Department  of  Health  and  Hums  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
REVITALIZING  THE  COMMUNITY 
SUPPORT  PROGRAM  OFFICE  OF INSPECTOR  GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 
amended, is to protect the integrity of the Department of Health and Human Services @HS) 
programs as well as the health and welfare of beneficiaries served by those programs.  This 
statutory mission is carried out through a nationwide network of audits, investigations, and 
inspections conducted by three OIG operating components: the OffIce of Audit Services, the 
OffIce of Investigations, and the Office of Evaluation and Inspections.  The OIG also informs the 
Secretary of HHS of program and management problems and recommends courses to correct them. 
OFFICE  OF AUDIT  SERVICES 
The OIGSOffIce of Audit Services (OAS) provides all auditing services for HHS, either by 
conducting audits with its own audit resources or by overseeing audit work done by others.  Audits 
examine the performance of HHS programs and/or its grantees and contractors in carrying out 
their respective responsibilities and are intended to provide independent assessments of HHS 
programs and operations in order to reduce waste, abuse, and mismanagement and to promote 
economy and efficiency throughout the Department. 
OFFICE  OF INVESTIGATIONS 
The OIGS0ft7ce of Investigations (01) conducts criminal, civil, and administrative investigations 
of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment 
by providers.  The investigative efforts of 01 lead to criminal convictions, administrative 
sanctions, or civil money penalties.  The 01 also oversees State Medicaid fraud control units which 
investigate and prosecute flaud and patient abuse in the Medicaid program. 
OFFICE  OF EVALUATION  AND  INSPECTIONS 
The OIGSOffIce of Evaluation and Inspections (OEI) conducts short-term management and 
program evaluations (called inspections) that focus on issues of concern to the Department, the 
Congress, and the public.  The findings and recommendations contained in these inspection reports 
generate rapid, accurate, and up-todate  information on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
This report was prepared under the direction of William Moran, the Regional Inspector General 
for the Office of Evaluation and Inspections, and Natalie Coen, Deputy Regional Inspector 
General, Office of Evaluation and Inspections, Region V.  Participating in this project were the 
followingpeople: 
Region V  Headauarters 
Barbara Butz	 Susan Hardwick 
David Wright  I  Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
REVITALIZING  THE  COMMUNITY 
SUPPORT  PROGRAM 
I 
m  1993  OEI-05-92-O0120  EXECUTIVE  SUMMARY 
PURPOSE 
To assist the planning efforts of the Center  for Mental  Health  Services  by gathering the 
perspectivesof key stakeholders about the Community Support Program. 
BACKGROUND 
On October 1, 1992, the Alcohol, Drug Abuse, and Mental Health Administration, within 
the Public Health Service (PHS), was reorganized into a new agency called the Substance 
Abuse and Mental Health Selviccs Administration (SAMHSA).  Within SAMHSA, the 
new Center for Mental Health Services (the Center) is charged with coordinating the 
Federal role in the prevention and treatment of mental illnesses and promotion of mental 
health.  It also administers severaI grant programs, including the Community Support 
Program (CSP). 
Created in 1977 by the National I@tute  of Mental Health (NIMH), CSP was designed to 
assist States and communities in improving opportunities and seMces  for adults with 
seriously disabling mental illnesses.  Funded at about $12 million for Fiscal Year (FY) 
1993, CSP provides grants to State mental health authorities for services research 
demonstrations, and projects involving primary consumersl and fties  in the 
development of services.  It aiso provides grants to technical assistance resource centers. 
We were requested by the Center to assist them in identifying t%turedirections for the 
Community Support Program, given the new mission and mandate of the Center.  We 
spokewith 124 persons nationwide for this study: Federal and congressional staff, 
researchers,  profwsionals,  and providers; State commissioners and CSP directors; 
consumer and family groupq  CSP grantees; and others. 
FINDINGS 
While the questions in this study were about CSP, most of the findings and 
recommen&tions  relate more broadly to the Center.  This is because most respondents 
quickly went beyond CSP to talk about the Center, or talked interchangeably about the 
both.  They believe that CSP has laid a strong conceptual foundation for the Centers 
activities.  They have many notions of how the Center should apply the philosophy and 
principles of CSP to its other activities in the future. 
The greatest impact of (XP  has been in changing attitudes and perceptions about 
serving adults with severe mental illnesses, rather than bringing about the widespread 
development of comprehensive community-based services. 
1 Defined as ex-patients, or as current  and  former  users of mental health services. 
i  Respondents say that to provide strong Federal leadership on behalf of persons with 
severe mental iUneases,the Center should adopt the principles of CSP -
rehabilitation, reeovery, and integration into the community - as its cornerstone. 
People want to see the Centers agenda fbcused on the implementation of comprehensive 
community-based services.  They seek strong linkages between CSP and other Center 
programs, and between the Center and other organizations. 
Respondents believe that a n@or thrust of the Center should be technical assistance 
to help States implement comprehensive community-based services. 
The call is overwhelming for technical assistance that fbcuses more on consultation and 
less on written information. 
Reapondentacall for the Center to redefine and revitalize CSP demonstrations. 
People agree that evaluation for future demonstrations should be strengthened, combining 
rigor with pragmatism. 
Consumer and family involvement is seen as valuable, but most respondents say a 
more strategic focus for thii part of CSP is now needed. 
The majority view is that the Center should refocus this part of CSP, and that they should 
evaluate consumer and family involvement.  People want to know more about how these 
g~ups  can help improve the accessibility and quality of comprehensive community-based 
services. 
RECOMMENDATIONS 
In implementing the concepts of CSP on behalf of persons with severe mental illnesses, 
we recommend that the Center take the following steps. 
Develop a strategic plan for the next 3 years. 
The plan should focus on the implementation of comprehensive community-based mental 
health servim.  It should include a national policy  agenda  and strategies for the Centers 
most important program activities.  It should contain objectives, timetables, and criteria to 
measure the impact of the Centers activities  on improving  the accessibility and quality of 
comprehensive community-based services  for persons  with  severe  mental  illnesses. 
Broaden ita constituency and maintain strong linkages with agencies and 
organizations within and outside government. 
Many respondents believe that CSP has  become  overly  focused on certain constituents to 
the exclusion of others.  We recommend that  the  Center  broaden  its base.  It should 
involve  a wide  variety  of constituents  in developing  and  carrying  out  the  strategic  plan.  It 
ii  should also maintain on-going relationships with a host of organizations and constituents at 
Federal, State and local levels. 
Develop a strategy to provide more practical technical assistance to the field, in 
addition to the dksemmation of written information. 
 
