Servces 
Department of Health and Human 

OFFICE OF

INSPECTOR GENERAL

DRUG ABUSE TREATMENT WAITING

LIST REDUCTION GRANT PROGRAM

stRVICts 
t-
Richard P. Kusserow 
INSPECfOR GENERA 
op 
1ti'd1a  OEI-02-90-0020  EXECUTIVE  SUMMAR 
PUROSE 
This inspection assesses the extent to which the Drug Abuse Treatment Waiting List 
Reduction Grant Program reduced waiting lists for drug treatment by expanding the 
capacity of existing programs. 
BACKGROUN 
The Drug Abuse Treatment Waiting List Reduction Grant Program, established under 
Section 509(E) of the Public Health Servce Act, was created to reduce treatment 
waiting lists by expanding existing drug treatment programs. Congress authorized $100 
milion for grants under the program, $75 milion of which was to be used in Fiscal 
Year (FY) 1989 and the remaining $25 milion in FY 1990. Six-nine grants covering 
361 local programs were awarded. An additional $40 milion for program grants was 
reauthorized for FY 1991. 
Both public and non-profit private entities were awarded grants, either independently 
or through a "State Umbrella Application." These grantees had to fulfil four 
requirements: (1) have experience in delivery of treatment servces for drug abuse; 
(2) demonstrate, as of the date the application was submitted, success in carrying out a 
program approved by the State; (3) be unable to admit any individual into treatment 
earlier than one month after the individual requests care; and (4) provide assurances 
that the program would have access to financial resources sufficient to continue its 
expanded capacity after the grant is terminated. The grant was originally awarded for 
a period . of 12 months. It was later amended to allow for a three or six month 
extension in response to problems that prevented programs from being able to spend 
their money within the allotted time. 
METHODOLOGY 
Telephone interviews were held with 98 grantees from a random sample of 100, 22 of 
the 23 State Agencies relating to our sample grantees, and 14 agencies which routinely 
refer clients to grantee programs. For purposes of this study, the State grantees are 
called the State and all other grantees and umbrella subgrantees are called grantees 
unless otherwse defined.  FININGS 
ALOST AL GRAES HAVE INCRED CAPACIT AN MOST HAVE 
WAIG 
REDUCE THIR  USTS 
Almost all grantees (94 percent) have already achieved their expansion goals or 
anticipate doing so by the end of their extension periods. Most have increased their 
capacity. Eighty-six percent have added to their number of treatment slots and 78 
percent serve more individuals now than before. Additionally, 75 percent report 
reducing their waiting lists and 72 percent also report reducing their waiting periods. 
Even with the grant, almost all grantee and State respondents believe there is a 
continued shortage in the number of publicly funded drug treatment slots in their 
State. 
REPONDENT' VIWS OF PROGRA'S SUCCE AR TEERED 
CONTD FUING 
CONCERNS OVER 
While 60 percent of the grantees rate the waiting list reduction grant program 
successful, 40 percent of these feel it can be truly successful only if continued funding 
is available. Two-thirds of the grantees who do not rate the grant program successful 
cite difficulties with continued funding; more than half the States rate it unsuccessful 
for the same reason. 
Many grantees and States consider the grant a temporary solution. While over half 
of these 
the grantees are certain of obtaining continued funding, more than half 
believe it wil only be for a limited time. States express similar concerns. 
ADMISTRTI 
REPONDENT EXPERIENCED SEVERA  PROBLEMS 
Almost two-thirds of grantees experienced some delay in receiving their funds, with 
most blaming the bureaucratic process. Similarly, over half the States report delays in 
receiving their money from the Federal government. 
Respondents believe the grant period should be longer, such as a three-year funding 
cycle, in light of the lengthy State legislative process and the kinds of problems 
experienced in expanding servces. 
WAIG USTS ALNE AR NOT VIWED AS A GOOD INICATOR OF 
NEED 
Most respondents believe treatment need is greater than waiting lists reflect. While 
most could not offer a better measure of treatment need, some suggest alternatives 
such as conducting prevalence studies, looking at program utilzation rates, recording 
data on calls to treatment hotlines, querying referral sources and performing outreach. 
Some respondents believe measuring waiting periods would be more accurate.  RECOMMNDATIONS 
(ADMA) 
The Alcohol, Drug and Mental Health Administration  should: 
Assure that waiting lists are not used as the sole basis for awarding a grant, but 
are considered in conjunction with other indicators of need such as utilzation 
rates and prevalence studies. 
Support a longer grant period in future legislation of this 
tye. Respondents 
recommend at least a three-year funding period to correspond with the States 
legislative cycles and to allow them time to start up and to get clients into 
treatment. At a minimum, some respondents recommend a longer time to 
draw down the funds. 
Require any future grants to have a maintenance of effort clause to enable 
programs to increase capacity without experiencing a concurrent cutback in 
State funds.

