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Linda ElamAssistant Secretary for Planning and EvaluationASPE
FY 16-17: Agency Priority Goal
Improve the timeliness of initiation into treatment for individuals with serious mental illness.
Priority Goal
Goal Overview
Serious mental illnesses often first arise in adolescence or early adulthood, and delays in treatment initiation are common. As a result, people with serious mental illness (SMI) may experience multiple episodes of acute illness accompanied by accumulating disability. The National Institute of Mental Health (NIMH) at the National Institutes of Health (NIH) estimates that the direct and indirect financial costs of serious mental illness—including health expenditures, disability benefits, and loss of earnings—exceed $300 billion per year in the United States.
Individuals with serious mental illness (SMI) are a high-need, high-cost population. They are frequent utilizers of emergency departments and have high rates of readmission to inpatient care, especially when co-occurring substance use disorders are present. In addition, people with SMI often have co-morbid physical health conditions and shorter life expectancies than people without SMI, primarily due to co-occurring physical health conditions that too often go unaddressed.
Individuals with serious mental illness (SMI) often experience barriers to treatment, including difficulty accessing and initiating treatment. Significant delays in the identification and treatment of SMI are common; for example, research has repeatedly found that individuals with psychosis in the U.S. often do not receive appropriate treatment for that condition for one to three years. Moreover, once they do receive care, individuals with serious mental illness might not receive evidence-based care, or care that is coordinated with medical care. There is a growing body of evidence highlighting the effectiveness of early intervention using evidence-based treatments to improve outcomes for individuals with SMI, including psychotherapy and education and employment supports. The use of peer supports is another promising practice with a growing evidence base.
Challenges that prevent the dissemination of these best practices in the provision of early intervention services include lack of funding, the need for technical assistance, the need to educate and engage consumers, and the need to further build the evidence base supporting the provision of early intervention services. These challenges impact the ability of states to establish and maintain early intervention programs using Community Mental Health Services Block Grant funding.
The SMI Initiative builds on activities that are currently underway in various HHS agencies; these activities are coordinated through the HHS Behavioral Health Coordinating Council (BHCC). The BHCC subcommittee on SMI is critical to the implementation of the Initiative, which is also oriented towards achievement of this Agency Priority Goal on SMI.
Strategies
~~The main strategy being used to increase the timeliness of initiation into treatment for individuals with serious mental illness is increasing access to evidence-based early intervention services. Early intervention activities are being supported through funding for direct services, technical assistance for providers, engaging consumers and families, and building the evidence base. This Agency Priority Goal is focused on funding for early intervention services is the SAMHSA Mental Health Block Grant (MHBG) 5 percent Set-Aside, which mandates that 5 percent of state allocations focus on evidence-based treatment for individuals experiencing the early stages of SMI, including a first episode of psychosis.
One example of an evidence-based model is Coordinated Specialty Care, which is a team-based, collaborative, recovery-oriented approach that includes a low dose of medication, cognitive and behavioral skills training, supported employment and supported education, case management, and family psychoeducation. SAMHSA, in collaboration with NIMH and ASPE, is conducting an evaluation of the MHBG set-aside for early intervention services. This research will evaluate the fidelity of programs funded through the set-aside to evidence-based best practices. The evaluation will also assess outcomes.
Technical assistance for early intervention is available through initiatives such as the Technical Assistance to Support the Implementation of Coordinated Specialty Care Programs for First Episode Psychosis via the Community Mental Health Services Block Grant program and the Agency for Healthcare Research and Quality Integration Academy. To support states in using the Mental Health Block Grant Block set-aside funding, SAMHSA continues to work closely with NIMH in this effort and has provided states with guidance to support their planning process. To date, 35 educational webinars have been offered, as well as onsite technical assistance to 12 states and territories.
Additionally, SAMHSA has provided states with a comprehensive environmental scan and various educational fact sheets, guidance manuals, and an on-line tutorial in order to support the efforts of states as they plan, implement, operate, and assess initiatives to meet the needs of persons experiencing a first episode of serious mental illness. In the future, the NIMH Early Psychosis Intervention Network (EPINET; under development), will apply a learning network approach to support coordinated specialty care (CSC) clinics as they establish and maintain early intervention programs. A primary component of EPINET will be to standardize the treatment and outcome measures that are used across CSC clinics and to develop informatics approaches for aggregating and analyzing pooled data. EPINET will focus on monitoring fidelity to evidence-based care in CSC clinics and enhancing continuous quality improvement efforts.
