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| | **OMB No: 0930-0168**                                            |  |
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| | **Approval Expires:07/31/2007**                                  |  |
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|                                                                       |
| **TRANSFORMING MENTAL HEALTH CARE**                                   |
|                                                                       |
| **IN AMERICA**                                                        |
|                                                                       |
| **COMMUNITY MENTAL HEALTH SERVICES**                                  |
|                                                                       |
| **BLOCK GRANT APPLICATION GUIDANCE AND INSTRUCTIONS**                 |
|                                                                       |
| **FY 2007**                                                           |
|                                                                       |
| **CFDA No. 93.958**                                                   |
|                                                                       |
| **Upon enactment of the President's FY 2007 Budget, States will be    |
| required to modify the FY 2007 plan to describe transformation        |
| activities and appropriate outcome measures that are consistent with  |
| the FY 2007 appropriations language.**                                |
|                                                                       |
| ![](media/image1.png){width="6.622222222222222in"                     |
| height="1.1236111111111111in"}                                        |
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**TABLE OF CONTENTS FOR APPLICATION GUIDANCE PACKAGE**

####### 

####### INTRODUCTION: 4

**PART A: Context and Overview of FY 2006-2007 MHBG Application**

> I. Statutory Authority 7
>
> II\. History and Goals of Federal Mental Health Funding and Planning
> Requirements 8
>
> III\. Planning Initiatives to Increase Accountability 11
>
> IV\. Plan Format: Child/Adult Plans; One Year and Multi-Year Plans 13

**PART B: Administrative Requirements, Fiscal Planning Assumptions, and
Special Guidance**

> I. Federal Funding Agreements, Certifications, Assurances &
> Requirements.
>
> (1). Funding Agreements 15
>
> (2). Certifications 15
>
> \(3\) Disclosure of Lobbying Activities 15
>
> (4). Assurances 16
>
> (5). DUNS Number 16
>
> (6). Public Comments on State Plans 16
>
> II\. Set-Aside for Children's Mental Health Services Report 17
>
> III\. Maintenance of Effort (MOE) Report 17
>
> \(1\) MOE Exclusion 18
>
> \(2\) MOE Shortfall 19
>
> IV\. Fiscal Planning Assumptions 19
>
> V. Submission Requirements and Due Dates 20
>
> VI\. State Mental Health Planning Council 21
>
> (1). Membership Requirements 21
>
> (2). State Mental Health Planning Council Membership List and
> Composition 22
>
> (3). Planning Council Charge, Role and Activities 22
>
> (4). State Mental Health Planning Council Comments and Recommendations
> 22

**PART C: Specific Guidance for State Applications and Plans**

Section I: Description of State Service System 26

Section II: Identification and Analysis of Service System's Strengths,
Needs and Priorities 26

Section III. Performance Goals and Action Plans to Improve the Service
System 31

> (1). Common Requirements for Adult and Child Plans 31
>
> (2). National Outcome Measures 31
>
> (***3). State Specific Transformation Outcome Measures 32***
>
> (4). Format of Plans 34
>
> \(a\) Adult Plan 34
>
> \(b\) Children's Plan 36
>
> **(*c) FY 2007 MHBG Transformation Reporting Form*
> *...................................\...38 ***

####### PART D: Implementation Report 39

####### I. Narrative Content of the Implementation Report 39

####### II. Performance Indicators 40

####### III. Accomplishments 41

####### 

####### PART E: Uniform Data on the Public Mental Health System 42

####### 

**Attachments:**

Attachment A: Funding Agreements 45

Attachment B: Certifications 49

Attachment C: Disclosure of Lobbying Activities 49

Attachment D: Assurances 49

Attachment E: Face Sheet 50

**Appendices:**

I. Format to Construct and Report Performance Indicators 51

II\. Examples of Mental Health Transformation Activities and Services 61

III\. Format for Table of Contents 63

***IV. FY 2007 Appropriations Language 65***

***V.* *Allocation Table for Transformation Funding 66***

### 

### Notice to Respondents

The annual reporting burden for collection of this information is
estimated to average 3*20* hours for a one-year application, 2*90* hours
for updating a two-year plan, and 25*9* hours for updating a three-year
application. This includes the time required for reviewing instructions
and preparing the application, requesting waivers and modifications,
writing the implementation report, and gathering, maintaining, and
reporting the needed data. Comments regarding this burden estimate or
any other aspect of this collection of information, including
suggestions for reducing the burden should be addressed to: SAMHSA
Reports Clearance Officer, Paperwork Reduction Project (0930-0168), Room
7-1045, One Choke Cherry Road, Rockville, MD 20857. An agency may not
conduct or sponsor or a person is not required to respond to a
collection of information unless it displays a currently valid OMB
control number. The OMB control number for this project is: 0930-0168.

**INTRODUCTION:**

The FY 2007 Community Mental Health Services (CMHS) Block Grant
Application Guidance and Instruction Packet that follows is intended to
provide specific guidance and instructions regarding the development and
submission of the required plan. The Guidance is based on the existing
CMHS Block Grant legislation and provides a foundation for further
transformation of the state mental health system. The existing five (5)
criteria continue to be the framework for the mental health system of
care and should be used to guide State planning efforts. There continues
to be an emphasis on the reporting and use of the National Outcome
Measures (NOMS).

States should submit the FY 2007 plan based upon the standard guidance
in this instruction packet. States will not be required to address
transformation as described below and in the FY 2007 appropriations
language until the appropriations language becomes law. For this
purpose, any reference made to the requirement for States to describe
and report transformation activities in this application guidance and
instructions will be provided in bold print.

***Should the President's FY 2007 Budget be enacted, States will be
required to modify the FY 2007 plan to describe transformation
activities and appropriate outcome measures that are consistent with the
FY 2007 appropriations language. See FY 2007 appropriations language in
Appendix IV. This Application Guidance is written to be consistent with
the President's FY 2007 Budget request for priority funding mental
health transformation through the Mental Health Block Grant. The budget
request requires States to use a portion of its Block Grant allotment to
fund mental health transformation activities and to report to CMHS
annually on the use of the funds and to report on the outcomes of
transformation activities. Additionally, the Guidance provides a
structure to identify and highlight state-specific transformation
activities, both infrastructure development and services, planned and
implemented by the State Mental Health Authority.***

***[The Federal Action Agenda: First Steps]{.underline} defines
transformation as "a bold vision to change the very form and function of
the mental health service delivery system to better meet the needs of
the individuals and families it is designed to serve". Transformation of
State mental health systems encompasses a process that occurs in a
non-linear fashion that requires collaboration, innovation, sustained
commitment, and willingness to learn from past mistakes. Transformation
has implication for policy, funding and practice as well as attitudes
and beliefs, is a continuous process that leads to profound change in
structure, culture, policy and programs, and grounded in principles that
are both consumer and family driven and focuses on facilitating recovery
and resilience.***[^1]

***Examples of State transformation activities: 1) a traditional day
treatment program that moves into supported employment and onto
competitive employment; 2) a partial hospitalization program that
transitions into a community stabilization/mobile treatment team; 3) the
initiation of peer support services as a demonstrated method of
community integration and means of building social relationships; and,
4) in rural communities where workforce shortages have existed,**
**specialized training may be provided to support use of telemedicine as
an effective means of providing mental health treatment. ***

***Other examples of transformation activities are referenced in the
Report of the President's New Freedom Commission on Mental Health and
include but are not limited to activities directed toward:***

-   ***reduction of the stigma associated with mental illness;***

-   ***suicide prevention***

-   ***linking mental health care with primary care***

-   ***improving coordination of care among multiple systems***

-   ***assuring individualized plans of care for all consumers***

-   ***facilitating consumers' access to employment and affordable
    housing***

-   ***development of culturally competent services***

-   ***removing disparities in access to and quality of care***

-   ***provision of Evidence Based Practices***

-   ***addressing needs of workforce***

-   ***aligning financing for mental health services for maximum
    benefit.***

The Application Guidance and Instructions Packet consist of five parts:

-   Part A provides a context and overview of the FY 2006 -- 2007
    application with a more detailed discussion of the transition to
    performance partnerships.

-   Part B outlines the administrative requirements, fiscal planning
    assumptions, and other special guidance that is required for
    submission of the application.

-   Part C provides guidance for development of the three sections of
    the plan, including a description of the State's Service System,
    Identification and Analysis of the Service System's Strengths,
    Needs, and Priorities, Mental Health Transformation Activities, and
    Performance Goals and Action Plans to Improve the Service System for
    adults and children separately.

-   Part D gives guidance for preparation and submission of the
    Implementation Report which is used to describe the extent to which
    the State has implemented its prior year plan.

-   Part E provides guidance on submission of the Basic and
    Developmental Data Tables from the Uniform Data Reporting System.

There are also several required attachments and several appendices that
provide useful resource information needed for the plan.

**PART A: CONTEXT AND OVERVIEW OF FY 2006-2007 CMHBG APPLICATION**

> **I. Statutory Authority**
>
> Under the authority of the Public Health Service Act (PHS Act)[^2] and
> subject to the availability of funds, the Secretary of the Department
> of Health and Human Services, through the Center for Mental Health
> Services (CMHS), Substance Abuse and Mental Health Services
> Administration (SAMHSA), awards Block Grants to States to establish or
> expand an organized community-based system for providing mental health
> services for adults with serious mental illness (SMI) and children
> with serious emotional disturbances (SED). In order for the Secretary
> to award these Block Grants, States, Territories and the District of
> Columbia (herein after referred to as States) are required to submit
> an application, prepared in accordance with the law, for each fiscal
> year for which the State is seeking funds. The funds awarded are to be
> used to carry out the State plan contained in the application, to
> evaluate programs and services set in place under the plan, and to
> conduct planning, administration and educational activities related to
> the provision of services under the plan.
>
> Specific authority for requiring data from the States is found in
> three different Sections of the law. First, the Secretary is required
> to establish definitions for SMI and SED.[^3] Second, in order to
> receive funding, States will provide to the Secretary any data
> required pursuant to Section 505, and will cooperate with the
> Secretary in the development of uniform criteria for the collection of
> data pursuant to such section. [^4] Third, the application (including
> the plan under Section 1912(a)), must be otherwise in such form, made
> in such manner, and contain such agreements, assurances, and
> information as the Secretary determines to be necessary to carry out
> this subpart.[^5] A grant may be made only if the plan meets the five
> (5) criteria in the law and is approved by CMHS. [^6] After review of
> the State plan implementation report for the previous fiscal year,
> CMHS must also determine that the State has completely implemented the
> plan approved for the previous fiscal year.

**II. History and Goals of Federal Mental Health Funding and Planning
Requirements**

Federal financial support of mental health programs has gone through
many transitions from its beginning in 1963 with passage of the
Community Mental Health Centers legislation to provide comprehensive
services in local communities, [^7] through conversion to block grants
in 1981, and passage of legislation in 1986 and 1990 requiring states to
develop and enhance comprehensive community-based systems of care.[^8]
In 1992, Congress passed legislation that moved responsibility for
administration of the mental health block grant and state planning
requirements from the National Institute of Mental Health to the newly
formed Center for Mental Health Services, part of the Substance Abuse
and Mental Health Services Administration of the Department of Health
and Human Services. Finally, in 2000, legislative changes allowed states
more flexibility in the use of block grant funds. [^9]

Over the past 20 years, the evolution of policy changes which tie the
mental health block grant funds to the development and implementation of
state plans has had the following key goals:

-   Access to a comprehensive system of care, including employment,
    housing, case management, rehabilitation, dental and health
    services, along with mental health services and supports;

-   Participation of consumers/survivors and their families in planning
    and evaluation of state systems;

-   Access for underserved populations, including homeless people and
    rural populations;

-   Promoting recovery and community integration of people with
    psychiatric disabilities; and,

-   Accountability through uniform reporting on access, quality, and
    outcomes of services.

These goals have been reaffirmed in recent years by several key federal
developments: the Surgeon General's Report on Mental Health (1999); the
New Freedom Initiative for People with Disabilities (2001); and the
report of the New Freedom Commission on Mental Health (2003). These
documents emphasize the importance of access to work, housing,
rehabilitation, and other services which support integration into the
community for people with psychiatric disabilities, as well as the other
goals listed above.

The President's New Freedom Commission on Mental Health was charged to
study the problems and gaps in the mental health system and make
concrete recommendations for immediate improvements that the Federal
government, State governments, local agencies, as well as public and
private health care providers could implement. The vision of the
Commission was "a future when everyone with a mental illnesses will
recover, when mental illnesses can be prevented or cured, when mental
illnesses are detected early, and when everyone with a mental illness at
any stage of life has access to effective treatment and supports --
essentials for living, working, learning, and participating fully in the
community. The Commission was formed to propose an agenda to transform
mental health care, which included the expansion of access to mental
health services; promotion of evidence based practices, more early
assessment and treatment; and consumer and family driven mental health
care. The July 2003 Final Report of this Commission, entitled "Achieving
the Promise: Transforming Mental Health Care in America," acknowledges
that the public mental health system is fragmented and in disarray, and
does not fulfill the promise of a meaningful life in the community for
people with psychiatric disabilities. The Report recommends six broad
goals for a transformed public mental health system that would promote
recovery:

1)  Americans understand that mental health is essential to overall
    health;

2)  Mental health care is consumer and family- driven;

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3)  Disparities in mental health services are eliminated;

4)  Early mental health screening, assessment and referral are common
    practice;

5)  Excellent mental health care is delivered and research is
    accelerated; and,

6)  Technology is used to access mental health care and
    information.[^10]

Each of these major goals has sub-goals; Goal 2, "Mental health care is
consumer and family-driven," has as one of its sub-goals a call for more
attention to comprehensive state mental health planning, and a call for
more accountability, not just to federal funders, but to consumers and
families as well.

