[Federal Register Volume 69, Number 64 (Friday, April 2, 2004)]
[Notices]
[Pages 17423-17437]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-7400]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration


Notice of Request for Applications for State Incentive Grants for 
Treatment of Persons with Co-Occurring Substance Related and Mental 
Disorders (COSIG)

AGENCY: Substance Abuse and Mental Health Services Administration, HHS.

ACTION: Notice of request for applications for State Incentive Grants 
for Treatment of Persons with Co-Occurring Substance Related and Mental 
Disorders (COSIG).

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    Authority: Sections 509 and 520A of the Public Health Service 
Act.

SUMMARY: The Substance Abuse and Mental Health Services Administration 
(SAMHSA), Center for Substance Abuse Treatment (CSAT), and Center for 
Mental Health Services (CMHS), are accepting applications for Fiscal 
Year 2004 grants to develop and enhance the infrastructure of States 
and their treatment service systems to increase the capacity to provide 
accessible, effective, comprehensive, coordinated/integrated, and 
evidence-based treatment services to persons with co-occurring 
substance abuse and mental health disorders, and their families. COSIG 
also provides an opportunity to participate in an evaluation of the 
feasibility, validity and reliability of the proposed co-occurring 
performance measures for the future Performance Partnership Grants 
(PPGs), and to participate in a national evaluation of the COSIG 
program.

DATES: Applications are due on June 8, 2004.

FOR FURTHER INFORMATION CONTACT: For questions on program issues 
contact: Richard E. Lopez, J.D., PhD., SAMHSA/CSAT/DSCA, 5600 Fishers 
Lane, Rockwall II, Suite 8-147, Rockville, MD 20857, Phone: (301) 443-
7615; E-Mail: [email protected]; or Lawrence Rickards, PhD., SAMHSA/
CMHS/DSSI, 5600 Fishers Lane, Room 11C-05, Rockville, MD 20857; Phone: 
301-443-3707; E-mail : [email protected].
    For questions on grants management issues contact: Kathleen Sample, 
SAMHSA/Division of Grants Management, 5600 Fishers Lane, Suite 630, 
Rockville, MD 20857, Phone: (301) 443-9667; E-mail: [email protected].

SUPPLEMENTARY INFORMATION:

State Incentive Grants for Treatment of Persons with Co-Occurring 
Substance Related and Mental Disorders (SM 04-012) (Initial 
Announcement)

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

Key Dates

Application Deadline.--Applications are due by June 8, 2004.
Intergovernmental Review (E.O. 12372).--Letters from State Single Point 
of Contact (SPOC) are due August 7, 2004.

Table of Contents

I. Funding Opportunity Description
    1. Introduction
    2. Expectations
II. Award Information
    1. Award Amount
    2. Funding Mechanism
III. Eligibility Information
    1. Eligible Applicants
    2. Cost-Sharing or Matching
    3. Other
IV. Application and Submission Information
    1. Addresses 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. Criteria
    2. Review and Selection Process
VI. Award Administration Information
    1. Award Notices
    2. Administrative and National Policy Requirements
    3. Reporting
VII. Agency Contacts
Appendix A: Checklist for Application Formatting Requirements
Appendix B: Glossary
Appendix C: Logic Model Resources
Appendix D: State Case Studies
Appendix E: Text from State Directors' Conceptual Framework

I. Funding Opportunity Description

1. Introduction

    As authorized under Section 509 and 520A of the Public Health 
Services Act, the Substance Abuse and Mental Health Services 
Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT), 
and Center for Mental Health Services (CMHS), announce the availability 
of funds for Fiscal Year 2004 grants. These grants will develop and

[[Page 17424]]

enhance the infrastructure of States and their treatment service 
systems to increase the capacity to provide accessible, effective, 
comprehensive, coordinated/integrated, and evidence-based treatment 
services to persons with co-occurring substance abuse and mental health 
disorders, and their families.

2. Expectations

2.1 Background
    There is a growing consensus among key stakeholders about the 
critical importance of improving services to people with co-occurring 
disorders and the action steps that are needed to do so. SAMHSA 
released a landmark Report to Congress on Co-occurring Disorders (RTC) 
on December 2, 2002, creating a critical opportunity for SAMHSA to 
provide leadership to support State efforts to improve services for 
people with co-occurring disorders.
    COSIG provides funding to the States to develop or enhance their 
infrastructure to increase their capacity to provide accessible, 
effective, comprehensive, coordinated/integrated, and evidence-based 
treatment services to persons with co-occurring substance abuse and 
mental disorders. COSIG also provides an opportunity to participate in 
an evaluation of the feasibility, validity and reliability of the 
proposed co-occurring performance measures for the future Performance 
Partnership Grants (PPGs), and to participate in a national evaluation 
of the COSIG program.
    COSIG is built on the following concepts and principles:
     COSIG uses the definition of co-occurring 
disorders developed by the consensus panel convened to draft SAMHSA's 
Treatment Improvement Protocol (TIP), Substance Abuse Treatment for 
Persons with Co-occurring Disorders: People with co-occurring substance 
abuse and mental disorders are * * * individuals who have at least one 
psychiatric disorder as well as an alcohol or drug use disorder. While 
these disorders may interact differently in any one person (e.g., an 
episode of depression may trigger a relapse into alcohol abuse, or 
cocaine use may exacerbate schizophrenic symptoms) at least one 
disorder of each type can be diagnosed independently of the other.''
     COSIG will support infrastructure development 
and services across the continuum of co-occurring disorders from least 
severe to most severe (i.e., Quadrants I, II, III, and IV of the State 
Directors' Conceptual Framework `` See Appendix E). However, under 
COSIG, SAMHSA's emphasis is on Quadrants II & III.
     COSIG is appropriate for States at any level of 
infrastructure development. States will not be at a disadvantage either 
for being at an early stage of development or at a more advanced stage. 
Some States and communities throughout the country already have 
initiated system-level changes and developed innovative programs that 
overcome barriers to providing services for individuals of all ages who 
have co-occurring substance abuse and mental disorders. The COSIG grant 
program reflects the experience of States to date. [See Appendix D for 
summaries of case studies of these efforts.]
2.2 Program Requirements
    In developing their COSIG applications, States will select one or 
more of the capacity building goals enunciated in SAMHSA's Report to 
Congress on Co-Occurring Disorders and will implement infrastructure 
development and enhancement activities (tailored to State needs) that 
will support the selected goal(s) (Report to Congress on the Prevention 
and Treatment of Co-Occurring Substance Abuse Disorders and Mental 
Disorders, USDHHS, SAMHSA, November 2002; Chapter V, Five-Year 
Blueprint for Action, Capacity, SAMHSA State Services and Treatment 
Capacity Goals, page 113). Applicants will identify measurable outcomes 
for each goal, establish targets, and describe how progress will be 
tracked and measured over the course of the grant. In addition, all 
COSIG grantees will be required to report on the proposed co-occurring 
performance measures for the PPGs and may be required to participate in 
an evaluation study to determine the feasibility, validity, and 
reliability of the co-occurring performance measures. This evaluation 
will be funded through a separate contract, though data collection and 
reporting costs are to be borne by the COSIG grantees.
    COSIG program will have two phases:
     Phase I--The first three years of the grant will 
focus on infrastructure development/enhancement (as described below). 
Awards will be for up to $1.1 million per year for the first three 
years.
     Phase II--An additional 2 years of funding will 
be provided at a lower level for evaluation and continued collection/
reporting of performance data. Grantees without service pilots (see 
below) will receive up to $100,000 per year in years 4 and 5. Grantees 
with service pilots will receive up to half of their third year award 
in year 4 and up to $100,000 in year 5.
    The capacity building goals in SAMHSA's Co-Occurring Report to 
Congress are as follows:
     Screen all individuals for the presence of co-
occurring disorders;
     Assess the level of severity of co-occurring 
disorders;
     Treat both disorders in a comprehensive and 
coordinated manner that is seamless to the client and, where feasible, 
that involves the client's family. This may involve consultation/
collaboration with other providers, if the provider does not have the 
ability to offer comprehensive treatment;
     Train providers to screen, assess, and develop 
preventive interventions and treatment plans for people who have co-
occurring disorders;
     Evaluate the impact of prevention and treatment 
services on individuals who have co-occurring disorders and their 
families.
    States will have flexibility to identify specific infrastructure 
development and enhancement activities that support the goals selected 
and respond to the needs and priorities identified by the State. 
However, the experience of other States suggests that certain areas of 
infrastructure development (e.g., standardized screening and 
assessment, complementary licensure and credentialing requirements, 
service coordination and network building, financial planning, and 
information sharing) reflect critical pathways for establishing 
complementary service delivery capacity in substance abuse and mental 
health service systems. Although COSIG awardees are not required to use 
COSIG funds in each of these areas, applicants must discuss in their 
applications the status of the State with regard to each area of 
infrastructure development, identify the area(s) that will be targeted 
with COSIG funds and describe how the State proposes to use COSIG funds 
in each area selected.
     Standardized Screening and Assessment: A number 
of screening and assessment instruments exist that can be used to 
identify and effectively assess the needs of persons with co-occurring 
disorders. At present, there is no standard for using these instruments 
or for ensuring that screening and assessment are even done in existing 
programs throughout the States. Adoption of acceptable protocols State-
wide can help ensure that the initial objectives of the SAMHSA Report 
to Congress are achieved.
     Complementary Licensure and Credentialing 
Requirements: State licensure, credentialing policies, and legal 
requirements often act as barriers to providing effective integrated 
services

