Testimony

INTRODUCTION

Mr. Chairman and Members of the Subcommittee, I am honored to present to you the vision, mission, and programs of the Substance Abuse and Mental Health Services Administration (SAMHSA or the Agency). Our mission, as envisioned by Congress when SAMHSA was created, is to "fully develop the Federal government's ability to target effectively substance abuse and mental health services to the people most in need and to translate research in these areas more effectively and more rapidly into the general health care system."

Over the years, SAMHSA and its three Centers, the Center for Substance Abuse Prevention, the Center for Substance Abuse Treatment and the Center for Mental Health Services, have worked with State and local governments, consumers, families, service providers, professional organizations, our colleagues in HHS, the Office of National Drug Control Policy, and Congress to achieve its mission.

The Agency's work has shown prevention, early intervention, and treatment for mental and substance use disorders pay off in terms of reduced HIV/AIDS, crime, violence, suicide, homelessness, injuries, and health care costs, and increased productivity, employment, and community participation. Data confirms that the human and economic cost is much lower when we prevent or intervene early with the best research-based tools available.

During my first year at SAMHSA, I led the Agency through a critical self-assessment of how it has met its statutory mandate during its first 10 years. Based on that assessment, we identified efficiencies, ways to strengthen our overall effectiveness, increase our capacity, and enhance our accountability both to you and to the populations this Agency has a responsibility to serve.

I also found that like many organizations, as SAMHSA continued to grow, "mission creep" had set in. The Agency's initial focus on increasing access to services and using research findings to improve the quality of services available had lost clarity. Increasingly, staff and resources were devoted to the important work of services research � what SAMHSA called "knowledge development." And, the operating principle had become let a thousand flowers bloom.

Today, consistent with Health and Human Services (HHS) Secretary Tommy G. Thompson's leadership and vision, we are nurturing a few sturdy redwoods. We have renewed and more sharply focused SAMHSA's mission and vision, aligning them both with HHS goals and President Bush's New Freedom Initiative and management agenda.. In keeping with the New Freedom Initiative, SAMHSA's vision is "a life in the community for everyone."

Working together with the States, national and local community-based and faith-based organizations, and public and private sector providers, we are working to ensure that people with or at risk for a mental or addictive disorder have an opportunity for a fulfilling life, a life that is rich and rewarding, that includes a job, a home, and meaningful relationships with family and friends.

We have defined a "rewarding life" not by what it might mean to the people who work at SAMHSA, but through talking to people in recovery. People in recovery do not say that they need a primary care physician or a caseworker to follow them around. They do not say they need a psychiatrist, an addictions counselor, or even a social worker. They say they need a job, a home, and meaningful personal relationships. They want a life, a real life with all of its rewards.

We are working to achieve that vision through a mission that fulfills our mandate from Congress and focuses our attention on the outcomes we are seeking: to build resilience and facilitate recovery for people with or at risk for substance abuse and mental illness.

To ensure that all SAMHSA programs are science-based, results-oriented, and aligned with the Agency's vision and mission, I initiated a strategic planning process that guides our decision making in planning, policy, communications, budget, and programs. The process is designed around three core objectives - Accountability, Capacity, and Effectiveness or, in short, ACE!

To guide our work and to keep our vision and mission real, we have created a Matrix of agency priorities and principles to guide program development and resource allocation. We have provided you with a copy of the Matrix. The Matrix is a visual depiction of our priorities and principles, among them: co-occurring mental and substance abuse disorders, seclusion and restraint, substance abuse treatment capacity, prevention and early intervention, transforming mental health care, criminal justice, children and families, aging, homelessness, disaster response, and HIV/AIDS. The Matrix was created to be a flexible management tool and it will adjust with the needs of the field and of the people we serve as time passes and new trends emerge.

With a Fiscal Year 2003 budget of just under $3.2 billion, SAMHSA's program dollars support formula grant programs, primarily the Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant, a portfolio of discretionary grants, and three major national surveys on substance use. In the interest of time, rather than discuss each of our program areas, I want to focus on three most central to our mission and vision.