Recognizing that "in the past decade, mental health consumers have
become involved in planning and evaluating the quality of mental health
care and in conducting sophisticated research to affect system reform,"
the Report goes on to recommend that "local, state, and federal
authorities must encourage consumers and families to participate in
planning and evaluating treatment and support services. The direct
participation of consumers and families in developing a range of
community-based, recovery-oriented treatment and support services is a
priority."[^11]

# III. Planning Initiatives 

The release of "Achieving the Promise: Transforming Mental Health Care
in America," is a critical and significant development at the national
level; and it is proving to be formative to the planning and goals of
the Mental Health Block Grant (MHBG). In July 2005, SAMHSA/CMHS
announced another major planning initiative to focus on the
collaboration among twenty-one (21) Federal agencies to support and
foster transformation of the nation's mental health system. This
initiative is described in the publication titled "The Federal Action
Agenda: First Steps." These developments support models for a
comprehensive, community-based system of care for individuals with
serious mental illness, the ultimate goal of the MHBG.

***The most recent initiative is a component of the President's FY 2007
Budget that proposes Federal support to States through the MHBG for
mental health transformation. The budget language proposes the following
\..." States that receive an allotment for the current fiscal year shall
use any amount it receives in fiscal year 2007 which is in excess of
what it received under such section in 1998 to support mental health
transformation activities such as the expansion of access, advancement
of evidence based practices, promotion of early assessment and
treatment, and promotion of consumer and family driven mental heatlh
care. A State that receives an allotment under section 1911 will report
annually to SAMHSA on its use of funds and the outcomes of mental health
transformation activities." See FY 2007 appropriations language in
Appendix IV.***

Accountability in the delivery of quality mental health services for
adults with serious mental illness and children with serious emotional
disturbance continues to be an integral part of the planning process and
will be measured by the collection of standardized data from the States
using uniform outcome measures (NOMS) and other measures specific to
mental health services as determined by the individual States according
to their priorities and needs. The NOMS are shown in Table 4 and are
derived from the Uniform Reporting System (URS) set of Basic and
Developmental Tables located in Appendices I and II.

These tables also serve as the basis for the Data Infrastructure Grants
(DIG) that were first offered to States and Territories in FY 2001 to
provide funding to improve their data collection activities that would
result in reporting uniform data that could be aggregated on a national
basis. CMHS, working with the States and Territories, are
operationalizing the measures included in the data tables through
monthly meetings of CMHS program staff and staff from the States.

All States and Territories that accepted a DIG are required to submit
data on the URS tables consistent with the work that has been
accomplished in the DIG including using the uniform definitions and
methods agreed to by the States and Territories. Likewise, the measures
that States and Territories will use for reporting and planning purposes
in their State plans should be consistent with and reflect the data
reported in the related URS table. Lastly, as the work progresses under
the DIG, States will be expected to begin reporting those items.
Instructions and expectations regarding the actual reporting and
implementation of NOMS that are currently under development will be
transmitted separately.

***The inclusion of a focus on specific activities directed toward
transformation of the State mental health system in the FY 2007
Application Guidance and Instructions continues the transformation of
the mental health block planning process. This focus, in addition to the
partnership with State Mental Health Authorities (SMHA), will lead to
the development of a comprehensive plan that will advance the goals and
recommendations of the Report of the President's New Freedom Commission
on Mental Health and will result in a service system that is consumer
driven and based on the principles of recovery and resilience.***

**IV. Plan Format: Child/Adult Plans; One Year and Multi-Year Plans**

Under Section 1912(b) of PHS Act (42 USC 300x-2), the State Plan must
address the five (5) legislated criteria. Criteria 1, 2, 4 and 5 must be
addressed for adults with SMI, and Criteria 1-5 must be addressed for
children with SED. States should submit a single plan in which services
for both adults with SMI and children with SED are addressed separately.
***Upon enactment of the President's FY 2007 Budget, States will be
required to submit a modified plan, which describes transformation
activities and appropriate outcome measures (see attached FY 2007
appropriations language.***

\(1\) [Application Overview for Single Year Plans in 2007]{.underline}

In preparing State Plans for FY 2007 (due September 1, 2006), States
should use this Application Guidance and Instructions. The application
must include a Face Sheet, a Table of Contents, an Executive Summary,
and all items required in Part B, Part C (Sections I-III). The
implementation report (Part D & E), due December 1, 2006, will describe
the extent to which the State implemented its mental health plan for FY
2006 and will include data from the Uniform Reporting System (URS
Tables).

The plan (Sections I-III) must address each element of the four (4)
criteria for adults and five (5) criteria for children as enumerated in
the block grant legislation*. **Mental health transformation activities
to be included in the planning process should be added within the
specific criterion to which they relate.*** The plan should contain
goals and targets for the NOMS. States that received approval to exclude
funds from the maintenance of effort calculation should include those
MOE approval documents, as well. If changes occur during the year that
affects the plan as submitted to CMHS, States may submit a modification
of the Plan to CMHS. States are also reminded that criterion 5 requires
information on how the grant will be expended and a funding plan.

[(3) Guidance Specific to Two or Three-Year Plans Approved in FY 2005
and 2006]{.underline}

States that were approved for three year plans in FY 2005 and/or two
year plans in FY 2006 will be required to submit all items in Part B.
Under Part C, Section I will not need to be re-submitted unless the
State's public mental health system has substantially changed and/or the
State Mental Health Agency's authority changes within the State's
organizational structure. Only modifications and changes to Sections II
and III must be submitted with the State's application, and should
describe changes in critical gaps and unmet needs, identify significant
achievements reflecting progress towards development of a comprehensive
community-based mental health system, and document any changes in the
original goals and targets.

***States that were approved for three year plans in FY 2005 and/or two
year plans in FY 2006 must submit adequate narrative to describe the
State's mental health transformation activities. Additionally,
multi-year plans are required to provide a description of how the State
plans to use its allotted MHBG funds to support mental health
transformation activities, include at least one State transformation
outcome measure and report the amount of Block Grant funds expended for
mental health transformation activities during the fiscal year. (See
Appendix II for list of transformation activities and services).***

All performance indicator tables must be updated each year to include
narrative as needed. States that submitted two-year plans in 2006 are
expected to ensure that their plans are updated to reflect the current
status of their mental health systems. ***State mental health
transformation outcome measures in the 2007 State plan must be clearly
labeled**.*

It is important that the MHBG Program be notified of changes made in the
State\'s mental health system after the Plan has been submitted through
written modification submitted to SAMHSA's Division of Grants Management
Office. Before submitting applications each year, States should assess
the impact of any positive or negative changes that occurred in the
previous year that will affect the State\'s ability to carry out the
proposed plan. If changes are necessary, States may modify the plan as
part of the application package (thus modifying the original plan). In
modifying previously approved plans, States should identify specific
changes referring to page numbers of the original plan, rather than
simply making changes to the original plan and resubmitting it. These
modifications should be discussed in detail within the context of the
affected criteria, goals, and targets and submitted to SAMHSA's Division
of Grants Management Office.

**PART B. ADMINISTRATIVE REQUIREMENTS, FISCAL PLANNING ASSUMPTIONS, AND
SPECIAL GUIDANCE**

**I. Federal funding agreements, certifications and assurances and
Requirements**

> Federal funding agreements, certifications, assurances and other
> requirements are necessary each year in order for States to receive
> mental health block grant funds.

**(1)** **Funding Agreements** (Attachment A)

> Do not retype the Funding Agreement; this may require re-submission of
> the agreement which could delay the award of funds. The Chief
> Executive Officer (Governor) or a formal designee must sign the
> statutory funding agreements, hereby attesting that the State will
> comply with them. If the funding agreements are signed by a designee,
> a letter from the Governor authorizing the person to sign must be
> included with the application.

**(2)** **Certifications -- PHS 5161-1** (Attachment B) - (OMB Approval
0920-0428)

> Do not retype any of the certifications; this may require
> re-submission of a certification, which could delay the award of
> funds.
>
> **(a) Debarment and Suspension**

A fully executed Debarment and Suspension Certification must be
included.

> **(b) Drug-Free Workplace Requirements**

A fully executed certification regarding Drug-Free Workplace
Requirements must be included with the application unless the State has
an acceptable FY 1997 Statewide or Agency-wide certification on file
with the Department of Health and Human Services. Federal regulations
regarding these requirements are found in 45 CFR Part 76.

> **(c) Lobbying and Disclosure**

A fully executed Lobbying Certification must be included for all awards
exceeding \$100,000. This certification must be signed by the Chief
Executive Officer of the State (Governor) or his/her formally authorized
designee. Additional information about this requirement can be found in
45 CFR Part 93.

Included in the FY 2007 Application Guidance and Instructions is a copy
of Standard Form-LLL "Disclosure of Lobbying Activities" and
instructions to report lobbying activities.

> **(d)** **Program Fraud Civil Remedies Act (PFCRA)**
>
> **(e)** **Environmental Tobacco Smoke**
>
> **(3) Assurances SF 424B** (Attachment C) - (OMB Approval 0348-0040)

Do not retype any of the assurances; this may require re-submission of
the assurance(s), which could delay the award of funds.

**(4)** **DATA UNIVERSAL NUMBERING SYSTEM (DUNS) NUMBER**

A DUNS number is a unique 9-digit number required for all applicants for
Federal grants and cooperative agreements, with the exception of
individuals other than sole proprietors. The number is used to identify
related organizations that receive funding under grants and cooperative
agreements, and to provide consistent name and address. The DUNS Number
should be entered on the Face Sheet of the State's Plan/Application.

**(5) PUBLIC COMMENT ON THE STATE PLAN**

Section 1941 of the Block Grant legislation stipulates that as a
condition of the funding agreement for the grant, States will provide
opportunity for the public to comment on the State Plan. States will
make the mental health plan public in such a manner to facilitate
comment from any person (including Federal or other public agency)
during the development of the plan (including any revisions) and after
the submission of the plan to the Secretary. States should describe
their efforts and procedures to obtain public comment on the plan in
this section.

**Ii. SET-ASIDE FOR CHILDREN'S MENTAL HEALTH SERVICES REPORT**

States are required to provide systems of integrated services for
children with serious emotional disturbances (SED).[^12] Each year the
State shall expend not less than the calculated amount for FY 1994.

Data Reported by:

# State FY \_\_\_\_\_\_\_\_\_\_\_\_\_ Federal FY\_\_\_\_\_\_\_\_\_\_\_\_\_

## State Expenditures for Mental Health Services

**Calculated FY 1995 Actual FY 2005 Estimate/Actual FY 2006**

\$ \_\_\_\_\_\_\_\_\_\_\_\_\_\_ \$ \_\_\_\_\_\_\_\_\_\_\_\_\_ \$
\_\_\_\_\_\_\_\_\_\_\_\_

**Waiver of Children's Mental Health Services**

If there is a shortfall in children's mental health services, the State
may request a waiver. A waiver may be granted if the Secretary
determines that the State is providing an adequate level of
comprehensive community mental health services for children with serious
emotional disturbance as indicated by a comparison of the number of such
children for which such services are sought with the availability of
services within the State. The Secretary shall approve or deny the
request for a waiver not later than 120 days after the request is made.
A waiver granted by the Secretary shall be applicable only for the
fiscal year in question.

**III. Maintenance of Effort (MOE) Report**

States are required to submit sufficient information for the Secretary
to make a determination of compliance with the statutory MOE
requirements.[^13] MOE information is necessary to document that the
State has maintained expenditures for community mental health services
at a level that is not less than the average level of such expenditures
maintained by the State for the 2-year period preceding the fiscal year
for which the State is applying for the grant.

# MOE Exclusion 

The Secretary may exclude from the aggregate amount any State funds
appropriated to the principle agency for authorized activities of a
non-recurring nature and for a specific purpose. [^14]

States must consider the following in order to request an exclusion from
the MOE requirements:

1.  The State shall request the exclusion separately from the
    application;

2.  The request shall be signed by the State's Chief Executive Officer
    or by an individual authorized to apply for CMHS Block Grant on
    behalf of the Chief Executive Officer;

3.  The State shall provide documentation that supports its position
    that the funds were appropriated by the State legislature for
    authorized activities which are of a non-recurring nature and for a
    specific purpose; indicates the length of time the project is
    expected to last in years and months; and affirms that these
    expenditures would be in addition to funds needed to otherwise meet
    the State's maintenance of effort requirement for the year for which
    it is applying for exclusion.

The State may not exclude funds from the MOE calculation until such time
as the Administrator of SAMHSA has approved in writing the State's
request for exclusion.

States are required to submit State expenditures in the following
format:

**MOE information reported by:**

# State FY \_\_\_\_\_\_\_\_\_\_\_\_\_ Federal FY\_\_\_\_\_\_\_\_\_\_\_\_\_ 

## State Expenditures for Mental Health Services

**Actual FY 2004 Actual FY 2005 Estimate/Actual FY 2006**

\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\$\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

####### MOE Shortfalls

States are expected to meet the MOE requirement. If they do not meet the
MOE requirement, the legislation permits relief, based on the
recognition that extenuating circumstances may explain the shortfall.
These conditions are described below.

(1). Waiver for Extraordinary Economic Conditions

A State may request a waiver to the MOE requirement if it can be
demonstrated that the MOE deficiency was the result of extraordinary
economic conditions that occurred during the SFY in question. An
extraordinary economic condition is defined as a financial crisis in
which the total tax revenues declined at least one and one-half percent,
and either the unemployment increases by at least one percentage point,
or employment declines by at least one and one-half percent. In order to
demonstrate that such conditions existed, the State must provide data
and reports generated by the State's management information system
and/or the State's accounting system.