[[Page 17425]]

for persons with co-occurring disorders. Review and revision of these 
laws and policies are a critical initial step toward improving services 
and extending effective substance abuse treatment to existing mental 
health treatment programs and vice versa.
     Service Coordination and Network Building: 
Conventional boundaries between single-focus agencies impede the 
clinical progress of persons with co-occurring disorders. Network 
building will help States develop more effective linkages across 
systems of care. This activity area also includes the development of a 
permanent State-level coordinating body and assignment of specific 
``boundary spanning'' responsibilities designed to ensure continuous 
coordination which yields the most efficient use of agency resources 
and the elimination of service redundancies.
     Financial Planning: Current reimbursement 
practices inhibit coordination/integration of services and effective 
treatment for persons with co-occurring disorders. Mental health and 
substance abuse services are funded through separate Federal, State, 
local, and private funding sources. The goal of comprehensive financial 
planning is the development of effective and innovative approaches for 
coordinating funds from these multiple programs to fund seamless 
services for individuals with co-occurring disorders--while maintaining 
accountability--and the removal of barriers that inhibit effective 
resource coordination.
     Information Sharing: Often there is little or no 
communication among various departments and levels of government that 
have separate administrative structures, constituencies, mandates, and 
target groups. The goal of information sharing, ideally through 
utilization of the State's integrated MIS, is to ensure communication 
between providers so that treatment is more suited to the person's 
personal needs and characteristics by linking services and information 
across different systems of care.
    The program will allow (but not require) up to 50% of the grant to 
be used for services pilots to test the infrastructure enhancements 
that are being made through the grant. In other words, these service 
pilots will help States that choose to implement them to determine 
whether the enhancements are feasible and whether they are resulting in 
the intended outcomes. Patient services are required in a pilot.
    Applicants must commit to cooperating with, coordinating with, and 
supporting the efforts of SAMHSA's Co-occurring Cross Training and 
Technical Assistance Center (separately funded). The purpose of the 
Center is to provide a broadly focused technical assistance and 
training to States and community agencies to enable them to provide 
effective prevention and treatment services to meet the needs of 
persons with, or at-risk of developing, co-occurring disorders 
(including the homeless), whether in the mental health, substance 
abuse, criminal justice, or other social/public health systems.
    Pre-Application Assistance: In addition to other application 
materials, applicants may want to obtain a draft copy of SAMHSA's 
Treatment Improvement Protocol (TIP), Substance Abuse Treatment for 
Persons with Co-occurring Disorders and the Co-Occurring Disorders: 
Integrated Dual Disorders Treatment Implementation Resource Kit, 
referred to in this grant announcement. These SAMHSA-funded resources 
are not yet available for distribution to the general public. We fully 
expect that the TIP will be available for use when the grant awards are 
made. The Resource Kit is currently undergoing pilot testing. In the 
interim, to assist the States in preparing applications in response to 
this RFA, a limited number of copies of the TIP and Resource Kit are 
available exclusively for use by potential applicants.
    Potential applicants must not reproduce these copies and should 
discard them after completing their grant application.
    To receive draft copies of Treatment Improvement Protocol (TIP), 
Substance Abuse Treatment for Persons with Co-occurring Disorders and 
the Co-Occurring Disorders: Integrated Dual Disorders Treatment 
Implementation Resource Kit for use in preparing the application, 
provide your name, position title, mailing address for receipt of 
packages, email address, and phone number to:

Richard E. Lopez, J.D., Ph.D., SAMHSA/CSAT/DSCA, 5600 Fishers Lane/
Rockwall II, 8-147, Rockville, MD 20857, (301) 443-7615, E-mail: 
[email protected],
     or
Lawrence Rickards, Ph.D., SAMHSA/CMHS/DSSI, 5600 Fishers Lane, 11C-05, 
Rockville, MD 20857, (301) 443-3707, E-mail: [email protected].
2.3 Data and Performance Measurement
    All awardees will use the co-occurring performance measures adopted 
by National Association of State Alcohol and Drug Abuse Directors 
(NASADAD), and the National Association of State Mental Health Program 
Directors (NASMHPD), in conjunction with SAMHSA, to monitor the growth 
of their service capacity for treating persons with co-occurring 
disorders. Costs for collecting and reporting data on these measures 
should be included in the proposed budget for the COSIG. The co-
occurring performance measures are as follows:
     Percentage of clients (adults and children/
adolescents) in mental health and substance abuse programs with 
symptoms of the corresponding co-occurring problem;
     Percent of treatment programs that:

--Screen for co-occurring disorders;
--Assess for co-occurring disorders;
--Provide treatment to clients through collaborative, consultative and 
integrated models of care;

     Percentage of clients who experience reduced 
impairment from their co-occurring disorders following treatment.
    Applicants must describe their current capacity to collect data 
relating to each of these measures, must present baseline data if 
available, and must project targets for these measures for each year of 
the COSIG grant. Applicants must describe how they will collect and 
report data related to the PPG measures during the first 6-8 months of 
the grant, and must demonstrate a capacity to do so.
    These measures will be used by all COSIG awardees. SAMHSA may award 
a separate contract to evaluate the interim measures for validity and 
reliability and to develop final standards.
    The terms and conditions of the grant award also will specify the 
data to be submitted to SAMHSA and the schedule for submission. 
Grantees will be required to adhere to these terms and conditions of 
award.
    Applicants should be aware that SAMHSA is working to develop a set 
of required core performance measures for four types of grants (i.e., 
Services Grants, Infrastructure Grants, Best Practices Planning and 
Implementation Grants, and Service-to-Science Grants). As this effort 
proceeds, some of the data collection and reporting requirements 
included in SAMHSA's programs may change. All grantees will be expected 
to comply with any changes in data collection requirements that occur 
during the grantee's project period.
2.4 Grantee Meetings
    Grantees must attend (and, thus must budget for) two technical 
assistance meetings during each year of the grant. Each meeting will be 
three days. At a

[[Page 17426]]

minimum, three persons (Project Director, Project Evaluator, and staff 
from the Governor's Office) are expected to attend each meeting. These 
meetings will usually be held in the Washington, DC area.
    SAMHSA will provide post award support to grantees through 
technical assistance on clinical, programmatic, and evaluation issues. 
Applicants must agree to participate in these activities.
2.5 Evaluation
    SAMHSA may require COSIG grantees to participate in an evaluation 
of the feasibility, validity, and reliability of the proposed co-
occurring performance measures for the PPGs.
    Grantees must evaluate their projects, and applicants are required 
to describe their evaluation plans in their applications. The 
evaluation should be designed to provide regular feedback to the 
project to improve services. The evaluation must include both process 
and outcome components. Process and outcome evaluations must measure 
change relating to project goals and objectives over time compared to 
baseline information. Control or comparison groups are not required. 
You must consider your evaluation plan when preparing the project 
budget.
    Process components should address issues such as:
     How closely did implementation match the plan?
     What types of deviation from the plan occurred?
     What led to the deviations?
     What impact did the deviations have on the 
intervention and evaluation?
     Who provided (program, staff) what services 
(modality, type, intensity, duration), to whom (individual 
characteristics), in what context (system, community), and at what cost 
(facilities, personnel, dollars)?
    Outcome components should address issues such as:
     What was the effect of infrastructure 
development on service capacity and other system outcomes?
     What program/contextual factors were associated 
with outcomes?
     What individual factors were associated with 
outcomes?
     How durable were the effects?
    If the project includes an implementation pilot involving services 
delivery, the evaluation should include client and system outcomes.
    SAMHSA may choose to implement a cross-site evaluation of the COSIG 
grant program. If conducted, the cross-site evaluation will be managed 
through a public/private collaboration. States will be required to 
collaborate in the evaluation by attending up to two meetings annually, 
participating in the development of a cross-site evaluation plan, and 
by submitting information consistent with the plan. Applicants must 
specifically agree to participate in a cross-site evaluation and must 
budget for attendance by two persons at two meetings annually. These 
two annual meetings are in addition to the two annual technical 
assistance meetings discussed above. Once the final standards for the 
performance measures are developed, COSIG awardees will be required to 
collect and report outcomes using the final standards for the remainder 
of their grants.
    No more than 20% of the total grant award may be used for 
evaluation and data collection. The evaluation and data collection may 
be considered ``Infrastructure'' and/or ``Implementation Pilots'' 
expenditures, depending on their purpose.
    CMHS has developed a variety of evaluation tools and guidelines 
that may assist applicants in the design and implementation of the 
evaluation. These materials are available for free downloads from: 
http://www.tecathsri.org.

II. Award Information

1. Award Amount

    It is expected $4.5 million will be available to fund up to 4 COSIG 
awards in FY 2004. The awards will range from $500,000 to $1.1 million 
in total costs (direct and indirect) per year. Grantees in years 1-3 
will receive up to $1.1 million per year. Grantees with service pilots 
will receive up to half of the third year award in the 4th year to 
phase down the services pilot and up to $100,000 for evaluation in year 
5. For example, if you ask for $1.1 million in year 3, you can request 
up to $550,000 in Year 4. If you request less than $1.1 million in year 
3, then your year 4 request must be proportionately less. Grantees 
without service pilots will receive up to $100,000 for evaluation in 
both years 4 and 5. Proposed budgets cannot exceed the allowable amount 
in any year of the proposed project. The actual amount available for 
the awards may vary, depending on unanticipated program requirements 
and the number and quality of the applications received.

2. Funding Mechanism

    Awards will be made as grants.