Develop a uniform definition of a waiting list and a systematic way of 
maintaining a waiting list for use by all States. This wil help both in planning 
future legislation and in providing more meaningful data on a current basis. 
COMMNT 
Comments on the draft report received from PHS, ASPE and the Office of National 
Drug Control Policy (ONDCP) concur with the recommendations of this report. 
Suggestions for changes in the wording and clarifications in the text have for the most 
part been incorporated into the final report. The actual comments can be found in 
Appendix II. 
iij  TABLE OF CONTENTS 
EXECU SUMY 
INODUCfON 
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 
Purpose 
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 
Background 
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 
METHODOLOGY 000000000000000000000000000000000000000000000000 
FININGS 
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4 
Almost All Grantees Have Increased Capacity and. 
Most Have Reduced Their Waiting Lists 0 0 000 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 
Respondents' Views of Program s Success are Tempered 
by Concerns Over Continued Funding 
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 . 
Respondents Experienced Several Administrative Problems 
0 0 0 0 0 0 0 0 0 0 0 0 . 0 0 
Waiting Lists Alone Are Not Viewed as a Good 
Indicator of Treatment Need 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9 
RECOMMATIONS 000000000000000000000000000000000000000000 
APPENDIX I 
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 
APPENDIX n 
0 0 0 0 0 0 0 0 0 0 0 0 . 0 0 0 0 . 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 
 INTRODUCTION

PUROSE 
This inspection assesses the extent to which the Drug Abuse Treatment Waiting List 
Reduction Grant Program reduced waiting lists for drug treatment by expanding the 
capacity of existing programs. 
BACKGROUN 
Drug abuse in the United States commands much public concern and attention. It is 
enough drug treatment programs available for all 
generally believed that there are not 
individuals seeking treatment. This is particularly true in areas of high heroin and 
cocaine/crack abuse and in low-income communities. Experts agree that if more 
treatment programs were available in areas where the demand for treatment exceeds 
the capacity, many more would attend them. 
Legilative History

Drug and alcohol treatment programs have always been primarily funded by State 
governments with a percentage provided by the Federal government through the 
Alcohol, Drug Abuse, and Mental Health Servces (ADMS) and the Alcohol and Drug 
Abuse Treatment and Rehabiltation (ADTR) block grants. To supplement these 
was 
grants the Drug Abuse Treatment Waiting List Reduction Grant Program 
established. Its purpose was to help existing drug abuse treatment programs rapidly 
expand their capacity to serve drug abusers who are waiting for treatment in an effort 
to provide "treatment on demand" for all. The authorization authority is found in 
section 509(E) of the Public Health Servce Act, as amended by Public Law 100-690 
Drug Abuse Act of 1988. The Waiting List Reduction Grant Program is 
the Anti-
, Drug 
administered by the Office of Treatment Improvement (OTI) in the Alcohol
and Mental Health Administration (ADAMHA). 
Redtin 
Drug Abuse Treatment Waitg List  Grants 
To receive a waiting list reduction grant, applicants had to fulfil four requirements: 
(2) demonstrate 
(1) have experience in delivery of treatment servces for drug abuse; 
was submitted, success in carryng out a program 
as of the date the application 
approved by the State; (3) be unable to admit any individual into treatment earlier 
than one month after the individual requests care; and (4) provide assurances that the 
program wil have access to financial resources sufficient to continue its expanded 
capacity after the grant is terminated. In addition, the State was required to provide 
letters of assurance giving applicants top priority for continued funding once the 
Federal grant terminated.  Programs could apply either independently or in a "State Umbrella Application." In 
an "umbrella" the State submitted one application on behalf of the programs and in 
some cases provided technical assistance and support to the individual programs. A 
State was able to use up to two percent of the grant funds to cover the administrative 
costs of managing the grant. The amount of the grant was based on the number of 
new treatment slots scheduled to be created by the program multiplied by the annual 
cost of each specific tye of slot created. The grant was originally awarded for a 
period of 12 months. It was later amended to allow a three- or six-month extension in 
response to problems that prevented programs from being able to spend their money 
within the allotted time. 
The OTI has given these grants to both public and non-profit private entities. Funds 
were usually awarded quickly, with priority going to those treatment programs judged 
to have the greatest need to expand their capacity. The programs chosen were those 
that proposed to create the most new treatment slots, were part of a State-wide plan 
to expand treatment capacity, provided State verification of their waiting lists and 
submitted the strongest assurances that funding for their expanded program would 
continue after the grant s termination. 
Congress authorized $100 milion for grants under the program, $75 milion of which 
was to be appropriated in Fiscal Year (FY) 1989 and the remaining $25 milion in FY 
1990. Twenty-nine grants, totallng $74.5 milion, were awarded by September 30 
1989, and an additional 40 grants, totallng $25 milion, were given out by April 1 
, the District of 
1990. These 69 grants covered 361 local programs in 34 States
received funding directly and the 
Columbia and Puerto Rico. Twenty-one programs 
remainder received funds through umbrella applications submitted by States. When 
the funds were awarded, the 361 grantees had an existing capacity of 76 772 slots; the 
Waiting List Reduction Grant Program resulted in the funding of 20 073 new slots, a 
26-percent increase. 
Re-authoriatin 
The Senate re-authorized an additional $40 milion for program grants in FY 1991. 
term "waiting 
The re-authorization legislation includes the following provisions: the 
list" is called "waiting period"; priority is given to programs servng pregnant and 
postpartum women; programs are encouraged to use up to 50 percent of their grant to 
provide aftercare in order to prevent relapse; and current and previous grantees can 
re-apply for funds. Also, the $40 milion had to be obligated by December 31, 1990 
and OTI was required to prepare a report to Congress on the efficacy of the program. 
METHODOLOGY 
The first phase included selection of a random sample of 100 grantees and 
during the first round of 
subgrantees out of a universe of 201 who received money 
The team intervewed 98 of these grantees who were from 
funding (see Appendix I). 
23 States and represented a mix of treatment modalities. The funding ranged from  568 for two slots to $3 152,500 for 845 slots. The grantees were asked by phone to 
, the 
(1) provide statistical data relating to the size and duration of their waiting lists
number of persons served and the number of treatment slots; (2) indicate the extent 
to which their program has been able to secure continued funding; and (3) give their 
time funding. Annual reports and 
views of waiting lists and this type of one-
was 
supporting documentation relating to waiting list data and continued funding 
requested which, when received, verified verbal responses. 
Second, 22 of the 23 State Agencies relating to our sample grantees were queried by 
telephone. Nineteen received umbrella grants; the remaining three did not but had 
independent grantees in their State. All were asked about the effectiveness of a one
, the success of grantees in obtaining permanent funding, and the validity of 
time grant
waiting lists as a measure of treatment need. 
For purposes of this study, the State grantees and those States that did not receive 
grants are called the State and all other grantees and umbrella subgrantees are called 
grantees, unless otherwse defined. 
Third, a subsample of 14 agencies who routinely refer clients to grantee programs 
were asked by telephone whether it was now easier to get clients into the grantee 
referring agencies include probation departments, courts, hospitals 
program. These 
and local drug and alcohol agencies in various parts of the country.  .......,....... ...-...  ...-... ...-.... .... .... ......... ... .... .... ....  ..... . .......... ..."  ..- " ...  ...  .....  .....  ... ,.....  ... , .........  .... . ... .... ....  ...................................,......................................

