The document summarizes key points from a presentation given by Pamela S. Hyde, Administrator of SAMHSA, at an annual research conference on September 2, 2010. Some of the main topics discussed include challenges facing adolescents with substance abuse issues, dramatic shifts in substance abuse treatment for pregnant teens, the prevalence of mental illness in America and its links to other health issues, and strategic initiatives being undertaken by SAMHSA to address issues like prevention, trauma, military families, and health insurance reform.

1. 9/7/2010
Behavioral Health 2010:
Challenges and Opportunities
Ch ll dO t iti
Pamela S. Hyde, J.D.
SAMHSA Administrator
Annual NPN Research Conference
Denver, Colorado • September 2, 2010
FULL OF CHALLENGES…FULL OF OPPORTUNITIES
A Day in the Life of American Adolescents
3
 U.S. Adolescents (12‐17) on an average day in 2008…
● 508,000 drink alcohol
● 641,000 use illicit drugs
● > than 1 million smoke cigarettes
 Adolescents who used illegal substances for the 1st time on an average day in 2008:
● Approximately 7,500 drank alcohol for the 1st time
● Approximately 4,360 used an illicit drug for the 1st time
● Around 3,900 smoked cigarettes for the 1st time
● Nearly 3,700 used marijuana for the 1st time
● ~ 2,500 abused pain relievers for the 1st time
 Current illicit drug use 2009 appears higher than 2008 – all ages
alcohol & tobacco use unchanged; perceived risk of harm declined
1

2. 9/7/2010
A NEW SAMHSA NATIONAL REPORT:
DRAMATIC PATTERN SHIFTS IN ADMISSION TO SUBSTANCE ABUSE
TREATMENT AMONG PREGNANT TEENS BETWEEN 1992 AND 2007
4
The proportion of pregnant teen
admissions for marijuana abuse more
than doubled from 19.3% in 1992 to
45.9% in 2007
Marijuana has surpassed alcohol as
the primary substance of abuse cited
in admissions for pregnant girls
The proportion of pregnant teen
admissions for methamphetamine use
has more than quadrupled, from 4.3%
in 1992 to18.8% in 2007
BEHAVIORAL HEALTH THREADS THROUGH
AMERICA’S HEALTH
5
Mental Illness affects one in four families
Almost ¼ of all adult stays in U.S. community hospitals
Involved mental or substance use disorders
Up to 83% of people with serious mental
g
illness are overweight or obese
People with serious mental illness have
shortened life‐spans, on average living
only until 53 years of age
44% of all cigarettes consumed in the U.S. are by
individuals with a mental illness or substance use
disorder
64% of antidepressants are prescribed by primary
care offices, hospitals, outpatient programs or surgical
offices
SUICIDE: NATIONWIDE
6
 3rd
leading cause of death among all youth 15‐24 years old
 1.8 times higher among American Indian/Alaska Native adolescents
and young adults age 15‐34
 Over 1.1 million Americans attempted suicide and over 8 million
seriously considered suicide
i l id d i id
 More than 33,000 suicides occurred in the U.S., equaling 91 suicides
per day; one suicide every 16 minutes
 Approximately 90% of individuals who die by suicide had a mental
disorder, and 40% had visited their primary care doctor within the
month ‐ the question of suicide was seldom raised
 Alcohol use is a factor in approximately 30% of all suicide deaths
2

3. 9/7/2010
SAMHSA’s DIRECTION
7
 Mission: To reduce the impact of substance abuse and
mental illness on America’s communities
 Roles:
● Voice and leadership
● Funding ‐ service capacity development
● Information/Communications
● Regulation and standard setting
● Improve practice
 Strategic initiatives
SAMHSA’s STRATEGIC INITIATIVES HELP TO:
8
 Provide focus
● Budget planning
● Program development (New RFAs)
 Align resources
Align resources
● Block Grants, formula grants, discretionary
grants, contracts
● Human capital/program management
 Create consistent message
 A work in progress
● Public input/open government
SAMHSA’s STRATEGIC INITIATIVES
9
1. Prevention of substance abuse and mental illness
2. Trauma and justice
3. Military families
4. Health insurance reform implementation
5. Health information technology
6. Housing and homelessness
7. Data, quality, and outcomes
8. Public awareness and support
3