III. Eligibility Information

1. Eligible Applicants

    Only the immediate Office of the Governor of States may apply. 
State-level agencies are not considered to be part of the immediate 
Office of the Governor. This means, for example, that the State Mental 
Health, or Substance Abuse Authorities, or other State-level agencies 
within the Office of the Governor, cannot apply independently. SAMHSA 
has limited the eligibility to Governors of States because the 
immediate Office of the Governor has the greatest potential to provide 
the multi-agency leadership needed to develop the State's 
infrastructure/treatment service systems to increase the State's 
capacity to provide accessible, effective, comprehensive, coordinated/
integrated, and evidence-based services to persons with co-occurring 
substance abuse and mental health disorders, and their families.
    The Governor may designate a lead official to be Program Director 
for the grant. The application must reflect substantial involvement of 
the State Mental Health Authority (SMHA) and the State Substance Abuse 
Authority (SSA), and other relevant agencies, and must reflect 
substantial involvement and oversight by the immediate Office of the 
Governor.
    The application face page (form 424) must be signed by the 
Governor.
    As defined in the Public Health Service (PHS) Act, the term 
``State'' includes all 50 States, the District of Columbia, Guam, the 
Commonwealth of Puerto Rico, the Northern Mariana Islands, the Virgin 
Islands, American Samoa, and the Trust Territory of the Pacific 
Islands. Applications from State agencies other than the Office of the 
Governor, or from government entities that do not meet the definition 
of ``State,'' are not eligible for funding.
    This grant program is appropriate for all States regardless of 
their level of infrastructure development.

2. Cost-Sharing

    Cost-sharing (see Appendix B. Glossary) is not required in this 
program, and applications will not be screened out on the basis of 
cost-sharing. However, you may include cash or in-kind contributions 
(see Glossary) in your proposal as evidence of commitment to the 
proposed project.

3. Other

    Applications must comply with the following requirements or they 
will be screened out and will not be reviewed: use of the PHS 5161-1 
application; application submission requirements in Section IV-3 of 
this document; and formatting requirements provided in Section IV-2.3 
of this document.

[[Page 17427]]

IV. Application and Submission Information

    (To ensure that you have met all submission requirements, a 
checklist is provided for your use in Appendix A of this document.)

1. Address to Request Application Package

    You may request a complete application kit by calling one of 
SAMHSA's national clearinghouses:
     National Clearinghouse for Alcohol and Drug 
Information (NCADI) at 1-800-729-6686; or
     National Mental Health Information Center at 1-
800-789-CMHS (2647).
    You 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:
     A technical assistance manual for potential 
applicants;
     Standard terms and conditions for SAMHSA grants;
     Guidelines and policies that relate to SAMHSA 
grants (e.g., guidelines on cultural competence, consumer and family 
participation, and evaluation); and
     Enhanced instructions for completing the PHS 
5161-1 application.

2. Content and Form of Application Submission

2.1 Required Documents
    SAMHSA application kits include the following documents:
     PHS 5161-1 (revised July 2000)--Includes the 
face page, budget forms, assurances, certification, and checklist. You 
must use the PHS 5161-1. Applications that are not submitted on the 
required application form will be screened out and will not be 
reviewed.
     Request for Applications (RFA)--Includes 
instructions for the grant application. This document is the RFA.
    You must use the above documents in completing your application.
2.2 Required Application Components
    To ensure equitable treatment of all applications, applications 
must be complete. In order for your application to be complete, it must 
include the required ten application components (Face Page, Abstract, 
Table of Contents, Budget Form, Project Narrative and Supporting 
Documentation, Appendices, Assurances, Certifications, Disclosure of 
Lobbying Activities, and Checklist).
     Face Page--Use Standard Form (SF) 424, which is 
part of the PHS 5161-1. [Note: Beginning October 1, 2003, applicants 
will need to provide a Dun and Bradstreet (DUNS) number to apply for a 
grant or cooperative agreement from the Federal Government. SAMHSA 
applicants will be 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, let Dun and Bradstreet know that you are a 
public/private nonprofit organization getting ready to submit a Federal 
grant application.]
     Abstract--Your total abstract should not be 
longer than 35 lines. In the first five lines or less of your abstract, 
write a summary of your project that can be used, if your project is 
funded, in publications, reporting to Congress, or press releases.
     Table of Contents--Include page numbers for each 
of the major sections of your application and for each appendix.
     Budget Form--Use SF 424A, which is part of the 
5161-1. Fill out Sections B, C, and E of the SF 424A.
     Project Narrative and Supporting Documentation--
The Project Narrative describes your project. It consists of Sections A 
through C. These sections in total may not be longer than 30 pages. 
More detailed instructions for completing each section of the Project 
Narrative are provided in ``Section V--Application Review Information'' 
of this document.
    The Supporting Documentation provides additional information 
necessary for the review of your application. This supporting 
documentation should be provided immediately following your Project 
Narrative in Sections D through G. There are no page limits for these 
sections, except for Section F, Biographical Sketches/Job Descriptions.
     Section D--Literature Citations. This section 
must contain complete citations, including titles and all authors, for 
any literature you cite in your application.
     Section E--Budget Justification, Existing 
Resources, Other Support. You must provide a narrative justification of 
the items included in your proposed budget, as well as a description of 
existing resources and other support you expect to receive for the 
proposed project. Be sure to show that no more than 20% of the total 
grant award will be used for data collection and evaluation, and no 
more than 50% of the grant will be used for services pilots, if 
applicable.
     Section F--Biographical Sketches and Job 
Descriptions.

--Include a biographical sketch for the Project Director and other key 
positions. Each sketch should be 2 pages or less. If the person has not 
been hired, include a letter of commitment from the individual with a 
current biographical sketch.
--Include job descriptions for key personnel. Job descriptions should 
be no longer than 1 page each.
--Sample sketches and job descriptions are listed on page 22, Item 6 in 
the Program Narrative section of the PHS 5161-1.
     Section G--Confidentiality and SAMHSA 
Participant Protection/Human Subjects. Section IV-2.4 of this document 
describes requirements for the protection of the confidentiality, 
rights and safety of participants in SAMHSA-funded activities. This 
section also includes guidelines for completing this part of your 
application.
     Appendices 1 through 3--Use only the appendices 
listed below. Do not use more than 30 pages (excluding data collection 
instruments and interview protocols) for the appendices. Do not use 
appendices to extend or replace any of the sections of the Project 
Narrative. Reviewers will not consider them if you do.
--Appendix 1: Letters of Commitment/Support from stakeholders and 
project participants/involved agencies.
--Appendix 2: Sample Consent Forms
--Appendix 3: Data Collection Instruments/Interview Protocols. (Note: 
Appendix 3 has no page limit.)
--Assurances--Non-Construction Programs. Use Standard Form 424B found 
in PHS 5161-1. Because grantees in the COSIG program may use some of 
the grants funds to provide direct substance abuse services, applicants 
are required to complete the Assurance of Compliance with SAMHSA 
Charitable Choice Statutes and Regulations, Form SMA 170. This form 
will be posted on SAMHSA's web site with the RFA and provided in the 
application kits available at the National Clearinghouse for Alcohol 
and Drug Information and the National Mental Health Information Center.
--Certifications--Use the ``Certifications'' forms found in PHS 5161-1.
--Disclosure of Lobbying Activities--Use Standard Form 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

[[Page 17428]]

use of the information designed to support or defeat legislation 
pending before the Congress or State legislatures. This includes 
``grass roots'' lobbying, which consists of appeals to members of the 
public suggesting that they contact their elected representatives to 
indicate their support for or opposition to pending legislation or to 
urge those representatives to vote in a particular way.
--Checklist--Use the Checklist found in PHS 5161-1. The Checklist 
ensures that you have obtained the proper signatures, assurances and 
certifications and is the last page of your application.
2.3 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.
     Information provided must be sufficient for 
review.
     Text must be legible.

--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.)
--Text in the Project Narrative cannot exceed 6 lines per vertical 
inch.

     Paper must be white paper and 8.5 inches by 11.0 
inches in size.
     To ensure equity among applications, the amount 
of space allowed for the Project Narrative cannot be exceeded.

--Applications would meet this requirement by using all margins (left, 
right, top, bottom) of at least one inch each, and adhering to the 30-
page limit for the Project Narrative.
--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 30. This number represents the full page less margins, 
multiplied by the total number of allowed pages.
--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.

     The 30-page limit for Appendices 1 and 2 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, following these guidelines will help reviewers 
to consider your application.
     Pages should be typed single-spaced with one 
column per page.
     Pages should not have printing on both sides.
     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.
    Send the original application and two copies to the mailing address 
in Section IV-6.1 of this document. 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.
2.4 SAMHSA Confidentiality and Participant Protection Requirements and 
Protection of Human Subjects Regulations
    You must describe your procedures relating to Confidentiality, 
Participant Protection and the Protection of Human Subjects Regulations 
in Section G of your application, using the guidelines provided below. 
Problems with confidentiality, participant protection, and protection 
of human subjects identified during peer review of your 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. You must describe how 
you will address these requirements.

1. Protect Clients and Staff From Potential Risks

     Identify and describe any foreseeable physical, 
medical, psychological, social, and legal risks or potential adverse 
effects as a result of the project itself or any data collection 
activity.

--Describe the procedures you will follow to minimize or protect 
participants against potential risks, including risks to 
confidentiality.
--Identify plans to provide guidance and assistance in the event there 
are adverse effects to participants.
--Where appropriate, describe alternative treatments and procedures 
that may be beneficial to the participants. If you choose not to use 
these other beneficial treatments, provide the reasons for not using 
them.