FINDINGS

ALOST AL GRAES HAVE INCRED CAPACIT AN MOST HAVE 
WAIG 
THIR 
REDUCED  LISTS 
Exand 
Most Grantees Have  Thir Programs 
Almost all grantees (94 percent) have already achieved their expansion goals or 
anticipate doing so by the end of their extension periods; the remaining six grantees 
were not certain because of slow start-ups and diffculty in acquiring additional staff 
their programs, most grantees used grant funds for new staff 
and space. In expanding 
increased salaries of existing staff, treatment servces, building and renovations 
operating expenses, equipment and supplies. 
Most grantees have increased the capacity of their program. Eighty-six percent have 
added to their number of treatment slots and seventy-eight percent serve more 
individuals now than they did before the grant (Graph I below). In some cases, while 
programs increased slots, now that the grant program has concluded they serve fewer 
individuals, primarily because they no longer have funding to treat that increased 
number of indigent clients. Amongst grantees, a slot is most commonly defined for in
patient programs as a bed; for out-patient programs it is the abilty to treat one 
individual in a given period of time or a unit of servce. 
GRAPH I 
MOST GRANTEES HAVE  MOST GRANTEES SERVE

I NCREASED SLOTS  MORE CL I ENTS 
10()  10() 
86H 
7811......
BD1  .. BD1 ...........................................

601  .. 601 
401 ..  .. 401 .. 
201 . 
1011  711 
411 
'11. TOHOF F G SRLNONTTES. ER   W" IOTHFS D LGEOCiTERSE EASS E  W" ITOFHS  lIGNTRSCAN STEEDES  '11"T OHOF FS  CAGLR IEANHN.TSEE ER   " O'11CFTLH  GIe FirEEsWE RS   " 'O1C1FTL HIGER MNATJNRSTEE E

