Catastrophic Disasters: Federal Efforts Help States Prepare for and Respond to Psychological Consequences, but FEMA's Crisis Counseling Program Needs Improvements
Published: 2008-02-29T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Catastrophic disasters, such as Hurricane Katrina, may result in trauma and other psychological consequences for the people who experience them. The federal government provides states with funding and other support to help them prepare for and respond to disasters. Because of congressional interest in these issues, GAO examined (1) federal agencies' actions to help states prepare for the psychological consequences of catastrophic disasters and (2) states' experiences obtaining and using grants from the Crisis Counseling Assistance and Training Program (CCP) to respond to the psychological consequences of catastrophic disasters. CCP is a program of the Department of Homeland Security's (DHS) Federal Emergency Management Agency (FEMA). GAO reviewed documents and interviewed program officials from federal agencies and conducted additional work in six states with experience responding to catastrophic disasters: Florida, Louisiana, Mississippi, New York, Texas, and Washington.
section_title: What GAO Found
paragraphs: Federal agencies have awarded grants and conducted other activities to help states prepare for the psychological consequences of catastrophic and other disasters. For example, in fiscal years 2003 and 2004, the Department of Health and Human Services' (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA) provided grants to mental health and substance abuse agencies in 35 states for disaster planning. In 2007, SAMHSA completed an assessment of mental health and substance abuse disaster plans developed by states that received a preparedness grant. SAMHSA found that, for the 34 states with plans available for review, these plans generally showed improvement over those that had been submitted by states as part of their application for its preparedness grant. The agency also identified several ways in which the plans could be improved. For example, about half the plans did not indicate specific planning and response actions that substance abuse agencies should take. Similarly, GAO's review of the plans available from six states found varying attention among the plans to covering substance abuse issues. SAMHSA officials said the agency is exploring methods of determining states' individual technical assistance needs. Other federal agencies--the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and DHS--have provided broader preparedness funding that states may use for mental health or substance abuse preparedness, but these agencies' data-reporting requirements do not produce information on the extent to which states used funds for this purpose. States in GAO's review experienced difficulties in applying for CCP funding and implementing their programs following catastrophic disasters. CCP, a key federal postdisaster response grant program to help states deliver crisis counseling services, is administered by FEMA in collaboration with SAMHSA. State officials said they had difficulty collecting information needed for their CCP applications and experienced lengthy application reviews. FEMA and SAMHSA officials said they have taken steps to improve the application submission and review process. State officials also said they experienced problems implementing their CCPs. For example, they said that FEMA's policy of not reimbursing states and their CCP service providers for indirect costs, such as certain administrative expenses, led to problems recruiting and retaining service providers. Other FEMA postdisaster response grant programs allow reimbursement for indirect costs. A FEMA official said the agency had been considering since 2006 whether to allow indirect cost reimbursement under CCP but did not know when a decision would be made. States also cited difficulties assisting people who needed more intensive crisis counseling services than those traditionally provided through state CCPs. FEMA and SAMHSA officials said they plan to consider options for adding other types of crisis counseling services to CCP, based in part on states' experiences with CCP pilot programs offering expanded crisis counseling services. The officials did not know when they would complete their review and reach a decision.

section_title: Letter
paragraphs: In this report, we consider disasters that are unusually devastating and require extensive  federal support to be catastrophic.
PTSD is an often debilitating and potentially chronic disorder that can develop after  experiencing or witnessing a traumatic event and includes such symptoms as distressing  dreams and intrusive memories.
GAO, Hurricane Katrina: Status of Hospital Inpatient and Emergency Departments in  the Greater New Orleans Area, GAO-06-1003 (Washington, D.C.: Sept. 29, 2006), 13. A list of  additional GAO products related to mental health and catastrophic disasters is included at  the end of this report.
For the purposes of this report, we are defining response to include both short-term  response after a disaster occurs and long-term recovery. meet the psychological needs that result from terrorism. It noted, for  example, that government agencies and service providers were not well  coordinated and mental health providers often did not have disaster  training.
For predisaster preparedness, the Department of Homeland Security  (DHS) is responsible for coordinating with federal, state, and local  agencies to develop plans, procedures, training, and other activities. In  coordination with DHS, the Department of Health and Human Services  (HHS) is responsible for helping the nation develop public health— including mental health and substance abuse—systems that are prepared  to meet the surge in medical needs that may occur following disasters.  Within HHS the Substance Abuse and Mental Health Services  Administration (SAMHSA) helps integrate mental health and substance  abuse services into these federal efforts. Federal agencies may carry out  these responsibilities through a variety of efforts, including the following  activities: the provision of grants to states for preparedness efforts,  development of training and guidance related to preparedness, assessment  of state activities, and development of plans for utilizing federal staff and  medical supplies to assist states.