(2). Material Compliance

If the State is unable to meet the requirements for a waiver under
extraordinary economic conditions, the authorizing legislation does
permit the Secretary, under certain circumstances, to make a finding
that even though there was a shortfall on the MOE, the State maintained
material compliance with the MOE requirement for the fiscal year in
question. Therefore, the State is given an opportunity to submit
information that might lead to a finding of material compliance. The
relevant factors that SAMHSA considers in making a recommendation to the
Secretary include: 1) whether the State maintained service levels, 2)
the State's mental health expenditure history, and 3) the State's future
commitment to funding mental health services.

**IV. Fiscal Planning Assumptions**

*For FY 2007, States are expected to develop their intended use of funds
based on their FY 2006 Mental Health Block Grant allocation**. However,
upon enactment of the President's FY 2007 Budget, States will be
required to submit a modified plan that provides a description of how
the State plans to expend the mental health block grant funds based on
the FY 2007 State Allocations and FY 1998 Actuals required for mental
health transformation activities. (See Allocation Table for
Transformation funding in Appendix V)*****.** Funds awarded under this
Block Grant must be obligated and expended within the two-year period.
For the FY 2007 block grant award, the period is October 1, 2006 through
September 30, 2008. States are also required to submit a Financial
Status Report (SF 269 Short Form) 90 days after the end of the
obligation and expenditure period which is December 31, 2008.

**V. Submission Requirements and Due Dates**

Please submit an original application plus two copies to Ms. LouEllen M.
Rice, Grants Management Officer, Division of Grants Management, OPS,
SAMHSA, 1 Choke Cherry Road,, Room 7-1091, Rockville, Maryland 20857
(for overnight/express mail, use zip code "20850". Parts B and C
(Sections I, II, & III) of the State plans/applications are due on
September 1, 2006, and Parts D (Implementation Report) and E (Uniform
Reporting System) are due December 1, 2006. These are statutorily set
due dates and waivers cannot be given. [^15] If your State application
and Implementation Report are not received in the Office of Grants
Management by these mandatory dates, it will be impossible for your
State to obtain a grant for the year indicated.

Detailed guidance and instructions for each section of this application
are provided. Upon request, CMHS will supply a 3.5\" MSWord disk
containing the application guidance and instructions. The application is
available at the SAMHSA web site as
[www.mhbg.samhsa.gov](http://www.mhbg.SAMHSA.gov/). With the exceptions
of the Federal Agreements, Certifications and Assurances, all parts of
the application may be completed electronically and e-mailed to Deborah
Baldwin, Project Officer, State Planning and Systems Development Branch,
at <deborah.baldwin@samhsa.hhs.gov>.

If the application is sent electronically, the signed original and two
copies of Part B, **and** the original Mental Health Planning Council
comments signed by the Chairperson, must be submitted to Ms. Rice by the
due date. Should you need additional information regarding submission of
the application, contact Ms. Rice at (240) 276-1404. Should you have
programmatic questions, contact your Federal Project Officer at (240)
276-1760.

It would be helpful to have a copy of each State's plan sent
electronically to expedite the Block Grant review process. Copies should
be emailed to <deborah.baldwin@samhsa.hhs.gov>.

The original and two (2) copies should be submitted unbound, without
staples, paper clips or fasteners. Do not attach or include anything
folded, pasted, or in a size other than 8^½"^ x11\" on white paper.
Heavy or lightweight paper should not be used, and submissions should be
printed only on one side. Do not condense type closer than 15 characters
per inch. Each sheet of the application should be numbered consecutively
from beginning to the end (for example, page 1 for the face sheet,
etc.). If appendices or additional materials are included, they should
be numbered continuing the same sequence. It is recommended that the
State plan be limited to 120 pages; if the application exceeds 120 pages
and /or is bound, please provide 10 copies.

**VI. State Mental Health Planning Council**

(1). [Membership Requirements]{.underline}

State Mental Health Planning Councils are required to conform to certain
membership requirements. [^16] This includes representatives of certain
principal State agencies;[^17] other public and private entities
concerned with the need, planning, operation, funding and use of mental
health services and related services; adults who are current or former
consumers of mental health services; family members of adults with
serious mental illness and children with serious emotional disturbances,
and representatives of organizations of individuals with mental illness
and their families and community groups advocating on their behalf.
Specifically, the law stipulates that not less than 50% of the members
of the planning council shall be individuals who are not State employees
or providers of mental health services. The law also requires that the
ratio of parents of children with SED to other members of the Council be
sufficient to provide adequate representation of such children in the
deliberations of the Council.

(2). [State Mental Health Planning Council Membership List and
Composition]{.underline}

To demonstrate compliance with the statutory membership requirements,
Tables 1 and 2 should be completed for the current fiscal year. In the
Table 1 column, "Type of Membership," indicate whether a member is a
consumer, a family member of a child with SED, a family member of an
adult with SMI, a provider, a state employee, or a representative not
otherwise stated in the legislation.

(3). [Planning Council Charge, Role and Activities]{.underline}

State Mental Health Planning Councils are required to perform certain
duties.[^18] If available, a charter or a narrative summarizing the
duties of the Planning Council should be included. This section should
also specify the policies and procedures for the selection of council
members, their terms, the conduct of meetings, and a report of the
Planning Council's efforts and related duties as mandated by law:

-   reviewing plans and submitting to the State any recommendations for
    modification

-   serving as an advocate for adults with serious mental illness,
    children with a severe emotional disturbance, and other individuals
    with mental illnesses or emotional problems,

-   monitoring, reviewing, and evaluating, not less than once each year,
    the allocation and adequacy of mental health services within the
    State.^25^

-   the role of the Planning Council in improving mental health services
    within the State.

***In addition to the duties mandated by law, States should include a
brief description of the role of the Planning Council in the State's
transformation activities that are described in Part C, Section II and
Section III.***

(4). [State Mental Health Planning Council Comments and
Recommendations]{.underline}

With the Plan submission, States are required to submit documentation
that the State Plan was shared with the Planning Council. Any comments
and recommendations to the State plan received from the Planning Council
must be submitted, regardless of whether the State has accepted the
recommendations. In the annual implementation report, States are also
required to submit documentation that the State Plan was shared with the
Planning Council and must include any comments from the Council on the
State's annual implementation report. The documentation, preferably in a
letter signed by the Chair, should indicate that the Council has
reviewed the State plan and the annual report with particular attention
to the transformation activities that are highlighted and specified in
the plan.

**TABLE 1.** List of Planning Council Members

+-----------------+-------------+--------------+---------------------+
| **Name**        | **Type of   | ##           | **Address, Phone &  |
|                 | Mem         | Agency or Or | Fax**               |
|                 | bership\*** | ganization R |                     |
|                 |             | epresented\* |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+
|                 |             |              |                     |
+-----------------+-------------+--------------+---------------------+

\*Council members should be listed only once by type of membership and
agency/organization represented. See type of membership in Table 2.

**TABLE 2. Planning Council Composition by Type of Member**

+----------------------------------------------+----------+-----------+
| ## Type of Membership                        | **       | **P       |
|                                              | Number** | ercentage |
|                                              |          | of Total  |
|                                              |          | Mem       |
|                                              |          | bership** |
+----------------------------------------------+----------+-----------+
| **TOTAL MEMBERSHIP**                         |          |           |
+----------------------------------------------+----------+-----------+
| **Consumers/Survivors/Ex-patients (C/S/X)**  |          |           |
+----------------------------------------------+----------+-----------+
| # Family Members of Children with SED        |          |           |
+----------------------------------------------+----------+-----------+
| **Family Members of Adults with SMI**        |          |           |
+----------------------------------------------+----------+-----------+
| **Vacancies (C/S/X & family members)**       |          |           |
+----------------------------------------------+----------+-----------+
| **Others (Not state employees or             |          |           |
| providers)**                                 |          |           |
+----------------------------------------------+----------+-----------+
| **Total C/S/X, Family Members & Others**     |          |           |
+----------------------------------------------+----------+-----------+
| **State Employees**                          |          |           |
+----------------------------------------------+----------+-----------+
| **Providers**                                |          |           |
+----------------------------------------------+----------+-----------+
| **Vacancies**                                |          |           |
+----------------------------------------------+----------+-----------+
| **Total State Employees & Providers**        |          |           |
+----------------------------------------------+----------+-----------+

[Note:]{.underline} 1) The ratio of parents of children with SED to
other members of the Council must be sufficient to provide adequate
representation of such children in the deliberations of the Council, 2)
State employee and provider members shall not exceed 50% of the total
members of the Planning Council, and 3) Other representatives may
include public and private entities concerned with the need, planning,
operation, funding, and use of mental health services and related
support services.

**PART C. SPECIFIC GUIDANCE FOR STATE APPLICATIONS AND PLANS**

**SECTION I. Description of State Service System**

In this section, States are requested to identify issues or initiatives
within the State that are important in understanding the State plan in
the context of the broader system. The section should include:

-   An overview of the State's mental health system: a brief description
    of how the public mental health system is currently organized at the
    State and local levels, including the State Mental Health Agency's
    authority in relation to other State agencies.

-   A brief summary of areas identified by the State in the previous
    State plan as needing particular attention, including the
    significant achievements in its previous fiscal year.

-   New developments and issues that affect mental health service
    delivery in the State, including structural changes such as Medicaid
    waivers, managed care, State Children's Health Insurance Program
    (SCHIP) and other contracting arrangements.

-   Legislative initiatives and changes, if any.

-   A brief description of regional/sub- State programs, community
    mental health centers, and resources of counties and cities, as
    applicable, to the provision of mental health services within the
    State.

-   A description of how the State mental health agency provides
    leadership in coordinating mental health services within the broader
    system.

**SECTION II. Identification and Analysis of the Service System's
Strengths, Needs and Priorities**

This section should be written primarily in narrative form with separate
discussions of services for adults and children. In preparing the
discussions, each presentation should be organized so that it follows
the five criteria established in law. Within the discussion, States
should separately address the following:

-   A discussion of the strengths and weaknesses of the service system;

-   An analysis of the unmet service needs and critical gaps within the
    current system, and identification of the source of data which was
    used to identify them

-   A statement of the State's priorities and plans to address unmet
    needs.

-   A brief summary of recent significant achievements that reflect
    progress towards the development of a comprehensive community-based
    mental health system of care.

-   A brief description of the comprehensive community-based public
    mental health system that the State envisions for the future*.*

***States are requested to integrate the discussion of mental health
transformation activities into the broader description, identification,
and analysis of the service system's strengths, needs, and priorities
using the goals from the Report of the President' New Freedom Commission
to structure the discussion.***

**Table 3.**

**Statutory Criteria and Transformation Activities to be addressed in
the State Plan**.

+-----------------------------------------------------------------------+
| **Criterion 1: Comprehensive Community-Based Mental Health Service    |
| Systems**                                                             |
|                                                                       |
| Provides for the establishment and implementation of an organized     |
| community-based system of care for individuals with mental illness.   |
|                                                                       |
| ● Describes available services and resources in a comprehensive       |
| system of care, including services for individuals with both mental   |
| illness and substance abuse. The description of the services in the   |
| comprehensive system of care to be provided with Federal, State, and  |
| other public and private resources to enable such individuals to      |
| function outside of inpatient or residential institutions to the      |
| maximum extent of their capabilities shall include:                   |
|                                                                       |
| • Health, mental health, and rehabilitation services;                 |
|                                                                       |
| • Employment services;                                                |
|                                                                       |
| • Housing services;                                                   |
|                                                                       |
| • Educational services;                                               |
|                                                                       |
| • Substance abuse services;                                           |
|                                                                       |
| • Medical and dental services;                                        |
|                                                                       |
| • Support services;                                                   |
|                                                                       |
| > • Services provided by local school systems under the Individuals   |
| > with Disabilities Education Act;                                    |
|                                                                       |
| • Case management services;                                           |
|                                                                       |
| > • Services for persons with co-occurring (substance abuse/mental    |
| > health) disorders; and                                              |
|                                                                       |
| • Other activities leading to reduction of hospitalization.           |
|                                                                       |
| -   ***Describes mental health transformation activities in the State |
|     in Criterion 1, providing reference to specific goal(s) of the    |
|     NFC Report to which they relate.***                               |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ##  Criterion 2: Mental Health System Data Epidemiology               |
|                                                                       |
| ● Contains an estimate of the incidence and prevalence in the State   |
| of serious mental illness among adults and serious emotional          |
| disturbance among children; and                                       |
|                                                                       |
| ● Presents quantitative targets to be achieved in the implementation  |
| of the system of care described under Criterion 1.                    |
|                                                                       |
| -   ***Describes mental health transformation activities in the State |
|     in Criterion 2, providing reference to specific goal(s) of the    |
|     NFC Report to which they relate.***                               |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ###  Criterion 3: Children's Services                                 |
|                                                                       |
| ● Provides for a system of integrated services appropriate for the    |
| multiple needs of children without expending the grant under Section  |
| 1911 for the fiscal year involved for any services under such system  |
| other than comprehensive community mental health services. Examples   |
| of integrated services include:                                       |
|                                                                       |
| > • Social services;                                                  |
| >                                                                     |
| > • Educational services, including services provided under the       |
| > Individuals with Disabilities Education Act;                        |
| >                                                                     |
| > • Juvenile justice services;                                        |
| >                                                                     |
| > • Substance abuse services; and                                     |
| >                                                                     |
| > • Health and mental health services.                                |
|                                                                       |
| -   ***Describes mental health transformation activities in the State |
|     in Criterion 3, providing reference to specific goal(s) of the    |
|     NFC Report to which they relate.***                               |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ### Criterion 4: Targeted Services to Rural and Homeless Populations  |
|                                                                       |
| ● Describes State's outreach to and services for individuals who are  |
| homeless;                                                             |
|                                                                       |
| ● Describes how community-based services will be provided to          |
| individuals in rural areas                                            |
|                                                                       |
| -   ***Describes mental health transformation activities in the State |
|     in Criterion 4, providing reference to specific goal(s) of the    |
|     NFC Report to which they relate.***                               |
|                                                                       |
| *.*                                                                   |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| **Criterion 5: Management Systems**                                   |
|                                                                       |
| ### Describes financial resources, staffing and                       |
| training for mental health services providers necessary for the plan. |
|                                                                       |
| ● Provides for training of providers of emergency health services     |
| regarding mental health.                                              |
|                                                                       |
| ● Describes the manner in which the State intends to expend the grant |
| under Section 1911                                                    |
|                                                                       |
| > for the fiscal years involved, *to include a description of how     |
| > funds will be expended for mental health system transformation.     |
| > (See Transformation Reporting Form)*                                |
|                                                                       |
| -   ***Describes mental health transformation activities in the State |
|     in Criterion 5, providing reference to specific goal(s) of the    |
|     NFC Report to which they relate.***                               |
+-----------------------------------------------------------------------+

Note: Criteria 1, 2, 4 and 5 must be addressed in the Adult Plan;
Criteria 1-5 must be addressed in the Children's Plan.