4. 9/7/2010
STRATEGIC INITIATIVE NO. 1:
PREVENTION OF SUBSTANCE ABUSE AND MENTAL ILLNESS
SAMHSA’s Strategic Initiatives
10
 SA/MI prevention; emotional health development
● Prevention Prepared Communities
● Tobacco use among persons with MI/SUDs
● Disabling impacts of mental illnesses
 Underage drinking/Alcohol policies
 Suicide
● Youth
● Tribal communities
● Military‐connected individuals
 Prescription drug abuse/misuse
2009 IOM REPORT
11
Common risk and resiliency factors
● Build emotional health in young children
● Prevent substance abuse, adolescent depression, conduct
disorders
Signs evident 2‐4 years before disorder
Intervene earlier, consistently and across multiple
institutions
● Parents, teachers, clergy, community, health practitioners
Coordinate/collaborate at policy levels
PREVENTION WORKS!
12
Widespread decreases in SU over the past several years in U.S. were
encouraging ‐ Illicit drug use may be ↑ and perceived risk of harm
stagnating
Cost‐benefit ratios for early treatment & prevention SA/MI programs
range from 1:2 to 1:10 meaning $1.00 in investment yields $2.00 to
$10.00 savings in health costs, criminal & juvenile justice costs,
$10 00 savings in health costs criminal & juvenile justice costs
educational costs, lost productivity, etc.
Project Success—1 of 58 substance abuse prevention interventions
listed on National Registry of Evidence‐based Programs and Practices
(NREPP):
● 37% decrease in alcohol, tobacco and other drug use (ATOD) after year one
● Of the students using ATOD at pretest, 23% stopped ATOD use
● At second year follow‐up, students who reported using ATOD at pretest, 33.3%
reportedly stopped using alcohol, 45.0% reportedly stopped using marijuana,
and 22.9% reportedly stopped using tobacco
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5. 9/7/2010
PREVENTION WORKS!
13
SAMHSA’s Safe School/Healthy Students Grant Program:
● Bullying ↓5%
● Fighting ↓8%
● Verbal Abuse ↓11%
↓
● Alcohol Use (past 30 days) ↓11%
● Cigarette Use at School ↓19%
● Feeling Unsafe at School ↓7%
Preventive intervention for adolescents can reduce the incidence
of depressive disorders by 23%
Almost one quarter (24%) of pediatric primary care office visits
involve behavioral and mental health problems
STRATEGIC INITIATIVE NO. 2: TRAUMA AND JUSTICE
SAMHSA’s Strategic Initiatives
14
 Public health approach to trauma
 Trauma informed care and screening; trauma
specific service
 Prevention & diversion from juvenile justice and
adult criminal justice systems
 Reduce impact of violence and trauma on
children/youth
STRATEGIC INITIATIVE NO. 3: MILITARY FAMILIES
– GUARD, RESERVE, AND VETERAN
SAMHSA’s Strategic Initiatives
15
 Improve access to care
 Suicide prevention
 Improve quality of care
 Knowledge of military culture
Knowledge of military culture
 Promote emotional & psychological health
 Build and support resilience
 Streamline policies & resources
● ↑Partnerships
● ↑Prevention for families
● ↓Homelessness
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6. 9/7/2010
STRATEGIC INITIATIVE NO. 4: HEALTH REFORM
SAMHSA’s Strategic Initiatives
16
 Affordable Care Act
 Medicaid/Medicare
 Parity
 Block Grants
 Primary Care/Behavioral Health Integration
IMPACT OF AFFORDABLE CARE ACT
17
MAJOR DRIVERS
● More people will have insurance coverage
● Medicaid will play a bigger role in MH/SUD than ever before
p y gg /
● Focus on primary care and coordination with specialty care
● Major emphasis on home and community based services and
less reliance on institutional care
● Preventing diseases and promoting wellness is a huge theme
WHAT’S IN AFFORDABLE CARE ACT FOR
BEHAVIORAL HEALTH?
18
COVERAGE
 32 million newly insured – expands Medicaid to 133% FPL ‐ estimated 16 million
new enrollees
• 4‐6 million Medicaid are likely to have significant MI/SUD service needs (6‐10
million total)
 High risk pools for those with pre‐existing conditions (2010)
 Youth covered through parents insurance until they turn 26 years old (2010)
 Expanded options in home and community‐based services for individuals with
mental health and substance use disorders supports recovery orientation
● 1915i
● Money follows the person extension
● Section 10202—increased FMAP for HCBS services
● Special need plans
6