For postdisaster response, DHS and HHS efforts may include providing  states with funding to assist their response to the psychological  consequences of the disaster. The primary long-standing federal  postdisaster grant program for helping states respond to short-term crisis  counseling needs following disasters is the Crisis Counseling Assistance  and Training Program (CCP), which is administered by DHS’s Federal  Emergency Management Agency (FEMA) and its federal partner,  SAMHSA. A state’s application for CCP funds must demonstrate that the  need for crisis counseling in the affected area is beyond the capacity of  state and local resources. If awarded funds, states typically contract with  community organizations to provide the crisis counseling services,  including outreach and public education, individual and group counseling,  and referral for other services. We and others have reported on difficulties  with CCP. In 2005, for example, we reported that following the September  2001 attack on the World Trade Center (WTC), limited financial oversight  of New York’s CCP by FEMA and SAMHSA made it difficult to determine  whether program funds were being used efficiently and effectively to help  alleviate psychological distress. In addition, other federal agencies have  reported on difficulties that states have experienced implementing their  CCPs.
Because of your interest in ensuring that our nation is prepared to respond  effectively to the psychological consequences of catastrophic disasters, we  examined the following questions: (1) What actions have federal agencies  taken to help states prepare for the psychological consequences of  catastrophic disasters? (2) What have been the states’ experiences in  obtaining and using CCP grants to respond to the psychological  consequences of catastrophic disasters?
In general, to address our objectives, we obtained program documents  from federal agencies involved in disaster preparedness and response  activities—including DHS and HHS. We also interviewed officials from  these agencies, academic institutions, and national organizations that  focus on mental health, substance abuse, and emergency management. We  conducted additional work in six judgmentally selected states. We  included New York, Florida, Louisiana, and Mississippi because they were  directly affected by one of three catastrophic disasters that we included in  our scope: the WTC attack in 2001, Hurricane Charley in 2004, and  Hurricane Katrina in 2005. We included Texas because it hosted a large  number of people displaced by Hurricane Katrina, and we included  Washington because it both hosted people displaced by Hurricane Katrina  and has features that make it vulnerable to natural and man-made  disasters, such as large ports. Results from this nongeneralizable sample of  states cannot be used to make inferences about other states.
To examine actions by federal agencies to help states prepare for the  psychological consequences of catastrophic disasters, we identified  federal grants awarded and other activities that occurred during fiscal year  2002 through fiscal year 2006 to help states prepare for the psychological  consequences of disasters. We also reviewed mental health and substance  abuse disaster plans from the six states in our review and interviewed  officials from these agencies. To examine states’ experiences in obtaining  and using CCP grants to respond to the psychological consequences of  catastrophic disasters, we interviewed mental health officials from the six  states in our review concerning their experiences in applying for CCP  funding and implementing their programs. We also reviewed CCP grant  applications or other relevant documentation submitted by the six states  in our review. In addition, we interviewed officials from FEMA and  SAMHSA to obtain their perspectives on the states’ applications and the  states’ experiences implementing programs using CCP funds. We also  reviewed reports by GAO and other entities and pertinent legislation. (For  additional information on our methodology, see app. I.) We conducted our  work from March 2006 through February 2008 in accordance with  generally accepted government auditing standards. Those standards  require that we plan and perform the audit to obtain sufficient, appropriate  evidence to provide a reasonable basis for our findings and conclusions  based on our audit objectives. We believe that the evidence obtained  provides a reasonable basis for our findings and conclusions based on our  audit objectives.
subsections: section_title: Background
paragraphs: A catastrophic disaster exposes residents and responders to a variety of  traumatic experiences that put them at risk for adverse psychological  consequences. Preparedness at the federal, state, and local levels is critical  to the nation’s ability to provide the services needed to address these  problems during response. In light of the emergence of threats posed by  terrorism and the complex issues involved in responding to those threats,  GAO has identified disaster preparedness and response as a major  challenge for the 21st century.
subsections: section_title: Psychological Consequences of Catastrophic Disasters
paragraphs: Research has shown that people who have experienced or witnessed  certain incidents during or after a catastrophic disaster—such as serious  physical injury, destruction of a home, or long-term displacement from the  community—can experience an array of psychological consequences. For  example, studies found that 1 to 2 months after the WTC attack, the rate of  probable PTSD was 11.2 percent among a sample of adults in the New  York City metropolitan area, compared with about 4 percent elsewhere in  the United States, and Manhattan residents reported increases in  smoking, alcohol consumption, and marijuana use. Research has also  shown that psychological effects can persist or emerge months or years  after the event has occurred. For example, a 2006 study on the use of  counseling services by people affected by the WTC attack found that some  people first sought counseling services more than 2 years after the event.