The remaining grantees do not report increased capacity (Graph I above). Some have 
the same number of slots and serve the same number of clients. A few grantees 
One grantee 
explain that the State cut their funding an amount equal to the grant. 
represents the sentiments of others by saying "The block grant was cut (by the State) 
right before the waiting list dollars came, so the waiting list dollars didn t increase 
anything, it just allowed us to continue at the same level." This was reported although  , ," " ..." ...." ..,...".'-." .-- . ... ...-...   ..-.  ...  ..-. ... ..-. ..... .. . -..., ...... .- 
..,... ..". -.......-...'.... ..........'.. .-.. ................'" ... "
the Request for Application clearly states  Grant funds must be used to supplement 
not supplant, existing treatment service delivery activities . Others initially expanded 
their programs, but had to cut back once their grant was terminated because of a lack 
of continued funding. A few reduced their programs for reasons unrelated to the 
grant. 
Per 
Reded Thir Waitg Lists and Waitg 
Most Grantee Have 
, including nine 
Seventy-five percent of grantees report a reduction in their waiting lists
who no longer have a waiting list (Graph II below). The 22 perce  t of grantees who 
report an increase in the size of their waiting lists most often mention that demand for 
their program increased when they received grant funding. As one State respondent 
asserts  Demand is driven by factors relating to awareness of servces." Another 
states  As treatment becomes more available, more people step forward. 
GRAPH II 
MOST GRANTEES HAVE

REDUCED WA I T I NG LISTS 
1001 
801 .... 
5'" ....

601 .. 
401 ...... 
201 .. 
316 
GRANTEES  GRNTEES  11 OF GRNTEES 
WITH SAE SIZE  WI TH INCREASED  WITH DECREAseO

WAITIII LISTS  WAIT1tG LISTS  WAITItG LISTS

The size of waiting lists varies significantly. Of the programs surveyed, waiting-list size 
ranges from between 2 to 408. The waiting-list size is priarily determined by 
, methadone 
program size and by tye of treatment modality. For instance
maintenance programs generally tend to have less turnover and, therefore, larger lists. 
Of the fourteen referring agencies surveyed, six mention that clients whom they refer 
funded programs have a shorter wait now to enter those programs than they 
to grant-
did before the grant; one reports that its clients no longer have to wait.  ,....................................................

.......  -. .. .. .. ..  .. ..  ." - .".  .- . . . . . . . ... .. . . .. . . . . .. . .... . ... ..  .. ...... .
Almost three-quarters of grantees (72 percent) also report a reduction in their waiting 
periods, the number of days a client must wait before entering a program (Graph III 
below). They include eight programs whose waiting times have been eliminated. 
with waiting-list size, the range of waiting periods also varies widely, from a few days 
to more than one year. 
GRAPH III 
MOST GRANTEES HAVE

REDUCED WA I T I NG PER IODS 
10D1 
8D1 .... 
7211 
6D1 ...............

4D1 
" OF GRANTEES  " OF GRNTEES  . OF GRANTEES

WI TH SAE SIZE  WITH I flREASED  WITH r.CAEASEO 
wAITItG PERIOOS  WAITIfI PERIODS  WAITI  PERIODS 
More Women and Minorities Were Served 
Over one-quarter of grantees (27 percent) notice an increase in the percentage of 
minorities served in their program since the grant; similarly, almost one-third of 
grantees (32 percent) notice a change in the number of women served. Respondents 
report both of these increases are attributable at least in part to the grant program. 
One grantee remarks that the abilty to serve more clients allows a program to 
consequently serve more minorities and women, particularly pregnant and post-partum 
women in need of services. One grantee states that with grant funding they were able 
to hire bilngual  addicts; another explains that 
counselors to do outreach for Hispanic 
they specifically targeted African-Americans with grant funds. 
Respondnts Claim a Shortage of Pulic Drug Treatmt Prgrms 
Almost all grantee and State respondents agree that there is a continued shortage in 
the number of publicly funded drug treatment slots in their State. Many, however 
mention that there are available slots in private programs for those who can pay for 
such treatment themselves or who have insurance. One State respondent asserts that 
If you have the right kind of insurance you can get into any program anywhere, but 
most people seeking treatment have no insurance." Another agrees: "Private  , " , " , " , "
programs are prolific. City programs are the treatment of last resort so they are 
inundated with those not eligible for Medicaid. 
In general, respondents feel there are more addicts needing treatment than there are 
programs to treat them. When asked if there are enough treatment slots in her State 
to serve the number of addicts seeking treatment, one grantee responds  If that were 
the case, we wouldn t have waiting lists. Addicts should really be able to get treatment 
on demand." Other respondents mention a shortage of programs specific to a client 
location. 
population, treatment modality or geographical 
REPONDENT' VIWS OF PROGRA'  SUCCE AR TEMPERED BY 
CONTD FUING 
CONCERNS OVER 
Respondents Lik Grant's Succes Wih Availbil of Cont Fung 
While 60 percent of the grantees rate the waiting list reduction grant program 
successful, 40 percent of them feel it can be truly successful only if continued funding 
is made available. Although States were required to provide letters of assurance 
giving applicants "top priority" for continued future funding once the Federal grant 
terminated, it was not a guarantee that continued funding would be available. Two-
thirds of the grantees who do not think the grant program is successful blame 
difficulties with continued funding. These concerns about continued funding are 
shared by States: less than half consider this grant program successful, with the 
problem of continued funding the most frequently mentioned reason. One grantee 
expresses the concern of many others when he states  A one-year grant is a band-aid 
when surgery is needed. We need more of a commitment from the State." One State 
respondent says  We hoped we d get State money (through the legislative process), 
but without some absolute guarantee of State money the grant is no good. We never 
know how finances wil be from one year to the next. This is a poor way for Congress 
to give money. It gets things going and brings them to a screeching halt, which is 
worse than not getting them at all. 
Many Grantees and States Consr the Grant Program a Temporary Soluon 
Over one-half of grantees are either very or fairly certain of obtaining continued 
funding, but more than one-half of these believe it will only be for a limited time 
blaming major cutbacks in the State budgets. Since they are unsure of the future 
many grantees consider the grant program a short-term solution. One grantee voices 
this common concern when she says  Short-term funding allows for a temporary 
solution to treatment needs in the community. Programs are developed to meet those 
needs, which raises expectations in the community. Programs abruptly end, leaving 
both addicts and the community disilusioned." Only 38 percent of the grantees report 
that their programs will continue indefinitely after the grant is terminated. Some 
programs say they wil have to resort to client fees when the grant ends, but feel very 
few clients, if any, can afford to pay for treatment.  , " , " , "
Two-thirds of the States are certain the programs in their State will obtain continued 
funding, but a quarter of them believe such funding will only continue for a limited 
time. Many State officials feel they are "at the mercy of the Federal block grant and 
State legislature" and cannot promise the programs indefinite funding. One State 
We were tied by our State legislature. It is even a political process 
respondent says 
to get an item on our own budget proposal to send to the State. 
Some Grantees  Grant Program Gave A Wuuw of Opportit for
Belie  Th 
Treatmnt 
Thirty-five percent of the grantees say the grant gave a window of opportunity to treat 
those people who otherwse would not have gotten help, the indigent clients in 
particular. Several States agree. One respondent sums up this sentiment when she 
states  The grant did turn some lives around and a lot of clients got treated who 
wouldn t have before the grant, so for that reason the grant was very good. 
ADMISTRTI 
REPONDENT EXPERINCED SEVERA  PROBLEMS 
Fun 
Initl 
Delas in Drawig Down 
Grantees and States Report 
Almost two-thirds of grantees (61 percent) experienced some delay in receiving their 
, funds were dispersed 
funds, with most blaming the bureaucratic process. In one State
before actually reaching the 
through several levels - from State to county to city -
program. One State respondent voices the concern of many when he admits that the 
programs (in the State umbrella grant) experienced even bigger delays to get through 
our bureaucracy.