**Note: *The identified transformation activities should be consumer and
family driven, recovery and resilience based, and as much as possible,
utilize existing evidence-based and promising practices including
approaches that are consumer owned and operated. ***

***A number of examples of such activities are referenced in the Report
of the New Freedom Commission on Mental Health and include but are not
limited to activities directed toward:***

-   ***reduction of the stigma associated with mental illness***

-   ***suicide prevention***

-   ***linking mental health care with primary care***

-   ***improving coordination of care among multiple systems***

-   ***assuring individualized plans of care for all consumers***

-   ***facilitating consumers' access to employment and affordable
    housing***

-   ***development of culturally competent services***

-   ***removing disparities in access to and quality of care***

-   ***provision of Evidence Based Practices***

-   ***addressing needs of workforce***

-   ***aligning financing for mental health services for maximum
    benefit.***

### 

### 

### SECTION III: Performance Goals and Action Plans to Improve the Service System

1\. [Common Requirements for Adult and Child Plans]{.underline}

SAMHSA, in partnership with the States, identified data to be used to
develop performance indicators that will increase accountability and
demonstrate on a state-by-state basis whether community-based services
lead to better outcomes for people served. SAMHSA has identified a set
of National Outcome Measures (NOMS) that States are expected to
integrate into their Mental Health Block Grant planning process.

This section should be organized in the same way as Section II above,
with separate discussions of services for adults and children and
organized so that it follows the five criteria, including the new
prompts for transformation activities. Rather than focusing on
strengths, needs and priorities, this section will focus on specific
performance goals and action plans. State plans should include a
description in narrative form of current activities in the context of
the five required criteria as well as goals, targets, and action plans
for the appropriate criterion using the NOMS (see Table 4 below), as
well as any state-specific indicators they may choose. The State
information will include specific performance goals and a description of
how the State intends to achieve the performance goals. States may
continue to develop and maintain state-specific performance indicators
that they find useful for tracking improvements in the public mental
health system. More detailed instructions for incorporating the
narrative for the five required criteria and the performance indicators
are presented in the instructions for the Adult and Child Plan below.

2\. National Outcome Measures

For each of the 5 criteria, States should continue to develop, maintain
and report on state-specific performance indicators that they find
useful for tracking improvements within the State and transformation of
the mental health system, in addition to incorporating the NOMS
discussed above. States should provide information on these indicators,
including specific performance goals, target performance levels, and a
description of how the State intends to achieve those performance goals.

**3. *State Transformation Outcome Measures***

***States are required to identify at least one state specific mental
health transformation outcome measure and to report a performance
indicator related to the measure. State specific transformation
performance indicator(s) shall be constructed according to the guidance
provided in this document under* *Item 4 of Section III: Format of
Plans, and should be labeled as transformation outcome measures. ***

Table 4 Illustrates the National Outcome Measures:

> 1\. The four National Outcome Measures required by the OMB PART.
> States are expected to incorporate these four measures along with the
> State-specific indicators in the FY 2007 Plan. In future years,
> requirements for reporting on the remaining NOMS will be phased in and
> updated as needed.

2\. The location of the four NOMS within the five criteria.

> 3\. The table distinguishes which NOMS are derived from the Basic
> Tables and Developmental Tables. Those derived from the Developmental
> Tables will require further collaborative work by SAMHSA and the
> States to specify and define the measures used to construct them. Once
> work on a Developmental Table is finalized through the DIG process, it
> is expected that States will begin reporting data and incorporating
> the measure into the plan. It is expected that all developmental
> measures will be finalized by the end of FY 2007.

**Table 4.**

**NATIONAL OUTCOME MEASURES (NOMS)**

+--------------+---------------+---------+---------------+-----------+
| **National   |               | **Rel   | **DIG         | **PART**  |
| Outcome      |               | evant** | Tables**      |           |
| Measures**   |               |         |               |           |
|              |               | **Crit  | **Basic &**   |           |
|              |               | erion** |               |           |
|              |               |         | **De          |           |
|              |               |         | velopmental** |           |
+--------------+---------------+---------+---------------+-----------+
| **INDICATORS |               |         |               |           |
| EXPECTED IN  |               |         |               |           |
| 2006 OR      |               |         |               |           |
| COMPLETE     |               |         |               |           |
| STATE LEVEL  |               |         |               |           |
| DATA         |               |         |               |           |
| REPORTING    |               |         |               |           |
| CAPACITY     |               |         |               |           |
| CHECKLIST    |               |         |               |           |
| \***         |               |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **1.         | Number of     | C       | Basic         | Yes       |
| Increased    | Persons       | riteria |               |           |
| Access to    | Served by     | 2 and 3 | Tables 2A and |           |
| Services\*** | Age, Gender,  |         | 2B            |           |
|              | and           |         |               |           |
|              | R             |         |               |           |
|              | ace/Ethnicity |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| ####         | Decreased     | C       | Developmental | Yes       |
|              | Rate of       | riteria |               |           |
| **2. Reduced | Readmission   | 1 and 3 | Table 20A     |           |
| Utilization  | to State      |         |               |           |
| of           | Psychiatric   |         |               |           |
| Psychiatric  | Hospitals     |         |               |           |
| Inpatient    | within 30     |         |               |           |
| Beds\***     | days and 180  |         |               |           |
|              | days          |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **3. Use of  | Number of     | C       | Developmental | Yes       |
| Ev           | E             | riteria |               |           |
| idence-Based | vidence-based | 1 and 3 | Tables 16 and |           |
| P            | Practices     |         | 17            |           |
| ractices\*** | Provided by   |         |               |           |
|              | State         |         |               |           |
+--------------+---------------+---------+---------------+-----------+
|              | Number of     | C       | Developmental | Yes       |
|              | Persons       | riteria |               |           |
|              | Receiving     | 1 and 3 | Tables 16 and |           |
|              | E             |         | 17            |           |
|              | vidence-based |         |               |           |
|              | Practice      |         |               |           |
|              | Services      |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **4. Client  | Clients       | C       | Basic         | Yes       |
| Perception   | Reporting     | riteria |               |           |
| of Care\***  | Positively    | 1 and 3 | Table 11      |           |
|              | About         |         |               |           |
|              | Outcomes      |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **INDICATORS |               |         |               |           |
| ENCOURAGED   |               |         |               |           |
| TO BE        |               |         |               |           |
| INCLUDED IN  |               |         |               |           |
| THE STATE    |               |         |               |           |
| PLAN IF      |               |         |               |           |
| STATE HAS    |               |         |               |           |
| CAPACITY TO  |               |         |               |           |
| REPORT**     |               |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **5.         | Profile of    | Cr      | Basic         | No        |
| Incre        | Adult Clients | iterion |               |           |
| ase/Retained | by Employment | 1       | Table 4       |           |
| Employment   | Status        |         |               |           |
| or Return    |               |         |               |           |
| to/Stay in   |               |         |               |           |
| School**     |               |         |               |           |
+--------------+---------------+---------+---------------+-----------+
|              | Increased     | C       | Developmental | No        |
|              | school        | riteria |               |           |
|              | attendance    | 1 and 3 | Table 19C     |           |
+--------------+---------------+---------+---------------+-----------+
| **6.         | Profile of    | C       | Developmental | No        |
| Decreased    | Client        | riteria |               |           |
| Criminal     | Involvement   | 1 and 3 | Table 19A and |           |
| Justice      | in Criminal   |         | 19B           |           |
| I            | and Juvenile  |         |               |           |
| nvolvement** | Justice       |         |               |           |
|              | Systems       |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **INDICATORS |               |         |               |           |
| IN           |               |         |               |           |
| D            |               |         |               |           |
| EVELOPMENT** |               |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **7.         | TO BE         | C       | Developmental | No        |
| Increased    | DETERMINED    | riteria |               |           |
| Social       |               | 1 and 3 | TBD           |           |
| Sup          |               |         |               |           |
| ports/Social |               |         |               |           |
| Con          |               |         |               |           |
| nectedness** |               |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **8,         | Profile of    | C       | Developmental | No        |
| Increased    | client's      | riteria |               |           |
| Stability in | change in     | 1 and 3 | Table 15      |           |
| Housing**    | living        |         |               |           |
|              | situation     |         |               |           |
|              | (including    |         |               |           |
|              | homeless      |         |               |           |
|              | status)       |         |               |           |
+--------------+---------------+---------+---------------+-----------+
| **9.         | TO BE         | C       | Developmental | No        |
| Improved     | DETERMINED    | riteria |               |           |
| Level of     |               | 1, 3,   | TBD           |           |
| F            |               | and 4   |               |           |
| unctioning** |               |         |               |           |
+--------------+---------------+---------+---------------+-----------+

The selection of specific goals and targets for NOMS is determined by
each State. States will also determine the goals and targets for State
selected performance indicators, to include mental health
transformation**.** The goal, targets, and performance indicators should
be prepared for each criterion following the one-page sample in Appendix
I, National Outcome Measures and State Specific Performance Indicators.
For each goal, target and corresponding performance indicator included
in the State plan, a similar one-page description employing the same
format should be included.

4\. [Format of Plans]{.underline}

#######  (a) Adult Mental Health Plan

> \(i\) Current Activities
>
> States should describe their adult mental health service system in a
> narrative that addresses Criteria 1, 2, 4, & 5 of Table 3 above.
> Narratives for each criterion should convey the extent to which the
> services required under the criterion have been implemented.
>
> \(ii\) Goals, Targets and Action Plans
>
> For each criterion, the plan should include goals, targets and action
> plans which include state specific performance indicators and state
> specific transformation performance indicators for adults with SMI
> that are useful for tracking improvements in the public mental health
> system within the State in addition to the NOMS discussed above. A
> narrative describing the State's actions toward achieving these
> improvements must accompany the indicators.

Further description of the construction of the indicators is shown in
Appendix I. If States are unable to collect and report the data for any
of the tables from which the NOMS are constructed, the State Level Data
Reporting Capacity Checklist should be completed or a narrative provided
that describes the State's efforts toward building capacity to collect
the data and an estimated completion data. However, States are
encouraged to complete and include in the plan all indicators that can
be constructed from available data in the URS Tables.

For each indicator, States must show the data for the past two years (to
the extent that it is available), and project a specific target for the
next year (or the next two years for multi-year plans.) The most common
table format for presenting indicators is provided below. Accompanying
narrative describing actions the State intends to take to achieve each
of its goals must also be presented. Further instructions related to
preparation of performance indicators are shown in Appendix I.

Performance Indicator Table for State Plan

**Name of Performance Indicator:**

**Population:**

**Criterion:**

**Related to Transformation** **Yes** **No**

+---------------------+----------+------------+----------+------------+
| \(1\)               | \(2\)    | \(3\)      | \(4\)    | \(5\)      |
+---------------------+----------+------------+----------+------------+
| Fiscal              | FY2004   | FY2005     | FY2006   | FY 2007    |
|                     |          |            |          |            |
| Year                | Actual   | Actual     | P        | Target     |
|                     |          |            | rojected |            |
+---------------------+----------+------------+----------+------------+
| Performance         |          |            |          |            |
|                     |          |            |          |            |
| Indicator           |          |            |          |            |
+---------------------+----------+------------+----------+------------+
| Numerator           |          |            | \-\--    | \-\--      |
+---------------------+----------+------------+----------+------------+
| Denominator         |          |            | \-\--    | \-\--      |
+---------------------+----------+------------+----------+------------+

> [Table Descriptors:]{.underline}
>
> **Name of Performance Indicator**: Brief name of the performance
> indicator (*e.g*., Increased Access to Services); ***clearly label
> transformation outcome measures.***
>
> **Population:** SED Children or name special population
>
> **Criterion:** *e.g*., "Criterion 1, Comprehensive Community-Based
> Mental Health Service System"
>
> **Target**: a target is specific, measurable, and expected to be
> achieved within a defined period of time, and, if attained, is
> expected to contribute to the realization of the goal
>
> **Performance Indicator**=Numerator divided by Denominator (except in
> cases where there is no denominator) and expressed as a percentage.
>
> [Columns:]{.underline}
>
> \(2\) Actual FY2004 value for the performance indicator, including
> both numerator and denominator if the performance indicator is a rate.
>
> \(3\) Actual FY2005 value for the performance indicator, including
> both numerator and denominator if the performance indicator is a rate.
>
> \(4\) State projected value for this performance indicator for FY2006;
> **it is not necessary to include the numerator and denominator.**
>
> \(6\) State target for FY2007;
>
> \(b\) Children's Mental Health Plan
>
> \(i\) Current Activities
>
> States should describe their adult mental health service system in a
> narrative that addresses Criteria 1, 2, 4, & 5 of Table 3 above.
> Narratives for each criterion should convey the extent to which the
> services required under the criterion have been implemented.
>
> \(ii\) Goals, Targets and Action Plans
>
> For each criterion, the plan should include goals, targets and action
> plans which include the state specific performance indicators and
> state specific transformation performance indicators for children with
> SED that are useful for tracking improvements in the public mental
> health system within the State in addition to the CMHS Core
> Performance Indicators discussed above. A narrative describing the
> State's actions toward achieving these improvements must accompany the
> indicators.