2. Fair Selection of Participants

     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 targeted 
groups.
     Explain the reasons for including groups of 
pregnant women, children, people with mental disabilities, people in 
institutions, prisoners, and individuals who are likely to be 
particularly vulnerable to HIV/AIDS.
     Explain the reasons for including or excluding 
participants.
     Explain how you will recruit and select 
participants. Identify who will select participants.

3. Absence of Coercion

     Explain if participation in the project is 
voluntary or required. Identify possible reasons why participation is 
required, for example, court orders requiring people to participate in 
a program.
     If you plan to compensate participants, state 
how participants will be awarded incentives (e.g., money, gifts, etc.).
     State how volunteer participants will be told 
that they may receive services intervention even if they do not 
participate in or complete the data collection component of the 
project.

4. Data Collection

     Identify from whom you will collect data (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.
     Identify what type of specimens (e.g., urine, 
blood) will be used, if any. State if the material will be used just 
for

[[Page 17429]]

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.
     Provide in Appendix 3, ``Data Collection 
Instruments/Interview Protocols,'' copies of all available data 
collection instruments and interview protocols that you plan to use.

5. Privacy and Confidentiality

     Explain how you will ensure privacy and 
confidentiality. Include who will collect data and how it will be 
collected.
     Describe:
--How you will use data collection instruments.
--Where data will be stored.
--Who will or will not have access to information.
--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.

6. Adequate Consent Procedures

     List what information will be given to people 
who participate in the project. Include the type and purpose of their 
participation. Identify the data that will be collected, how the data 
will be used and how you will keep the data private.
     State:
--Whether or not their participation is voluntary.
--Their right to leave the project at any time without problems.
--Possible risks from participation in the project.
--Plans to protect clients from these risks.
     Explain how you will get consent 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, you must obtain written 
informed consent.

     Indicate if you will obtain informed consent 
from participants or assent from minors along with consent from their 
parents or legal guardians. Describe how the consent will be 
documented. For example: Will you read the consent forms? Will you ask 
prospective participants questions to be sure they understand the 
forms? Will you give them copies of what they sign?
     Include, as appropriate, sample consent forms 
that provide for: (1) Informed consent for participation in service 
intervention; (2) informed consent for participation in the data 
collection component of the project; and (3) informed consent for the 
exchange (releasing or requesting) of confidential information. The 
sample forms must be included in Appendix 2, ``Sample Consent Forms'', 
of your application. 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 your project or its agents from liability for negligence.

     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?
     Additionally, if other consents (e.g., consents 
to release information to others or gather information from others) 
will be used in your project, provide a description of the consents. 
Will individuals who do not consent to having individually identifiable 
data collected for evaluation purposes be allowed to participate in the 
project?

7. 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
    Depending on the evaluation and data collection requirements of the 
particular funding opportunity for which you are applying or the 
evaluation design you propose in your application, you may have to 
comply with the Protection of Human Subjects Regulations (45 CFR part 
46).
    Applicants must be aware that even if the Protection of Human 
Subjects Regulations do not apply to all projects funded under a given 
funding opportunity, the specific evaluation design proposed by the 
applicant may require compliance with these regulations.
    Applicants whose projects must comply with the Protection of Human 
Subjects Regulations must describe the process for obtaining 
Institutional Review Board (IRB) approval fully in their applications. 
While IRB approval is not required at the time of grant award, these 
applicants will be required, as a condition of award, to provide the 
documentation that an Assurance of Compliance is on file with the 
Office for Human Research Protections (OHRP) and that IRB approval has 
been received prior to enrolling any clients in the proposed project.
    Additional information about Protection of Human Subjects 
Regulations can be obtained on the web at http://ohrp.osophs.dhhs.gov. 
You may also contact OHRP by e-mail ([email protected]) or by phone 
(301-496-7005).

3. Submission Dates and Times

    Applications are due by close of business on June 8, 2004. Your 
application must be received by the application deadline. Applications 
sent through postal mail and 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.
    You will be notified by postal mail that your application has been 
received.
    Applications not received by the application deadline or not 
postmarked by a week prior to the application deadline will be screened 
out and will not be reviewed.

4. Intergovernmental Review (E.O. 12372) Requirements

    Executive Order 12372, as implemented through Department of Health 
and Human Services (DHHS) regulation at 45 CFR part 100, sets up a 
system for State and local review of applications for Federal financial 
assistance. A current listing of State Single Points of Contact (SPOCs) 
is included in the application kit and can be downloaded from the 
Office of Management and Budget (OMB) Web site at www.whitehouse.gov/omb/grants/spoc.html.
     Check the list to determine whether your State 
participates in this program. You do not need to do this if you are a 
federally recognized Indian tribal government.
     If your State participates, contact your SPOC as 
early as possible to alert him/her to the prospective application(s) 
and to receive any necessary instructions on the State's review 
process.
     For proposed projects serving more than one 
State, you are advised to contact the SPOC of each affiliated State.
     The SPOC should send any State review process 
recommendations to the following address within 60 days of the 
application deadline: Substance Abuse and Mental Health Services 
Administration, Office of Program Services, Review Branch, 5600 Fishers 
Lane, Room 17-89, Rockville, Maryland

[[Page 17430]]

20857, ATTN: SPOC--Funding Announcement No. [fill in pertinent funding 
opportunity number from the NOFA].

5. Funding Limitations/Restrictions

    Cost principles describing allowable and unallowable expenditures 
for Federal grantees, including SAMHSA grantees, are provided in the 
following documents:
     Institutions of Higher Education: OMB Circular 
A-21
     State and Local Governments: OMB Circular A-87
     Nonprofit Organizations: OMB Circular A-122
     Appendix E Hospitals: 45 CFR Part 74
    In addition, grant recipients must comply with the following 
funding restrictions:
     Grant funds must be used for purposes supported 
by the program.
     Grant funds may not be used to pay for the 
purchase or construction of any building or structure to house any part 
of the grant project. Applications may request up to $75,000 for 
renovations and alterations of existing facilities.

6. Other Submission Requirements

6.1 Where to Send Applications
    Send applications to the following address: Substance Abuse and 
Mental Health Services Administration, Office of Program Services, 
Review Branch,5600 Fishers Lane, Room 17-89, Rockville, Maryland 20857.
    Be sure to include the short title and funding announcement number 
(COSIG, SM 04-012) in item number 10 on the face page of the 
application. If you require a phone number for delivery, you may use 
(301) 443-4266.
6.2 How to Send Applications
    Mail an original application and 2 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.
    You must use a recognized commercial or governmental carrier. Hand 
carried applications will not be accepted. Faxed or e-mailed 
applications will not be accepted.

V. Application Review Information

1. Criteria

    Your application will be reviewed and scored according to the 
quality of your response to the requirements listed below for 
developing the Project Narrative (Sections A-C). These sections 
describe what you intend to do with your project.
     In developing the Project Narrative section of 
your application, use these instructions, which have been tailored to 
this program. These are to be used instead of the ``Program Narrative'' 
instructions found in the PHS 5161-1.
     You must use the three sections/headings listed 
below in developing your Project Narrative. Be sure to place the 
required information in the correct section, or it will not be 
considered. Your application will be scored according to how well you 
address the requirements for each section.
     Reviewers will be looking for evidence of 
cultural competence in each section of the Project Narrative. Points 
will be assigned based on how well you address the cultural competence 
aspects of the evaluation criteria. SAMHSA's guidelines for cultural 
competence can be found on the SAMHSA Web site at http://www.samhsa.gov. Click on ``Grant Opportunities.''
     The Supporting Documentation you provide in 
Sections D-G and Appendices 1-3 will be considered by reviewers in 
assessing your response, along with the material in the Project 
Narrative.
     The number of points after each heading below is 
the maximum number of points a review committee may assign to that 
section of your Project Narrative. Bullet statements in each section do 
not have points assigned to them. They are provided to invite the 
attention of applicants and reviewers to important areas within each 
section.
Section A: Documentation of Need/Proposed Approach (55 points)

    Note:
    If the applicant does not propose a Services Pilot, 55 points 
are allocated to Section A.1. If the applicant does propose a 
Services Pilot, 40 points are allocated to Section A.1. and 15 
points are allocated to Section A.2.]

Section A.1. Current System and Proposed Activities
    Specifically state in this section that the applicant is the Office 
of the Governor and that the Governor has signed the application. 
Describe the current system and the proposed activities for affecting 
positive system change. Address plans to implement the requirements in 
Section I-2.2, Program Requirements. Applicants are encouraged to use 
organizational charts and/or logic model depictions (see Appendix C) to 
illustrate the current elements, linkages, lines of communications, 
coordination mechanisms, responsibilities, and authorities, as well as 
areas where potential improvements or attention are needed.
     State that the applicant is the Office of the 
Governor and that the Governor has signed the application.
     Demonstrate a thorough understanding of co-
occurring substance abuse and mental disorders, and the state-of-the 
art in providing a system of services for persons with co-occurring 
disorders.
     Demonstrate a thorough understanding of the 
State's current system of services for persons with co-occurring 
disorders. Describe the State's current infrastructure and capacity for 
providing coordinated/integrated services to persons with co-occurring 
disorders within both the State Mental Health Authority (SMHA) and 
Substance AbuseAuthority (SSA) and other relevant agencies/systems. 
Describe structural components, such as dedicated staff time, routine 
training activities, organizational roles and responsibilities, and 
relationships and priority areas for the provision of coordinated/
integrated services to persons with co-occurring disorders across all 
four Quadrants. Describe any major limitations or challenges within 
both the SMHA and the SSA and other relevant agencies/systems including 
staffing limitations, limits to statutory authorities, organizational 
imperatives, or budget constraints.
     Present and justify the State's plan for using 
COSIG funds to improve infrastructure and capacity to serve persons 
with co-occurring disorders. State clearly which (one or more) of the 
five SAMHSA capacity building goals the State is selecting to 
implement. Describe how the State will implement these goals, through 
specific infrastructure development/enhancement activities. Applicants 
must identify measurable outcomes for each goal, establish targets, and 
describe how progress will be tracked and measured over the course of 
the grant. Be sure to address all the critical areas of infrastructure 
development identified in Section I-2.2, Program Requirements. Specify 
how gaps in the system will be narrowed and other expected results, 
including any products to be developed through the project. State which 
Quadrants will be affected by proposed activities and demonstrate how 
the proposed plan is consistent with SAMHSA's emphasis on 
infrastructure improvements within Quadrants II and III.
     Describe the involvement of the SMHA and the SSA 
and of other relevant systems/agencies, such as primary care, criminal 
justice, labor, housing, and social service agencies in the proposed 
project. Demonstrate how involvement of these systems or

