SAMHSA Grants: Shift Would Make Youth Agencies Show Impact

Patrick Boyle
October 1, 1999

Think your agency provides pretty good mental health or substance abuse services to youth? Get ready to prove it, or risk losing a chunk of your government funds.

That’s the upshot of a congressional bill that would require performance measurements from agencies that get block grants from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) — perhaps the biggest single source of grants for those services, at $2 billion a year.

The Senate bill to reauthorize SAMHSA gives the states more flexibility in how they spend the block grants in exchange for providing more data to show that the money is having an impact. The shift is part of a national movement toward “performance outcome measures” in social services. “It’s the wave of the future,” said John Gustafson, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD).

The Youth Drug and Mental Health Services Act (S.976) also includes a $100 million authorization to increase collaboration between juvenile justice, school and mental health officials to combat youth violence; a $50 million authorization to research ways of identifying and treating victims of school, domestic and community violence; a program of mental health and substance abuse services for youth in the juvenile justice system; and transfers the authority of the Children of Substance Abusers Act (COSA), intended to help kids of drug-using parents, from the Health Resources and Services Administration to SAMHSA.

“It is clearly the congressional intent that more emphasis be placed on providing service to younger clients,” Gustafson said.

But there is some question about whether Capitol Hill lawmakers, who seem determined to drag the phrase “do-nothing Congress” down to a new level, will let the SAMHSA bill wither. Although the Senate Committee on Health, Education, Labor and Pensions approved the bill in July, the House Commerce Committee has taken no action. If Congress doesn’t act by the end of the year, the bill will have to be taken up again next year. Advocates believe that will just delay the inevitable move toward performance-based grants.

“This is the way it has to be,” said Marie Danforth, acting chief of state planning and systems development at the U.S. Center for Mental Health Services.

The issue for youth substance abuse and mental health agencies is whether they will be overburdened with the job of collecting data, and whether the data will be used to improve services for kids — or just to fill filing cabinets.

Grants in a Straightjacket

SAMHSA and its grantees have been seeking the changes for several years, contending that they could get more bang for the agency’s bucks. The agency’s block grants account for 40 percent of all substance abuse funding in the states and 15 percent of all mental health service funding in the states, Sen. William Frist (R-Tenn.) said when introducing the bill, which he sponsored. In Fiscal Year 1999 SAMHSA distributed $1.58 billion in substance abuse block grants and $288 million in mental health block grants.

While the state agencies carry out some of the block grant-funded programs themselves, much of the money filters down to community-based organizations to run the services under contract. In Colorado, the state Division of Mental Health Services (DMHS) uses its $4.5 million annually from the block grants to help fund 17 nonprofit agencies that run the state’s community mental health network. Just outside Littleton, for instance, the Jefferson Center for Mental Health uses the block grant and other funds to run an array of services such as in-school counselors, crisis intervention for families, in-home family preservation, substance abuse counseling, mental health clinics for children and families, child and adolescent day treatment centers, and therapists at juvenile detention centers.

But the grants come wrapped in some thick strings. The substance abuse grants require that 35 percent of the funds be used for alcohol-related activities and 35 percent for drug-related activities. “Some states have more need in the drug area, some have more need in the alcohol area,” says former NASADAD president Bill Butynski, now director of policy at the New Hampshire Charitable Foundation, based in Concord, N.H. “They’ve pushed for a long time for more flexibility.”

The bill eliminates those restrictions, as well as the requirement that the states maintain a $100,000 revolving fund to support “recovery homes.” In addition, states could apply for waivers from the Department of Health and Human Services (which oversees SAMHSA) for several other requirements, such as setting aside certain portions of their funds for pregnant addicts and women with children, improving referral services and providing continuing education to their counselors. The states would have to demonstrate that they meet the criteria for waivers, which HHS would develop with the states.

But while “we want to give them [states] flexibility,” said Joseph Faha, director of legislation for SAMHSA, “we want to make sure that something is happening as a result of us giving you all these dollars.” So the bill turns the funds into “performance partnership” grants, requiring data to demonstrate outcomes from the services.
“It’s important to be able to say whether those services make a difference,” said Karabelle Pizzigati, public policy director at the Child Welfare League of America (CWLA). “Are the kids and families better off when they leave than when they entered?”

Measure What?

