[Federal Register Volume 80, Number 5 (Thursday, January 8, 2015)]
[Notices]
[Pages 1032-1036]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-00063]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration


Agency Information Collection Activities: Proposed Collection; 
Comment Request

    In compliance with Section 3506(c)(2)(A) of the Paperwork Reduction 
Act of 1995 concerning opportunity for public comment on proposed 
collections of information, the Substance Abuse and Mental Health 
Services Administration (SAMHSA) will publish periodic summaries of 
proposed projects. To request more information on the proposed projects 
or to obtain a copy of the information collection plans, call the 
SAMHSA Reports Clearance Officer on (240) 276-1243.
    Comments are invited on: (a) Whether the proposed collections of 
information are necessary for the proper performance of the functions 
of the

[[Page 1033]]

agency, including whether the information shall have practical utility; 
(b) the accuracy of the agency's estimate of the burden of the proposed 
collection of information; (c) ways to enhance the quality, utility, 
and clarity of the information to be collected; and (d) ways to 
minimize the burden of the collection of information on respondents, 
including through the use of automated collection techniques or other 
forms of information technology.

Project: Community Mental Health Services Block Grant and Substance 
Abuse and Prevention Treatment Block Grant FY 2016-2017 Plan and Report 
Guidance and Instructions (OMB No. 0930-0168)--Revision

    The Substance Abuse and Mental Health Services Administration 
(SAMHSA), is requesting approval from the Office of Management and 
Budget (OMB) for a revision of the 2016 and 2017 Community Mental 
Health Services Block Grant (MHBG) and Substance Abuse Prevention and 
Treatment Block Grant (SABG) Plan and Report Guidance and Instructions.
    Currently, the SABG and the MHBG differ on a number of their 
practices (e.g., data collection at individual or aggregate levels) and 
statutory authorities (e.g., method of calculating MOE, stakeholder 
input requirements for planning, set asides for specific populations or 
programs, etc.). Historically, the Centers within SAMHSA that 
administer these block grants have had different approaches to 
application requirements and reporting. To compound this variation, 
states have different structures for accepting, planning, and 
accounting for the block grants and the prevention set aside within the 
SABG. As a result, how these dollars are spent and what is known about 
the services and clients that receive these funds varies by block grant 
and by state.
    Increasingly, under the Affordable Care Act, more individuals are 
eligible for Medicaid and private insurance. This expansion of health 
insurance coverage will continue to have a significant impact on how 
State Mental Health Authorities (SMHAs) and Single State Agencies 
(SSAs) use their limited resources. In 2009, more than 39 percent of 
individuals with serious mental illnesses (SMI) or serious emotional 
disturbances (SED) were uninsured. Sixty percent of individuals with 
substance use disorders whose treatment and recovery support services 
were supported wholly or in part by SAMHSA block grant funds were also 
uninsured. A substantial proportion of this population, as many as six 
million people, will gain health insurance coverage in 2014 and will 
have various outpatient and other services covered through Medicaid, 
Medicare, or private insurance. However, these plans will not provide 
access to the full range of support services necessary to achieve and 
maintain recovery for most of these individuals and their families.
    Given these changes, SAMHSA has conveyed that block grant funds be 
directed toward four purposes: (1) To fund priority treatment and 
support services for individuals without insurance or who cycle in and 
out of health insurance coverage; (2) to fund those priority treatment 
and support services not covered by Medicaid, Medicare or private 
insurance offered through the exchanges and that demonstrate success in 
improving outcomes and/or supporting recovery; (3) to fund universal, 
selective and targeted prevention activities and services; and (4) to 
collect performance and outcome data to determine the ongoing 
effectiveness of behavioral health prevention, treatment and recovery 
support services and to plan the implementation of new services on a 
nationwide basis.
    To help states meet the challenges of 2016 and beyond, and to 
foster the implementation of an integrated physical health and mental 
health and addiction service system, SAMHSA must establish standards 
and expectations that will lead to an improved system of care for 
individuals with or at risk of mental and substance use disorders. 
Therefore, this application package includes fully exercising SAMHSA's 
existing authority regarding states', territories' and the Red Lake 
Band of the Chippewa Tribe's (subsequently referred to as ``states'') 
use of block grant funds, and a shift in SAMHSA staff functions to 
support and provide technical assistance for states receiving block 
grant funds as they fully integrate behavioral health services into 
health care.
    Consistent with previous applications, the FY 2016-2017 application 
has sections that are required and other sections where additional 
information is requested. The FY 2016-2017 application requires states 
to submit a face sheet, a table of contents, a behavioral health 
assessment and plan, reports of expenditures and persons served, an 
executive summary, and funding agreements and certifications. In 
addition, SAMHSA is requesting information on key areas that are 
critical to the states success in addressing health care integration. 
Therefore, as part of this block grant planning process, SAMHSA is 
asking states to identify their technical assistance needs to implement 
the strategies they identify in their plans for FY 2016 and 2017.
    To facilitate an efficient application process for states in FY 
2016-2017, SAMHSA convened an internal workgroup to develop the 
application for the block grant planning section. In addition, SAMHSA 
consulted with representatives from SMHAs and SSAs to receive input 
regarding proposed changes to the block grant. Based on these 
discussions with states, SAMHSA is proposing several changes to the 
block grant programs, discussed in greater detail below.