7. 9/7/2010
IMPACT OF AFFORDABLE CARE ACT:
MEDICAID
19
$370 billion spent on individuals with Medicaid and
Medicare ‐ 60% of these individuals have a ID or MH/SUD
39% of individuals served by SMHAs have no insurance
(CMHS)
61% of the individuals served by SSAs have no insurance
Services for some of these individuals are purchased with
BG Funds
Many will be covered in 2014 (or sooner) – most likely by
the expansion in Medicaid
WHAT’S IN AFFORDABLE CARE ACT FOR
BEHAVIORAL HEALTH?
20
SERVICES
● Allows state Medicaid programs to establish health homes for those with chronic
illnesses – states must consult/coordinate with SAMHSA re: MH/SUD prevention &
treatment
● Grant dollars will be for community prevention, wellness, and support services not
p
paid for through insurance benefit plans
g p
● Parity required in essential benefits plans offered through exchanges and in private
health plans that choose to offer MH/SUD
● Grants to community MH programs for co‐locating primary and specialty care
services
● Establishes CLASS Program – voluntary, self‐funded long‐term care insurance
program for people currently employed – flexible funds for support services to
people with disabilities including Mental illness
● Establishes a “Medicaid Emergency Psychiatric Demonstration”
WHAT’S IN AFFORDABLE CARE ACT
FOR BEHAVIORAL HEALTH?
21
FOCUS ON PRIMARY CARE
● 5 different medical home initiatives to focus on coordinating
primary and specialty care
● Enhanced federal incentives (Medicaid and Medicare) for
Enhanced federal incentives (Medicaid and Medicare) for
these initiatives
● Significant grant funds to educate primary care
FOCUS ON HOME AND COMMUNITY BASED SERVICES
● Expansion of Medicaid to additional HCBS services and for
individuals in institutional care (PRTFs/IMD 65+)
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8. 9/7/2010
WHAT’S IN AFFORDABLE CARE ACT FOR
BEHAVIORAL HEALTH?
22
TRAINING & RESEARCH
 Increased patient‐centered health research
 Training grants for behavioral health workforce
 Training on MH/SUD for primary care extender
SUPPORT FOR WORKFORCE DEVELOPMENT
 Funding for residencies for behavioral health included with other
disciplines (HRSA)
 Loan repayment programs
 Push towards more national certification standards and re‐
licensure/re‐certification
 Primary care/behavioral health integration ‐‐ bidirectional
WHAT’S IN AFFORDABLE CARE ACT FOR
PREVENTION?
23
Prevention research programs and national prevention
plans
Coverage of preventive services in private insurance and
Medicare including SBIRT, without cost‐sharing and with a
financial incentive to do the same in Medicaid
financial incentive to do the same in Medicaid
Prevention Trust Fund (2010)
Allows Medicare payments for annual wellness visits
including assessment and recommendations to address
MH conditions or risks
Establishes a national public/private outreach and
education campaign re: prevention
WHAT’S IN AFFORDABLE CARE ACT FOR
PREVENTION?
24
 The Affordable Care Act requires health plans to cover a number of preventive
services related to behavioral health without cost sharing (for plans effective on
or after 09/23/10)
 Adults
● Alcohol misuse screening and counseling
● Tobacco use screening & cessation interventions
● Depression screening
● HIV screening for those at higher risk
HIV screening for those at higher risk
● Obesity screening and counseling
 Pregnant Women
● Special, pregnancy‐tailored counseling for tobacco cessation and avoiding alcohol use
 Children
● HIV screening for those at higher risk
● Sexually transmitted infection prevention and counseling for adolescents at higher risk
● Alcohol and drug use assessments and screening for depression for adolescents
● Behavioral assessments for children of all ages
● Developmental screening (under age 3) and surveillance (throughout childhood)
● Autism screening for children at 18 and 24 months
● Obesity screening and counseling
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9. 9/7/2010
SAMHSA’s ROLE IN MOVING IMPLEMENTATION OF
AFFORDABLE CARE ACT FORWARD
25
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
National Prevention, Health Promotion and Public Health Council
Prevention and Public Health Fund
Prevention and Public Health Fund
Education and Outreach Campaign
School‐Based Health Centers include MH/SUD
Incentives for Prevention of Chronic Diseases in Medicaid
SAMHSA’s ROLE IN MOVING IMPLEMENTATION OF
AFFORDABLE CARE ACT FORWARD
26
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Maternal, Infant, and Early Childhood Home Visiting Program
Community Transformation Grants
Evaluation of Community‐Based Prevention and
g
Wellness Programs
Technical Assistance for Employer‐Based Wellness Programs
Pediatric Health Care Workforce
Grants to Accredited Programs and MH
g g
Organizations for training BH Professionals
SAMHSA’s ROLE IN MOVING IMPLEMENTATION OF
AFFORDABLE CARE ACT FORWARD
27
Consultation regarding health homes
● Start date: 5 months and counting
● States amend Medicaid state plan
p
● 90% match initially—big incentives for states
● Definitional work on services and providers
● Protocol for states to request/receive TA from states
● SMD letter
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10. 9/7/2010
SAMHSA’s ROLE IN MOVING IMPLEMENTATION OF
AFFORDABLE CARE ACT FORWARD
28
Developing quality measures for HCR
Primary care/behavioral health integration
(both directions)
(both directions)
● Expansion of current sites
● Proposed expansion of 15 more sites
● TA center
● Interface with CMS and health homes
SAMHSA’s ROLE IN MOVING IMPLEMENTATION OF
AFFORDABLE CARE ACT FORWARD
29
Home Visiting Program
● Major focus on families that have or are at risk of
having an SUD
● Immediate ‐ responses to initial RFA submitted
● SAMHSA active participant in work group
● SSAs must sign off on application
SAMHSA’s ROLE IN MOVING IMPLEMENTATION OF
AFFORDABLE CARE ACT FORWARD
30
Specific work regarding post‐partum depression (HRSA
has lead)
Prevention! Prevention! Prevention!
 i ! i ! i !
● Regulations
● Focused strategies for adding services to USPSTF
Health information technology changes
10