Building Substance Abuse Treatment Capacity

The Substance Abuse Prevention and Treatment Block Grant, with its required maintenance of effort, supports and maintains the basic treatment infrastructure that exists in the Nation. Targeted Capacity Expansion (TCE) grants address new and emerging substance abuse trends. By focusing on local needs, these grants provide the flexibility and agility to meet treatment and treatment system needs in the most relevant way. In the current fiscal year, we have developed a new State TCE program that includes a focus on screening and both early and brief interventions. This focus will help expand the continuum of care available in States.

Together, both the Block Grant and TCE programs have made strides in expanding our capacity for substance abuse treatment. They are necessary; they are effective; but alone, they have not yet proven to be sufficient. Our National Household Survey on Drug Abuse found that in 2001, 5 million of the 6.1 million people needing treatment for an illicit drug problem never got help. Of the 5 million, only 377,000 reported that they felt they needed treatment for their drug problem. In fact, 101,000 people who knew that they needed treatment sought help but were unable to find care.

President Bush emphasized this very point in his January 2003 State of the Union Address when he said, "Too many Americans in search of treatment cannot get it." He reaffirmed his commitment to expand the Nation's substance abuse treatment capacity by proposing Access to Recovery, a $600-million program to help an additional 300,000 Americans receive treatment over the next three years. The first $200 million installment is included in the President's proposed Fiscal Year 2004 budget for SAMHSA under current legislative authorities.

The President's substance abuse treatment initiative, Access to Recovery, will use vouchers to purchase substance abuse treatment and support services. It enables us to achieve key objectives identified by substance abuse treatment administrators and providers, legislators and policy makers, and people in recovery and their families as critical to moving the substance abuse treatment field forward.

First, it acknowledges that there are many pathways to recovery. Using vouchers, individuals, for the first time, will be empowered to choose the provider who best meets their needs, whether the setting is non-profit, proprietary, community-based, or faith-based. The voucher mechanism allows recovery to be pursued in an individualized way, providing consumer choice, the epitome of accountability.

Second, it will reward performance by offering financial incentives for providers who produce results. Outcomes that demonstrate patient success - measures of recovery - such as cessation of drug or alcohol use, no involvement with the criminal justice system, securing employment, social supports, living situations, access to care, and retention in care will determine reimbursement.

Third, it will increase treatment capacity by expanding access to treatment and the array of support services that are critical to recovery. The initial $200 million investment is expected to result in treatment availability for an additional 100,000 people per year.

This initiative, coupled with SAMHSA's ongoing programs to build treatment capacity, can help create profound change in the delivery and accountability of substance abuse treatment services that can help make a difference in the lives of millions of Americans.

The Senate Fiscal Year 2004 Labor, Health and Human Services, and Education Appropriations Committee bill provides no funding for this initiative. We strongly urge the Senate to appropriate the full $200 million requested for this critical activity and would appreciate any help you can provide.

We are confident that States are prepared to successfully implement this program at the $200 million level. We are working aggressively to prepare States for this initiative and work through implementation issues related to assessments, accreditation, administrative expenses, and other key areas.

Prevention/Early Intervention

To help achieve the goal of the President's National Drug Control Policy to reduce illegal drug use by young people and adults by 25% each within five years, SAMHSA is reengineering its approach to substance abuse prevention. Over the years, SAMHSA's work has shown that substance abuse prevention can be incredibly effective, if it is done right.

Prevention not only can reduce the numbers of individuals who become dependent on substances of abuse, but also it can deter substance abuse in the first place. It can pay off not only in terms of health care costs, but also in terms of crime and violence, homelessness, and joblessness. It also can help us enhance treatment capacity by simply reducing the absolute numbers of people who are abusing or dependent on illicit drugs.

We have growing evidence that tells us which models of prevention work well, which promising models need further evaluation, and which models lack any strong evidence of effectiveness. We do not need to re-invent that knowledge. We need to apply what we know. We need to ensure that our dollars support known effective prevention programs, programs built on a solid evidence base of ongoing research.

To that end, over the past year, SAMHSA has been working to create a strategic framework for prevention, built on both science-based theory and evidence-based practices. We know from ongoing evaluation of our programs that to succeed, prevention programs must be built at the level of families and communities and must engage individuals, families, and entire communities.