Changes to Assessment and Planning Activities

    The proposed revisions reflect changes within the planning section 
of the application. The most significant of these changes relate to 
evidenced based practice for early intervention for the MHBG, 
participant directed care, medication assisted treatment for the SABG, 
crisis services, pregnant women and women with dependent children, 
community living and the implementation of Olmstead, and quality and 
data readiness collection.
    The FY2014-2015 application sections on the Affordable Care Act, 
health insurance marketplace, enrollment and primary and behavioral 
health care integration have been consolidated into a Health Care 
System and Integration section moving the emphasis to implementation of 
health care systems rather than preparation of the Affordable Care Act. 
Additionally, the FY2014-2015 Quality, Data and Information Technology 
sections have been consolidated into one section in the FY2016-2017 
application. SAMHSA has provided a set of guiding questions to 
stimulate and direct the dialogue that states may engage in to 
determine the various approaches used to develop their responses to 
each of the focus areas.
    The proposed revisions are described below:
     Health Care System and Integration--This section is a 
consolidation of the FY2014-2015 sections on the Affordable Care Act, 
health insurance marketplace, enrollment and primary and behavioral 
health care integration. It is vital that SMHAs and SSAs programming 
and planning reflect the strong connection between behavioral and 
physical health. Fragmented or discontinuous care may result in 
inadequate diagnosis and treatment of both physical and behavioral 
conditions, including co-occurring disorders. Health care

[[Page 1034]]