####### Further description of the construction of the indicators is shown in Appendix I. If States are unable to collect and report the data for any of the tables from which the CMHS Core Performance Indicators are constructed, the State Level Data Reporting Capacity Checklist should be completed or a narrative provided that describes the State's efforts toward building capacity to collect the data and an estimated completion date. However, States are encouraged to complete and include in the plan all indicators that can be constructed from available data in the URS Tables. 

####### 

####### For each indicator, States must show the data for the past two years (to the extent that it is available), and project a specific target for the next year (or the next two years for multi-year plans.) The Table format for presenting each indicator is presented below. Accompanying narrative describing actions the State intends to take to reach each of its goals must also be presented.

Performance Indicator Table for State Plan

**Name of Performance Indicator:**

**Population:**

**Criterion:**

**Related to Transformation** **Yes** **No**

+---------------------+----------+------------+----------+------------+
| \(1\)               | \(2\)    | \(3\)      | \(4\)    | \(5\)      |
+---------------------+----------+------------+----------+------------+
| Fiscal              | FY2004   | FY2005     | FY2006   | FY 2007    |
|                     |          |            |          |            |
| Year                | Actual   | Actual     | P        | Target     |
|                     |          |            | rojected |            |
+---------------------+----------+------------+----------+------------+
| Performance         |          |            |          |            |
|                     |          |            |          |            |
| Indicator           |          |            |          |            |
+---------------------+----------+------------+----------+------------+
| Numerator           |          |            | \-\--    | \-\--      |
+---------------------+----------+------------+----------+------------+
| Denominator         |          |            | \-\--    | \-\--      |
+---------------------+----------+------------+----------+------------+

> [Table Descriptors:]{.underline}
>
> **Name of Performance Indicator**: Brief name of the performance
> indicator (*e.g*., Increased Access to Services); ***clearly label
> transformation outcome measures.***
>
> **Population:** SED Children or name special population
>
> **Criterion:** *e.g*., "Criterion 1, Comprehensive Community-Based
> Mental Health Service System"
>
> **Target**: a target is specific, measurable, and expected to be
> achieved within a defined period of time, and, if attained, is
> expected to contribute to the realization of the goal
>
> **Performance Indicator**=Numerator divided by Denominator (except in
> cases where there is no denominator) and expressed as a percentage.
>
> [Columns:]{.underline}
>
> \(2\) Actual FY2004 value for the performance indicator, including
> both numerator and denominator if the performance indicator is a rate.
>
> \(3\) Actual FY2005 value for the performance indicator, including
> both numerator and denominator if the performance indicator is a rate.
>
> \(4\) State projected value for this performance indicator for FY2006;
> **it is not necessary to include the numerator and denominator.**
>
> \(5\) State target for FY2007;

***Table 5. FY 2007 MHBG Transformation Reporting Form***

***FY 2007 MHBG Transformation Reporting Form***

### *State: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_*

### 

### *2007 Transformation Allocation Amount:* \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### *See Allocation Table for Transformation Funding in Appendix V.*

+-------------------------------+----------+--------+-----------------+
| ***State Transformation***    | **       | ***NFC | ***FY 2007 MHBG |
|                               | *MHBG*** | Goal   | Planned***      |
| ***Activity***                |          | No.*** |                 |
|                               | ***Cri   |        | ***Expenditure  |
|                               | teria*** |        | Amount for      |
|                               |          |        | Transformation  |
|                               |          |        | \****           |
+-------------------------------+----------+--------+-----------------+
|                               |          |        |                 |
+-------------------------------+----------+--------+-----------------+
| ***Describe why the State     |          |        |                 |
| identifies this activity as   |          |        |                 |
| transformational.***          |          |        |                 |
+-------------------------------+----------+--------+-----------------+

***\*Total should equal the FY 2007 Transformation Allocation amount
stated above.***

### 

### 

### 

### 

### 

### 

### 

### 

### 

### 

### 

### 

### 

### 

**PART D. Implementation Report**

This section will contain the State Plan Implementation Report for FY
2007 as required by the PHS Act[^19] States are requested to prepare and
submit their implementation reports for the last completed FY in the
format provided in this guidance. *This will contain a report on the
purposes for which the Community Mental Health Services Block Grant
monies were expended**,** the recipients of grant funds, and a
description of block grant-funded activities*.[^20] ***Should the FY
2007 budget appropriations language become law, States will be required
to include BG expenditures for mental health transformation
activities.*** The report shall focus on the extent to which the State
has implemented its plan for the FY, with particular attention given to
the goals and performance indicators. This section should also contain
any comments from the mental health planning council, preferably in the
form of a letter.[^21] The Data Tables (presented in Part E) are
considered a component of the Implementation Report. Please submit an
original implementation report plus two copies to Ms. LouEllen M. Rice,
Grants Management Officer, Division of Grants Management, OPS, SAMHSA, 1
Choke Cherry Road, Room 7-1091, Rockville, Maryland 20857 by December 1,
2006. As noted above, electronic submissions are allowed and should be
mailed to Deborah Baldwin, Project Officer, at
<deborah.baldwin@samhsa.hhs.gov>. If an electronic copy is submitted,
two additional hard copies mentioned above must also be mailed to the
Grants Management Office. Please note that if your Implementation Report
is not received in the Office of Grants Management by December 1, your
State will not obtain a grant for the year indicated.

**I. Narrative Content of the Implementation Report**

> 1\) [Report Summary]{.underline}

-   Areas which the State identified in the prior FY's approved Plan as
    needing improvement;

-   The most significant events that impacted the mental health system
    of the State in the previous FY; and

-   A report on the purposes for which the block grant monies for State
    FY were expended, the recipients of grant funds, and a description
    of activities funded by the grant*, **to include Block Grant funds
    expended for activities for mental health transformation. See Table
    V.***

**II. Performance Indicators**

1\) **Performance Indicators.** States are required to complete the
Performance **Indicator Table for the Implementation Report** as
presented below**.** The purpose of this table is to show data for the
State-selected performance indicators and the CMHS NOMS over time.
Narrative discussion of performance indicators (see discussion in
Section IV) should be provided with these tables.

**Performance Indicator Table for Implementation Plan**

**Name of Performance Indicator:**

**Population:**

**Criterion:**

**Related to Transformation** **Yes** **No**

+------------+--------+--------+--------+--------+--------+--------+
| \(1\)      | \(2\)  | \(3\)  | \(4\)  | \(5\)  | \(6\)  | \(7\)  |
+------------+--------+--------+--------+--------+--------+--------+
| Fiscal     | FY2005 | FY2006 | FY2006 | FY     | FY2007 | FY     |
|            |        |        |        | 2007   |        | 2007   |
| Year       | Actual | Actual | \%     | Target | Actual |        |
|            |        |        | At     |        |        | \%     |
|            |        |        | tained |        |        | At     |
|            |        |        |        |        |        | tained |
+------------+--------+--------+--------+--------+--------+--------+
| P          |        |        |        |        |        |        |
| erformance |        |        |        |        |        |        |
|            |        |        |        |        |        |        |
| Indicator  |        |        |        |        |        |        |
+------------+--------+--------+--------+--------+--------+--------+
| Numerator  |        |        | \-\--  | \-\--  |        | \-\--  |
+------------+--------+--------+--------+--------+--------+--------+
| D          |        |        | \-\--  | \-\--  |        | \-\--  |
| enominator |        |        |        |        |        |        |
+------------+--------+--------+--------+--------+--------+--------+

> [Table Descriptors:]{.underline}
>
> **Name of Performance Indicator**: Brief name of the performance
> indicator (*e.g*., Increased Access to Services); ***clearly label
> transformation outcome measures.***
>
> **Population:** SMI Adult or SED Children or name special population
>
> **Criterion:** *e.g*., "Criterion 1, Comprehensive Community-Based
> Mental Health Service System"
>
> **Target**: a target is specific, measurable, and expected to be
> achieved within a defined period of time, and which, if attained, is
> expected to contribute to the realization of the goal
>
> **Performance Indicator:** Numerator divided by Denominator (except in
> cases where there is no denominator) and expressed as a percentage.
>
> [Columns:]{.underline}
>
> \(2\) Actual FY2005 value for the performance indicator, including
> both numerator and denominator if the performance indicator is a rate.
>
> \(3\) Actual FY2006 value for the performance indicator, including
> both numerator and denominator if the performance indicator is a rate.
>
> \(4\) Percentage attained for indicator in FY 2006
>
> \(5\) State Target for FY 2007
>
> \(6\) Actual FY2007 value for the performance indicator, including
> both numerator and denominator if the performance indicator is a rate.
>
> \(7\) Percent attained is equal to dividing column (6) by column (5).
> If less than 100%, State did not achieve its target; if greater than
> 100%, State surpassed its target.

######## III. Accomplishments

This section should be integrated with the data presentation above. For
each of the targets and corresponding performance indicators, the State
should provide a brief narrative containing the following information:

-   Documentation of the activities under each indicator for each
    criterion. This shall include data to support the State's report
    about its accomplishments for each target and performance indicator
    identified in the Plan for the prior FY. ***The documentation shall
    also address the State's progress and achievements toward mental
    health system transformation;,***

-   Description of activities and strategies the State used to address
    the performance indicator;

-   Any changes in the implementation strategy described in the Plan for
    the prior State FY;

-   Any innovative or exemplary model of mental health service delivery
    that the State developed, and its unique features;

-   At the end of each indicator's narrative, the report should clearly
    state whether or not the particular target identified in the Plan
    for the prior State FY for adults with SMI or children with SED was
    "achieved" or "not achieved"; and

-   If the targets were "not achieved," explain why.

### PART E: Uniform Data on Public Mental Health System

This section guides States in the reporting of uniform data on public
mental health services in the State (with special focus on community
mental health services) [in a series of basic and developmental data
tables]{.mark}. [The completion of Part E is a term and condition for
funding for States and Territories that were awarded Data Infrastructure
Grants; all States and Territories that accepted the grant agreed to
submit Part E as part of the FY 2006 Implementation Report]{.mark}. The
Report for FY 2006 is due December 1, 2006 with Part D, the
Implementation Report. States and Territories that did not receive a
Data Infrastructure Grant are encouraged to submit data under Part E.
[If a State cannot provide data in tables, the State must indicate its
reporting capacity in the State Level Data Reporting Capacity Checklist.
To ensure uniformity, the data reported shall be based on the data
definitions agreed to in the Mental Health Data Infrastructure Project.
States are requested to report data based on the last completed fiscal
year.]{.mark}

[]{.mark}

Uniform data on the public mental health system are required to improve
planning and oversight of community mental health services provided
under the Community Mental Health Services Block Grant and Performance
Partnerships. Block grant funds further the capacity of the publicly
funded community mental health system in each state. The flexible
funding of the block grant allows States to fund gap-filling, new and
innovative services. To understand the value and usage of block grant
funds, it is critical that both CMHS and the State Mental Health
Authorities (SMHAs) have accurate and uniform data on the public mental
health system in each State. Towards this end, the data requested in the
tables described in this Section answer five basic questions: 1) What
are the mental health service needs of the population in your State? 2)
Who in your State gets access to publicly funded mental health services?
3) What types of services are being provided in your State? 4) What are
the outcomes of the services provided? and 5) What financial resources
are expended for the services?

All client data will be aggregated at the State level. No individual
client data are requested or should be submitted. State identifiers are
required for each table. CMHS, working with its contractor, the National
Association of State Mental Health Program Directors (NASMHPD) National
Research Institute (NRI), will create all derived measures from the
primary data provided by the States. CMHS will review the
State-submitted data and make requests for revision, clarification, or
additional information as appropriate from the State MHAs. After the
final review and analysis of the data is completed, CMHS will make
State-by-State data profiles available, as well as summary tables that
examine performance across all States for selected data elements.

**ATTACHMENTS**

**A. Federal Funding Agreements**

**B. Certifications**

**C. Disclosure of Lobbying Activities**

# D. Assurances

### E. Face Sheet

**Attachment A**

**COMMUNITY MENTAL HEALTH SERVICES BLOCK GRANT FUNDING AGREEMENTS**

FISCAL YEAR 2007

I hereby certify that
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
agrees to comply with the following sections of Title V of the Public
Health Service Act \[42 U.S.C. 300x-1 [et]{.underline}
[seq]{.underline}.\]

**Section 1911:**

Subject to Section 1916, the State[^22] will expend the grant only for
the purpose of:

> i\. Carrying out the plan under Section 1912(a) \[State Plan for
> Comprehensive
>
> Community Mental Health Services\] by the State for the fiscal year
> involved:
>
> ii\. Evaluating programs and services carried out under the plan; and
>
> iii\. Planning, administration, and educational activities related to
> providing services under the plan.

**Section 1912**

> (c)(1)& (2) \[As a funding agreement for a grant under Section 1911 of
> this title\] The Secretary establishes and disseminates definitions
> for the terms "adults with a serious mental illness" and "children
> with a severe emotional disturbance" and the States will utilize such
> methods \[standardized methods, established by the Secretary\] in
> making estimates \[of the incidence and prevalence in the State of
> serious mental illness among adults and serious emotional disturbance
> among children\].