SAMHSA's State Incentive Grants (SIG) for Community-based Action are a stepping-off point to achieve that end. It forms the foundation on which our strategic prevention framework rests. The SIG program provides funds to the Governors' offices of individual States and territories. It also is based on those prevention practices that we know are effective. It enables Governors to develop a coordinated approach to prevention and to determine where and what the greatest needs are. At least 85 percent of funds are then directed by the Governor to community-level prevention programs.

Last year, the SIG program provided resources to over 2,700 community-based and faith-based organizations, community anti-drug partnerships and coalitions, local governments, schools, and school districts. It has promoted the development of thoughtfully crafted, evidence-based state-community partnerships and strategies that enable communities to work on their own greatest challenges in substance abuse prevention.

Most of the community programs have adopted science-based substance abuse prevention strategies, many of which have been evaluated and endorsed by SAMHSA as effective models. These model programs, listed in our National Registry of Effective Prevention Programs, yield on average a 25 percent reduction in substance use by program participants.

Our strategic prevention framework sets into place a step-by-step process that empowers communities to identify risk and protective factors for substance abuse in their communities and to implement the best and most effective prevention efforts for their specific needs. Critically, the framework includes feedback to ensure accountability and effectiveness of our program efforts.

Transforming Mental Health Care

SAMHSA's vision and mission of a life in the community for everyone is a direct outgrowth of the President's New Freedom Initiative. That same vision and mission guides our efforts to help ensure that people with mental illness have access to effective and appropriate, community-based mental health services that can help them become or remain engaged participants in the life of their communities.

Consistent with other areas of SAMHSA's programming, accountability, capacity, and effectiveness are central to our mental health services discretionary and formula grant programs and activities. Three of those programs are the Projects for Assistance in Transition from Homelessness, the Children's Mental Health Services Program, and the Community Mental Health Services Block Grant.

The Projects for Assistance in Transition from Homelessness (PATH) program continues to generate positive results by bringing an estimated 147,000 homeless people into treatment for mental disorders and substance abuse, as well as providing referrals for housing. PATH gives States flexibility in designing their programs, but helps ensure efficiency by requiring States to match funds with one dollar for every three dollars received in Federal funds. In recent years, State and local support has been more than double the sums required by the match. Over its history, the program has continued to exceed its targets for reaching this often difficult to serve population.

The Children's Mental Health Services Program builds community-based systems of care for children with serious emotional disturbances (SED) and their families. The program supports services for almost 17,000 children and adolescents with SED and their families. It creates a web of services, linking school, family, juvenile justice, and mental health and other health care together to provide an integrated approach to meeting the highly individualized needs of children with SED and their families. Outcome data continue to show that this integration decreases use of inpatient care, increases school attendance and performance, and decreases contacts with the juvenile justice system. Several states have adopted statutes mandating this kind of approach to treatment for children with SED, but the value of a similar approach for other populations of individuals with serious mental illnesses cannot be discounted, either.

The Community Mental Health Services Block Grant program provides funds to the States to provide comprehensive community mental health services to adults with serious mental illness and children with SED. The program's overall goal is to move care for these adults and children from costly and restrictive inpatient hospital care to the community. The Block Grant is funded at $437 million this fiscal year, or about 2.5% of State expenditures on mental health services.

As you may know, the President's New Freedom Commission on Mental Health has completed its work, and its final report to the President is expected soon. Once the final report is submitted to the President, the Administration will evaluate the report and its recommendations.

As a result, we expect there may ultimately be some far-reaching implications for SAMHSA's mental health programs. We look forward to working with the Congress to implement the steps needed to improve the mental health service delivery system in America.

National Surveys

Another area of SAMHSA responsibility is to inform the President, the Congress, the substance abuse prevention and treatment and mental health service fields, and the American public on the status of substance use and treatment services in the Nation. One of those measures is provided by our National Household Survey on Drug Abuse. The National Household Survey provides national and comparable state-level estimates of substance use, abuse, and dependence. It also provides an ongoing source of nationally representative information on mental health and access to mental health services. The analysis of trends over time from the survey, alone and in combination with other data sources, provides an invaluable tool to measure outcomes of the National Drug Control Strategy and to report our progress to Congress.