Several initiatives in Medicaid are complementary to the MHBG set-aside funding, and can also help build capacity for early intervention. On October 16, 2015, a Joint Informational Bulletin was released by CMS, NIH, and SAMHSA to guide states regarding coverage of early intervention services in Medicaid for first episode psychosis. Several other SAMHSA initiatives support prevention and early intervention activities, including Healthy Transitions and the National Child Traumatic Stress Initiative (NCTSI), which improves behavioral health treatment, services, and interventions for children and adolescents exposed to traumatic events by developing and promoting effective community practices and improving access to services for children who have experienced trauma.
Evidence-based practices, quality improvement activities, performance measurement reporting, person-centered treatment planning, and staff training are requirements to participate in the Medicaid Certified Community Behavioral Health Clinics (CCBHC) demonstration program, which will be launched in eight states in the first half of 2017. Crisis and early intervention services are required services in the demonstration. New quality measure specifications were made available to CCBHC planning grantees, and to all states, including a resource manual, technical specifications, and data reporting templates to facilitate assessment and documentation of performance and treatment in behavioral health clinics. A series of webinars is underway to review the measure specifications.
Another initiative that promotes the use of evidence-based practices is the Medicaid Health Homes for Enrollees with Chronic Conditions initiative; some health homes focus on individuals with SMI. Use of the Medicaid health home state plan option, created under Section 2703 of the Affordable Care Act, continues to expand. As of March 2016, 19 states including the District of Columbia have a total of 27 approved Medicaid health home models. Additional states are drafting health home proposals. The third annual report from the independent national program evaluation contract for the of the Medicaid health home state plan option was posted on the website of the Office of the Assistant Secretary for Planning and Evaluation (ASPE). Another new report on the ASPE website summarizes the results of a project exploring best practices in providing Supported Education services to promote educational attainment and employment among individuals with serious mental illness.
The Innovation Accelerator Program (IAP) funded through the Centers for Medicare & Medicaid Services (CMS), in partnership with HUD, SAMHSA, ASPE, and the U.S. Interagency Council for Homelessness, is targeting program support to state Medicaid agencies seeking to promote partnerships with Housing Agencies. This effort is intended to strengthen state-level collaboration between health and housing agencies to bring to scale permanent supportive housing by coordinating housing resources with Medicaid-covered services, as well as support community integration for people with long-term services and supports needs. The first training session took place in April with California, Connecticut, Hawaii, Illinois, Kentucky, New Jersey, Nevada, and Oregon in May 2016. This 6-month IAP program is designed to be intensive and hands-on to move selected states closer toward building collaborations with key housing partners in their states. The IAP will also offer program support as part of a three-session webinar series focused on supporting housing tenancy.
The Innovation Accelerator Program is also providing program support to nine states to enhance or expand their physical and mental health integration efforts. In this track of IAP, CMS is working with states to support integration across varied settings (e.g., primary care, community mental health centers, school-based health centers), for different populations (e.g., adults and children, individuals with serious mental illness), and/or a variety of evidence-based models of integrated care (collaborative care, co-location, primary care-oriented, etc.). Through this effort, IAP is providing states with technical support to improve or expand diverse integration approaches, including data analytics, payment and delivery system reforms, and measurement. Participating states have developed detailed work plans that emphasize efforts to be undertaken in the six-month timeframe ending in January 2017.
In addition to Medicaid, grant programs are complementary to the MHBG set-aside and help to build capacity for delivering early intervention services. In addition to the efforts focused on increasing engagement with treatment by expanding the availability of early intervention services, two complementary strategies are also being used to ensure that once patients initiate treatment for SMI, they receive high-quality care and linkages to community-based supports, when appropriate. Improving the quality of care will be accomplished through programs such as the SAMHSA Primary and Behavioral Health Integration (PBHCI) program, which promote evidence-based care that is coordinated with medical treatment.
Once individuals with SMI are engaged with treatment, it is critical to connect them to community-based supports. Individuals with serious mental illness are more likely to face housing instability, and stable housing can be a key part of recovery. Several SAMHSA initiatives focus on improving linkages with community-based supports for individuals experiencing homelessness, including the Cooperative Agreements to Benefit Homeless Individuals (CABHI), the Projects for Assistance in Transition from Homelessness (PATH), and the Homeless and Housing Resource Network. Supported Employment is an evidence-based practice, and a SAMHSA program called Transforming Lives Through Supported Employment provides funding. In addition, different approaches to connecting individuals with SMI to Supported Education are being explored by a research project funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE). Another ASPE study, Innovative Models of Peer Support Services in Behavioral Health to Reduce Preventable Acute Hospitalization and Readmission, will explore how peers can improve engagement in treatment and connect individuals with SMI with community supports.