**Section 1913:**

> (a)(1)(C) In the case for a grant for fiscal year 2007, the State will
> expend for such system \[of integrated services described in section
> 1912(b)(3)\] not less than an amount equal to the amount expended by
> the State for the fiscal year 1994.
>
> \[A system of integrated social services, educational services,
> juvenile services and substance abuse services that, together with
> health and mental health services, will be provided in order for such
> children to receive care appropriate for their multiple needs (which
> includes services provided under the Individuals with Disabilities
> Education Act)\].
>
> (b)(1) The State will provide services under the plan only through
> appropriate, qualified community programs (which may include community
> mental health centers, child mental-health programs, psychosocial
> rehabilitation programs, mental health peer-support programs, and
> mental-health primary consumer-directed programs).
>
> (b)(2) The State agrees that services under the plan will be provided
> through community mental health centers only if the centers meet the
> criteria specified in subsection (c).
>
> (C)(1) With respect to mental health services, the centers provide
> services as follows:
>
> \(A\) Services principally to individuals residing in a defined
> geographic area (referred to as a "service area")
>
> \(B\) Outpatient services, including specialized outpatient services
> for children, the elderly, individuals with a serious mental illness,
> and residents of the service areas of the centers who have been
> discharged from inpatient treatment at a mental health facility.

\(C\) 24-hour-a-day emergency care services.

> \(D\) Day treatment or other partial hospitalization services, or
> psychosocial rehabilitation services.
>
> \(E\) Screening for patients being considered for admissions to State
> mental health facilities to determine the appropriateness of such
> admission.
>
> \(2\) The mental health services of the centers are provided, within
> the limits of the capacities of the centers, to any individual
> residing or employed in the service area of the center regardless of
> ability to pay for such services.
>
> \(3\) The mental health services of the centers are available and
> accessible promptly, as appropriate and in a manner which preserves
> human dignity and assures continuity and high quality care.

**Section 1914:**

> The State will establish and maintain a State mental health planning
> council in accordance with the conditions described in this section.

\(b\) The duties of the Council are:

> \(1\) to review plans provided to the Council pursuant to section
> 1915(a) by the State involved and to submit to the State any
> recommendations of the Council for modifications to the plans;
>
> \(2\) to serve as an advocate for adults with a serious mental
> illness, children with a severe emotional disturbance, and other
> individuals with mental illness or emotional problems; and
>
> \(3\) to monitor, review, and evaluate, not less than once each year,
> the allocation and adequacy of mental health services within the
> State.
>
> (c)(1) A condition under subsection (a) for a Council is that the
> Council is to be composed of residents of the State, including
> representatives of:

\(A\) the principle State agencies with respect to:

> \(i\) mental health, education, vocational rehabilitation, criminal
> justice, housing, and social services; and
>
> \(ii\) the development of the plan submitted pursuant to Title XIX of
> the Social Security Act;
>
> \(B\) public and private entities concerned with the need, planning,
> operation, funding, and use of mental health services and related
> support services;
>
> \(C\) adults with serious mental illnesses who are receiving (or have
> received) mental health services; and

\(D\) the families of such adults or families of children with emotional
disturbance.

\(2\) A condition under subsection (a) for a Council is that:

> \(A\) with respect to the membership of the Council, the ratio of
> parents of children with a serious emotional disturbance to other
> members of the Council is sufficient to provide adequate
> representation of such children in the deliberations of the Council;
> and
>
> \(B\) not less than 50 percent of the members of the Council are
> individuals who are not State employees or providers of mental health
> services.

**Section 1915:**

> (a)(1) State will make available to the State mental health planning
> council for its review under section 1914 the State plan submitted
> under section 1912(a) with respect to the grant and the report of the
> State under section 1942(a) concerning the preceding fiscal year.
>
> \(2\) The State will submit to the Secretary any recommendations
> received by the State from the Council for modifications to the State
> plan submitted under section 1912(a) (without regard to whether the
> State has made the recommended modifications) and comments on the
> State plan implementation report on the preceding fiscal year under
> section 1942(a).
>
> (b)(1) The State will maintain State expenditures for community mental
> health services at a level that is not less than the average level of
> such expenditures maintained by the State for the 2-year period
> preceding the fiscal year for which the State is applying for the
> grant.

**Section 1916:**

\(a\) The State agrees that it will not expend the grant:

\(1\) to provide inpatient services;

\(2\) to make cash payments to intended recipients of health services;

> \(3\) to purchase or improve land, purchase, construct, or permanently
> improve (other than minor remodeling) any building or other facility,
> or purchase major medical equipment;
>
> \(4\) to satisfy any requirement for the expenditure of non-Federal
> funds as a condition of the receipt of Federal funds; or
>
> \(5\) to provide financial assistance to any entity other than a
> public or nonprofit entity.
>
> \(b\) The State agrees to expend not more than 5 percent of the grant
> for administrative expenses with respect to the grant.

**Section 1941:**

> The State will make the plan required in section 1912 as well as the
> State plan implementation report for the preceding fiscal year
> required under Section 1942(a) public within the State in such manner
> as to facilitate comment from any person (including any Federal or
> other public agency) during the development of the plan (including any
> revisions) and after the submission of the plan to the Secretary.

**Section 1942:**

> \(a\) The State agrees that it will submit to the Secretary a report
> in such form and containing such information as the Secretary
> determines (after consultation with the States) to be necessary for
> securing a record and description of:
>
> \(1\) the purposes for which the grant received by the State for the
> preceding fiscal year under the program involved were expended and a
> description of the activities of the State under the program; and

\(2\) the recipients of amounts provided in the grant.

> \(b\) The State will, with respect to the grant, comply with Chapter
> 75 of Title 31, United Stated Code. \[Audit Provision\]

\(c\) The State will:

> \(1\) make copies of the reports and audits described in this section
> available for public inspection within the State; and
>
> \(2\) provide copies of the report under subsection (a), upon request,
> to any interested person (including any public agency).

**Section 1943:**

\(a\) The State will:

> (1)(A) for the fiscal year for which the grant involved is provided,
> provide for independent peer review to assess the quality,
> appropriateness, and efficacy of treatment services provided in the
> State to individuals under the program involved; and
>
> \(B\) ensure that, in the conduct of such peer review, not fewer than
> 5 percent of the entities providing services in the State under such
> program are reviewed (which 5 percent is representative of the total
> population of such entities);
>
> \(2\) permit and cooperate with Federal investigations undertaken in
> accordance with section 1945 \[Failure to Comply with Agreements\];
> and
>
> \(3\) provide to the Secretary any data required by the Secretary
> pursuant to section 505 and will cooperate with the Secretary in the
> development of uniform criteria for the collection of data pursuant to
> such section
>
> \(b\) The State has in effect a system to protect from inappropriate
> disclosure patient records maintained by the State in connection with
> an activity funded under the program involved or by any entity, which
> is receiving amounts from the grant.

***Notice: Should the President's FY 2007 Budget be enacted, the
following statement applies only to States that received the Mental
Health Transformation State Infrastructure Grants:***

***This Agreement certifies that States that received the Mental Health
Transformation State Infrastructure Grants shall not use FY 2007 Mental
Health Block Grant transformation funding to supplant activities funded
by the Mental Health Transformation Infrastructure Grants.***

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Governor Date

# 

**B. Certifications**

http://www.mhbg.samhsa.gov/certification.pdf

**C. Disclosure of Lobbying Activities**

<http://www.mhbg.samhsa.gov/disclosure.pdf>

# D. Assurances

# http://www.mhbg.samhsa.gov/assurance.pdf 

# Attachment E 

**FACE SHEET**

> ***COMMUNITY MENTAL HEALTH SERVICES BLOCK GRANT***

**\_\_\_\_\_ FY 2007**

STATE NAME:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

DUNS #: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**I. AGENCY TO RECEIVE GRANT**

AGENCY:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

ORGANIZATIONAL UNIT:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

STREET ADDRESS:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

CITY: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_STATE:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ ZIP:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

TELEPHONE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ FAX:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

II\. OFFICIAL IDENTIFIED BY GOVERNOR AS RESPONSIBLE FOR ADMINISTRATION
OF THE GRANT

NAME: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TITLE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AGENCY
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

ORGANIZATIONAL UNIT:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

STREET ADDRESS:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

CITY:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_STATE:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ZIP: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

TELEPHONE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ FAX:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**III. STATE FISCAL YEAR**

FROM: \_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_ TO:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Month Year Month Year

**IV. PERSON TO CONTACT WITH QUESTIONS REGARDING THE APPLICATION**

NAME:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
TITLE:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AGENCY:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

ORGANIZATIONAL
UNIT:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

STREET
ADDRESS:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

CITY:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_STATE:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
ZIP: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

TELEPHONE: \_\_\_\_\_\_\_\_\_\_\_\_\_\_ FAX:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ EMAIL:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Appendix I. Format for Constructing and Reporting Performance
Indicators**

As described in PART C: Section III of the State Plan Guidance, in
submission of the State's MH Plan, States are expected to continue to
develop, maintain and report on state specific performance indicators
that are useful for tracking improvements in the public mental health
system within the State, in addition to incorporating the set of CMHS
NOMS discussed in Section III.

The purpose of this section is to describe the construction and
reporting of both types of performance indicators. The section begins
with a sample table to be employed with the State Plan and a sample
table to be used with the Implementation Report.

# 

# Sample Performance Indicator Table for State Plan

**Name of Performance Indicator: Percentage of Inpatient Readmissions at
30 days** [(Reduced Utilization of Psychiatric Inpatient
Beds)]{.underline}

**Population: Adult SMI**

**Criterion: Criterion 1: Comprehensive Community-Based Mental Health
Service Systems**

+----------------+-------+---------+----------+----------+----------+
| \(1\)          | \(2\) | \(3\)   | \(4\)    | \(5\)    | \(6\)    |
+----------------+-------+---------+----------+----------+----------+
| Fiscal         | F     | FY2004  | FY2005   | FY 2006  | FY 2007  |
|                | Y2003 |         |          |          |          |
| Year           |       | Actual  | P        | Target   | Target   |
|                | A     |         | rojected |          |          |
|                | ctual |         |          |          |          |
+----------------+-------+---------+----------+----------+----------+
| Performance    | 20%   | 20%     | 15%      | 15%      | 15%      |
|                |       |         |          |          |          |
| Indicator      |       |         |          |          |          |
+----------------+-------+---------+----------+----------+----------+
| Numerator      | 2,000 | 2,000   | \--      | \--      | \--      |
+----------------+-------+---------+----------+----------+----------+
| Denominator    | 1     | 10,000  | \--      | \--      | \--      |
|                | 0,000 |         |          |          |          |
+----------------+-------+---------+----------+----------+----------+

####### 

####### This table indicates that: 

####### Column (2) in FY2003, there were 2,000 adults who were readmitted within 30 days out of 10,000 persons discharged from a State Hospital during the past year. That yields a performance indicator of 20% readmitted. 

####### Column (3) For FY2004 the same number of readmissions and discharges occurred resulting in a performance indicator of 20%. 

####### Column (4) For FY 2005, it is projected that 15% of adults discharged from a State Hospital will be readmitted within 30 days. 

Column (5) For FY 2006 a target of 15% is set.

Column (6) State target of 15% set for FY2007; required for multi-year
plans only.

**Sample** **Performance Indicator Table for Implementation Plan**

**Name of Performance Indicator: Percentage of Inpatient Readmissions at
30 days** [(Reduced Utilization of Psychiatric Inpatient
Beds)]{.underline}

**Population: Adult SMI**

**Criterion: Criterion 1: Comprehensive Community-Based Mental Health
Service Systems**

+----------+-------+-------+-------+--------+--------+--------+------+
| \(1\)    | \(2\) | \(3\) | \(4\) | \(5\)  | \(6\)  | \(7\)  | \    |
|          |       |       |       |        |        |        | (8\) |
+----------+-------+-------+-------+--------+--------+--------+------+
| Fiscal   | F     | F     | F     | FY     | FY2006 | FY     | FY   |
|          | Y2004 | Y2005 | Y2005 | 2006   |        | 2006   | 2007 |
| Year     |       |       |       | Target | Actual |        |      |
|          | A     | A     | \%    |        |        | \%     | Ta   |
|          | ctual | ctual | Att   |        |        | At     | rget |
|          |       |       | ained |        |        | tained |      |
+----------+-------+-------+-------+--------+--------+--------+------+
| Per      | 20%   | 20%   | 100%  | 15%    | 15%    | 100%   | 12%  |
| formance |       |       |       |        |        |        |      |
|          |       |       |       |        |        |        |      |
| I        |       |       |       |        |        |        |      |
| ndicator |       |       |       |        |        |        |      |
+----------+-------+-------+-------+--------+--------+--------+------+
| N        | 2,000 | 2,000 | \-\-- | \--    | 1,500  | \-\--  |      |
| umerator |       |       |       |        |        |        |      |
+----------+-------+-------+-------+--------+--------+--------+------+
| Den      | 1     | 1     | \-\-- | \--    | 10,000 | \-\--  |      |
| ominator | 0,000 | 0,000 |       |        |        |        |      |
+----------+-------+-------+-------+--------+--------+--------+------+

####### This table indicates that: 

####### Column (2) in FY2004, there were 2,000 adults who were readmitted within 30 days out of 10,000 persons discharged from a State Hospital during the past year. That yields a performance indicator of 20% readmitted. 

####### Column (3) For FY2005 the same number of readmissions and discharges occurred which resulted in a performance indicator of 20%. 

Column (4) the percentage attained was 100% as reported in the FY 2005
Implementation Report

####### Column (5) For FY 2006, a target of 15% readmitted was set

####### Column (6) For FY 2006 1,500 readmissions occurred out of 10,000 discharges resulting in a performance indicator rate of 15%

####### Column (7) For FY 2006 the State met 100% of its goal (Column (6) divided by column (5).

Column (8) For FY 2007 a target of 12% was set (only if a multi-year
plan was submitted)

Immediately following the table, there should be narrative discussion
indicating whether the results are satisfactory or what actions the
State plans to take to improve performance on this indicator in the
future

> 1\. [CMHS NOMS]{.underline}

####### All but the developmental NOMS may be derived from the Basic or Developmental Data Tables (See Table below)\... If States are unable to collect and report the data for any of the tables from which the NOMS are constructed, the State Level Data Reporting Capacity Checklist should be completed or a narrative provided that describes the State's efforts toward building capacity to collect the data and an estimated completion date. . However, States are encouraged to complete and include in the plan all indicators that can be constructed from available data in the URS Tables. 