Certain populations may be especially vulnerable to psychological  consequences following a disaster. These include children and survivors of  past traumatic events. Others who may be especially vulnerable include  people who had a preexisting mental illness at the time of a disaster.  Research has also shown that disaster responders may be especially  vulnerable because of the direct and protracted nature of their exposure to  traumatic experiences, extended working hours, and sleep deprivation. A  CDC survey of New Orleans firefighters and police officers about 2 to 3  months following Hurricane Katrina found that about one-third of  respondents reported symptoms of depression or PTSD, or both.
Psychological responses can also be affected by the characteristics of the  particular disaster and its aftermath. Terrorism differs from natural  disasters in that it can create a general sense of fear in the population  outside the affected area. The Institute of Medicine noted that although  terrorism and other disasters may share important characteristics, “the  malicious intent and unpredictable nature of terrorism may carry a  particularly devastating impact for those directly and indirectly affected.”
During the recovery phase of a catastrophic natural disaster, ongoing  stress due to the perceived loss of support associated with large-scale  dislocation of the population can also affect mental health. In an  assessment of health-related needs for residents returning to the New  Orleans area 7 weeks after Hurricane Katrina, researchers found that  many respondents had emotional concerns—such as feeling isolated or  crowded—and about half had levels of distress that indicated a possible  need for mental health services.
section_title: Federal Role in Public Health Preparedness and Response
paragraphs: The Robert T. Stafford Disaster Relief and Emergency Assistance Act  (Stafford Act) is the principal federal statute governing federal disaster  assistance and relief. State and local governments have the primary  responsibility for disaster response, and the Stafford Act established the  process for states to request a presidential disaster declaration for affected  counties in order to obtain supplemental assistance—such as physical  assets, personnel, and funding—from the federal government when a  disaster exceeds state and local capabilities and resources. The President  may make a disaster declaration for both catastrophic disasters and  smaller-scale disasters that exceed a state’s ability to respond.
The Stafford Act and FEMA’s regulations contain provisions related to  disaster preparedness. The act encourages each state to have a plan that  stipulates the state’s overall responses in the event of an emergency.  FEMA regulations require that, as a condition of receiving CCP funds to  respond to a disaster, states agree to include mental health disaster  planning in their overall plans. The regulations do not require that state  mental health and substance abuse agencies develop their own disaster  plans, but such plans are recommended by SAMHSA as important  components of disaster preparedness. In 2003, SAMHSA issued mental  health disaster planning guidance to help state and local mental health  agencies create or revise disaster plans. The agency recommends, for  example, that plans describe the specific responsibilities of state mental  health agencies and other organizations in responding to a disaster and  responsibilities for maintaining and revising a disaster plan. In 2004,  SAMHSA issued guidance recommending that state substance abuse  agencies develop all-hazard substance abuse disaster plans. The guidance  recommends, among other things, that these plans include information on  working with other agencies and providers and on providing medications,  such as methadone.
DHS created the National Response Plan in December 2004 to provide an  all-discipline, all-hazards approach for the management across  jurisdictions of domestic incidents such as catastrophic natural disasters  and terrorist attacks when federal involvement is necessary. The National  Response Plan details the missions, policies, structures, and  responsibilities of federal agencies for coordinating resource and  programmatic support to states, tribes, and other federal agencies.
DHS has responsibility for coordinating the federal government’s response  to disasters, including administering the provisions of the Stafford Act.  FEMA administers funding for disaster relief by reimbursing federal, state,  and local government agencies and certain nongovernmental organizations  for eligible disaster-related expenditures. The National Response Plan  also gives FEMA responsibility to coordinate mass care, housing, and  human services, including coordinating the provision of immediate, short- term assistance for people dealing with the anxieties, stress, and trauma  associated with a disaster. In addition, HHS is designated as the primary  agency for coordinating public health and hospital emergency  preparedness activities and coordinating the federal government’s public  health and medical response. Depending on the circumstances of a  disaster, HHS’s responsibilities may include assessing mental health and  substance abuse needs, providing disaster mental health training  materials, and providing expertise in long-term mental health services.  Other agencies—including the Departments of Defense, Justice, Labor,  and Veterans Affairs (VA)—support HHS’s preparedness and response  efforts.
section_title: Primary Federal Response Program for Crisis Counseling Services
paragraphs: For over 30 years, the federal government has used CCP to support short- term crisis counseling and public education services to help alleviate the  psychological distress caused or aggravated by disasters for which a  presidential disaster declaration has been made. FEMA administers CCP  in conjunction with SAMHSA, which provides technical assistance,  develops program guidance, and conducts oversight on behalf of FEMA.