The Center should ensure that technical assistance is provided by individuals with expert 
knowledge of programs and experience in implementing comprehensive community-based 
senices. 
Incorporate practical yet reliable evaluation methodologies into CSP demonstrations 
of services* 
Respondents need reliable information on effective community-based services.  The Center 
should conduct CSP demonstrations which evaluate the cost, process, and outcome of such 
services on the lives of clients, and employ the most rigorous designs applicable to 
address the questions being asked. 
COMMENTS 
The PHS commented on this repo~,  the fill  text of their comments is in Appendix A. 
They concurred with our recommendations and described steps taken to implement them. 
We thank them for their comments. 
#.. 
111  TABLE  OF  CONTENTS 
PAGE 
=EcuTwE 
SUMMARY

INTRODUCTION  . . . . . . . . . . . . . . . . .  . .  .  .  . .  .  .  .  .  .  .  .  . .  .-.  .  .  .  .  . ...1(cid:1)
FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . ...4	
ImpactofCSP  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4	
Federal Leadership and CSP  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...5	
Technical Assistance  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...7	
Demonstrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Consumer and FamiiyInvolvement  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  11	
RECOMMENDATIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12	
Develop aStrategic  Plan  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12	
Broaden Center Constituency  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  12	
Provide Assistance tothe  Field  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13	
Improve Evaluation ofDemons@tions  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  13	
APPENDIXA  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..  A-l  INTRODUCTION 
PURPOSE 
To assist the planning efforts of the Center for Mental Health Services by gathering the 
perspectives of key stakeholders about the Community Support Program. 
BACKGROUND 
On October 1, 1992, pursuant to Public Law 102-321, the Alcohol. Drug Abuse, and 
Mental Health Admir&tration within the Public Heal~  Service wasreorganized into a new 
agency called the Substance Abuse and Mental Health Services Administration 
(SAMHSA).  Two centers in SAMHSA target substance abuse services.  The new Center 
for Mental Health ServiceS (the Center) is charged with coordinating the Federal role in 
the prevention and treatment of mental illnesses and promotion of mental health.  It also 
administers several grant programs, including the Community Support Program (CSP), 
child and adolescent mental health grants, grants for the benefit of homeless individuals, 
for State protection and advocacy and human resource development programs, and mental 
health seMces  block grants.  The Center also coordinates evaluations, assessments, and 
policy  studies  relevant to mental health services.  The National Institute of Mental Health 
_  ~fis  _nsibfity  for mental health research, including seMces  research. 
.
unatv-tt  RVIZ-
Created in 1977 by NIMH, CSP was designed as a pilot program to stimulate and assist 
States and communities in improving opportunities and services for adults with seriously 
disabling mental illnesses.  Initially CSP was fimded through contracts with State mental 
health agencies.  Funding was converted in 1980 to grants, with a focus on State systems 
change.  Today CSP is funded at about $12 million for FY 1993. 
The CSP followed on the heels of the reinstitutionalization  movement and was the first 
FederaLinitiative devoted exclusively to improving care of persons with severe mental 
illnesses in the community.  Its fimdamental premise is that such individuals can be helped 
to live productive lives in the community.  Prior to CSP, the focus was on mental health 
treatment alone.  A new concept, or model, called the community support system was 
developed within CSP as a basis for planning and organizing seMces  for this population. 
It reflects an integrated, comprehensive systemo fcare,in cluding not only mental health
services but an array of rehabilitation and social services as well: client identification and 
outreach; crisis response serviax;  housing; income support and benefits; health care; 
rehabilitation, vocational training and employment assistance; alcohol and/or other drug 
abuse treatment; consumer,  f~y,  and peer support; and protection and advocacy. 
Currently,  CSP promotes the development of community seMce  systems primarily 
through grants to State mental health authorities.  The two major thrusts are 
1  demonstrations, and statewide service system improvement projects to involve primary 
consumers and families in the planning, provision, and assessment of services.  A third, 
smaller, CSP emphasis is grants to resource centers that provide technical assistance on 
housing, consumer self-help, and rehabilitation research and training.  All States have 
been CSP grantees at some time during the life of the program. 
The population of concern for CSP is aduks with severe mental illnesses: individuals 18 
years and older with a severe and persistent mental disorder that seriously impairs 
functioning in the primary aspects of daily living such as interpersonal relations, living 
arrangements, or employment.   According to the 1989 National Health Interview Survey, 
as many as 4 to 5 million adults in the U.S. suffer from severe mental illnesses. 
From  1955 to 1985, large State institutions reduced their patient population by 80 percent. 
Now, according to projections in the 1989 National Heahh Interview Survey, about two-
thirds of the severely mentally ill population reside in the community.  A report by the 
Federal Task Force on Hopelessness  and Mental Illness notes that as a group, this 
population is younger, more heterogeneous - including more minorities - and more 
troubled than in the past.  It includes many people in their 20s and 30s who have spent 
little or no time in an institution. Their  incidence of hopelessness,  and contact with the 
criminal justice system, have been on the rise. 
Nationality, about 60 percent of State mental health finding  still goes for in-patient care 
rather than community-based services, even though the majority of this population resides 
in the community.  The Federal share of funding for services remains small compared to 
the State and local shares.  For example, in 1985, States supplied over 78 percent of the 
funding to support State mental health agencies; the remainder was provided by Federal 
sources including block grants, Medicare, and Medicaid. 
One of the most important national issues which could affect health and mental health 
services for this population is national health care reform.  The extent to which mental 
health services are a part of this reform is not yet known, but it could have a significant 
impact on the Centers programs. 
The Mental Health Sewices block grant, formerly part of the Alcohol, Drug Abuse, and 
Mental Health Services block grant, is the largest program at the Center providing fhnds 
for servica  for this population, with an appropriation of some $280 million for FY 1993. 
Comprehensive State mental health planning requirements, which stem tim  Public Law 
%660,  are now an integral part of the block grant.  States are required to submit both 
annual plans and implementation reports. 
The Center also fhnds two programs for homeless persons.  Projects for Assistance in 
Transition from Hopelessness,  a formula grant program funded at about $30 million in 
FY 1993, serves homeless persons with m&@l ;lln;sses,  including those with substance 
abuse disorders.  Access to Community Care and Effective Services and Supports grants, 
2  funded for the first time in FY 1993 at approximately $22 million, require States to 
implement an integrated set of services to meet the needs of homeless severely mentally ill 
and/or substance abusing persons.  The program resulted from a recommen&tion  by the 