**[Sources of NOMS in Basic and Developmental Data
Tables.]{.underline}**

  ---------------- ---------------- --------------- ---------------- -----------------
  **Adult NOMS**                    **Table         **Numerator**    **Denominator**
                                    Reference**                      

  1\. Increased    Adults served by Basic Table 2A  Persons served   NONE
  Access to        gender and                       over the age of  
  Services         race/ethnicity                   18 by gender,    
                                                    race/ethnicity   
                                                    and total.       

  2\. Reduced      Decreased rate   Developmental   Number of        Number of
  utilization of   of readmissions  Table 20A       persons, aged    persons, aged
  psychiatric      to State                         18+, who are     18+, discharged
  inpatient beds   Psychiatric                      readmitted to a  from a State
                   Hospitals within                 State hospital   Hospital during
                   30 days                          within 30 days   the past year

                   Decreased rate   Developmental   Number of        Number of
                   of readmissions  Table 20A       persons, aged    persons, aged
                   to State                         18+, who are     18+, discharged
                   Psychiatric                      readmitted to a  from a State
                   Hospitals within                 State hospital   Hospital during
                   180 days                         within 180 days  the past year

  3\.              Actual           Developmental   For each of      NONE
  Evidence-based   evidence-based   Tables 16-17    eight            
  practices        practices                        evidence-based   
                   provided in                      practices,       
                   State                            indicate         
                                                    (Yes-No) whether 
                                                    it being         
                                                    provided         

                   Number of SMI    Developmental   Number of SMI    NONE
                   adults receiving Tables 16-17    adults, aged     
                   evidence-based                   18+, who are     
                   practices                        receiving any of 
                                                    the eight        
                                                    evidence-based   
                                                    practices        

  4\. Client       Clients          Basic Table 11  Number of        Total responses
  Perception of    reporting                        positive         reported in the
  Care             positively about                 responses        outcome domain on
                   outcomes                         reported in the  the adult
                                                    outcome domain   consumer survey
                                                    on the adult     
                                                    consumer survey  

  **INDICATORS                                                       
  ENCOURAGED TO BE                                                   
  INCLUDED IN THE                                                    
  STATE PLAN IF                                                      
  STATE HAS                                                          
  CAPACITY TO                                                        
  REPORT**                                                           

  5\. Increase/    Profile of Adult Basic Table 4   Number employed  Number employed
  Retained         Clients by                                        plus number
  Employment or    Employment                                        unemployed
  Return/Stay in   Status                                            
  School                                                             

  6\. Decreased    Profile of       Developmental   Total C (number  Total B (number
  Criminal Justice Client           Table 19A       with criminal    for whom data are
  Involvement      Involvement in                   justice          available)
                   Criminal Justice                 involvement)     
                   System                                            
  ---------------- ---------------- --------------- ---------------- -----------------

  ------------------- ----------------- --------------- ---------------- -----------------
  **Child NOMS**                        **Table         **Numerator**    **Denominator**
                                        Reference**                      

  1\. Increased       Children served   Basic Table 2A  Persons served   NONE
  Access to Services  by gender, and                    under the age of 
                      race/ethnicity.                   18 by gender,    
                                                        race/ethnicity   
                                                        and total.       

  2\. Reduced         Decreased rate of Developmental   Number of        Number of
  utilization of      readmissions to   Table 20A       persons, aged    persons, aged
  psychiatric         State Psychiatric                 0-17, who are    0-17 , discharged
  inpatient beds      Hospitals within                  readmitted to a  from a State
                      30 days                           State hospital   Hospital during
                                                        within 30 days   the past year

                      Decreased rate of Developmental   Number of        Number of
                      readmissions to   Table 20A       persons, aged    persons, aged
                      State Psychiatric                 0-17, who are    0-17 , discharged
                      Hospitals within                  readmitted to a  from a State
                      180 days                          State hospital   Hospital during
                                                        within 180 days  the past year

  3\. Evidence-based  Actual            Developmental   Indicate whether NONE
  practices           evidence-based    Tables 16-17    therapeutic      
                      practices                         foster care is   
                      provided in State                 being provided.  

                      Number of SED     Developmental   Number of SED    NONE
                      children          Tables 16-17    children, aged   
                      receiving                         0-17, who are    
                      evidence-based                    receiving        
                      practices                         therapeutic      
                                                        foster care      

  4\. Client          Clients reporting Basic Table 11  Number of        Total responses
  Perception of Care  positively about                  positive         reported in the
                      outcomes                          responses        outcome domain on
                                                        reported in the  the child
                                                        outcome domain   consumer survey
                                                        on the child     
                                                        consumer survey  

  **INDICATORS                                                           
  ENCOURAGED TO BE                                                       
  INCLUDED IN THE                                                        
  STATE PLAN IF STATE                                                    
  HAS CAPACITY TO                                                        
  REPORT**                                                               

  5\.                 Increased school  Developmental   Total C (number  Total B (number
  Increase/Retained   attendance        Table 19C       attending        for whom data are
  Employment or                                         school)          available)
  Return to/Stay in                                                      
  School                                                                 

  6\. Decreased       Profile of Client Developmental   Total C (number  Total B (number
  Juvenile Justice    Involvement in    Table 19B       with juvenile    for whom data are
  Involvement         Juvenile Justice                  justice          available)
                      System                            involvement)     
  ------------------- ----------------- --------------- ---------------- -----------------

2\. [State Developed Performance Indicators]{.underline}

Over the past years, states have been required to develop state-specific
indicators for each of the criteria for the adult and child plans. For
this application, they are expected to continue to report on performance
indicators that they have considered being important in tracking the
progress of the public mental health system in the past, to develop new
indicators, as appropriate, as well as incorporating the NOMS.

### 3. Administrative Goals, Targets and Indicators

Not all goals set by a State need to be immediately associated with
service delivery. Some may be related to changes in the structure of the
administration of the public mental health system. For example, State
mental health authorities may wish to develop a mechanism to pool or
blend funding for children's mental health services under the
jurisdiction of multiple State and/or local government agencies, in
order to promote the reallocation of resources from State inpatient care
to community-based services. For objectives identified under such goals,
the performance indicator might be an interagency memorandum of
agreement, new statutory authority conferred by the Legislature and the
Governor, or changes in regulations or contracting procedures.

States are also expected to set administrative goals and targets and to
select performance indicators appropriate to them. They should be
included within the most appropriate of the mental health block grant
criterion. No special format is offered here. States can adapt the
format for describing quantitative performance indicators for this
purpose.

4\. Description of Indicators

The performance indicator tables presented above should be employed to
present both plans and results. The guidance below is intended to assure
a common approach to describing these indicators. In addition to the
performance indicator table, for each indicator there must be a fuller,
more descriptive title, as well as other information about the design of
the performance indicator. It is to be included following the "Format
for Performance Indicator Description," presented below. This
description should cover the following elements (see examples below):

-   The goal of the State plan under each criterion;

-   Specific, measurable objective(s) identified to reach the goal;

-   The relevant population group (SMI or SED);

-   The relevant mental health block grant criterion;

-   Brief name for the indicator *with transformation outcome measures
    clearly labeled*

-   Full, descriptive indicator;

-   Description of the measure(s) employed to construct the indicator
    (i.e., contract reporting system, Medicaid claims data, recipient
    survey);

-   Explanatory note, if any;

-   Sources of information employed to obtain data for the indicator
    (i.e., contract reporting system, Medicaid claims, recipient
    survey);

-   Special issues, if any; and

-   Significance of the identified objective for the Community Mental
    Health Services program; please explain the importance of this
    indicator in impacting on the state system of care.

**Examples of Format for Performance Indicator Description**

### Criterion 1 - Example A

**Goal**: To significantly reduce the inpatient census of State and
county-operated mental health specialty facilities by placing all
eligible individuals with mental illness appropriately in the community.

**Target**: Reduction in inpatient census of State and county operated
mental health specialty facilities by another fifty individuals from the
current level.

**Population**: Adults with a serious mental illness.

**Criterion**: Comprehensive, community-based mental health system.

**Brief Name**: State & county inpatient census.

**Indicator**: Number of patients-in-residence in State and county
hospitals among persons who are SMI or SED.

**Measure**: This number may be either (1) the number of patients who
are in residence in State and county mental health specialty hospitals
at the end of the State's fiscal year OR (2) the average daily inpatient
census for the State's fiscal year.

NOTE: If the State contracts out for care that formerly would have been
provided in its inpatient system, patients-in-residence or daily average
census for these contracts should be incorporated and explained on this
indicator page. Separate performance indicators should be maintained for
adults and for children. [For adults, States should indicate whether
forensic inpatient information is included in the total.]{.underline} In
some states it may be appropriate to focus on inpatients with a civil
commitment status only.

**Sources(s) of Information**: State hospital reporting system; contract
reporting system.

Special Issues: In many States, reduced utilization of State hospital
care may be the result of expanded utilization of general hospital
psychiatric inpatient beds, particularly by persons who are eligible for
Medicaid and Medicare. States may wish to track utilization of
psychiatric inpatient care under these and other auspices. This
indicator would not include persons served in residential treatment
facilities. States may wish to track this utilization separately or
include it under the indicator percentage of children with SED who are
placed out-of-home (e.g., foster care, residential home, juvenile
detention).

**Significance:** A major outcome of the development of a
community-based system of care is expected to be reduced utilization of
state and county-operated psychiatric inpatient beds.

##### Criterion 1 - Example B

**Goal**: To provide case management services for all persons who
receive substantial amounts of public funds or services.

**Target**: Expansion of access to case management services among
persons who receive substantial amounts of public funds or services by
5%.

**Population:** Adults with a serious mental illness.

**Criterion**: Comprehensive, community-based mental health system.

**Brief Name**: Percentage receiving case management.

**Indicator**: Percentage of adults with serious mental illness who
receive case management services among those who receive substantial
amounts of public funds or services.

**Measure**: Numerator: The number of adult recipients with a serious
mental illness who are receiving case management services during the
fiscal year.

Denominator: The number of adults who receive a substantial amount of
mental-health related public funds or services during the fiscal year.

**Sources of Information:** Contract reporting system, Medicaid
management information system, SMHA client information system, and
estimates of treated prevalence.

**Special Issues**: States must define key terms. The count of persons
receiving case management might include only those enrolled in formal
case management programs, or might extend to those who receive case
management services in any program which offers those services in
conjunction with other mental health services. States must also
operationally define the concept of "adults who receive substantial
amount of mental-health related public funds or services during the
fiscal year". This definition will depend upon what information is most
readily available to the State.

**Significance**: Assuring access to case management services for
persons with a serious mental illness is a primary goal of the mental
health block grant legislation.

##### Criterion 1 - Example C

**Goal**: To provide assertive community treatment to all eligible
individuals who request it.

**Target:** An increase of 40 in the number of persons receiving
assertive community treatment (ACT).

**Population:** Adults with a serious mental illness.

**Criterion:** Comprehensive, community-based health system.

**Brief Name:** Persons receiving ACT.

**Indicator:** The number of persons receiving assertive community
treatment during the fiscal year.

**Measure:** Count of persons receiving services through a formal ACT
program.

**Sources of Information:** Contract reporting, Medicaid management
information system

**Significance:** Research evidence supports the development of ACT
programs to meet the needs of persons with serious mental illness.

**Criterion 2 - Example:**

**Goal:** Expand access to mental health services for all persons who
have a serious mental illness.

**Target**: Expansion of access to mental health services to 4% more of
the population of persons with a serious mental illness.

**Criterion**: Prevalence and treated prevalence of mental illnesses

**Population**: Adults with a serious mental illness.

**Brief Name**: Treated prevalence of serious mental illness.

**Indicator:** The percentage of adults with a serious mental illness
who receive mental health services during the fiscal year.

**Measure**: Numerator: Estimated number of adults with a serious mental
illness and who have received mental health services during the fiscal
year.

Denominator: Estimated number of adults who annually have a serious
mental illness in the State.

**Sources of Information**: Numerator: State client information system,
Medicaid management information system.

**Special Issues**: States may use the CMHS definition for "serious
mental illness" and "serious emotional disturbance," and estimates of
"prevalence" as an appropriate basis for planning in the public mental
health system. If States adopt an alternative definition and a different
estimate of prevalence, both the definition and prevalence estimation
method should be carefully described and well-justified

**Significance**: Setting quantitative goals for the number of adults
with a serious mental illness to be served in the public mental health
system is a key requirement for the mental health block grant
legislation.