Educating consumers and families is a key strategy. The SAMHSA Bringing Recovery Supports to Scale Technical Assistance Center Strategy (BRSS TACS) initiative continues to implement activities that support partnerships with people in recovery from mental and substance use disorders and their family members to guide the behavioral health system in promoting the four dimensions of recovery: Home, Health, Purpose and Community. The 2016 BRSS TACS State Policy Academies will assist states, territories, and tribal governments in building their capacity by bringing together stakeholders and change agents from different backgrounds and agencies to build communication, remove barriers, and develop action plans.
The Peer-Run/Recovery Community Organizations (PRO/RCOs) continue efforts in support of Affordable Care Act (ACA) implementation efforts in the state, district, territory, or federally recognized American Indian/Alaska Native (AI/AN) tribal jurisdiction in which they operate. Technical assistance requests have included assistance in app development to enhance user interface and material development tailored to meet the needs of specific audiences. One recipient is also working collaboratively with partners to disseminate informational materials regarding opportunities expand the use of Peer Support Specialists.
To educate and engage consumers with SMI and families, SAMHSA is developing guidelines on effective methods to engage individuals with serious mental illnesses in treatment, to support patient activation in recovery, as well as guidelines for family to assist them with navigating the options for services and supports for their loved ones with SMI. There is work underway to build the evidence base in this area through NIMH-funded studies aimed at reducing the duration of untreated psychosis.
Advancing research is a key strategy to addressing the need for early intervention services among individuals with serious mental illness. The National Institute of Mental Health released a Funding Opportunity Announcement (FOA) entitled “Reducing the Duration of Untreated Psychosis in the United States” on May 17, 2016. Initial applications will be reviewed in early FY17. The FOA was informed by a meeting hosted by NIMH entitled “Reducing the Duration of Untreated Psychosis (DUP)" on February 12, 2016 that brought together more than a dozen leading researchers in DUP reduction with the aim of leveraging NIMH’s initial investment and accelerating future research on reducing DUP. The meeting served to sharpen NIMH’s research DUP reduction research agenda. To date, NIMH has funded 7 grants and one contract on research projects exploring how to reduce the duration of untreated psychosis.
Several projects funded by the Agency for Healthcare Research and Quality (AHRQ) will help build the evidence base in areas such as disparities in outcomes for individuals with SMI, reducing psychiatric readmissions, effective treatment for bipolar disorder, and the use of antipsychotics in children and young adults. Finally, several of the CMS Health Care Innovations Awards are focused on testing promising practices for treating individuals with SMI.
The evidence base is being supported in the area of increasing community living and participation through several ACL-funded Rehabilitation Research and Training Centers (RRTCs). Multiple ACL-funded RRTCs are providing training, technical assistance, and dissemination to increase utilization of evidence based supported employment and integrated supported employment and education for youth and young adults with serious mental health conditions and psychiatric disabilities.
Notably, serious mental illness can co-occur with substance use disorder in many individuals. To assist with future measure development and quality improvement efforts, an overview of clinical guidelines for medication-assisted treatment was posted to the ASPE website in June 2016. Also new to the ASPE website is a white paper with case study findings on the MHBG set-aside.
The President’s FY2017 budget, released in February, includes items to increase access to care among individuals with SMI, including a proposed expansion of the Certified Community Behavioral Health Clinic demonstration from 8 to 14 states. The budget also includes a proposal to establish a formula grant to enable all states to establish at least one early intervention program. The FY 2017 proposed budget also includes $10 million for the Increasing Crisis Access Response Efforts (ICARE). ICARE is a demonstration activity to help communities build, fund, and sustain crisis systems capable of preventing and deescalating behavioral health crises as well as connecting individuals and families with needed post-crisis services. These grants would help mitigate the demand for inpatient beds by those with serious mental illnesses and substance use disorders by coordinating effective crisis response with ongoing outpatient services and supports. The project would fund many communities to develop the necessary infrastructure between crisis response providers in the community, law enforcement and other agencies including data sharing agreements, coordinated response protocols, and workforce development.
Progress on the SMI APG is supported and coordinated by the Secretary’s SMI Initiative, which is an effort to coordinate activities among programs to reduce the duration of untreated SMI in individuals through early engagement in care. The SMI Initiative also aims to improve the quality of care by measuring performance more accurately and increase access to community-based treatment and support services. By tracking progress toward milestones and promoting collaboration between different HHS agencies, the SMI Initiative supports the SMI APG. The SMI APG was briefly discussed at a quarterly meeting of the HHS Behavioral Health Coordinating Council (BHCC); this cross-agency group coordinates behavioral health activities across the department. The BHCC subcommittee on SMI is critical to the implementation of the Secretary’s SMI Initiative.