Federal Task Force on Hopelessness  and Severe Mental Illness; the Task Force was 
created by the Secretaries of the Departments of Housing and Urban Development (HUD) 
and Health and Human Services (HHS), and chaired by NIMH. 
Another related program in the Center is the State Human Resources Development 
Program,  which provides grants to States to develop and disseminate knowledge and 
technology related to human resource development issues and problems. 
Other Federal programs outside the Center provide significant fimding for this population. 
In HHS, Supplemental Security Income and Social Security Disability Insurance in the 
Social Security Administration (SSA) provide income.  Medicaid, in the Health Care 
Financing Administration (HCFA), fimds health care, case management, and other 
community-based services.  Housing programs in HUD, and vocational rehabilitation 
programs in the Department of Education (_E.D.),are two other examples. 
SCOPE AND METHODOLOGY 
To help guide planning efforts, the Center requested our assistance in gathering the 
WSPCZtiVeSof a vfiew  of stiholders  on the accomplishments, weaknesses, and fhture 
direction of CSP.  We did not conduct a formal evaluation of the program. 
Following a review of literature,  we spoke with 124 persons nationwide between October 
and December 1992: persons ffom the Office of the Assistant Secretary for Health, the 
Center and NIMH: congressional sti,  researchers; mental health professionals and 
providers;  State mental health commissioners (commissioners in this report) and CSP 
directors;  consumer and fdy  groups; present and former CSP grantees; persons from 
foundations and other national organizations; and others.  Some responded to our 
questions in writing, but we talked to the majority by telephone or in person. 
We spoke with consumers and fmy  members at a conference of CSP service system 
improvement grantees in October.  We visited Dane  County  (Madison, Wisconsin) in 
December to observe programs,  not funded by CSP, which are nationally renowned for 
their approach to serving this population; we talked to providers and consumers there. 
We asked the following questions: (1) What have been the major accomplishments of 
CSP, and have there been problems associated with it?; (2) In the future, what one 
problem relative to community services for people with severe mental illnesses is it most 
important for CSP to address, and why?; (3) Would you change the way CSP is 
structured, administered or ftmded (assuming the level  of finding  remains unchanged)?; 
and (4) What role should CSP play relative to other Center programs? 
This inspection was ccmductedin accordance with the Interim Standardsfor  Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
3  FINDINGS 
The findings in this report are based on the opinions of 124 persons with a wide range of 
experience rdative  to adults with severe mental illnesses. 
Readers will note that while the questions in this study were about CSP, most of the 
findings and recommendations relate more broadly to the Center.  This is because most 
respondents quickly went beyond CSP to talk about the Center, or talked interchangeably 
about both.  They believe that CSP has laid a strong conceptual foundation for the 
Centers activities.  They have many notions of how the Center should apply the 
philosophy and principles of CSP to its other activities in the fhture. 
The greatest impact of CSP has been in changing attitudes and perceptions about 
serving adults with severe mental illnesses, rather than bringing about the widespread 
development of comprehensive community-based services. 
Respondents identified a number of strengths and weaknesses associated with CSP.  In 
general, comments reflect the view that the program had its greatest impact before the 
mid-1980s, when they say that support from NIMH waned in favor of biomedical 
research. 
Respondents CIWUCSP with creating a new conceptual f~ework  for  serving adults 
with severe mental illhesses, which has tien  mot across the count~. 
We found strong agreement that a great accomplishment of CSP was that it articulated a 
philosophy of comprehensive community-based care for adults with severe mental 
illnesses.  People praise CSP for providing Federal leadership on behalf of this population 
and say it stirred things around by emphasizing new thinking and creativity.  One of the 
most important results of the cdaboration  between Federal staff and others outside 
government was the development of the Community Support System (CSS) concept, which 
conveyed the importance of providing social welfare supports along with mental health 
treatment. 
The consensus view is that because of Federal leadership via CSP, there is now broad 
recognition of the value of comprehensive community-based services for persons with 
severe mental illnesses, and the CSP philosophy and the CSS have been accepted across 
the country. 
However, d appeam that (3P  accomplished less in leading to the widespread 
implementation of the comprehensive community-based servkes  it envisioned. 
The question of how much CSP has contributed to  widespread  implementation  of 
community-based  services  is more  difficult  to answer. 
4	 Many people believe that CSP has helped implement new services.  State CSP directors 
credit the program with driving the development of new senkes  with its emphasis on 
networking, information dissemination on models, demonstrations, and consumer 
involvement.  Commissioners, many of whom have been involved with CSP for years and 
whose States have been CSP grantees, praised the program, especially in the early years, 
for its vision, moral leadership, and extraordinarily effective use of a small amount 
of money to catalyze and accelerate a formative movement.  
Others were more restrained but also credited CSP with helping establish new services. 
The program  single-mindedlypromoted the development of community semice systems. 
Funds were targeted at strategic, change-oriented activities and represented the only 
Federal dollars with the flexibility to respond to emerging issues and needs in the field. 
People say that CSP has become synonymous with innovation, wproviding funds for 
commissioners to try new services that their States would otherwise not have funded. 
Staff spread the word about new seMces  by highlighting grantees and their activities at 
national conferences, in speeches, and in reports disseminated to the fieid. 
Praise notwithstanding, however, people described a number of factors that weakened the 
impact of CSP, particularly after the mid-1980s: inadequate funding to accomplish 
widespread change; inadequate technical assistance; an excessive focus on consumers and 
families to the exclusion of the treatment community; and turnover of State and local 
leadership (commissioners, especially) who could implement change.  Another weakness -
poor evaluation of the demonstrations - is discussed separately in this report. 
In summary, it seems plausible that CSP has been a catalyst in introducing new ideas 
about serving severely mentally ill adults, and in some States where key people were 
receptive to these ideas, introducing new services.  However, since the vast majority of 
State finding  nationally still goes to hospital rather than community care, it is difficult to 
conclude that States have wholeheartedly endorsed community-based services, whether in 
response to CSP or not.  We suspect that some respondents, by virtue of their long and 
close relationship with CSP, may believe that it has had greater impact nationwide than is 
actually the case. 
Respondents say that to provide strong Federal leadership on behalf of pemons with 
severe mental illnesses, the Center should adopt the principles of CSP -
rehabilitation, reeovery, and integration into the community - as its cornerstone. 
For the respondents in this study, the most important role the Center can play is to widely 
promote the CSP concepts of rehabilitation and recovery for persons with severe mental 
illnes~,  and push for the greatest possible integration of this population in the 