States seeking CCP funding following a presidentially declared disaster  can apply to FEMA for an immediate grant and, if necessary, a longer-term  grant. The Immediate Services Program (ISP) grant funds CCP services  for up to 60 days following a disaster declaration, and states applying for  the grant must do so within 14 days of the declaration. The Regular  Services Program (RSP) grant is designed to help states meet a continuing  need for crisis counseling services for up to an additional 9 months.  States applying for an RSP grant must do so within 60 days of a disaster  declaration. If a state decides to apply for an RSP grant, the ISP grant can  be extended until the RSP application is reviewed and a funding decision  has been made. A state’s CCP application must demonstrate that the need  for crisis counseling in the affected area is beyond the capacity of state  and local resources. A state must develop its needs assessment by using a  prescribed formula that, among other things, includes the estimated  numbers of deaths, persons injured, and damaged or destroyed homes  attributable to the disaster. This needs assessment is critical for  developing a state’s program plan and budget request, which must also be  included in its application. FEMA reviews all ISP and RSP applications and  receives input from SAMHSA, which also reviews the applications. FEMA  has final authority for all funding decisions. Both ISP and RSP grants are  generally managed by state mental health agencies, which typically  contract with community organizations to provide CCP services.
The CCP model was designed to meet the short-term mental health needs  of people affected by disasters through outreach that involves education,  individual and group counseling, and referral for other services. The main  focus of the model is to help people regain their predisaster level of  functioning by, among other things, providing emotional support,  mitigating additional stress, and providing referrals to additional resources  that may help them recover. CCP services, which are to be provided  anonymously and free of charge, are primarily delivered through direct  contact with disaster survivors in familiar settings—such as homes,  schools, community centers, and places of religious worship. Services are  designed to be delivered by teams of mental health professionals and  paraprofessionals from the community affected by the disaster. The  mental health professionals, who have prior specialized mental health or  counseling training and are usually licensed by the state, typically  coordinate and supervise paraprofessionals who may not have had  previous training as mental health professionals. Paraprofessionals  working as CCP crisis counselors provide outreach, crisis counseling, and  referrals. All members of the teams are to be trained in the basics of crisis  counseling and CCP. States cannot use CCP funds to provide longer-term  services such as treatment for psychiatric disorders or substance abuse,  office-based therapy, or medications. The state programs are expected to  refer survivors who may need such services to an appropriate agency or  licensed mental health professional.
From fiscal year 2001 through fiscal year 2006, the majority of CCP grant  funding has been used to meet needs following catastrophic disasters.  According to FEMA, during this period, the agency obligated a total of  about $424 million in CCP funds, with about $289 million (about   68 percent) obligated for states that responded to the three catastrophic  disasters in our review—the WTC attack, Hurricane Charley, and  Hurricane Katrina. According to FEMA, the agency obligated about   $167 million for New York and other states that responded to the WTC  attack; about $7 million for Florida to respond to Hurricane Charley; and  about $51 and $23 million in CCP funds for Louisiana and Mississippi,  respectively, to respond to Hurricane Katrina. In addition, FEMA allowed  26 additional states, commonly called “host states,” to apply for CCP  funding to assist people displaced as a result of Hurricane Katrina.  According to FEMA, the agency obligated for these host states a total of  about $37 million, ranging from about $13,000 to about $13 million each.  For example, the agency obligated about $13 million and $129,000 for  Texas and Washington, respectively.
At SAMHSA’s request, VA’s National Center for PTSD (NCPTSD)  conducted an evaluation of CCP and provided its report in June 2005.  NCPTSD researchers examined state CCPs that were for disasters  occurring from October 1996 through September 2001 and that concluded  by December 2003, which resulted in an examination of programs  implemented by 27 states to respond to 28 disasters. The evaluation also  included case studies of four specific disasters—the bombing of the  Murrah Federal Building in Oklahoma City, Oklahoma, in 1995; Hurricane  Floyd in 1999; the WTC attack in 2001; and the Rhode Island nightclub fire  in 2003. Although NCPTSD’s evaluation found that CCP performed well in  certain respects, it identified a number of ways in which states had  difficulties implementing their CCPs, and it indicated that drawing  conclusions about some aspects of the program was difficult because data  were of poor quality and incomplete.
