Department of Health and Human 
 Servces 

OFFICE OF


INSPECTOR GENERAL


DRUG ABUSE TREATMENT WAITING


LIST REDUCTION GRANT PROGRAM


t- stRVICts 

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 

REDUCE THIR WAIG 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 

CONCERNS OVER CONTD FUING 

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 

the grantees are certain of obtaining continued funding, more than half of these 

believe it wil only be for a limited time. States express similar concerns. 

REPONDENT EXPERIENCED SEVERA ADMISTRTI 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 

The Alcohol, Drug and Mental Health Administration (ADMA) 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 

generally believed that there are not enough drug treatment programs available for all 

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 

grants the Drug Abuse Treatment Waiting List Reduction Grant Program was 

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 

the Anti-Drug Abuse Act of 1988. The Waiting List Reduction Grant Program is 

administered by the Office of Treatment Improvement (OTI) in the Alcohol, Drug 

and Mental Health Administration (ADAMHA). 

Drug Abuse Treatment Waitg List Redtin Grants 

To receive a waiting list reduction grant, applicants 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 carryng 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 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 

1990. These 69 grants covered 361 local programs in 34 States, the District of 

Columbia and Puerto Rico. Twenty-one programs received funding directly and the 

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. 

The re-authorization legislation includes the following provisions: the term "waiting 

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 

subgrantees out of a universe of 201 who received money during the first round of 

funding (see Appendix I). The team intervewed 98 of these grantees who were from 

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 

(1) provide statistical data relating to the size and duration of their waiting lists, the 

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 

views of waiting lists and this type of one-time funding. Annual reports and 

supporting documentation relating to waiting list data and continued funding was 

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 onetime grant, the success of grantees in obtaining permanent funding, and the validity of 

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 

program. These referring agencies include probation departments, courts, hospitals 

and local drug and alcohol agencies in various parts of the country. 
..... 

.. ....... ....................... ,.................... ....... ... .. . .. .. . . . ... ... ....... ,........ ,...... . . ...................................... ................ ,...................

FINDINGS


ALOST AL GRAES HAVE INCRED CAPACIT AN MOST HAVE 

REDUCED THIR WAIG LISTS 

Most Grantees Have Exand 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 

and space. In expanding their programs, most grantees used grant funds for new staff 

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 inpatient 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 

" OF GRANTEE
 . OF GRNTEE " OF GiEES " OF GRANTEES " OF GRAHTEE " OF GiEES 

'11TH N.R WITH DECREASE WITH INCSED '11TH SA N.ER '11TH FEWR '11TH MJRE 

SLOTS SlTS OF CLIENS CL Iers CLIENTS OF SLOTS 

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 

explain that the State cut their funding an amount equal to the grant. One grantee 

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. 

Most Grantee Have Reded Thir Waitg Lists and Waitg Per 

Seventy-five percent of grantees report a reduction in their waiting lists, including nine 

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 

program size and by tye of treatment modality. For instance, methadone 

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 

to grant-funded programs have a shorter wait now to enter those programs than they 

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 counselors to do outreach for Hispanic addicts; another explains that 

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 

population, treatment modality or geographical location. 

REPONDENT' VIWS OF PROGRA' SUCCE AR TEMPERED BY 

CONCERNS OVER CONTD FUING 

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. Twothirds 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 

respondent says We were tied by our State legislature. It is even a political process 

to get an item on our own budget proposal to send to the State. 

Some Grantees Belie Th Grant Program Gave A Wuuw of Opportit for

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. 

REPONDENT EXPERINCED SEVERA ADMISTRTI PROBLEMS 

Grantees and States Report Initl Delas in Drawig Down Fun 

Almost two-thirds of grantees (61 percent) experienced some delay in receiving their 

funds, with most blaming the bureaucratic process. In one State, funds were dispersed 

through several levels - from State to county to city - before actually reaching the 

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 Cycle for the Grant Program 

State respondents believe the grant period should be longer, such as a three-year 

funding cycle, due to the lengthy State legislative process. States would like more time 

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 

three years, even if less money is given each year." Respondents would also prefer 

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 

in expanding services as reasons why a longer grant period is needed. The grantees 

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, 

especially if there are construction problems. Grantees also feel that one year is not 

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 

referrals, which equals shorter/smaller waiting lists, which deceives funding sources into 

believing there is no problem." A State grantee contends that "waiting lists are an 

indicator of gross need for service, but are not accurate in showing magnitude. 

In contrast, 15 percent of grantees believe that waiting lists are a good indicator of 

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. 