community. 
People want to see the Centers agendiabased on CSP principles and focused  on the 
implernenttxtionof contpwhenmvecommunity-based semces. 
Respondents say unequivocally that the Center should adopt CSP principles as its guiding 
5  principles.  In addition to the philosophy of rehabilitation and recovery, the principles 
respondents mentioned most were: an unrelenting focus on the severely mentally ill 
population, emphasis on creativity and new, innovative services, a flexible approach to 
adapting to State and local needs, and involvement of consumers and families. 
People expect the Center to be in the forefront of the debate on nationaI issues affecting 
persons with severe mental illnesses.  In riding the wave of newness, as one person put 
it, respondents want the Center to develop a strategic agenda setting forth the policies and 
priorities around which all of its programs will revolve.  The most important priority, 
they say, is the widespread implementation of services, for which CSP has set the stage. 
They want CSP and other Center pmgnzms to be more clhsely integmted. 
People see close collaboration and teamwork between CSP, homeless programs,  the block 
grant, and the Human Resource Development Program as important to creating 
comprehensive community-based services for people with severe mental illnesses.  They 
say the Center should seek to model the kind of coordination and linkage among its 
programs that the Federal Government requires of States. 
Short of actually combining programs,  which a number of respondents advocate, the 
Center could use joint planning, and task forces or work groups, for these programs to 
address cross-cutting issues and otherwise coordinate their activities.  Comments show that 
respondents think of CSP as the framework or moral compass of these other programs. 
This was especially true of those, particularly the commissioners, who called for a 
complete overhaul of the Human Resource Development Program, to better fit the CSP 
mission and link the programs more closely. 
Many people favor joining the block grant and CSP in some way, so the programs can be 
used more strategically, together, to foster the development of new services.  Besides the 
general notion that the State plans should embody CSP principles, the most frequent 
suggestion was that CSP dollars be used as an incentive, or carrot,  for States to fund 
new initiatives directly related to State plan priorities.  Respondents urged the Center to 
tind ways such as this to provide incentives rather than penalties for States to develop new 
seMces. 
Other ideas about CSP and the block grant wm  that: they be used together to promote a 
national policy agenda designed to revitalize= the mental health system; CSP 
demonstrations should test and prove services which then could be implemented through 
the block gran~ and, the results of CSP demonstrations be used as the basis for 
establishing priorities,  guidelines, or requirements attached to the block grant. 
Xhey want the Center to establish strong, stmtegic linkages, using the inclusive, 
colikbonzhveapproach of CSP% eariy yearn. 
In talking about CSPSaccomplishments, we noticed a tone approaching nostalgia in the 
comments of people who have been involved with the program since its inception.  They 
6  applaud the highly collaborative approach that CSP stafl took with people outside 
government, especially in its early years.  They urge the Center to  approach 
U*  the  same 
in establishing a wide variety of linkages both within and outside government to carry out 
its mission. 
In the Federal arena, respondents call for the Center to collaborate with a host of agencies 
to represent the severely mentally ill population on key national policy and finding issues, 
to promote the CSP philosophy of rehabilitation, and to disseminate the results of 
demonstrations on services to them.  Center staff should have special expertise in the 
programs most affecting the population, and linkages with HCFA, SSA, HUD, and E.D. 
are particularly important.  Some people view the Federal Task Force on Hopelessness 
and Severe Mental Illness as a model for Federal interaction, with the caveat that what 
really matters is whether the recommendations of the Task Force are implemented. 
The issue of greatest urgency to respondents is clearly national health care reform.  There 
is great concern that the needs of this population will be overlooked unless the Center is 
actively involved in the national debate on their behalf.  On a positive note, some see CSP 
concepts as compatible with the concept of managed care, which is being discussed today 
in connection with health care reform. 
In addition, respondents ask the Center to collaborate with many other organizations and 
constituents, to bring about significant, lasting systemic changes in the balance between 
institutional and community care for persons with severe mental illnesses.  This includes 
Congress; State legislators, governors,  and heads of State Medicaid agenciw, 
commissioners and the National Association of State Mental Health Program Directors 
(NASMHPD); county governments; mental health treatment providers,  including 
community mental health centers (CMHC) and hospitals; human semice providers; 
acadeti,  foundations; and national organizations representing various constituents. 
Respondents believe that a @or  thrust of the Center should be technical assistance 
to help States implement comprehensive community-based services. 
Of all the issues in this study, technical assistance engendered the greatest agreement. 
Two-thirds of all respondents say that technical  assistance  - in  short, getting good models 
out to a broader constituency - should be a major priority for the Center.  They also see 
human resource development as a key issue related to technical assistance. 
l%e call is overwhekningfor  a technical assistance effoti going beyond the 
dissemination of wdten  iqjlonnation. 
People commented very favorably about CSP technical assistance before the mid-1980s. 
They say that the program funded people getting together in a number of ways to 
stimulate cross-fertilization across the country about new ideas.  Staff reached out to 
States, asking how they could help.  Respondents found learning conferences interesting, 
stimulating, and inspiring.  The program sent people to other States to observe new 
services frost hand, giving them new ideas they went on to implement in their own States. 
7  It brought experts in to work with States, or held common concerns meetings where a 
small group from several States could grapple with one particular issue. 
The impact of technical assistance may have waned in recent years.  We heard that 
resource centers, while a good concept, reach relatively few people and over-emphasize 
written information.  Some people said that conferences too often preach to the 
converted by including the same participants and consultants, over and over.  State CSP 
directors object that they do not meet separately to discuss issues germane only to them. 
People want many things from technical assistance, but the bottom line is that the Center 
should create a do tank rather than a think tank, with more hands-on consultation and 
less emphasis on writing and publishing, teaching and preaching.   Following are some 
specific suggestions. 
	 Bring more, and different, constituents together on a national, regional, or 
State-to-State basis. 
	 Help commissioners and CSP directors strategize ways to bring governors, 
legislators, or State Medicaid agencies into the process of developing 
community services, since financing is such a key issue. 
	 Broaden the circle of national experts drawn upon to provide technical 
assistance, to include more State and local players who have successfidly 
implemented services in the field. 
	 Use technology (teleconferencing and interactive video were two examples) 
more, and more creatively. 
	 Set up regional centers; or, examine the Centers for Disease Control or 