[[Page 17431]]

agencies will contribute to enduring infrastructure improvements. Note: 
Applicants are required to include letters of commitment and 
cooperation from these agencies. [Letters of Commitment/Support from 
each of the involved agencies and stakeholders must be provided in 
Appendix 1 of the application]. Identify any cash or in-kind 
contributions that will be made to the project.
     Describe the process for linking State-level 
planning and infrastructure development to regional, county, and 
community-based mental health and substance abuse organizations and 
their representatives. Describe the process for obtaining input and 
involving a diverse array of participants, including representation 
from cultural/ethnic communities, potential service recipients, mental 
health consumers and their families, the recovery communities, public 
and private service providers, businesses, faith communities, primary 
care professionals and other relevant community groups. Demonstrate 
that these processes will contribute to enduring infrastructure 
improvements.
     Demonstrate that the proposed project is 
feasible and practical. Demonstrate that the applicant's history of 
working toward systems coordination/integration will contribute to the 
success of the project. Demonstrate the scope and feasibility of 
successful collaboration among State entities involved in the proposed 
project--e.g., inclusion of treatment and prevention; inclusion of 
public health entities other than those dealing with mental health and/
or substance abuse (e.g., primary care providers, communicable 
diseases, school health); inclusion of funding-related entities, 
especially Medicaid; inclusion of corrections and criminal justice; 
linkage with drug courts; collaborations with social/welfare/vocational 
services, etc.
Section A.2. Services Pilot
    In this Section, the applicant should describe and justify the 
implementation of a Services Pilot Project, if applicable. Applicants 
that do not plan to conduct a services pilot must state this intent.
     Describe and justify the proposed services 
pilot. State the goals and objectives of the proposed pilot and 
document that the services pilot will support the overall goals of your 
grant project. Describe the geographic area to be served. What are the 
demographic and clinical characteristics of persons who will receive 
services? Who will provide the services, and what services? Demonstrate 
the need for implementing the services pilot in the proposed area(s) 
and with the proposed population(s). Provide an unduplicated estimate 
of the number of persons to be served through the pilot for each year 
of the grant.
     Provide relevant and recent literature 
supporting your services pilot plan. Demonstrate that the proposed 
service model is a science/evidence-based practice based on 
scientifically derived theory.
     Demonstrate that the services pilot will help 
test the feasibility of the infrastructure enhancement at various 
levels, with the goal of improving the effectiveness and efficiency of 
service delivery, and will contribute to statewide changes in the 
system.
     Describe how the project will address age, race/
ethnic, cultural, language, sexual orientation, disability, literacy, 
and gender issues relative to the target population.
     Demonstrate the effective involvement of the 
target population in the planning and design of the proposed services 
pilot and in interpretation of results.
Section B: Organizational and Staffing Plans (30 points)
     Demonstrate the organizational capability to 
implement the proposed plan. Describe the organizational structure, 
lines of supervision, and management oversight for the proposed 
project. Specifically, describe the plans for partnership between the 
Governor's Office, the SMHA and the SSA, and proposed protocols for 
ongoing communications and joint planning activities. Identify a lead 
agency, if appropriate, for purposes of administering the grant, and 
describe the rationale for selecting this agency as the lead.
     Demonstrate the qualifications and roles of key 
personnel including evaluation staff and the Program Director.
     Provide an organizational chart showing the 
organizational placement of key personnel involved in the project. The 
applicant may also provide other visual diagrams showing key 
organizational components involved in the planning efforts and the 
structure for the involvement of organizational leadership.
     Demonstrate that the facilities and equipment 
that will be used to implement the proposed work plan are adequate. 
Indicate if the facilities will be compliant with the requirements of 
the American with Disabilities Act (ADA).
     Affirm a commitment to comply with reporting 
requirements, to attend two technical assistance meetings annually, to 
participate in technical assistance activities, and to cooperate and 
coordinate with SAMHSA's Co-occurring Cross Training and Technical 
Assistance Activity [see Section I-2.2, Program Requirements], and to 
participate in the cross-site evaluation, if SAMHSA elects to conduct 
it [see Section I-2.3 Data and Performance Measurement].
Section C: Evaluation/Methodology (15 points)
     Describe the State's current capacity to collect 
data related to the PPG measures. Present baseline data, if available, 
and project targets for these measures for each year of the grant. 
Describe plans to collect and report data related to the PPG measures 
during the first 6-8 months of the grant, and demonstrate a capacity to 
do so. Describe steps to be taken to enable the State to comply fully 
with PPG reporting requirements, and demonstrate the feasibility of 
implementing these steps.
     Describe a local evaluation plan that will 
provide useful information to the State about project progress. 
Describe plans for using evaluation findings to monitor and improve 
project implementation and to help implement durable improvements in 
the service delivery system. Describe and justify the targets and 
measures the applicant will use to track progress toward accomplishing 
implementation of the goals, plans to assess implementation fidelity, 
process and outcome, and plans to ensure the cultural appropriateness 
of the evaluation.
     Demonstrate appropriate plans for including 
members of the target population and/or their advocates in the design 
and implementation of the evaluation and in the interpretation of 
findings.

    Note: Although the budget for the proposed project is not a 
review criterion, the Review Group will be asked to comment on the 
appropriateness of the budget after the merits of the application 
have been considered. Please remember that Grantees in years 1-3 
will receive up to $1.1 million per year. Grantees with service 
pilots will receive up to half of the third year award in the 4th 
year to phase down the services pilot and up to $100,000 for 
evaluation in year 5. For example, if you ask for $1.1 million in 
year 3, you can request up to $550,000 in Year 4. If you request 
less than $1.1 million in year 3, then your year 4 request must be 
proportionately less. Grantees without service pilots will receive 
up to $100,000 for evaluation in both years 4 and 5. The actual 
amount available for the awards may vary, depending on unanticipated 
program requirements and the number and quality of the applications 
received.


[[Page 17432]]



2. Review and Selection Process

    SAMHSA applications are peer-reviewed according to the review 
criteria listed above. For those programs where the individual award is 
over $100,000, applications must also be reviewed by the appropriate 
National Advisory Council.
    Only one award will be made per State.
    Decisions to fund are based on:
     The strengths and weaknesses of the application 
as identified by peer reviewers and, when appropriate, approved by the 
appropriate National Advisory Council.
     Availability of funds.
     Considerations to help achieve the COSIG goal of 
being a national program based on population, geographic, and service 
characteristics. To achieve this goal, SAMHSA may distribute awards to 
achieve balance among areas of the country, or with differing 
population, or urban/rural characteristics.
     It is SAMHSA's intent to make awards to States 
at different levels of readiness or infrastructure development.
     SAMHSA will not award a COSIG grant to a State 
that already has one.
     After applying the aforementioned criteria, the 
following method for breaking ties: When funds are not available to 
fund all applications with identical scores, SAMHSA will make award 
decisions based on the application(s) that received the greatest number 
of points by peer reviewers on the evaluation criterion in Section V-1 
with the highest number of possible points, Section A: Documentation of 
Need/Proposed Approach (55 points). Should a tie still exist, the 
evaluation criterion with the next highest possible point value will be 
used, continuing sequentially to the evaluation criterion with the 
lowest possible point value, should that be necessary to break all 
ties.

VI. Award Administration Information

1. Award Notices

    After your application has been reviewed, you will receive a letter 
from SAMHSA through postal mail that describes the general results of 
the review, including the score that your application received.
    If you are approved for funding, you 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 and it contains the terms and conditions of the grant. It is 
sent by postal mail and is addressed to the contact person listed on 
the face page of the application.
    If you are not funded, you can re-apply if there is another receipt 
date for the program.

2. Administrative and National Policy Requirements

     You must comply with all terms and conditions of 
the grant award. SAMHSA's standard terms and conditions are available 
on the SAMHSA Web site http://www.samhsa.gov/grants/2004/useful_info.asp.
     Depending on the nature of the specific funding 
opportunity and/or the proposed project as identified during review, 
additional terms and conditions may be negotiated with the grantee 
prior to grant award. These may include, for example:
--Actions required to be in compliance with human subjects 
requirements;
--Requirements relating to additional data collection and reporting;
--Requirements relating to participation in a cross-site evaluation; or
--Requirements to address problems identified in review of the 
application.
     You will be held accountable for the information 
provided in the application relating to performance targets. SAMHSA 
program officials will consider your progress in meeting goals and 
objectives, as well as your 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.
     In an effort to improve access to funding 
opportunities for applicants, SAMHSA is participating in the U.S. 
Department of Health and Human Services ``Survey on Ensuring Equal 
Opportunity for Applicants.'' This survey is included in the 
application kit for SAMHSA grants. Applicants are encouraged to 
complete the survey and return it, using the instructions provided on 
the survey form.