professionals, consumers of mental, substance use disorders, co-
occurring mental, and substance use disorders treatment recognize the 
need for improved coordination of care and integration of primary and 
behavioral health care. Health information technology, including 
electronic health records (EHRs) and telehealth are examples of 
important strategies to promote integrated care. Use of EHRs--in full 
compliance with applicable legal requirements--may allow providers to 
share information, coordinate care and improve billing practices.
    Implementation by SMHAs, SSAs and their partners of the Affordable 
Care Act is an important part of efforts to ensure access to care and 
better integrate care. In a recent report, the Congressional Budget 
Office estimates that by 2018, 25 million persons will have enrolled in 
the Affordable Care Act Marketplace and 12 million in Medicaid and the 
State Children's Health Insurance Program (SCHIP). The Department of 
Health and Human Services Assistant Secretary for Planning and 
Evaluation (ASPE) estimates that 32 million Americans will acquire 
coverage for mental and substance use disorder treatment as a result of 
the Affordable Care Act, including both previously uninsured persons 
and those enrolled in plans that lacked adequate coverage. In 2014, 
non-grandfathered health plans sold in the individual or the small 
group health insurance markets offered coverage for mental and 
substance use disorders as an essential health benefit.
     Evidenced-Based Practices for Early Intervention for the 
MHBG--In its FY 2014 appropriation, SAMHSA was directed to require that 
states set aside 5 percent of their MHBG allocation to support 
evidence-based programs that provide treatment to those with early SMI 
including but not limited to psychosis at any age. SAMHSA worked 
collaboratively with the National Institutes of Health, National 
Institute on Mental Health (NIMH) to review evidence showing efficacy 
of specific practices in ameliorating SMI and promoting improved 
functioning. NIMH has released information on Components of Coordinated 
Specialty Care (CSC) for First Episode Psychosis. Results from the NIMH 
funded Recovery After an Initial Schizophrenia Episode (RAISE) 
initiative, a research project of the NIMH, suggest that mental health 
providers across multiple disciplines can learn the principles of CSC 
for First Episode of Psychosis (FEP), and apply these skills to engage 
and treat persons in the early stages of psychotic illness.
    States can implement models across a continuum, which have 
demonstrated efficacy, including the range of services and principles 
identified by NIMH. Utilizing these principles, regardless of the 
amount of investment, and with leveraging funds through inclusion of 
services reimbursed by Medicaid or private insurance, every state will 
be able to begin to move their system toward earlier intervention, or 
enhance the services already being implemented.
     Participant Directed Care--As states implement policies 
that support self-determination and improve person-centered service 
delivery, one option that states can consider is the role that vouchers 
may play in their overall financing strategy. Many states have 
implemented voucher and self-directed care programs to help individuals 
gain expanded access to care and to enable individuals to play a more 
significant role in the development of their prevention, treatment and 
recovery services. The major goal of a voucher program is to ensure 
individuals have a genuine, free, and independent choice among a 
network of eligible providers. The implementation of a voucher program 
expands mental and substance use disorder treatment capacity and 
promotes choice among clinical treatment and recovery support 
providers, providing individuals with the ability to secure the best 
treatment options available to meet their specific needs. A voucher 
program facilitates linking clinical treatment with critical recovery 
support services, such as care coordination, childcare, motivational 
development, early/brief intervention, outpatient treatment, medical 
services, housing support, employment/education support, peer 
resources, family/parenting services or transportation.
    States interested in utilizing a voucher system should create or 
maintain a voucher management system to support vouchering and the 
reporting of data to enhance accountability by measuring outcomes. 
Meeting these voucher program challenges by creating and coordinating a 
wide array of service providers, leading them though the innovations 
and inherent system change processes results in the building of an 
integrated system that provides holistic care to individuals recovering 
from mental and substance use disorders.
     Medication Assisted Treatment (MAT)--There is a voluminous 
literature on the efficacy of Food and Drug Administration (FDA)-
approved medications for the treatment of substance use disorders. 
However, many treatment programs in the U.S. still offer only 
abstinence-based treatment for these conditions. The evidence base for 
medication assisted treatment of these disorders is described in 
several of SAMHSA's Treatment Improvement Protocol Series (TIPS) 
publications numbered 40, 43, 45, and 49. SAMHSA strongly encourages 
the states to require that treatment facilities providing clinical care 
to those with substance use disorders be required to either have the 
capacity and staff expertise to utilize MAT or have collaborative 
relationships with other providers such that these MATs can be accessed 
as clinically indicated for patient need. Individuals with substance 
use disorders who have failed abstinence based treatment in the past 
and who have a disorder for which there is an FDA-approved medication 
treatment should have access to those treatments.
     Crisis Services--In the on-going development of efforts to 
build an evidence-based robust system of care for adults diagnosed with 
an SMI, children with a serious emotional disturbance (SED) and persons 
with addictive disorders and their families via a coordinated continuum 
of treatments, services and supports, growing attention is being paid 
across the country to how states and local communities identify and 
effectively respond to behavioral health crises. SAMHSA has taken a 
leadership role in deepening the understanding of what it means to be 
in crisis and how to effectively respond to crisis as experienced by 
people with behavioral health conditions.
    A crisis response system will have the capacity to recognize and 
respond to crises across a continuum, from crisis planning, to early 
stages of support and respite, to crisis stabilization and 
intervention, to post-crisis follow-up and support for the individual 
and their family. SAMHSA expects that states will build on the emerging 
and growing body of evidence for effective community-based crisis 
response systems. Given the multi-system involvement of many 
individuals with behavioral health issues, the crisis response system 
approach provides the infrastructure to improve care coordination and 
outcomes, manage costs and better invest resources.
     Pregnant Women and Women With Dependent Children--
Substance-abusing pregnant women have been a leading priority 
population throughout the history of the SABG (Section 1922(b) of Title 
XIX, Part B, Subpart II, of the PHS Act (42 U.S.C. 300x-22(b)). The 
authorizing legislation required states to expend not less than 5 
percent of the FY 1993 and FY 1994 SABG to increase the availability of 
treatment services designed for pregnant women and women with dependent 
children. The purpose of these programs is to expand