Agricultural Extension Service as models of effective approaches to technical 
assistance. 
	 Provide more written information in summary form.  State and local programs 
can not aHord journal  subscriptions, and few staff in the field read journals. 
Respondents also advocate an eqnwded  human resoume devekbpment eflort to tnun 
Wf  in the de~very of comprehensive community-based services. 
Respondents say that local implementation of new services is severely hampered by the 
lack of staff adequately trained in providing community-based services.  There is a strong 
call for the Center to strengthen the Human Resource Development Program and 
otherwise step up its efforts to address this problem, fwusing  on certification, restraining, 
and skill-building.  Training is needed not only for mental health profmsionals such as 
psychiatrists,  nurses and social workers, but also vocational rehabilitation workers, 
employment counselors and others who work with persons with severe mental illnesses in 
the community. 
8  Respondents call for the Center to redefine and revitalize CSP demonstrations. 
The CSP demonstration program has changed over the years.  The earlier demonstrations 
were pure services demonstrations, with little attention to the importance of evaluation. 
Over the past 5 years, increasing efforts have been placed on improving the rigor of these 
demonstrations.  More recent studies therefore employ rigorous experimental designs with 
control or comparison groups. 
Respondents db not view demonstrations as a major accomplishment of CSP.  Zhey say 
tluat weUdengneddemonsttuiions are still needed. 
Opinion is mixed about the usefidmxs of past CSP demonstrations.  However,  many 
respondents agree that, notwithstanding NIMH efforts to strengthen it, evaluation has 
been 
weak. 
Some people praise early CSP demonstrations as the first, and only, source of information 
about new services or as a carrot for States to try new seMces  they would not 
otherwise have fimded.  They have found some of the information useful but also 
acknowledge that evaluation was fm too weak.  Others criticize them for yielding too little 
empirical data, largely due to poor evaluation.  This made it difficult, they say, for CSP 
staff to respond to challenges about the vdldity  or effectiveness of community-based 
services, which in turn weakened the credibility of the program as a whole.  In fact, a few 
respondents went so fti  as to criticize CSP for promoting, as panaceas, specific services 
or models which were essentially unproven; case management was mentioned here.  One 
said further that the lack of reliable data on service eff~tiveness  has meant that the 
replication and spread of new services has been remarkably slow. 
Respondents are hungry for demonstrations that identify real solutions for real problems 
and efficient,  eff~tive  models of service at a time of budget cuts.   Most advocate a 
broad, systems change focus, although there is some sentiment to continue to study 
specific services (self-help and psychosocial rehabilitation were two examples) or sawices 
for subpcqxdations, especially those suffering from both mental illnesses and substance 
abuse. 
There is a wealth of ideas on how future demonstrations should be focused and structured. 
One suggestion is that the Center conduct a short termevaluation  to document the 
accomplishments and national impact of CSP on the development of services.  The Center 
would publicize the results, giving CSP public credit for the change it has brought about. 
Following are a few of the many other suggestions we heard: 
  Focus demonstrations on one or more centerpiece priorities or themes; 
s study new or cutting edge services, policies or ideas of national significance, 
looking for the next subjects of scientific research years down the road; 
9  	 replicate proven or promising services, to learn about implementing services in 
real life situations, and what outcomes they produce in the lives of clients; 
  study services integration or linkage; and, 
	 involve consumers for real, then validate how they help; look at their 
participation in policy development, planning, and service delivery, including 
self-help and other consumer-run services. 
As for how demonstrations might be structured, respondents also had many ideas.  Fund 
them for up to 5 years, with built-in self correction allowed and the option to end them 
at various intervals if grantees fail to meet interim goals.  Include a staff training 
component and evaluate this also.  Test the same service in several sites in one State, 
several States in a region, or several regions in the country.  Require States to include 
several counties, or to reconfigure their spending by putting more dollars into community-
based services. 
Most respondents say that State mental health authorities should continue to be the 
primary grantees.  As the major players in State mental health policy and services, they 
must be involved for systems change to occur.  On the other hand, some favor working 
from the bottom up in States where mental health services are greatly decentralind  or 
State mental health authorities are slow to embrace change.  In such cases, they say, the 
Center should fund local grantees directly, with some sort of State sign-off.  They think 
this might promote increased interest in community-based services at the State level. 
Respondents urge collaboration between the Center and NIMH on planning 
demonstrations.  One view is that the Center should pickup  where NIMH leaves off, that 
is, conducting effectiveness testing of services researched by NIMH, focusing on how to 
implement them.  Another is that NIMH should research promising sefice  models 
emerging from Center demonstrations.  The intent of such collaboration would be to foster 
the implementation of services which have been proven eff~tive,  and to promote studies 
which meet State and local needs. 
People say that evaluatiim forjkture  demonstmtions should combine rigor with 
ptugmatism. 
Respondents agree that evaluation should document three things: client outcome (i.e. the 
effectiveness of services in producing positive changes in the Iives of clients), the cost of 
semices,  and how services actually work.  Some added that consumer input is especially 
valuable in designing demonstrations. 
On the subject of what constitutes good evaluation, people favor some sort of middle 
ground,  the most rigorous design possible yet practical and applied.  It should be built 
in up front by providers and researchers together and based on what services are needed 
rather than what research question is to be answered.  Given widespread praise for CSPS 
historical emphasis on creativity and innovation, we were not surprised to hear comments 
10  such as: Replication isnt always scientific.  Combine rigor with pragmatism and 
creativity, and, CSP should loosen its tie but keep it on, and focus on the cutting edge.  
Commissioners were particularly eloquent about striking a balance between the need for 
new services, now, and the need for empirical data. 
People are concerned that many States lack the technical ability to conduct good 
evaluation and propose several ways to address this lack.  One is to conduct evaluation 
centrally with a group of experts established by the Center.  Another is to provide 
technical assistance on evaluation to prospective grantees, rather than after-the-fact which 
is now the case.  A third is to mandate strong linkages between State mental health 
authorities and universities; this would increase State buy-in to the need for evaluation, 
ensure that the services studied are the ones States value, and increase the chances for 
replication by the State once the demonstration is over. 
Consumer and family involvement is seen as valuable, but most respondents say a 
more strategic focus for this part of CSP is now needed. 
Respondents, including two-thirds of the State CSP directors and half of the 
commissioners, credit CSP to a great extent with creating and nurturing the consumer and 
family movements.  They also say CSP provided valuable policy guidance and technical 