***Appendix II. Examples of Mental Health Transformation Activities***

***I. Examples of Mental Health Transformation Infrastructure
Activities***

-   ***Needs and resource assessment***

-   ***Strategic planning***

-   ***Coordination, alignment, pooling, and/or braiding of funding
    streams and other strategies for addressing financing issues***

-   ***Development or expansion of provider, consumer, and family
    networks***

-   ***Workforce development***

-   ***Communications/public awareness activities***

-   ***Policy formulation and implementation to support needed service
    system improvements***

-   ***Data infrastructure***

***II. Examples of Mental Health Transformation Services***

-   ***Individualized plan of care***

-   ***Transportation***

-   ***Supported Housing***

-   ***Supported Employment***

-   ***Medication Management***

-   ***Suicide Prevention***

-   ***Jail Diversion***

-   ***Peer Services***

-   ***School Based Mental Health Services***

-   ***Collaborative Treatment with Primary Care***

-   ***Co-occurring Services***

-   ***Intervention with Homeless Individuals***

***Other examples of mental health transformation activities and
services may be found under the six (6) goals of the President's New
Freedom Commission on Mental Health Report. Mental health transformation
services and activities should be consumer and family driven, culturally
competent, recovery based, and as much as possible, utilize existing
evidence-based approaches and promising practices. Emphasis should be
placed on services that are consumer controlled and consumer run.***

**Appendix III. Format for Table of Contents**

**TABLE of CONTENTS**

**STATE BLOCK GRANT APPLICATIONS and Plans**

####### Face Sheet

**Executive Summary**

**PART B. Administrative Requirements, Fiscal Planning Assumptions, and
Special Guidance**

> I. Federal Funding Agreements, Certifications and Assurances
>
> \(1\) Funding Agreements
>
> \(2\) Certifications
>
> \(3\) Assurances
>
> \(4\) Public Comments on the State Plan
>
> II\. Set-Aside for Children's Mental Health Services Report
>
> III\. Maintenance of Effort Report (MOE)
>
> IV\. State Mental Health Planning Council Requirements
>
> 1\. Membership Requirements
>
> 2\. State Mental Health Planning Council Membership List and
> Composition
>
> 3\. Planning Council Charge, Role and Activities
>
> 4\. State Mental Health Planning Council Comments and Recommendations

**PART C. State Plan**

> Section I. Description of State Service System
>
> Section II. Identification and Analysis of the Service System's
> Strengths, Needs, and Priorities
>
> a\) Adult Mental Health System
>
> b\) Children's Mental Health System
>
> Section III. Performance Goals and Action Plans to Improve the Service
> System
>
> a\) Adult Plan

1)  Current Activities

```{=html}
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i.  Comprehensive community-based mental health services

ii. Mental health system data epidemiology

iii. Not applicable

iv. Targeted services to rural and homeless populations

v.  Management systems

```{=html}
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```
2)  Goals, Targets and Action Plans

> b\) Children's Plan
>
> 1\) Current Activities

i.  Comprehensive community-based mental health services

ii. Mental health system data epidemiology

iii. Children's services

iv. Targeted services to rural and homeless populations

v.  Management systems

> 2\) Goals, Targets and Action Plans

####### Part D. Implementation Report

> I. Narrative Content of the Implementation Report
>
> II\. Performance Indicators
>
> III\. Accomplishments

####### Part E. Uniform Data on Public Mental Health System

Basic and Developmental URS Tables

**Attachments**

A. Federal Funding Agreements

B. Certifications

C. Disclosure of Lobbying Activities

D. Assurances

***Appendix IV. FY 2007 Appropriations Language***

***Substance Abuse and Mental Health Services Administration***

***Appropriation Language***

***For carrying out titles V and XIX of the Public Health Service Act
(''PHS Act'') with***

***respect to substance abuse and mental health services, the Protection
and Advocacy for***

***Individuals with Mental Illness Act, and section 301 of the PHS Act
with respect to***

***program management, \[\$3,237,813,000\] \$3,165,527,000: Provided,
That***

***notwithstanding section 520A(f)(2) of the PHS Act, no funds
appropriated for carrying***

***out section 520A are available for carrying out section 1971 of the
PHS Act: Provided***

***further, That in addition to amounts provided herein, the following
amounts shall be***

***available under section 241 of the PHS Act: (1) \$79,200,000 to carry
out subpart II of***

***part B of title XIX of the PHS Act to fund section 1935(b) technical
assistance, national***

***data, data collection and evaluation activities, and further that the
total available under***

***this Act for section 1935(b) activities shall not exceed 5 percent of
the amounts***

***appropriated for subpart II of part B of title XIX; (2) \$21,803,000
to carry out subpart I***

***of part B of title XIX of the PHS Act to fund section 1920(b)
technical assistance,***

***national data, data collection and evaluation activities, and further
that the total***

***available under this Act for section 1920(b) activities shall not
exceed 5 percent of the***

***amounts appropriated for subpart I of part B of title XIX; (3)
\[\$16,000,000\]***

***\$21,000,000 to carry out national surveys on drug abuse; and (4)
\$4,300,000 to evaluate***

***substance abuse treatment programs. Notwithstanding section 1911(b)
of the Public***

***Health Service Act, a State that receives an allotment under section
1911 of the Act for***

***the current fiscal year shall use any amount it receives in fiscal
year 2007 which is in***

***excess of what it received under such section in 1998 to support one
or more of the***

***mental health transformation activities such as the expansion of
access; advancement of***

***evidence-based practices; promotion of early assessment and
treatment; and promotion***

***of consumer- and family-driven mental health care. A State that
receives an allotment***

***under section 1911 will report annually to the Substance Abuse and
Mental Health***

***Services Administration on its use of funds and the outcomes of
mental health***

***transformation activities. (Department of Health and Human Services
Appropriations***

***Act, 2006.)***

***Appendix V.** **MHBG Allocation Table for Transformation***

  ---------------------- ------------------- ----------- ------------------- ------------------- --------- --- --------- ------------
  **Center for Mental                                                                                                    
  Health Services**                                                                                                      

  **Community Mental                                                                                                     
  Health Services Block                                                                                                  
  Grant Program**                                                                                                        

  **State / Territory**  **FY 1998\                      **FY 2007\          **Difference +/-                             
                         Actuals**                       Estimate**          (allotted to MH                             
                                                                             transformation)**                           

                                                                             **\$**              **%**         **Mean    **Median**
                                                                                                               (Avg)**   

                                                                                                                          

  Alabama                3,875,371                       6,262,551           2,387,180           38%           33%       33%

  Alaska                 429,159                         736,870             307,711             42%                      

  Arizona                3,870,297                       8,505,426           4,635,129           54%                      

  Arkansas               2,232,840                       3,725,765           1,492,925           40%                      

  California             34,513,517                      55,061,465          20,547,948          37%                      

  Colorado               3,750,325                       6,224,556           2,474,231           40%                      

  Connecticut            3,241,039                       4,444,709           1,203,670           27%                      

  Delaware               730,894                         754,909             24,015              3%                       

  District Of Columbia   596,523                         771,392             174,869             23%                      

  Florida                12,239,345                      27,115,633          14,876,288          55%                      

  Georgia                6,194,485                       12,361,924          6,167,439           50%                      

  Hawaii                 1,243,596                       1,924,367           680,771             35%                      

  Idaho                  1,070,863                       1,773,727           702,864             40%                      

  Illinois               11,194,433                      16,441,527          5,247,094           32%                      

  Indiana                6,332,808                       7,805,227           1,472,419           19%                      

  Iowa                   2,740,750                       3,575,338           834,588             23%                      

  Kansas                 2,374,949                       3,183,123           808,174             25%                      

  Kentucky               3,670,758                       5,439,376           1,768,618           33%                      

  Louisiana              4,376,363                       6,309,615           1,933,252           31%                      

  Maine                  1,265,584                       1,716,406           450,822             26%                      

  Maryland               5,707,845                       7,765,802           2,057,957           27%                      

  Massachusetts          6,360,517           8,086,241                       1,725,724           21%                      

  Michigan               10,771,969                      13,429,543          2,657,574           20%                      

  Minnesota              4,438,360                       6,938,342           2,499,982           36%                      

  Mississippi            2,456,254                       4,130,235           1,673,981           41%                      

  Missouri               4,797,839                       6,982,169           2,184,330           31%                      

  Montana                873,926                         1,238,982           365,056             29%                      

  Nebraska               1,300,783                       2,006,208           705,425             35%                      

  Nevada                 1,450,044                       3,662,214           2,212,170           60%                      

  New Hampshire          1,154,144                       1,624,119           469,975             29%                      

  New Jersey             8,090,233                       11,793,701          3,703,468           31%                      

  New Mexico             1,426,307                       2,403,117           976,810             41%                      

  New York               17,669,287                      25,532,478          7,863,191           31%                      

  North Carolina         6,238,341                       10,916,330          4,677,989           43%                      

  North Dakota           548,729                         796,147             247,418             31%                      

  Ohio                   12,772,348                      14,278,769          1,506,421           11%                      

  Oklahoma               3,049,628                       4,621,617           1,571,989           34%                      

  Oregon                 3,228,481                       4,840,841           1,612,360           33%                      

  Pennsylvania           12,024,336                      15,242,122          3,217,786           21%                      

  Rhode Island           895,462                         1,575,795           680,333             43%                      

  South Carolina         3,386,545                       5,653,591           2,267,046           40%                      

  South Dakota           579,888                         878,747             298,859             34%                      

  Tennessee              4,613,933                       7,896,737           3,282,804           42%                      

  Texas                  16,264,840                      31,563,988          15,299,148          48%                      

  Utah                   1,579,290                       2,820,006           1,240,716           44%                      

  Vermont                611,017                         780,471             169,454             22%                      

  Virginia               6,162,479                       10,238,437          4,075,958           40%                      

  Washington             6,001,118                       8,347,942           2,346,824           28%                      

  West Virginia          1,941,957                       2,506,780           564,823             23%                      

  Wisconsin              5,001,980                       7,538,575           2,536,595           34%                      

  Wyoming                382,485                         516,866             134,381             26%                      

                                                                                                                          

  **State Sub-total**    **\$257,724,264**               **\$400,740,818**   **143,016,554**     **36%**                 ** **

                                                                                                                          

  Palau                  50,000                          50,000              \-                  0%                       

  Marshall Islands       50,000                          70,636              20,636              29%                      

  Micronesia             102,115                         148,674             46,559              31%                      

  Virgin Islands         98,168                          150,903             52,735              35%                      

  Puerto Rico            3,396,063                       5,291,584           1,895,521           36%                      

  American Samoa         50,000                          79,599              29,599              37%                      

  Guam                   128,389                         215,082             86,693              40%                      

  Northern Marianas      50,000                          96,174              46,174              48%                      

                                                                                                                         

  **Territory            **\$3,924,735**                 **\$6,102,652**     **2,177,917**       **36%**                  
  Sub-total**                                                                                                            

                                                                                                                          

  **Total                **\$261,648,999**               **\$406,843,470**   **145,194,471**     **36%**                  
  States/Territories**                                                                                                   

  SAMHSA Set-Aside       13,771,001                      21,412,530          7,641,529           36%                      

  Unexpended                                             216,000             216,000             100%                     
  Set-side^1/^                                                                                                           

  **GRAND TOTAL**        **275,420,000**                 **428,472,000**     **153,052,000**     **36%**                 ** **

  ^1/^ The PHS                                                                                                           
  Evaluation Funds can                                                                                                   
  only support Block                                                                                                     
  Grant set-aside                                                                                                        
  activities. Based on                                                                                                   
  the statutory formula                                                                                                  
  for this program, the                                                                                                  
  set-aside activities                                                                                                   
  cannot exceed 5% of                                                                                                    
  the program level.                                                                                                     
  Therefore, this figure                                                                                                 
  represents the                                                                                                         
  difference between the                                                                                                 
  PHS Evaluation funds                                                                                                   
  and 5% of the                                                                                                          
  allowable set-aside                                                                                                    
  activity level.                                                                                                        

                                                                                                                          
  ---------------------- ------------------- ----------- ------------------- ------------------- --------- --- --------- ------------

Basic and Developmental Data Tables

**The URS Basic & Developmental Tables, Guidelines, and Data Definitions
for 2005 Reporting are posted in Excel and Word versions on the SDICC
site (<http://www.nri-inc.org/SDICC/defsdicc.cfm>). You will also find
the 2005 Data Reporting Capacity Checklist on this site.**

**The only changes for 2005 not included on the 2005 tables are the EBP
guidance on reporting that the EBP workgroup has been developing. This
guidance will not change the definitions, but will provide more
instructions and examples of when to count a state\'s service as an EBP
service. The additional EBP guidance will be sent to states as soon as
they are final.**

**You will also find on the SDICC website the SMI and SED Prevalence
Estimates that have been updated using the latest U.S. Census Bureau
population data. These are used for URS Table 1 and may be helpful in
completing the MHBG Application.**

[^1]: Transforming Mental Health Care in America (2005). The Federal
    Action Agenda: First Steps. DHHS Pub. No. SMA-05-4060. Rockville,
    MD: Department of Health and Human Services.

[^2]: . Sections 1911-1920 and 1941-1954 of the Public Health Service
    Act (PHS Act)

[^3]: Section 1912(c)(1) and (2) (42 U.S.C. 300x-2)

[^4]: . Section 1943(a)(3) (42 U.S. C. 300x-53)

[^5]: . Section 1917(a)(7)

[^6]: . Section 1912 (b)

[^7]: . Gerald N. Grob, *From Asylum to Community: Mental Health Policy
    in Modern America*. Princeton, NJ: Princeton University Press, 1991,
    113-114.

[^8]: . Joseph N. De Raismes, III, *The Evolution of Federal Mental
    Health Planning Legislation*.
    http://www.namhpac.org/pages/bckground/back_evolution.html

[^9]: . De Raismes,
    http://www.namhpac.org/pages/bckground/back_evolution.html

[^10]: . The President's New Freedom Commission on Mental Health, 5-6.

[^11]: . The President's New Freedom Commission on Mental Health, 18.

[^12]: . Section 1913(a) of the PHS Act

[^13]: . Section 1915(b)(1) of the PHS Act

[^14]: . Section 1915(b)(2) of the PHS Act

[^15]: . As required by Section 1917(a)(1) (42USC 300x-6) of the PHS Act

[^16]: . Section 1914(c) of the PHS Act

[^17]: . The principal State agencies are: Mental Health, Education,
    Medicaid, Vocational Rehabilitation, Housing, Social Services and
    Criminal Justice.

[^18]: . Section 1914(b) of the PHS Act (42 U.S.C. 300x-4)

[^19]: . Section 1912(d)(1) of PHS Act (42 USC 300x-2)

[^20]: As required by Section 1942(a)(1) and (2) of PHS Act (42 U.S.C.
    300x-52).

[^21]: As required by Section 1915 (a)(2) of PHS Act.

[^22]: 21\. The term State shall hereafter be understood to include
    Territories.