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the availability of comprehensive, residential substance use disorder 
treatment, and recovery support services for pregnant and postpartum 
women and their minor children, including services for non-residential 
family members. This population continues to be of utmost concern, 
since by helping such women along their recovery journey, additional 
benefits may result: Fetal alcohol spectrum disorder may be prevented; 
a normal birth-weight may be achieved; and intergenerational 
transmission of addiction may be interrupted. Women with dependent 
children are also identified as a priority for specialized treatment 
(as opposed to treatment as usual) in the implementing regulations 
governing the SABG. In 1995 and subsequent fiscal years states are 
required to expend no less than an amount equal to that spent by the 
state in prior fiscal years for treatment services designed for 
pregnant women and women with dependent children.
     Community Living and the Implementation of Olmstead--The 
community living and Olmsted section was included in the environmental 
factors/background section of the FY2014-2015 application and has been 
added to the planning section of the FY2016-2017 application. The 
integration mandate in Title II of the Americans with Disabilities Act 
(ADA) and the Supreme Court's decision in Olmstead v. L.C., 527 U.S. 
581 (1999), provide legal requirements that are consistent with 
SAMHSA's mission to reduce the impact of substance abuse and mental 
illness on America's communities. Being an active member of a community 
is an important part of recovery for persons with behavioral health 
conditions. Title II of the ADA and the regulations promulgated for its 
enforcement require that states provide services in the most integrated 
arrangement appropriate and prohibit needless institutionalization and 
segregation in work, living, and other settings. In response to the 
tenth anniversary of the Supreme Court's Olmstead decision, then HHS 
Secretary Sebelius directed the creation of the Coordinating Council on 
Community Living at the HHS. SAMHSA has been a key member of the 
Coordinating Council on Community Living and has funded a number of 
technical assistance opportunities to promote integrated services for 
people with behavioral health needs, including a policy academy to 
share effective practices with states.
    Community living has been a priority across the federal government 
with recent changes to Section 811 and other housing programs operated 
by the Department of Housing and Urban Development (HUD). HUD and HHS 
collaborate to support housing opportunities for persons with 
disabilities, including persons with mental/substance use disorders. 
The Department of Justice (DOJ) and HHS Office of Civil Rights (OCR) 
cooperate on enforcement and compliance measures. DOJ and HHS OCR have 
expressed concern about some aspects of state mental health systems 
including use of traditional institutions and other residences that 
have institutional characteristics to house persons whose needs could 
be better met in community settings. More recently, there has been 
litigation regarding certain supported employment services such as 
sheltered workshops. States should ensure Block Grant funds are 
allocated to support treatment and recovery services in community 
settings whenever feasible and remain committed, as SAMHSA is, to 
ensuring services are implemented in accordance with Olmstead and Title 
II of the ADA.
     Quality and Data Collection--The FY2014-2015 Quality, Data 
and Information Technology sections have been consolidated into one 
section in the FY2016-2017 application and is part of the planning 
section. SAMHSA is moving forward on the task of advancing a system for 
the collection of client level substance abuse and mental health 
treatment data. As such, SAMHSA is undertaking a series of efforts 
designed to develop a set of common core performance, quality, and cost 
measures to demonstrate the impact of SAMHSA's discretionary and block 
grant programs and guide SAMHSA's evaluation activities.
    The foundation of this effort is National Quality Behavioral Health 
Framework, which derives from the National Quality Strategy and seeks 
to improve the delivery of health care services, individual patient 
health outcomes, and the overall health of the population. The 
overarching goals are to ensure that services are evidence-based and 
effective; that they are person/family-centered; that care is 
coordinated across systems; that services promote healthy living; and 
that they are safe, accessible and affordable.
    For the FY 2016-2017 MHBG and SABG reports, achieving these goals 
will result in a more coordinated behavioral health data collection 
program that complements other existing systems (e.g., Medicaid 
administrative and billing data systems; and state mental health and 
substance abuse data systems), ensures consistency in the use of 
measures that are harmonized across various agencies and reporting 
systems, and provides a more complete understanding of the delivery of 
mental health and substance abuse services. Both goals can only be 
achieved through continuous collaboration with and feedback from 
SAMHSA's state partners.
    SAMHSA anticipates this movement is consistent with the current 
state authority's movement toward system integration and will minimize 
challenges associated with changing operational logistics of data 
collection and reporting. SAMHSA understands some modifications to data 
collection systems may be necessary, but will work with the states to 
minimize the impact of these changes.

