[Federal Register Volume 80, Number 58 (Thursday, March 26, 2015)]
[Notices]
[Pages 16013-16016]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-06915]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Agency Information Collection Activities: Submission for OMB
Review; Comment Request
Periodically, the Substance Abuse and Mental Health Services
Administration (SAMHSA) will publish a summary of information
collection requests under OMB review, in compliance with the Paperwork
Reduction Act (44 U.S.C. Chapter 35). To request a copy of these
documents, call the SAMHSA Reports Clearance Officer on (240) 276-1243.
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 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 FY 2014-2015 application sections on the Affordable Care Act,
health insurance marketplace,
[[Page 16014]]
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 FY 2014-2015
Quality, Data and Information Technology sections have been
consolidated into one section in the FY 2016-2017 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 FY 2014-2015 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
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 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.
[[Page 16015]]
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 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 FY 2014-2015 application and has been
added to the planning section of the FY 2016-2017 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 settings that have
institutional characteristics to serve persons whose needs could be
better met in community settings. More recently, there has been
litigation regarding certain 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 FY 2014-2015 Quality,
Data and Information Technology sections have been consolidated into
one section in the FY 2016-2017 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.
[[Page 16016]]
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.
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)
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Application Burden
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Yr One Plan (separate submissions).... 30 (CMHS)............... 1 282 16,920
30 (SAPT)...............
Yr One Plan (combined submission...... 30...................... 1 282 8,460
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Application Sub-total............. 60...................... .............. .............. 25,380
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Reporting Burden
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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
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Reporting Subtotal................ 60...................... .............. .............. 24,259
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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
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Burden/
Application element Number respondents Responses/ response Total burden
respondents (hours)
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Application Burden
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Yr Two Plan........................... 24...................... 1 40 960
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Application Sub-total............. 24...................... .............. .............. 960
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Reporting Burden
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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
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Reporting Subtotal................ 60...................... .............. .............. 24,259
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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.
Written comments and recommendations concerning the proposed
information collection should be sent by April 27, 2015 to the SAMHSA
Desk Officer at the Office of Information and Regulatory Affairs,
Office of Management and Budget (OMB). To ensure timely receipt of
comments, and to avoid potential delays in OMB's receipt and processing
of mail sent through the U.S. Postal Service, commenters are encouraged
to submit their comments to OMB via email to:
[email protected]. Although commenters are encouraged to send
their comments via email, commenters may also fax their comments to:
202-395-7285. Commenters may also mail them to: Office of Management
and Budget, Office of Information and Regulatory Affairs, New Executive
Office Building, Room 10102, Washington, DC 20503.
Summer King,
Statistician.
[FR Doc. 2015-06915 Filed 3-25-15; 8:45 am]
BILLING CODE 4162-20-P