3. Reporting Requirements

3.1 Progress and Financial Reports
     Grantees must submit quarterly progress reports 
and a final report. Each report must include evaluation results and 
required co-occurring performance measures.
     The final report must summarize information from 
the quarterly reports and describe the accomplishments of the project 
and planned next steps for continuing to implement service delivery 
improvements after the grant period.
     Grantees must provide annual and final financial 
status reports. These reports may be included as separate sections of 
progress reports or can be separate documents. Because SAMHSA is 
extremely interested in ensuring that infrastructure development and 
enhancement efforts can be sustained, your financial reports must 
explain plans to ensure the sustainability (see Glossary) of efforts 
initiated under this grant. Initial plans for sustainability should be 
described in year 1 of the grant. In each subsequent year, you should 
describe the status of the project, successes achieved and obstacles 
encountered in that year.
     SAMHSA will provide guidelines and requirements 
for these reports to grantees at the time of award and at the initial 
grantee orientation meeting after award. SAMHSA staff will use the 
information contained in the reports to determine the grantee's 
progress toward meeting its goals.
3.2 Publications
    If you are funded under this grant program, you are 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 project that are accepted for publication.
    In addition, SAMHSA requests that grantees:
     Provide the GPO and SAMHSA Publications 
Clearance Officer with advance copies of publications.
     Include acknowledgment of the SAMHSA grant 
program as the source of funding for the project.
     Include a disclaimer stating that 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 Additional Information

    For questions about program issues, contact:

Richard E. Lopez, J.D., PhD, SAMHSA/CSAT/DSCA, 5600 Fishers Lane/
Rockwall II, 8-147, Rockville, MD

[[Page 17433]]

20857, (301) 443-7615, E-mail: [email protected];
     or
Lawrence Rickards, PhD, SAMHSA/CMHS/DSSI, 5600 Fishers Lane, 11C-05, 
Rockville, MD 20857, (301) 443-3707, E-mail: [email protected].

    For questions on grants management issues, contact: Gwendolyn 
Simpson, SAMHSA/Division of Grants Management, 5600 Fishers Lane, Room 
13-103, Rockville, MD 20857, (301) 443-4456, E-mail: 
[email protected].

Appendix A--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.
     Use the PHS 5161-1 application.
     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.
     Information provided must be sufficient for 
review.
     Text must be legible.

--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.)
--Text in the Project Narrative cannot exceed 6 lines per vertical 
inch.
     Paper must be white paper and 8.5 inches by 
11.0 inches in size. To ensure equity among applications, the amount 
of space allowed for the Project Narrative cannot be exceeded.

--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.
--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.
--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.

 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 
your application must be sufficient for review. Following these 
guidelines will help ensure your application is complete, and will 
help reviewers to consider your application.
     The 10 application components required for 
SAMHSA applications should be included.
    These are:

Face Page (Standard Form 424, which is in PHS 5161-1)
Abstract
Table of Contents
Budget Form (Standard Form 424A, which is in PHS 5161-1)
Project Narrative and Supporting Documentation
Appendices
Assurances (Standard Form 424B, which is in PHS 5161-1)
Certifications (a form in PHS 5161-1)
Disclosure of Lobbying Activities (Standard Form LLL, which is in 
PHS 5161-1)
Checklist (a form in PHS 5161-1)

     Applications should comply with the following 
requirements:

--Provisions relating to confidentiality, participant protection and 
the protection of human subjects specified in Section IV-2.4 of the 
specific funding announcement.
--Budgetary limitations as specified in Sections I, II, and IV-5 of 
the specific funding announcement.
--Documentation of nonprofit status as required in the PHS 5161-1.

     Pages should be typed single-spaced with one 
column per page.
     Pages should not have printing on both sides.
     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.
     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 B--Glossary

    Best Practice: Best practices are practices that incorporate the 
best objective information currently available regarding 
effectiveness and acceptability.
    Catchment Area: A catchment area is the geographic area from 
which the target population to be served by a program will be drawn.
    Cooperative Agreement: A cooperative agreement is a form of 
Federal grant. Cooperative agreements are distinguished from other 
grants in that, under a cooperative agreement, substantial 
involvement is anticipated between the awarding office and the 
recipient during performance of the funded activity. This 
involvement may include collaboration, participation, or 
intervention in the activity. HHS awarding offices use grants or 
cooperative agreements (rather than contracts) when the principal 
purpose of the transaction is the transfer of money, property, 
services, or anything of value to accomplish a public purpose of 
support or stimulation authorized by Federal statute. The primary 
beneficiary under a grant or cooperative agreement is the public, as 
opposed to the Federal Government.
    Cost-Sharing or Matching: Cost-sharing refers to the value of 
allowable non-Federal contributions toward the allowable costs of a 
Federal grant project or program. Such contributions may be cash or 
in-kind contributions. For SAMHSA grants, cost-sharing or matching 
is not required, and applications will not be screened out on the 
basis of cost-sharing. However, applicants often include cash or in-
kind contributions in their proposals as evidence of commitment to 
the proposed project. This is allowed, and this information may be 
considered by reviewers in evaluating the quality of the 
application.
    Fidelity: Fidelity is the degree to which a specific 
implementation of a program or practice resembles, adheres to, or is 
faithful to the evidence-based model on which it is based. Fidelity 
is formally assessed using rating scales of the major elements of 
the evidence-based model. A toolkit on how to develop and use 
fidelity instruments is available from the SAMHSA-funded Evaluation 
Technical Assistance Center at http://tecathsri.org or by calling 
(617) 876-0426.
    Grant: A grant is the funding mechanism used by the Federal 
Government when the principal purpose of the transaction is the 
transfer of money, property, services, or anything of value to 
accomplish a public purpose of support or stimulation authorized by 
Federal statute. The primary beneficiary under a grant or 
cooperative agreement is the public, as opposed to the Federal 
Government.
    In-Kind Contribution: In-kind contributions toward a grant 
project are non-cash contributions (e.g., facilities, space, 
services) that are derived from non-Federal sources, such as State 
or sub-State non-Federal revenues, foundation grants, or 
contributions from other non-Federal public or private entities.

[[Page 17434]]

    Logic Model: A logic model is a diagrammatic representation of a 
theoretical framework. A logic model describes the logical linkages 
among program resources, conditions, strategies, short-term 
outcomes, and long-term impact. More information on how to develop 
logics models and examples can be found through the resources listed 
in Appendix C.
    Practice: A practice is any activity, or collective set of 
activities, intended to improve outcomes for people with or at risk 
for substance abuse and/or mental illness. Such activities may 
include direct service provision, or they may be supportive 
activities, such as efforts to improve access to and retention in 
services, organizational efficiency or effectiveness, community 
readiness, collaboration among stakeholder groups, education, 
awareness, training, or any other activity that is designed to 
improve outcomes for people with or at risk for substance abuse or 
mental illness.
    Practice Support System: This term refers to contextual factors 
that affect practice delivery and effectiveness in the pre-adoption 
phase, delivery phase, and post-delivery phase, such as (a) 
community collaboration and consensus building, (b) training and 
overall readiness of those implementing the practice, and (c) 
sufficient ongoing supervision for those implementing the practice.
    Stakeholder: A stakeholder is an individual, organization, 
constituent group, or other entity that has an interest in and will 
be affected by a proposed grant project.
    Sustainability: Sustainability is the ability to continue a 
program or practice after SAMHSA grant funding has ended.
    Target Population: The target population is the specific 
population of people whom a particular program or practice is 
designed to serve or reach.
    Wraparound Service: Wraparound services are non-clinical 
supportive services--such as child care, vocational, educational, 
and transportation services--that are designed to improve the 
individual's access to and retention in the proposed project.

Appendix C--Logic Model Resources

    Chen, W.W., Cato, B.M., & Rainford, N. (1998-9). Using a logic 
model to plan and evaluate a community intervention program: A case 
study. International Quarterly of Community Health Education, 18(4), 
449-458.
    Edwards, E.D., Seaman, J.R., Drews, J., & Edwards, M.E. (1995). 
A community approach for Native American drug and alcohol prevention 
programs: A logic model framework. Alcoholism Treatment Quarterly, 
13(2), 43-62.
    Hernandez, M. & Hodges, S. (2003). Crafting Logic Models for 
Systems of Care: Ideas into Action. [Making children's mental health 
services successful series, volume 1]. Tampa, FL: University of 
South Florida, The Louis de la Parte Florida Mental Health 
Institute, Department of Child & Family Studies. http://cfs.fmhi.usf.edu or phone (813) 974-4651
    Hernandez, M. & Hodges, S. (2001). Theory-based accountability. 
In M. Hernandez & S. Hodges (Eds.), Developing Outcome Strategies in 
Children's Mental Health, pp. 21-40. Baltimore: Brookes.
    Julian, D.A. (1997). Utilization of the logic model as a system 
level planning and evaluation device. Evaluation and Planning, 
20(3), 251-257.
    Julian, D.A., Jones, A., & Deyo, D. (1995). Open systems 
evaluation and the logic model: Program planning and evaluation 
tools. Evaluation and Program Planning, 18(4), 333-341.
    Patton, M.Q. (1997). Utilization-Focused Evaluation (3rd Ed.), 
pp. 19, 22, 241. Thousand Oaks, CA: Sage.
    Wholey, J.S., Hatry, H.P., Newcome, K.E. (Eds.) (1994). Handbook 
of Practical Program Evaluation. San Francisco, CA: Jossey-Bass Inc.