Other Changes

    The overall format has been streamlined to integrate the 
environmental factors throughout the behavioral health assessment and 
plan narrative. This has reduced the length of the application by 10 
pages.
    While the statutory deadlines and block grant award periods remain 
unchanged, SAMHSA encourages states to turn in their application as 
early as possible to allow for a full discussion and review by SAMHSA. 
Applications for the MHBG-only is due no later than September 1, 2015. 
The application for SABG-only is due no later than October 1, 2015. A 
single application for MHBG and SABG is due no later than September 1, 
2015.

Estimates of Annualized Hour Burden

    The estimated annualized burden for a uniform application is 37, 
429 hours. Burden estimates are broken out in the following tables 
showing burden separately for Year 1 and Year 2. Year 1 includes the 
estimates of burden for the uniform application and annual reporting. 
Year 2 includes the estimates of burden for the application update and 
annual reporting. The reporting burden remains constant for both years.

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                        Table 1--Estimates of Application and Reporting Burden for Year 1
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                                                                                      Burden/
          Application element              Number respondents       Responses/       response      Total burden
                                                                    respondents       (hours)
----------------------------------------------------------------------------------------------------------------
Application Burden:...................
Yr One Plan (separate submissions)....  30 (CMHS)...............               1             282          16,920
                                        30 (SAPT)...............
Yr One Plan (combined submission).....  30......................               1             282           8,460
Application Sub-total.................  60......................  ..............  ..............          25,380
Reporting Burden:.....................
MHBG Report...........................  59......................               1             186          10,974
URS Tables............................  59......................               1              35           2,065
SAPTBG Report.........................  60 \1\..................               1             186          11,160
Table 5...............................  15 \2\..................               1               4              60
Reporting Subtotal....................  60......................  ..............  ..............          24,259
    Total.............................  119.....................  ..............  ..............          49,639
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\1\ Redlake Band of the Chippewa Indians from MN receives a grant.
\2\ Only 15 States have a management information system to complete Table 5.


                        Table 2--Estimates of Application and Reporting Burden for Year 2
----------------------------------------------------------------------------------------------------------------
                                                                                      Burden/
               Application element                    Number        Responses/       response      Total burden
                                                    respondents     respondents       (hours)
----------------------------------------------------------------------------------------------------------------
Application Burden:.............................
Yr Two Plan.....................................              24               1              40             960
Application Sub-total...........................              24  ..............  ..............             960
Reporting Burden:...............................
MHBG Report.....................................              59               1             186          10,974
URS Tables......................................              59               1              35           2,065
SAPTBG Report...................................              60               1             186          11,160
Table 5.........................................              15               1               4              60
Reporting Subtotal..............................              60  ..............  ..............          24,259
    Total.......................................             119  ..............  ..............          25,219
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    The total annualized burden for the application and reporting is 
37,429 hours (49,639 + 25,219 = 74,858/2 years = 37,429).
    Link for the application: http://www.samhsa.gov/grants/block-grants.
    Send all comments via email to [email protected]. Written 
comments should be received by March 9, 2015.

Summer King,
Statistician.
[FR Doc. 2015-00063 Filed 1-7-15; 8:45 am]
BILLING CODE 4162-20-P