Similarly, over half the States report delays in receiving their money from the Federal 
government. One respondent states  We can spend money as long as we get the 
(grant) award letter. Getting the award letter late delayed us." Another explains that 
while all five programs on the State application were approved, only two of these 
received funding, so that the State was forced to wait to see which programs got 
money and how much. Another State blames the delay on the paperwork needed to 
obtain funding.

Delays in receiving funding also resulted in many of the extensions requested by 
grantees to complete their expansion. Seventy percent of grantees required extensions 
of up to six months. The most frequently cited reasons include: (1) slow start-ups due 
to delays in obtaining funding; (2) difficulties in hiring new staff; (3) problems in 
procuring additional space; and (4) time needed to renovate present quarters. 
Grantees and States Want a Diferent Funing  Grant Program 
Cycle for the 
, such as a three-year 
State respondents believe the grant period should be longer
, due to the lengthy State legislative process. States would like more time 
funding cycle
to adjust their budgets, and feel one year is not enough time to develop a permanent  , "
alternative funding source. In the absence of increased funding, some recommend 
lesser amounts per year for a longer period. At the very minimum they recommend at 
least a longer time to draw down the funds. As one respondent states  It was an 
incredible hassle for one year. If they do it again they should do it for a minimum of 
also prefer 
, even if less money is given each year." Respondents would 
three years
that the grant fit into their funding cycle to reduce the problems which arise from the 
differences in State and Federal fiscal years. 
Grantees agree with the States, citing administrative and other problems experienced 
The grantees 
in expanding services as reasons why a longer grant period is needed. 
would like more time to find qualified staff, a particularly difficult problem in rural 
areas. Adding new space and renovating existing quarters is time consuming, 
Grantees also feel that one year is not 
especially if there are construction problems. 
long enough to establish a presence in the community. 
WAIG LISTS ALNE AR NOT VIWED AS A GOOD INICATOR OF 
TRTMNT 
NEED 
Most Respondnts Say Treatmt Need is Greater Thn Waitg Lists Refct 
Two-thirds of grantees and more than half the States believe waiting lists do not give 
an accurate picture of the number of people seeking treatment, nor do they reflect the 
number needing treatment. One grantee reflects the' views of others in saying: " 
waiting list does not reflect the true need for treatment. It often does not include the 
discouraged addict, nor the non-referrals from discouraged referral sources. That is 
when funding is scarce and lists are long, people tend to give up. That reduces 
, which deceives funding sources into 
referrals, which equals shorter/smaller waiting lists
believing there is no problem." A State grantee contends that "waiting lists are an 
, but are not accurate in showing magnitude. 
indicator of gross need for service
, 15 percent of grantees believe that waiting lists are a good indicator of 
In contrast
treatment need, or at least the best measure available. They feel that waiting lists at 
least show demand, if not the magnitude of demand. 
More than half the grantees feel waiting lists underrepresent treatment need. Some 
claim that this is a population that does not wait: people who call for treatment during 
a crisis are not interested if not treated immediately. One grantee asserts that it is 
traumatic if "there is a waiting-list message on a machine - it is like a suicide hotline 
putting you on hold." Other grantees note there are some geographical areas not 
having treatment programs at all. 
Only 27 percent of States systematically collect waiting-list data. The definition of 
waiting list varies from State to State and among different programs within a State. 
keep 
Some programs evaluate prospective clients before putting them on a list; others 
the names of all callers, and stil others do not routinely keep waiting-list data. Some 
keep people on the list and offer limited servces while they wait. The States not  , "
list data survey their programs when they get an external 
routinely collecting waiting-
request for such information. 
Respondnt suggest better meases of  need 
treatm 
While most respondents could not offer a better measure of treatment need, some do 
suggest alternatives. These include doing studies of the prevalence of drug and 
alcohol use in a particular population, looking at utilzation rates in programs, and 
recording data on calls to treatment hotlines or admission requests. Other suggestions 
include conducting outreach programs, having a central intake process for referrals 
and querying referral sources such as hospitals and courts. 
Some respondents thought that measuring waiting periods would be a more accurate 
indicator than waiting lists. As one respondent says  Waiting periods tell the length of 
time someone must wait before getting treatment. It gives a truer picture of needs. 
Lists just tell how many - they could be waiting for weeks, months or years." However 
most feel that a combination of waiting lists and waiting periods gives a more 
complete picture.  RECOMMENDA TIONS