Some programs evaluate prospective clients before putting them on a list; others keep 

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 
, 

routinely collecting waiting-list data survey their programs when they get an external 

request for such information. 

Respondnt suggest better meases of treatm need 

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


The Alcohol, Drug and Mental Health Administration (ADMA) 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 

the State had access to the grant funds shortly after award, but chose not to access the 

funds. Regarding this delay, we are reporting information obtained during the course 

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 

The universe of drug abuse treatment centers initially consisted of 361 facilties; 

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 onehalf was then applied to each stratum for a total sample of 100 treatment centers. 

The following table ilustrates the sampling design: 

TABLE I 

Status of Facility 

Completed program 

3-month extension 

6-month extension 

Universe Sample Size 

Totals 201 100 

As simple random sampling was used to draw the sample within each strata, any 

estimates made from the sample are unbiased. 
APPENDIX II


COMM TO TH DRA REORT

.,.&,.. \ ) , : , . :. .: . :.: , ;) .. ,... . , , ...:(j

7r- 4-

h So....


DEPARTMENT OP HEATH &. HUMA SERVICES 

:.::I 

P"blk: H.. 

JUL 29 1991 

Date 

From Assistant Secretary for Health 

Subject PHS Comments on the Office of Inspector General (OIG) Draft 

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 . 

The report provides useful data on the extent to which the Drug
 reduces Abuse Treatment Waiting List Reduction Grant Program 

waiting lists for drug treatment by expanding the capacity of 

existing programs. 

We concur wi th the report s re commends t ions and have taken 0 

are taking action to implement them. 

0, 

Mason, M. D. , Dr.


Attachment 

C) -..

:-11 rr; 

=.,1 1_­

r-:, 

. . ;:1 ri: ')0 

PDIG 

DIG-AS 

DIG EI 

DIG-O! 

AlG-MP 

QGC/IG V r EXSEC 

DATE SE 
OF TH LIC TH S VICE (PHS' ON THE

(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 opportunity to
 report. The report provides important Inspector General draft ADAM in 

information and observations which will assist type. structuring any future programs of this 


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


State the report should distinguish between the programs which
 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 accordance with the
 o the knowledge
 schedule published in the grant announcement.this. program, receipt of
 of grants management staff handling 


the grant award letters was not delayed from the Federal
 Fuds 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 removed which indicate that
 gove3:ent. In every 

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


aCcess the funds.


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


their applications to the State, and (2J subrecipients were


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


with other


awarding a grant, but are considered in conjuncti


indicators of need such as utilization rates and prevalence


Assure that waiting lists are not used as the sole basis for


studies. 

PHS comment
 scheduled 

We concur. The Waiting List/Period Program is no Program for reauthorization. However, a new capaei' ty Expansi 

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


support a longer grant period in future legislation of thisyear type. Respondents recommend funding for at least a threeperiod to correspond with the States' legislati cycles and to 

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


clause to enable programs to inc ease capacity without


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


a maintenance of effort olause. To use qrant funds to fund


programs currently funded by the State is supplantation which


would not be allowed. 

OIG Recommendation 

Develop a unifor. definition of a waiting list and a systemati
 States. This 

way of maintaining a waiting list for use by all
 legislati 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


509(e)" should be "509(.E). 

Page i, second paragraph, "


Page i, third paraqriaph" (2) 1 atatement should be addedwas stating, "demonstrate, as (,f the date the applica.t.i 

submitted, success... 
.. 

II grantees" means Page ii, fifth paragraph, it is not clear if


subgrantees the State as the grantees or direct grantees other


than the State. 

Page ii, the fifth paragraph. the second sentence, and page 


last paragraph reads: over half the States report delays
 See our


in receiving their money from the Federal Governent.
 funds. general comment regarding delays of Federal 


Public Health
 Page 1, third paragraph, ninth line, after "


service Act, " in&ert II as amended by" and before "Public... 

Page 1, fourth paragraph, ( 2 ), a statement should be added


was 

stating "demonstrate, as of the date the applicati
 submitted, success... 

Page 2, second full paragraph, second line, "to be used" should 

be replaced with li to be appropriated. 

Page 2, last paragraph, first line, "100 grantees and


subgrantees. 

Page 2, last paragraph, last line, "who" should be replaced


wi th "which.