11. 9/7/2010
WHAT WORK HAS BEEN DONE?
31
 Identifying services that comprise a “good” and “modern” mental health and
addiction system—foundational work
● From prevention to recovery
 Identifying BH Measures that will be in the first round of meaningful use
y g g
measures for EHRs
● Initiation and Engagement of Other Drug Dependence Treatment
● New Episode of Depression
 Prevention Trust Fund (2010 $$ for Primary Care/BH integration)
 Prevention Task Force report
 Home Visiting RFA—significant focus on addictions
WHAT WORK HAS BEEN DONE?
32
Work plans for each provision where SAMHSA has responsibility
● Primary care behavioral health initiative
● COE for depression
● Post‐partum depression
Review of Policies and Regulations (28)
Review of Policies and Regulations (28)
● High risk pools
● Prevention
● Grandfathering of plans
● Medicare payment regulations
● SMD letters
Work with HHS on web portal www.HealthCare.gov
Working meeting with CMS regarding parity
WHAT WORK REMAINS?
33
 Developing additional services that can be used for the exchange (prevention,
recovery, support services for children and families)
 Supporting states, providers, individuals and families to understand the changing
environment
● R d
Roadmap for states
f t t
● Dealing with addiction services gap
● Cross association provider infrastructure support
● Lessons learned from 6 states
● HCR basics
 Developing quality measures for BH that can be used for us and other purchasers
 SAMHSA is active participant in all HHS health care reform workgroups
11

