund that program component after subtracting out the costs 
of required data collection and submission.

    Dated: February 27, 2004.
James Stone,
Deputy Administrator, Substance Abuse and Mental Health, Services 
Administration.

[FR Doc. 04-4733 Filed 3-3-04; 8:45 am]
BILLING CODE 4162-20-P