Appendix D: State Case Studies

Arizona

    The SAPT and CMHS Block Grants have been used creatively to 
promote the development of services for people with co-occurring 
disorders. The original impetus for the Arizona Integrated Treatment 
Initiative was a SAMHSA Community Action Grant for Service System 
Change, coupled with other resources, including State appropriations 
and tobacco settlement funds.
    Recognizing that individuals with co-occurring disorders were 
commonly found in both substance abuse and mental health service 
settings, the Arizona Department of Health Services' Division of 
Behavioral Health Services launched a major initiative in 1999 to 
develop a best practice treatment model for individuals with co-
occurring disorders. The result was a statewide refocusing of 
service practices in the behavioral health care system.
    In particular, the State chose to pursue a consensus-based 
practice development model to identify the principles and practices 
of integrated treatment within Arizona, with the knowledge that 
implementation of this model would vary within the State based on 
local resources and the characteristics of the individuals being 
served. Among the outcomes of this effort were:
    1. New Contract Language. Contracts for regional behavioral 
health authorities were revised to include language regarding co-
occurring disorders consistent with that contained in the CMHS Block 
Grant statute.
    2. New Policies and Guidelines. A work group of local and 
national experts developed Service Planning Guidelines for Co-
Occurring Disorders and revised the State's eligibility policy for 
people with serious mental illnesses. The new policy expedites entry 
into services, regardless of concurrent substance use, and allows 
for an expanded time frame to gather necessary records. This means 
that individuals are not denied eligibility based on the inability 
to clinically differentiate multiple disorders or for lack of 
information.
    Consensus-Based System Change. One of the most significant 
findings of the Arizona initiative was that consensus-based system 
change encourages and sustains community action. System planners 
determined that had the initiative been developed in isolation at 
the State level and simply mandated by administrative requirement, 
the level of community ``buy-in'' needed to make change happen 
simply would not have taken place.

Connecticut

    In 1995 the State of Connecticut created the Department of 
Mental Health and Addiction Services (DMHAS) as the Single State 
Agency for both mental health and substance abuse services for 
adults. The Connecticut Department of Children and Families (DCF) is 
charged with the care of youth for behavioral health services.
    SAPT Block Grant funds are distributed across all DMHAS-funded 
substance abuse treatment programs, including programs that provide 
addiction services for people with both substance abuse disorders 
and co-occurring mental disorders. DMHAS, in coordination with DCF, 
uses CMHS Block Grant funds to fund and administer services for 
youth with serious emotional disturbances and adults with serious 
mental illness. Over the past several years, both an Alcohol and 
Drug Policy Council and a Mental Health Policy Council, with broad 
stakeholder representations jointly address policy and service 
issues related to the planning and coordination of adult and 
children's behavioral health services including those persons with 
co-occurring disorders.
    DMHAS has directly focused SAPT Block Grant funds to provide 
services to adults with co-occurring substance abuse disorders and 
mental disorders in three methadone maintenance programs. These 
programs have implemented screening and assessment protocols to help 
identify clients with co-occurring mental disorders. Clients 
identified as possibly having a mental health disorder receive a 
full psychiatric assessment.
    Clients determined to have a mild or moderate mental illness are 
seen by an on-site psychiatrist for medication review. They are 
assigned to a dual diagnosis counselor, and receive ongoing case 
management. The counselors also provide intensive, individual, or 
group counseling to these clients. Individuals diagnosed with a 
serious mental illness are referred to appropriate mental health 
services; care is coordinated across the two programs.
    DMHAS continues to explore ways to enhance access to appropriate 
care for people with co-occurring substance abuse disorders and 
mental disorders. Various policy making and planning bodies within 
the State are involved in ongoing discussions regarding care 
coordination and implementation of best practices. The State has 
used State general fund dollars and other non-Block Grant resources 
to promote a coordinated system of care for individuals with co-
occurring disorders.

New Mexico

    In 1997, the State of New Mexico combined the Division of Mental 
Health and the Division of Substance Abuse into the Behavioral 
Health Services Division. The Division administers the SAPT and CMHS 
Block Grants and non-Medicaid mental health and substance abuse 
treatment funds. This integration has fostered significant 
collaboration between disciplines in policy and program 
implementation.

[[Page 17435]]

    SAPT and CMHS Block Grant funds, as well as State appropriations 
in mental health and substance abuse, are used to develop system 
capacity for people with co-occurring disorders. As part of a 
statewide managed care initiative, the Behavioral Health Service 
Division implemented a regional model of service delivery that 
includes the following features:
    I. Five regional contractors that are responsible for the 
delivery of continuum of care in mental health and substance abuse 
treatment;
    II. Comprehensive Behavioral Health Standards established by the 
Division to guide service delivery, network management, and 
performance/outcome requirements; and
    III. A Behavioral Health Information System to monitor contract 
compliance and service delivery protocols through standardized 
reporting and site visits.
    Because New Mexico's system is based on the assumption that co-
occurring disorders are an expectation and not an exception, both 
substance abuse and mental health treatment programs must screen all 
individuals for the presence of both disorders on a routine basis. 
All programs employ a ``no wrong door'' approach that welcomes and 
supports the individual. In addition to screening, standard 
practices include assessment by appropriately licensed 
practitioners, integrated treatment planning, and direct services 
for both substance abuse and mental disorders provided at the same 
time.
    Some programs for individuals with co-occurring disorders have 
the in-house capacity to deliver services for both disorders; others 
coordinate services as part of a network of community partners. In 
addition, the system includes the capacity to address treatment and 
service needs throughout the entire continuum, including residential 
and hospital-based levels of care. The goal is to create a system 
that meets the standards of accessibility, integration, continuity, 
and comprehensiveness (Minkoff, 1998). A more comprehensive report 
on New Mexico's integrated services can be obtained by contacting 
SAMHSA's Office of Program, Planning, and Budget at (301) 443-4111.

Pennsylvania

    In 1997, the Office of Mental Health and Substance Abuse 
Services in the Department of Public Welfare and the Bureau of Drug 
and Alcohol Programs in the Department of Health jointly sponsored a 
statewide Mental Illness and Substance Abuse (MISA) Consortium to 
examine integrated approaches in working with people who have co-
occurring substance abuse disorders and mental disorders. 
Stakeholders from the mental health and drug and alcohol systems 
participated. The group's 1999 report recommended service and 
systems integration in four areas: assessment, professional 
credentialing and training, service standards, and adolescent 
services. Pennsylvania's MISA Pilot Project is the embodiment of 
those recommendations.
    The MISA Pilot Project is a product of a collaboration between 
the State Departments of Health and the State Department of Public 
Welfare. Designed to promote systems and services integration for 
individuals with co-occurring substance abuse disorders and mental 
disorders, the project is composed of five county systems and a 
network of 11 providers offering integrated services. The network 
continues to expand as additional providers meet the required 
integrated service criteria. The projects total funding is $3.3 
million annually and comes from the combined resources of three 
funding sources: State Intergovernmental Transfer Funds, CMHS Block 
Grant Funds, and the SAPT Block Grant Funds. Traditional reporting 
mechanisms are used for tracking and accountability.
    Based on the consortium's recommendations, the State issued a 
solicitation for pilot projects to interested county mental health 
administrators and substance abuse directors. Available funds were 
to be used as seed money for development of program models that 
combine resources and expertise from both the community mental 
health and drug and alcohol systems. Four adult and one child/
adolescent proposal were selected for funding.
    Mental health and drug and alcohol funds have been allocated to 
the projects over a 2-year period, with an additional year for 
evaluation by the Center for Mental Health Policy and Services 
Research at the University of Pennsylvania. All pilot projects 
provide a varying number of services that meet criteria for 
enhanced/integrated services for co-occurring disorders.
    The pilot projects are being evaluated to determine the impact 
of integrated treatment and systems of care on client outcomes; the 
impact on client satisfaction; the potential of specialized co-
occurring disorders integrated treatment and support services; and 
best practice models of system integration, representing a variety 
of strategies that can be replicated for adult and adolescent 
services. Ultimately, the projects are expected to generate ideas 
for future policy and program development and identify potential 
funding sources for co-occurring disorders services.

Texas

    The Texas Commission on Alcohol and Drug Abuse and the Texas 
Department of Mental Health and Mental Retardation created and 
funded a dual diagnosis coordinator position in 1995 to help ensure 
coordination between the two agencies. This position is funded with 
SAPT and CMHS Block Grant and general revenue funds. These monies 
also are funding 16 dual diagnosis projects throughout Texas.
    The Commission on Alcohol and Drug Abuse purchases ``dual 
diagnosis specialized services'' to offer a coordinated approach to 
the delivery of integrated substance abuse and mental health 
services. The programs link patients to mainstream substance abuse 
and mental health services through research-based engagement 
strategies, and provide specialized dual diagnosis training and case 
consultation to service providers.
    The target population includes people with substance abuse or 
dependence and a serious mental illness, including schizophrenia, 
major depression, and bipolar disorder. The State requires that 
``dual diagnosis specialized services'' respond competently to age, 
gender, sexuality, geography, and culture for all people needing 
services in Texas. The Commission also provides statewide 
conferences on co-occurring disorders throughout the year to train 
staff and expand capacity to serve this population.
    The Texas alcohol and drug and mental health agencies also have 
implemented significant system changes. To strengthen the ability of 
substance abuse providers to meet the multiple needs of people with 
co-occurring disorders and their families, the Commission on Alcohol 
and Drug Abuse has adopted statewide rules and regulations which 
require that mental health expertise be incorporated into existing 
programs and/or coordinated with other providers. These rules 
address requirements, including those for screening and admission, 
assessment, and treatment services for facilities licensed by the 
Commission. The two agencies operate under a Memorandum of 
Understanding (MOU) that addresses principles and practices for 
treating individuals with co-occurring disorders.