Answering those questions can be scary for providers. Measuring outcomes of mental health and drug abuse services “is certainly difficult,” said Tom Barrett, Colorado’s mental health services director. But “if we’re going to improve ... we have to have good outcome information.”

The question is, what outcomes should be measured? “Data collection is meaningless unless you’re collecting the right kind of data,” said Jennifer Collier, director of national policy at the D.C.-based Legal Action Center, which has been following this legislation.
The legislation gives HHS two years to decide exactly what outcomes would be measured. NASADAD and the National Association of State Mental Health Program Directors (NASMHPD) have workgroups to devise performance measures; they are working with SAMHSA in hopes that their suggested measures would be adopted.
For example, the measures drawn up by the mental health group include information about children receiving in-home services, children in out-of-home placements, family involvement in treatment for children and adolescents, the use of seclusion and restraint, and readmission for services within 30 days after discharge. In states that have their own performance measurement systems (Colorado, Washington and Texas are among the leaders), the measures include school attendance and performance, holding a job, refraining from substance abuse, and arrests.

But both state agencies and their nonprofit contractors worry about the staffing, time and money it would take to set up and operate a data collection system. “One of the concerns we’ve always had with this bill is lack of resources” to help state agencies and their service providers carry out the mandate, says Jenifer Urf, director of government relations at NASMHPD.

“Many of the states do not have the capability now to collect, analyze and report on performance measures,” said Faha. “Without the benefit of getting some infusion of money, they will have a difficult time.” The bill authorizes HHS to establish grants to help states develop the data systems. The amounts to be appropriated, if any, remain unclear.

States that already have performance measurement systems try to limit the workload on providers by asking for information that the providers already collect for themselves. That way, said Barrett of Colorado, “we’re not detracting significantly from a service providers’ ability to provide the service.”

In Texas the data collection is woven into the routine of providing service, said Ashley Hofman, child and adolescent behavior health director at the nonprofit Lubbock Regional Mental Health Mental Retardation Center, a nonprofit that provides services to five counties under state contract. “Yes it is paperwork,” she said, but the information helps her agency measure its performance. “We think we have good services, but in the days of managed care, you can just say that. You have to have data to show it.”

Paper Pushing?

But would all of this data be put to any useful purpose? For instance, would providers lose funding if they fall short?

“It’s always a concern for any program to be measured against a yardstick for other programs,” said Gustafson of NASADAD. Barrett of Colorado said it’s important to put the data into context: for example, some agencies take on more difficult clients than do others. He said that in the nearly 15 years that Colorado has had a performance measurement system for its mental health services, no community mental health center has been dropped because it didn’t meet performance standards.

In Texas, Vijay Ganju, senior administrator of the Texas Department of Health and Mental Retardation, said the state has withheld money from providers who didn’t perform up to standards. He and Barrett said that when an agency falls short, their states prefer to provide technical assistance to help those agencies improve rather than trying to seek new contractors. Colorado even rewards agencies that perform exceptionally well on specific indicators; each year it hands out $50,000 in bonuses.

But aside from the rare case where an agency’s funding is held up until it fixes a problem, it’s not clear that state-mandated performance measures have improved services for kids. “It’s useful to know, but I don’t know how much people are using the information,” said Heidi Crane, director of quality improvement at Behavioral Health Care, a nonprofit agency that provides managed care oversight for three nonprofit mental health centers in Colorado. She says her own agency has “developed many other outcomes measures that are more useful” in helping the health centers address their shortcomings.

It’s vital, said Pizzigati, that outcome measures are relevant and are used to improve services. “This cannot be a paper pushing exercise, it can’t be a number crunching exercise ... to simply satisfy a reporting requirement,” she said.

For now, it’s an exercise in waiting. “As time passes one becomes less positive that the reauthorization will go through” this year, former NASADAD president Luceille Fleming, director of the Ohio Department of Alcohol and Drug Abuse Services, said late last month. The House Commerce Committee has appeared unsure of whether it even wants to bother with the bill. “We are trying to persuade the House to accept the Senate bill without writing their own,” Fleming said, seeing that as the only chance of getting a bill passed before Congress adjourns this year.

If that doesn’t happen, said Fleming and others, just wait ‘til next year. Performance measures are coming, even if Congress performs slowly.

Boyle, Patrick. "SAMHSA Grants: Shift Would Make Youth Agencies Show Impact." Youth Today, October 1999, p. 30.

©2000 Youth Today. Reprinted with permission from Youth Today. All rights reserved.