Progress Update
~~From a baseline of 13 states in 2015, the number of states with evidence-based early intervention programs for individuals with serious mental illness funded through the Mental Health Services Block Grant increased to 25 states as of September 30, 2016.
In addition to the 25 states that have at least one fully implemented evidence-based early intervention program for individuals with serious mental illness, 16 states are currently in the process of implementing evidence-based programs. Ten states are still in the planning phase.
Individuals with serious mental illness are disproportionally likely to experience housing instability. Stable housing can be a key part of recovery. In fiscal year 2015, the SAMHSA Projects for Assistance in Transition from Homelessness (PATH) program outreached to 181,336 individuals experiencing homelessness. Sixty percent of individuals with serious mental illness who engaged with outreach efforts agreed to engage in the program. Additionally, 53 percent of enrolled individuals were experiencing a co-occurring substance use disorder. In addition, PATH assisted 17,232 individuals with addressing complex housing needs and referred 25,911 individuals to housing assistance agencies in their communities. The services provided by the PATH program fill gaps in existing community resources and play a crucial role in communities’ strategic plans to end homelessness.
The Cooperative Agreements to Benefit Homeless Individuals (CABHI) program is another SAMSHA initiative that serves many individuals with serious mental illness. Thirty CABHI applications were recently funded, including three states, 12 local governments, and 15 community-based organizations. CABHI grants will increase the capacity to provide accessible, effective, comprehensive, coordinated, integrated, and evidence-based treatment services; permanent supportive housing; peer supports; and other critical services.
The SAMHSA SOAR technical assistance center launched a learning community and pilot with 12 states that received the Cooperative Agreement to Benefit Homeless Individuals (CABHI) States Enhancement Grant. Four of these states also receive support through the SAMHSA Supported Employment grant program. The recently launched CABHI: SOAR and IPS Pilot is a year-long pilot that aims to integrate SOAR and Individual Placement and Support (IPS) employment services. The goal is connecting individuals receiving income support services from one or both programs with the appropriate services.
Individuals with serious mental illness are at increased risk for suicide. Zero Suicide is a commitment, a goal, and a campaign led by the National Action Alliance for Suicide Prevention and its partners, and supported by NIMH. The Zero Suicide effort seeks to improve the ability within the health care systems to identify who is at risk, as well as to identify and implement effective treatments for at-risk individuals. Optimally, these improvements will also encourage the development of ‘learning health care systems’ by promoting agility in how health care providers can reduce suicide risk. NIMH recently funded three studies focused on adult and youth based suicide prevention practices in health care settings.
Next Steps
~~As described in the Strategies section, there are numerous activities underway related to the SMI APG. These efforts are ongoing, and the efforts are coordinated by the SMI subcommittee of the Behavioral Health Coordinating Council. Any new initiatives or programs that are relevant will be highlighted in future progress updates, along with progress on the activities described above.
Salient next steps include continuing to include the Mental Health Block Grant Set-Aside, which clearly sets access to early intervention services as a priority. Please note that in FY2016, the set-aside was increased from 5 to 10 percent. In addition to dedicated funding, technical assistance is critical; technical assistance that is currently available through mechanisms such as Technical Assistance to Support the Implementation of Coordinated Specialty Care Programs for First Episode Psychosis via the Community Mental Health Services Block Grant program will continue to be offered. In addition, the NIMH Early Psychosis Intervention Network (EPINET)—a learning healthcare network for coordinated specialty care clinics that offer early intervention services—is under development. The initial phase is nearing completion; in the initial phase, standardized performance measures that can be used for fidelity monitoring and quality improvement activities were identified.
Expand All
Performance Indicators
Increase access to early intervention services by increasing the number of states with early intervention programs by 50 percent.
Contributing Programs & Other Factors
~~Related initiatives and programs include the SAMHSA Mental Health Block Grant (MHBG) 5 percent Set-Aside, the SAMHSA Healthy Transitions program, the SAMHSA National Child Traumatic Stress Initiative (NCTSI), the SAMHSA Primary and Behavioral Health Integration (PBHCI) program, and the Medicaid Certified Community Behavioral Health Clinics (CCBHC) demonstration program that is being launched by SAMHSA and CMS. Technical assistance is available through programs such as the Technical Assistance to Support the Implementation of Coordinated Specialty Care Programs for First Episode Psychosis via the Community Mental Health Services Block Grant program.
Several different agencies have critical roles in pursuing the SMI APG, including Substance Abuse and Mental Health Services Administration, the National Institute of Mental Health in the National Institutes of Health, the Assistant Secretary for Planning and Evaluation, the Administration for Community Living, and the Agency for Healthcare Research and Quality.
No Data Available