(ADMA) 
The Alcohol, Drug and Mental Health Administration  should: 
Assure that waiting lists are not used as the sole basis for awarding a grant, but 
are considered in conjunction with other indicators of need suc;h as utilzation 
rates and prevalence studies. 
Support a longer grant period in future legislation of this tye. Respondents 
recommend funding for at least a three-year period to correspond with the 
States' legislative cycles and to allow them time to start up and to get clients 
into treatment. At a minimum, some respondents recommend a longer time to 
draw down the funds. 
Require any future grants to have a maintenance of effort clause to enable 
programs to increase capacity without experiencing a concurrent cutback in 
State funds.

Develop a uniform definition of a waiting list and a systematic way of 
maintaining a waiting list for use by all States. This will help both in planning 
future legislation and providing more meaningful data on a current basis. 
COMM 
Comments on the draft report received from PHS, ASPE and the Office of National 
Drug Control Policy (ONDCP) concur with the recommendations of this report. 
Suggestions for changes in the wording and clarifications in the text have for the most 
part been incorporated into the final report. The actual comments received are in 
Appendix II. 
The PHS claims that receipt of the grant award letters was not delayed from the 
Federal government, and that in every instance where a program received funds late 
after award, but chose not to access the 
the State had access to the grant funds shortly 
this delay, we are reporting information obtained during the course 
funds. Regarding 
of the study. However, in light of PHS' s comments we will investigate this further. 
The PHS claims that major construction and renovation costs were not allowed in the 
grant s legislation. Respondents reported building and renovation in order to expand 
services. In response to PHS's comments we will also investigate this further. 
The ONDCP characterizes this report as a condensed version of the Waiting List 
Reduction Report prepared by OTI for Congress. In response, we would note that 
the data for this report was collected from OIG telephone intervews and was not 
based on OTI information. However, we provided OTI information based upon our 
data for purposes of their report.  APPENDIX I

SAMLING METHODOLOY 
consisted of 361 facilties; 
The universe of drug abuse treatment centers initially 
however, the grants were awarded in two rounds. The first-round grants were 
awarded to 201 treatment centers by September 30, 1989; the remaining funds were 
awarded to 160 treatment centers by April 1, 1990. The universe was restricted to the 
201 treatment centers which received. funding by the September 30, 1989 date. 
The universe of 201 facilties was stratified into three groups according to the date of 
program completion or requested extension. The first group included 61 centers 
which had successfully completed their expansion program. The second consisted of 
72 centers which had requested a 3-month extension. The final group consisted of 68 
centers that had requested a 6-month extension. A uniform sampling fraction of one-
100 treatment centers. 
half was then applied to each stratum for a total sample of 
The following table ilustrates the sampling design: 
TABLE I 
Status of Facility  Universe  Sample Size 
Completed program 
3-month extension 
6-month extension 
Totals  201  100 
, any 
As simple random sampling was used to draw the sample within each strata
estimates made from the sample are unbiased.  APPENDIX II