Wisconsin

    In May 1996, then-Governor Tommy Thompson of Wisconsin, created 
the Blue Ribbon Commission on Mental Health to examine the mental 
health delivery system and propose changes that fostered system 
effectiveness in an environment emphasizing managed care, client 
outcomes, and performance contracting. The Bureau of Substance Abuse 
Services and the Bureau of Community Mental Health are currently 
working cooperatively to develop a coordinated and flexible managed 
care model of service delivery, that includes the design, 
implementation and evaluation of a single entry point for consumers 
of mental health, alcohol, and drug services. The initiative 
emphasizes recovery principles and a consumer-focused approach with 
long-term care enrollees. The target group for this model includes 
individuals with severe and persistent mental illness, including 
individuals in that group who have co-occurring disorders.
    During fiscal year 2000, Wisconsin developed a coalition to 
address co-occurring substance abuse disorders and mental disorders 
among the aging population. Five regional training sessions with 
over 450 participants in attendance educated about, and enhanced 
coordination of, mental health and substance abuse interventions, 
including the provision of integrated treatment, for older adults. 
Both the coalition and training efforts have been in operation for 
approximately 2 years. Funding is aggregated from multiple sources, 
including the CMHS Block Grant.
    In addition, the Bureau of Substance Abuse Services used SAPT 
Block Grant funding to develop eight women-specific treatment 
programs that either provide or refer their clients to qualified 
mental health services. Coordination of mental health services for 
substance abuse clients is required for State program certification.

Appendix E: Text from State Directors' Conceptual Framework

    Just as individuals with co-occurring disorders are unique, so 
too are the service

[[Page 17436]]

systems through which they receive their care. The conceptual 
framework that meeting participants proposed, which is outlined in 
this section, provides a common set of reference points and allows 
policy makers, providers, and funders to plan services for 
individuals regardless of their specific diagnoses or the current 
structure of the health care delivery system in their State or 
community.

The New York Model

    James Stone, M.S.W., Commissioner of the New York State Office 
of Mental Health, presented a model his State uses to locate 
individuals with co-occurring mental health and substance abuse 
disorders on a continuum of care. The underlying assumption of the 
New York model is the fact that people with co-occurring disorders 
vary in the severity of their mental health and substance abuse 
disorders, from less severe mental health and substance abuse 
disorders to more severe mental health and substance abuse 
disorders. Individuals for whom one or the other disorder is 
predominant fall between these two groups.
    Further, the model is based on the fact that these differences 
in severity determine the service system location in which 
individuals receive their care, including the primary health care, 
mental health care, and alcohol and other drug treatment systems, as 
well as the criminal justice system, the homeless service system, 
and so on.
    Participants chose to elaborate on the framework by expanding on 
these specific areas of concern. Most importantly, it was agreed 
that the framework could accommodate service coordination needs and 
(at some future point) funding sources quite well. Each of three 
areas--severity, primary locus of care, and service coordination--is 
discussed below.

The Revised Framework

    The conceptual framework that meeting participants developed 
expands on the New York model and represents a new paradigm for 
considering both the needs of individuals with co-occurring 
substance abuse and mental health disorders and the system 
characteristics required to address these needs. Unique features of 
this approach include the following:
     The revised framework is based on symptom 
multiplicity and severity, not on specific diagnoses, and uses 
language familiar to both mental health and substance abuse 
providers. As such, it encompasses the full range of people who have 
co-occurring substance abuse and mental health disorders. In 
addition, it points to windows of opportunity within which providers 
can act to prevent exacerbation of symptom severity.
     The framework permits discussion of co-
occurring disorders along several dimensions, including symptom 
multiplicity and severity, locus of care, and degree of service 
coordination. It permits a number of key decisions to flow from it, 
including the level of service coordination required and the best 
use of available resources.
     The framework accommodates different levels 
of service coordination rather than specifying discrete service 
interventions. It represents a flexible approach that can be adopted 
or adapted for use in any service setting.
     The framework identifies two levels of 
service coordination--consultation and collaboration--that do not 
require fully integrated services. It points to the fact that 
individuals can be appropriately served with interventions that do 
not require full service integration. This is important for those 
service settings in which integration is not feasible or desirable, 
and for those individuals whose needs can be addressed with a 
minimum amount of system change.
    Regardless of specific diagnoses, meeting participants agreed 
that individuals with co-occurring disorders fall into one of four 
major quadrants based on the severity of their mental health and 
substance abuse disorders:
     Quadrant I: Less severe mental disorder/less 
severe substance disorder.
     Quadrant II: More severe mental disorder/less 
severe substance disorder.
     Quadrant III: Less severe mental disorder/
more severe substance disorder.
     Quadrant IV: More severe mental disorder/more 
severe substance disorder.
    This is a simplified categorization that permits further 
discussion. Individuals at various stages of recovery from mental 
health and substance abuse disorders may move back and forth among 
these quadrants during the course of their disease. States need to 
be most concerned with individuals in quadrants I and IV, meeting 
participants agreed. While individuals in quadrants II and III may 
be receiving some level of care in the substance abuse and mental 
health systems, respectively, quadrant I--those individuals whose 
disorders are not severe enough to bring them to the attention of 
the mental health or substance abuse treatment systems at this 
time--is largely ignored. This group is of particular concern 
because it includes many children and adolescents at risk for 
developing more serious disease. Meeting participants agreed that 
providers may have the greatest impact in minimizing future disease 
by providing appropriate prevention and early intervention 
strategies for people in quadrant I.
    Members of quadrant IV--those with more severe mental health and 
substance abuse disorders--are more likely to be found in 
inappropriate settings (e.g., jails, homeless), to use the most 
resources, and to have the worst outcomes. This group includes those 
with severe, chronic disease who may be the most difficult to serve. 
Because those in quadrant IV consume the bulk of a system's 
resources, attention to people in this group may help reduce 
treatment costs and produce better consumer outcomes.
    Using the revised framework, States can decide how best to 
direct their mental health and substance abuse efforts. For example, 
the framework encourages States to respond to the needs of those 
individuals who fall into quadrant I by expanding their prevention 
and early intervention efforts. By the same token, States may choose 
to reduce expenses and improve outcomes associated with serving 
persons in quadrant IV by diverting them from inappropriate and more 
costly treatment settings. In general, the framework supports State-
directed efforts to work toward meaningful integration of services 
for these persons with the most severe mental health and substance 
abuse disorders.
    Based on the severity of their disorders, people with co-
occurring mental health and substance abuse disorders currently tend 
to receive their care in the following settings:
     Setting I: Primary health care settings, 
school-based clinics, community programs; no care.
     Setting II: Mental health system.
     Setting III: Substance abuse system.
     Setting IV: State hospitals, jails, prisons, 
forensic units, emergency rooms, homeless service programs, mental 
health and/or substance abuse system; no care.
    As with categories of illness, the use of such clearly 
delineated settings is for ease of discussion. In reality, there is 
a great deal of overlap between and among these settings; 
individuals with different combinations of severity are served in 
all of the systems highlighted above. In addition, individuals may 
move back and forth throughout the system of care based on their 
level of recovery at any given time.

Service Coordination by Severity

    Based on the severity of their disorders and the location of 
their care, the following levels of coordination among the substance 
abuse, mental health and primary health care systems is recommended 
to address the needs of individuals with co-occurring mental health 
and substance abuse disorders:
     Level I: Consultation. Those informal 
relationships among providers that ensure both mental illness and 
substance abuse problems are addressed, especially with regard to 
identification, engagement, prevention, and early intervention. An 
example of such consultation might include a telephone request for 
information or advice regarding the etiology and clinical course of 
depression in a person abusing alcohol or drugs.
     Levels II & III: Collaboration. Those more 
formal relationships among providers that ensure both mental illness 
and substance abuse problems are included in the treatment regimen. 
An example of such collaboration might include interagency staffing 
conferences where representatives of both substance abuse and mental 
health agencies specifically contribute to the design of a treatment 
program for individuals with co-occurring disorders and contribute 
to service delivery.
     Level IV: Integrated Services. Those 
relationships among mental health and substance abuse providers in 
which the contributions of professionals in both fields are merged 
into a single treatment setting and treatment regimen.

Putting the Pieces Together

    The revised framework has implications for funding strategies. 
For example, Dr. Bert Pepper strongly recommended making better use 
of existing resources through coordinated or shared funding at the 
local service delivery level. This may be of particularly value for 
those individuals who fall in quadrants II and III. Reducing the use 
of inappropriate service settings (e.g. jails and prisons) for 
people in quadrant IV would

[[Page 17437]]

help save costs. Recognizing that a topic of such significance could 
not adequately be addressed within the scope of the current meeting, 
participants stressed that future attention be paid to the topic of 
funding opportunities.
    Finally, the framework is a necessary, but not sufficient, piece 
of the puzzle. To accomplish system change for people with co-
occurring mental health and substance abuse disorders, policy 
makers, funders, and providers must define an effective system of 
care and delineate what successful consultation, collaboration, and 
integration look like.
    The complete report is available for free download from: http://www.nasadad.org/Departments/Research/ConsensusFramework/national_dialogue_on.htm.

    Dated: March 26, 2004.
Margaret Gilliam,
Acting Director, Office of Policy Planning and Budget, Substance Abuse 
and Mental Health Services Administration.

[FR Doc. 04-7400 Filed 4-1-04; 8:45 am]
BILLING CODE 4162-20-P