Two other major national survey's conducted by SAMHSA include the Drug Abuse Warning Network (DAWN) and the Drug and Alcohol Services Information System (DASIS). The DAWN obtains information on drug-related admissions to emergency departments and drug-related deaths identified by medical examiners. The DASIS consists of three data sets developed with State governments. These data collection efforts provide national and State-level information on the substance abuse treatment system.

Improved Management Of SAMHSA Resources

SAMHSA is working to develop an overall data strategy and to shift the block grants to performance partnership grants. With regard to Performance Partnership Grants, or PPGs, SAMHSA has been working on this for sometime, and I am pleased to say our plans for transforming the block grants will be submitted to you very soon as we prepare to send a report to Congress, as requested, on these plans.

Currently, SAMHSA and the States have agreed on performance measures. We have identified the core measures on which all States will report. We are working to revise the Fiscal Year 2005 block grant applications to include performance data collection. Given that the PPGs comprise almost 80 percent of SAMHSA's budget, we are working to align the PPG performance measures with the Access to Recovery initiative and with potential recommendations of the President's New Freedom Commission on Mental Health.

Through both the Access to Recovery initiative and the PPGs, we have identified seven domains for specific data needed to capture the concept of recovery and determine the effectiveness of our programs. As I mentioned before, these include: drug or alcohol use, involvement with the criminal justice system, securing employment, social supports, living situations, access to care, and retention in care. These domains, when finalized through the PPG performance measures and the work we are doing on Access to Recovery, will likely become the same ones used across all of our programs. It just makes sense to use consistent measures across programs that have the main goal of building resilience and facilitating recovery.

To make sure we are moving in the right direction when it comes to collecting, analyzing, aggregating, and ultimately turning data into action, I have set up what I call the "Data Strategy Workgroup." I am determined to build a system that uses the health information technology we have today to help us measure and manage performance and in the end benefit the client � which is and always should be our overriding goal.

In many ways the "Data Strategy" is starting from a grassroots perspective. The workgroup contains key SAMHSA staff who will be looking at ways to build a collection system that, while protecting confidentiality, will be able to capture a clear picture of the situation and the needs and treatment status of the individual. Such information can then be gleaned to provide a picture at the local/county level.

That information then will be translated to create a State-level picture and combined to create a National-level picture of outcomes. Capturing and using the best data, especially where the PPGs and voucher program are concerned, will allow us, as never before, to clearly recognize outcomes as part of the quality and effectiveness equation. Using a limited number of domains will gather data on a handful of accurate measures, rather than create a sea of minimally useful data, thus trimming and reducing the reporting requirements of the States.

Finally, SAMHSA is actively promoting a Science to Services agenda. After years of discussion about SAMHSA's role in "knowledge development", we are reinforcing our mission in services and in bringing evidence-based, effective products of research to community programs nationwide. We are also reinforcing the clear expectation contained in our authorizing legislation that SAMHSA and the National Institutes of Health (NIH) should collaborate to promote the study, dissemination, and implementation of research findings that improve the delivery and effectiveness of substance abuse and mental health services. As a result, we have recently taken steps to expand our partnership with the NIH to produce a comprehensive "Science to Services" agenda that is responsive to the needs of the field. We have initiated a dialogue with the Directors of NIH's National Institute on Alcohol Abuse and Alcoholism, National Institute on Drug Abuse, and National Institute of Mental Health, and we have made a common commitment to this agenda. We are working to define and develop a "Science to Services" cycle that reduces the time between the discovery of an effective treatment or intervention and its adoption as part of community-based care, which the Institute of Medicine tells us today can take up to 20 years.

Conclusion

Mr. Chairman and Members of the Subcommittee, as the Administrator of SAMHSA, I have taken a hard look and taken steps to clarify SAMHSA's vision and mission. We have set the Agency on a new course being guided by accountability, capacity, and effectiveness. We will continue to manage to the Matrix. With the imperative of the President's commitment to grow our substance abuse treatment capacity coupled with the findings of the New Freedom Mental Health Commission, and with your support SAMHSA, we will continue to work toward achieving a vision of a life in the community for everyone.

Thank you for the opportunity to appear today. I will be pleased to answer any questions you may have.

Last Revised: July 28, 2003

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