COMM  TH DRA REORT

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DEPARTMENT OP 
JUL 29 1991 
Date 
Health 
From  Assistant Secretary for 
(OIG) Draft 
of Inspector General 
Subject  PHS Comments on the Office 
Report " Drug A.buse Treatment Waiting List Reduction Grant 
Program 
Inspector General, OS

At t ached a re the PHS commen ts on  he subj ect OIG re por t . 
to which the Drug

The report provides useful data on the extent 
reduces
Abuse Treatment Waiting List Reduction Grant Program 
the capacity of 
waiting lists for drug treatment by expanding 
existing programs. 
We concur wi  s re commends t ions and have taken 0 
th the report  implement them. 
are taking action to 
0, 
Mason, M. D. , Dr.

Attachment 
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EXSEC 
DATE SE  TH S  VICE (PHS' ON THE
OF TH 
LIC  (OIG' DRAT REPOR
OFFICE  OF INSPECTOR G 
DRUG ABUSE TREATMENT WAITING LIST REDUCTION 
GRAT PROGRA, " OEI-02-91-0Q420 
General Comments

comment on this Office of

We appreciate the opporturneiptyo rtto.
 
The report provides important
Inspector General draft  ADAM in 
information and observations which will atyspsies.t
structuring any future programs of this 

Inasmuch as the grantee in most cases for these grants waS the

the report should distinguish between the programs which

State  grantees which were

were snbqrantees of the State and  umrella application.
independents not attached to the state 
The awards for this program were made in accordanoc et hwei tkhn otwhlee
dge

schedule published in the grant announcement.this. 
program, receipt of

of grants management staff handling 

the grant award letters was not delayeFdu dfrso m the Federal

were available to 
governent as stated in the report. 

States for drawdown two or three days following mailing of the

grant award. Therefore, unless there are other facts to

support the statement that Federal funds were delayed, we

believe that statements should be remogvoedv ew3hi:cehn ti.n dInic aetvee rtyh at

payment was delayed from the Federal

funds late, the State had

instance where a program received 

access to the grant funds shortly after award but chose not to

funds.

aCcess the 
Office for Treatment

The reasons most frequently given to the-

Improvement staff by programs requesting extensions were:

(1) subrecipients claimed that in order to receive the grant

to revise and resubmit

funds from the State they were required

State, and (2J subrecipients were

their applications to the 
s requirements (such as

required to meet their State  funds, a

legislati 
approval) before being assured grant

months. 
process that could take up to six 

OIG Recommendation

Assure that waiting lists are not used as the sole bawsiitsh  footrh
er

awarding a grant, but are considered in conjuncti

indicators of need such as utilization rates and prevalence

studies. 
PHS comment

scheduled 
Wfeo rc roenacuurth.o Trhize aWtaioitni.n gH oLwisetv/ePre, rai noedw P craopgareaim'  tiys  Enxop ansi  Program
1992 budget proposal.

was proposed by the Department in the FY 
 s other than waiting

This program is proposed to include facto

list/period as 
criteria. for award. 
OIG Recommendation

year
support a longer grant period in future legislation of this
type. 
Respondents recommend funding for at least a three-
States' legislati  cycles and to 
period to correspond with the 
allow them time to start up and to get clients into treatment. 
At a min  um, some respondents recommend a lQnger time to draw

down the funds.

PHS Comments

We concur. The new Capacity Expansion program is proposed for

a five year period.

OIG Recommendation 
Require any future grants to have a maintenance of effort

ease capacity without

clause to enable programs to inc 
experiencing a concurrent cutback in State funds.

PHS Cornen 
we concur. Any grant program to increase capacity without

experiencing a concurrent cutback in State funds should include

olause. To use qrant funds to fund

a maintenance of effort 
programs currently funded by the State is supplantation which

allowed. 
would not be 
OIG Recommendation 
States. 
Develop a unifor. definition of a waiting list and a systemTahtiis 

way of maintaining a waiting list fleorg iusslea tbi y all

and providing
will help both in planning future basis.
more meaningful data on a current 

PHS Comments

We concur. We will define the parameters of an acceptable

wai tinq list through a consensus development process with the
field. 
Technical Comments

E). 
509(e)" should be "509(.
Page i, second paragraph, "

Page i, third paraqriaph" (2) 1 atatement shaopulpdli cbae. t.ai ddedwas
stating, "demonstrate, as (,f the date the 
submitted, success...  " .. 
II grantees" means
Page ii, fifth paragraph, it is not clear if

the State as the grantees or direct grantees other

stubhgranateesn the State. 
paragraph. the second sentence, and page 

Page ii, the fifth 
over half the States report delays

last paragraph reads:  See our

in receiving their money from the Federal Gofvuenrdnse.n t.

general comment regarding delays of Federal 

Public Health

Page 1, third paragraph, ninth line,"  aafntde rb e"f
 ore "Public... 
" in&ert II as amended by
service Act, 
a statement should be added