assistance relative to these groups.  Their view is that the activities of these groups have 
led States, and those in the mental health field generally, to gradually adopt a community 
support philosophy.  People tend to see consumers as particularly important since, as one 
put it,  they know what works and what doesnt.  This is what causes change.  
People also believe that CSP has become overidentified with - that is, favors consumers 
and families over others involved with CSP, or consumers over families, or even certain 
consumers over others.  This meant, they say, that CSP excluded and ultimately alienated 
many in the treatment community, professionals such as psychiatrists, and providers such 
as CMHCS and hospitals.  The sense of many of the criticisms about overidentification 
was that no one gruup should define CSP.  
Some people, especially State CSP directors,  favor continuing this part of CSP for f-
that many incipient organizations - consumer organizations, especially - will die without 
Federal fimding.  The majority view, however, is that the Center should refocus this part 
of CSP to bring about collaboration that produces positive life outcomes for persons 
with severe mental illnesses.  People suggested: a national theme for this part of CSP 
related to strategic State issueq  grants to develop the capacity of these groups to 
participate in State policy development and planning, specifically; and fimding a national 
consumer center or hiring consumers as Center staff.  Many suggested focusing 
demonstrations on consumer and family involvement. 
A secondary theme is that no matter how consumers and families are involved, the Center 
should evaluate these efforts to find out if what they are doing works, and how. 
Respondents want to know more  about  how  these  groups  can  help  improve  the 
accessibility and quality of services. 
11  RECOMMENDATIONS 
This study shows that CSP stakeholders have strong expectations for the Center beyond 
how it might alter CSP.  Their fear is that without strong Federal leadership, the incipient 
community support network developed during the last 15 years will weaken, placing 
impossible demands on State and local governments and potentially leading to the 
rehospitalhation  of millions of people.  They request information and assistance from the 
Center to expand and strengthen that network.  And they are eager to be included in 
developing the Centers mission and strategy. 
In response to the findings in this report, we recommend that the Center take the steps 
outlined below,  The first recommendation is broad; the others provide more specifics 
about how the Center should maintain a broad base, and implement technical assistance 
and CSP demonstrations. 
The Center should develop a strategic plan for the next 3 years. 
The Center should develop a strategic plan focused on the implementation of 
comprehensive community-based services.  The plan should first include a national policy 
agenda addressing legislative, regulatory, finding,  and other issues affecting seMces  to 
persons with severe mental illnesses.  In addition, it should include strategies to: provide 
technical assistance  conduct demonstrations of services; involve consumers and t%milies; 
more closely integrate Center programs; and expand  human  resource  development  efforts. 
The Center should establish objectives and timetables for each of the plans components, 
and criteria to measure their impact on improving the accessibility and quality of services 
for persons with severe mental illnesses.  It is important for the Center to fmus its 
activities on improving client outcomes. 
The Center should broaden its constituency and maintain strong linkages with 
agencies and organizations within and outside government. 
This sttidy points out that many respondents believe that CSP has become overly focused 
on certain constituents to the exclusion of others.  They are asking the Center to broaden 
its base, and to revive the inclusive, collaborative approach of CSPSearly years. 
We agree.  First,  we recommend that the Center involve a wide variety of constituents in 
developing - and carrying out - its strategic plan.  We recommend firther  that they give 
particular attention to refwusing  - and broadening - the participation of consumers and 
fties,  and the mental health treatment community.  Secondly, the Center should 
establish strong on-going relationships with Federal agencies, State and local governments, 
NASHMPD, universities, foundations, and national organizations sewing this population. 
12  The Center should develop a strategy to provide more practical technid  assistance to 
the field, in addition to the dissemination of written information. 
This recommendation responds to the call from respondents for technical assistance.  The 
Center is charged with establishing an information clearinghouse.  To complement the 
clearinghouse, we recommend that the Center identify an office charged with providing 
technical assistance to persons in the field.  If placed at a high level in the Center,  this 
office would promote program integration by serving as the focal point for technical 
assistance for all Center programs.  Just as important, it would convey the message that 
Center leadership consi&rs technical assistance focused on implementation to be a 
plidy. 
The Center should staff this technical assistance effort with individuals with expert 
knowledge  of Federal programs most affecting persons with severe mental illnesses, and 
first-hand experience implementing comprehensive community-based services in the field. 
In addition, we think that a summary of the information from past CSP demonstrations 
would be helpful, not only summarizing what has been learned but identifying important 
knowledge gaps which the Center could address in its strategic plan. 
Demonstrations in CSP should incorporate practical yet reliable evakation 
methodologies. 
As noted in this report, respondents are eager for reliable information on effwtive 
services.  We recommend that the Center base CSP demonstrations on a strategic theme 
or themes.  They should develop a methodology, or methodologies, to evaluate the cost, 
process,  and client outcomes of semices,  methodologies including consumer feedback on 
outcome, and designs should be the most rigorous applicable to address the questions 
being asked.  Demonstrations should be for a period of up to 5 years, with the option to 
discontinue at 2, 3 or 4 year intervals if grantees do  not  meet  interim  goals.  We also 
suggest that the Center consider requiring States to include a number of CQuntiesin their 
demonstrations, to encourage local implementation of new services. 
We agree with respondents that the Center and NIMH should collaborate with respect to 
services demonstrations and services research. 
COMMENTS 
The  PHS commented on this report; the full text of their comments is in Appendm A. 
They concurred with our recommendations and described steps taken to implement them. 
We thank them for their comments. 
13  APPENDIX  A 
A-1  =!4 
HEALTHA HUMAN!WM!ES  AMclinuhsuvlcg
DEPART&UNz  OF 
%**  f
Memorandum 
JuNf1993r 
ha(R 
As8istant WmBtary  fos  Health 
!. 
the Coannuntty- SUP~rt  P~ti,    0151-0!5=92~001Z0 
To 
Acting  baPOCtOX  9ezla~l  ,  OS 
Attached  are  thffPu&lfc  Health Sen7ice  c~tgf  On the  uubject
Zepoxt  ,  we Cone  with  the  repozt  8a  Zammmendations and Oiir 
casament8delineate  tb  aotions.  taken 0s planned  to implement
them. 
. 
Attachment 
. 
A-2
 ~- . 
The carltefoss   Mental Health Servfeag(~  1,  **  i8 a 
Jc r  xmnt of PHS Substance Mae  and llena ~ealti SexVices
01(3 the ComuaniW 
nistratiozxt  xegmated  that  rwiew 
Suppost  P%ogW#m  (C!3P)to  assist  CMish  idmt&f@$lg future 
&Z@CtL@n8  fQZ the  Csp,  giv~  m  new tisa&~  ~d  m&t8  Of 
CMiS.  We appreciatethe effortthat OXG made, and 
ptioularly  tiah to acknowledgeOIGa wiU.LnqnesSto assist 
us on such Shorn notice. It U  appaxent a  tmaueadou 
that 
amount of work wee involvedin oontamin~ ~  LOO key pessans
Icnowhdgeableof the CSP.