12. 9/7/2010
WHAT WORK REMAINS?
34
Preparing field to expand access
● Capacity to provide MH/SU services (workforce)
● Accessing and developing strategies to improve infrastructure
(data, HIT)
● Facilitating linkage with primary care and other providers
Review current block grant spending
● Different services to support individuals/families in recovery &
resiliency
● Use for services and individuals not covered by Medicaid and/or
commercial insurance 34
ROLE OF STATES IN AFFORDABLE
CARE ACT IMPLEMENTATION
35
General
● Role as payer expanding
● Role in preparing state Medicaid programs now for expansion in
2014 (enrollment, benefit plans, payments, etc.)
2014 ( ll b fi l )
● Role in HIT is expanding
● Role in high risk pools unfolding
● Role in insurance exchanges unfolding through HHS
● Role in evaluating state insurance markets and weighing against
possible benefits of new exchanges
ROLE OF STATES IN AFFORDABLE
CARE ACT IMPLEMENTATION
36
State substance abuse and mental health agencies
● New kind of leadership required with and by state
agencies – (Medicaid, insurance commissioner, HIT
g ( , ,
coordinator)
● Change in use of block grant dollars (moving demos to
practice)
● Supporting communities selected for discretionary
grants
12

13. 9/7/2010
ROLE OF PROVIDERS
IN AFFORDABLE CARE ACT IMPLEMENTATION
37
Develop partnerships with primary care and other
specialty care systems—identify what roles they can play
in or as medical homes
Improve their infrastructure
I th i i f t t
● Operations (e.g. billing)
● Electronic health records
● Compliance
Developing a competent workforce including use of
peers or recovery coaches
STRATEGIC INITIATIVE NO. 5:
HEALTH INFORMATION TECHNOLOGY
38
BH provider adoption/implementation of EHRs
EHR standards and quality measures
EHR standards and quality measures
Privacy/confidentiality issues
Engage state HIT leaders
STRATEGIC INITIATIVE NO. 6:
HOUSING & HOMELESSNESS
39
Prevent homelessness
Create permanent stable housing
Implement supportive housing
services
Focus on families and persons
who are experiencing chronic
homelessness
13

14. 9/7/2010
STRATEGIC INITIATIVE NO. 7:
DATA, QUALITY, AND OUTCOMES
SAMHSA’s Strategic Initiatives
40
 Integrated approach – single SAMHSA data platform
 Common data requirements for states to improve quality
and outcomes
● Trauma and military families
● Prevention billing codes
● Recovery measures
 Common evaluation and service system research
framework
● For SAMHSA programs
● Working with researchers to move findings to practice
● Improvement of NREPP as registry for EBPs
SAMHSA COLLECTS AND REPORTS
41
General population data
State level data
Community level data
Program level data
Treatment services data
Emergency departments and mortality data
INFORMATION IN…
42
National Survey on Drug Use and Health (NSDUH)
Drug Abuse Warning Network (DAWN)
Drug and Alcohol Services Information System (DASIS)
Treatment Episode Data Set (TEDS)
Treatment Episode Data Set (TEDS)
National Survey of Substance Abuse Treatment Services (N‐SSATS)
Alcohol and Drug Services Study (ADSS)
Drug Services Research Survey (DSRS)
CSAT Substance Abuse Information System (SAIS)
CMHS TRACS and CSAP Prevention Data System
14

15. 9/7/2010
INFORMATION OUT…
43
Substance Abuse & Mental Health Data Archive (SAMHDA)
SAMHSA Office of Applied Studies (OAS) Reports
SAMHSA’s National Clearinghouses (NCADI & NMHIC)
Substance Abuse Treatment Facility Locator
S b Ab T F ili L
NREPP – National Registry of Evidence‐based Programs and Practices
(164 current interventions)
EBP Toolkits
Knowledge Application Programs (KAP)
Treatment Improvement Protocols (TIPs)
STRATEGIC INITIATIVE NO. 8:
PUBLIC AWARENESS AND SUPPORT
SAMHSA’s 10 Strategic Initiatives
44
 Understanding of and access to services
 Cohesive SAMHSA identity
● SAMHSA branding
● Consolidation of websites
Consolidation of websites
● Common fact sheets
● Single 800 #
 Consistent messages – communications plan for
initiatives
● Use of social media
 Tools to improve policy and practice
 ↑Social inclusion and ↓discrimination
SAMHSA PRINCIPLES
45
 People
● Stay focused on the goal
 Partnership
● Cannot do it alone
 Performance
● Make a measurable difference
15