Page 1, fourth paragraph, ( 2 ),  was 
stating "demonstrate, as of the date the applicati

submitted, success... 
used" should 
paragraph, second line, "to be 
Page 2, second full 
be replaced with lito be appropriated. 
line, "100 grantees and

Page 2, last paragraph, first 
subgrantees. 
line, "who" should be replaced

Page 2, last paragraph, last 
which.

wi th "
The block grant was cut right before the

Page 5, first line, "
came, so the waiting list dollars didn't

waiting list dollars 
us to continue at the same

increase anything, it just allowed 
for Applicatio

level. " This is supplantation. The Request 

clearly stated that the waiting list funds were not to be used

funds, which were meant to

to substitute/supersede State  past.
continue assisting programs as they had in the 

line, it should, also, be clarified that any

Page 5, first 
s apportionment

reduction in the block grant was in the State'

to the subgrantees of the block grant funds which the Federal

governent  his sentence without

awarded to the State.  governent reduced the

explanation suggests that the Federal 

block grant to the State which it did not.

AR 
TEMPERED BY 
S SUCCESS 
page 7, "RESPONDENTS' VIEW OF PROGRA' 
The report should include

CONCERNS OVER CONTINUED FUNDINGr.eqired to provide letters of
the statement that States were 
assurance giving applicants, submitted under the state
top priority" for continued future

umbrella application,  termnated.

funding once the Federal grant 

sentence, since

Page 9, third full paragraph, fourth 

(except for minor changes) costs 
const:.ruction and renovation 
legislation for the grants, we are 
were not allowed in th 
plication that grantees have expended
concerned with this 
 items which were not

Federal funds for heavy construction

allowed. 
Page 8, last sentence, it shogulodv ebern celnart itfoi ethd ew h$ettahteer  otrh eo tahwearr d

was delayed from the Federal 

State to the subgrantees.

qrantee or was delayed from the 
av in recei vina funds which 
The following statements concern 

we believe should be more clearly attributed to the States and

not to the Federal program:

paragraph, second. sentence, "Funds were 
Page 2, first complete 
usually awarded quickly, with priority going to those treatment 
greatest need to expand their

programs judged to have the 
trea tment. " 
sentence, "One State respondent

Page 8, fourth paragraph, last  programs
voices the concern of many when he admits that the '

(in the State umrella grant) experienced even bigger delays to 
get through our bureaucracy. 
Page 9, first paragraph, end of etxhtee ntshiiornds ,l i" n(e 1 )w hsilochw  asdtadrrteuspsses

reasons for grantees requirifungn
 ding...
due to delays in obtaining 
 :::.  
-- ,

J;:J  '-I
DEPARTMENT OF HEALTH &. HUMAN SERVICES 
t.t',ece of the Secetary 
;,."'la 
ashingon. D.C. 20201 
JU 
1 / 199/ 
TO:.	 Richard P. Kusserow

Inspector General

FROM:	 Assistant Secretary for

Planning and Evaluation

SUBJECT:	 OIG Draft Report: "Drug Abuse Treatment Waiting List 
, II 
Reduction Grant Program OEI-02-90-00420 --
COMMNT 
Thank you for the opportunity to review the above-named draft
report. I 
think the report provides useful guidance regarding 
the problems posed by one-year qrant programs such as the Waiting
List Reduction Program. 
The study also proved timely as it
contributed to a Congressionally required study on this 
program.
I would like to clarify, however, that while the idea for this
study resulted from the routine OIG and ASPE staff level 
"brainstorminq" discussions
, the study should not be 
characterized as one that was formally 
 equested by ASPE.

If you have any questions
, please call Elise Smith at 245-1870. 
Martin H. Gerry

(-;0 
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DATE  I&VU 
/91  "20247:10285  HHS DRUG COl:NSEL 
18' 10: 26	
Counsl to the Seretary
DEPARTMENT OF HEALTH &. HUMAN SERVICES	
for Org Aase PoliCy 
C. 
wasnington. D.
DICKU
RATO 
NSORGE

rcMcB  A

TO'1 
DRABPO 
FO 
SUEC:	 Draft Repfirt of the Of Ice of Inspector General entitled 
DruG AbYsl Yreatment Wa  .duct'olJ Granl 
proeram  COMMEN 
I am trsmitg  mment from the Ofce oaf lN ational Dru control poncy
(ON DC?) ravew of tsht t od youo 	 ent whic  revaseBd aaanld   ors. I understad that
C. Comolli of my  has spoken with Emlie  from your offce concerning the 
you may have concerng these 
ONDCP reiew. preas let me know of an quG$ns 
comments. 
atentn 
Thank you for your  to this matter. 
AITACH  ~~~ :!  =- 
003 
2024750US  HaS DRUG COliNSEL 
,'1.2/91  10: 26 
July 3, 1991

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