Page 5, first line, " The block grant was cut right before the


waiting list dollars came, so the waiting list dollars didn't


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


to substitute/supersede State funds, which were meant to
 past. continue assisting programs as they had in the 


Page 5, first line, it should, also, be clarified that any
 s apportionment
 reduction in the block grant was in the State'


to the subgrantees of the block grant funds which the Federal
 his sentence without
 governent awarded to the State. governent reduced the


explanation suggests that the Federal 


block grant to the State which it did not.


page 7, "RESPONDENTS' VIEW OF PROGRA' S SUCCESS AR TEMPERED BY 

The report should include
 CONCERNS OVER CONTINUED FUNDING.reqired 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 


const:.ruction and renovation (except for minor changes) costs 

were not allowed in th legislation for the grants, we are 

plication that grantees have expended concerned with this 

items which were not
 Federal funds for heavy construction


allowed. 

Page 8, last sentence, it should be clarified whether the award
 governent to the $tate or other 

was delayed from the Federal 


qrantee or was delayed from the State to the subgrantees.


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:


Page 2, first complete paragraph, second. sentence, "Funds were 

usually awarded quickly, with priority going to those treatment 

programs judged to have the greatest need to expand their


trea tment. " 

Page 8, fourth paragraph, last sentence, "One State respondent
 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 the third line which addresses
 extensions, " ( 1) slow startups reasons for grantees requiring
 funding... due to delays in obtaining 

:: 

,:. 

J;:J '-IDEPARTMENT 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 

Reduction Grant Program, II 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 

- z 

G') 1"11 rT1 moO-n "j


V1 :: -. rn -- , .

7 VJ 

c: 

PDIC!


DIG-AS


DIG-EI


DIG­


AIG-MP
 V" 

OGC/IG 

EX BEC


DATE 
I&VU 

18'/91 10: 26	 "20247:10285 HHS DRUG COl:NSEL 

Counsl to the Seretary DEPARTMENT OF HEALTH &. HUMAN SERVICES	 for Org Aase PoliCy 

wasnington. D.C. 

RATO DICKU NSORGE


rMBA
 cc TO'1 

FO DRABPO 

SUEC:	 Draft Repfirt of the Of Ice of Inspector General entitled 

DruG AbYsl Yreatment Wa .duct'olJ Granl 

proeram COMMEN 

mment from the Ofce of National Dru control poncy I am trsmitg to you 	 al ors. I understad that (ON DC?) ravew of th doent whic revased and 

C. Comolli of my st has spoken with Emlie Baal from your offce concerning the 

ONDCP reiew. preas let me know of an quG$ns you may have concerng these 

comments. 

Thank you for your atentn to this matter. 

AITACH 
:! 

003 

,'1.2/91 10: 26 2024750US HaS DRUG COliNSEL 

July 3, 1991


kEORAUH !' no: Barar 

KA BAS -_ 'tetagl1a 

ST.nC1: us. T aiti L.s e1:iQn Grant 

rogram 

Hak-, 80m for the c!lay in rQ 1ng. Belew are C!oltents along \!ith SQme pa .a with ecU:ts. 

'ms re is 1y a 
 ve of 't Wa:i: L:t:

Red OQ Repo 'ti: wa p b7 on far Ii: 

reviews tM &D he i1: ha xew: 11s1:8. !' %G' 1J t'on aurt cu 
 leg!.slat:ve

P:epQMls i.uding 

uec fO# "t soe .81. fOJ iI g:aD. 1. 8 ve gc oint 

we abc1 us :t't to 't se'ton 510 Of 

ua= 'tt li u. ar I1 

wbah ,'t 2J't ortes as 

i: Capa1: 10 cr:!t:. 8\ lon

bUl 

g%aM pe tu't 1e:laJUOD of tA. . Ou CB aJow f 'ts bo8V8r 0K ma 

oppo th cn. 

re fu1: ":!"ft of di"or lm" aD;ta 1: ha'W cl a. tmaz dehi1: of a wd: lu't aD a 

SI7Ii't Uc wa of 
 ...-r.f Ift a wa'tg Ur.

B'a:tea ;f , i1: f 't stat:e 'tt ;i;t :La ba on)'ar c:t: es ID cf i: gran1: have read.. 

1ons h July l5 an 'tor uve DO s\1:t.te4 data 

to HH. 

In. add 1:1cm, th :EG report t 1: wa: 11s 88:t:ed 

2.0, 073 tdou. Howve, 't () :report 't CCs 

prem i:ba:t 

HB h& IX 
 CI:mt:on I= $101: we act1y creetoo. 'rfor. th :tG repel: t stuld 8'1: thi: 20, 073 8101: 

we ftmed.