!Cha01C3mm  &deatifio8  changing  attittade8&  pgCOptiOn8 
about se=iag  indivtduahg  with  wreze  menta~ Umaa.  Also? 
LtdLsoueeet8he aatual developmentof a eompreh~ive 
~ty-band  8e=@e  system  au  the  inten~  by-preduotofa 
  aignlgieant  dung.  in  a~tudes  remultig m  pederal  and 
State Ieademhip and -f fort8 
I*  -id  have bem  I@pti  w ZaHlY3Lgi%iiisrg?%iz?--s 
componentsof tb  CSP wexe 
mat  irithmat.Sal  h  d~ing 
attLtudest  the Ckmonasation gmnts, confemoes.  Lntesauermv

..- . 
wosk~ 0s 6yatexachange @fforts:

l,.	 Thm CMliSshould develop a  stzategic  plan  fex  the next 
3 yeara. 
We conm.  We agse* wLth the impoxtamcm develdplng  a 
of 
nat~ona~ polioy a- focused  on issuesaffeotAng awwice  to 
am 
persons.  w%*  mental illnessand acknow3edtithat  CMHS 
91~ R~c~  tfoq 
2.  The CMHS 8houid broaden  con8t&tuen  and maintain

its 
Stxoag  linkageswith ag,nclas  and  0~  a  Satfons  Withlll 
and outside the govemxuent. 
A-3
 2

Collaboxaticm 
fora aomss  the  nation  ta  an effok  6  madh  its  base.  We 
agree wA*  the report  be baaed on 
that  the  m  a  mm  s&ould 
CSP ~iXIC~  U,u  and  fmtaaed a  IAo  ~  !~~~  of  oommunit~
bamd  $ezv?cats.  W.alsoagsee #hould  be lxxthe 
that  cam 
~ose~%ontot the debata on nationali88ueuaffeotingpemon8
WLth reveremental UZM88 
 
It  8ho@4  b~  noted  tha~  ~~aiagly  SLgn.ificaxat  Mzx&q.a 
among  Fedozal  agenoies  have  become the oomemton @Qfc?5s 
pm~ama.  Pos -2**  theACCXSS(Maws  to  ~ 
Mfative SuppozatnadSenicea)p=

and 
of  Demoaatration  @  @maEy*ii!i  %#iYiiRn 
with  rwponalbilf  a  t!w%%#ia  - --WIWY  -~  of 
m- with  Uf$rJiiYo axlt affiuatfona  With  tlm  Depmam3
. Housing  aad Urbau Dewl 
t,  Agrtoultumi#,  Siabor,  and 
Vetezaa#8 Affdrs,  as  as  with  the  Health  care  IMllalloing 
~atxatim  and  thgesOglew&yy  ~gmtioxa  In 
 
additfont  the  admiaM8  ~ty  Mental  Eealth 
Samiee  SIQolc forJkaBlstanci*a

Great,  aad  #m  pm  jeots 
ZsanaitionfromEomeAwanaaaFonuulat3xan*a
llowfos the 
develo~t  of  atzong  FedmlJState  mlaUonsMps. 
3*	 lb - ahmdd  develop  a  strategy  to 
pXaOt&caA  teubnioa~as8Smance to  the 
to  the  dims-tim  of  wsitten infozmaUoa. 
We concw  thae headson te~caz  assi~ee  (~  the part OS

w-)  *S often bdpful  in the effost to aeate  a ohanged

tam of ~  fos SVMUU8  with s~  ~t~  $llnesa. We

aTae  am  tdtdz tb  ~  that  thts  assfitanoe  ahouZd be 
fetezg aoupladwith the di8mrUatfoa  of tittwl 
~=tim.  - oont3auesto analyze wqs  to prev$d~
twhniuaL assistants  is  a more effectivemanam. 
AdditiOmUy,  when  pe~ttti  w$thin  its  ma~  level,  W 
hen  made modest effozta  to augment the type and aamaat of 
teohnical ami8tanoe provided. 
4*	 Demonstiatlms in CSP sltoulci  inco~ozata  praC~Ca&  yet 
=mlQZ.  ~Luatiw  smthodologies
 
A-4
 3

..

We concus.  TM=  xecoxmiendation has  pa~$mlaz  rehmranca  mid 
upaaif~city  to  tho  future  at C!SP.  One  CSP c%itical  objective
$8 tha genexatfonof knowledgederimd fm  ml~~esigned  and 
Lnplement*ddemonstrations. Progmm  currently
staff  axe 
identifying  specif$~  themes fo% demonswatims.  The 
suggestionto  cievelop  Lnter*  goaz~ for **g  Continuation 
4s  Welcolns  , 
0  .  Xt would  have  baen helptti  to aepaxate 
out  tha  responses  of d~ffexent  constitumcies  and dr8w 
bpl$catio~  fxom  them.  In readingthe  eclfics that 
undexlfe  #tome of  the  xemxxmendati~r  ~t ? s  elaar  that 
the  miou8  constituencimahave  diffexent,often 
confliatlnggoals fox the CSP.  I* WOUld be  beneficial 
fo~  the  report to acknowledgeand Mffmmtlate  these 
Cufferencms. 
o	 m=JLtsu*  It is uncleaewhy Dane County in W2sCon8Ln 
was selected88 tho sole loaatfon  for a site visit.  Dane 
County has nave% recaivedany CSP fun-g  and was  not 
recommendedus  an  example  of  8  local~~  tilat  has  treed  CSP 
px$ncfplesin developing8 community support Sywxzll.
The%e era many othes  sites that would  have appropriately 
and usefullydemonstratedthe impact at tlm PedesalCSP 
effoxt. 
o	 ae 11. P-aQh  t.  Statementstn two sentencesseem 
tO ba  contzadiato~.  The ~$rst sentence states that CSP 
has become ovu~dentiti~  with...con8umem 
f-ilies  The next smtence states that CS3?F8 
 
overidentifytig*with consumms ~  famizieq. 
A-5 
.