section_title: Federal Agencies Have Awarded Grants to States to Support Preparation for Psychological Consequences of Catastrophic Disasters, and SAMHSA Has Assessed States’ Disaster Plans
paragraphs: Federal grants have helped states prepare for the psychological  consequences of catastrophic and other disasters, and SAMHSA has  conducted an assessment of disaster plans from many state mental health  and substance abuse agencies. In fiscal years 2003 and 2004, SAMHSA  awarded grants to mental health and substance abuse agencies in 35 states  specifically for disaster planning. CDC, HRSA, and DHS have also provided  preparedness funding that states may use for mental health or substance  abuse preparedness, but the agencies’ data-reporting requirements do not  produce information on the extent to which states used funds for this  purpose. In 2007, SAMHSA completed an assessment of mental health and  substance abuse disaster plans developed by states that received its  preparedness grant. SAMHSA found that these plans showed  improvements over those that had been submitted by states as part of their  application for the preparedness grant. The agency also identified several  ways in which the plans could be improved. In addition to assisting states  with their preparedness, HHS is taking steps to be better prepared to send  federal resources to help states respond to the psychological  consequences of disasters.
subsections: section_title: Federal Grants Have Supported States’ Mental Health and Substance Abuse Preparedness for Catastrophic and Other Disasters
paragraphs: SAMHSA awarded $6.8 million over fiscal years 2003 and 2004 specifically  to help state mental health and substance abuse agencies prepare for the  psychological consequences of catastrophic and other disasters. The  agency awarded 35 states; the total amount awarded to each individual  state ranged from about $105,000 to about $200,000. Two of the six states  in our review, New York and Texas, received a SAMHSA grant. New York,  which already had a mental health disaster plan, used the funds to develop  a plan for its state substance abuse agency. Texas, which was already  developing a mental health disaster plan, used the grant to help fund a  consortium of state agencies with postdisaster mental health  responsibilities—including mental health, public safety, and victims’  services—and to increase the role of substance abuse providers in  preparedness activities. Mental health officials from one of the four states  in our review that did not apply for a SAMHSA grant told us their agency  did not apply because it was already engaged in planning with the state  public health agency, and officials from the other three states said they did  not apply due to competing demands on their time.
CDC, HRSA, and DHS public health and homeland security preparedness  grant funds can also be used by states to prepare for the psychological  consequences of disasters, and we found examples of states using CDC  and HRSA funds for this purpose. During fiscal years 2002 through 2006,  CDC and HRSA awarded about $6.1 billion in grants to states and selected  urban areas to improve public health and hospital preparedness, and DHS  provided about $12.1 billion in grants to states and localities for broad  preparedness efforts. CDC and HRSA require that states document how  they plan to engage in certain mental health and substance abuse  preparedness activities, and although there is no requirement that states  spend their DHS grant funds to prepare for the psychological  consequences of disasters, a state may choose to do so. These grant  programs fund broader preparedness efforts, and their data-reporting  requirements do not produce information on the full extent to which states  used funds for mental health and substance abuse preparedness activities.  We found that, according to state officials, public health agencies in five of  the six states in our review—all but Mississippi—used either CDC or  HRSA preparedness funds to support mental health and substance abuse  agencies’ activities at least once during fiscal years 2002 through 2006.  For example, in Florida, Texas, and Washington, public health agencies  allocated funds to mental health and substance abuse agencies for the  development of a disaster plan or to pay the salaries of disaster planners.  In Louisiana, the mental health agency received funds to, among other  things, develop criteria for a registry of volunteer mental health  professionals and help mental health and substance abuse treatment  facilities develop disaster plans. Mental health or substance abuse officials  in the six states we reviewed told us their agencies were not allocated  funds from their state’s DHS grant during fiscal years 2002 through 2006.
In addition to awarding grants to states, federal agencies have funded  training and developed guidance to enhance states’ preparedness for the  psychological consequences of disasters. For example, SAMHSA  established its Disaster Technical Assistance Center in fiscal year 2003 to  provide training and technical assistance to state mental health and  substance abuse agencies. SAMHSA also distributes various guidance  documents, such as guidance to help prevent and manage stress in disaster  response workers before, during, and after a disaster. In addition, CDC,  HRSA, and DHS fund the development of training activities that can  benefit the preparedness of states’ mental health providers. For example,  HRSA officials told us that the agency’s Bioterrorism Training and  Curriculum Development Program awarded a contract in 2006 to an  accrediting body for counseling programs to incorporate mental health  disaster preparedness into its educational standards, and CDC’s Centers  for Public Health Preparedness Program awarded grants to academic  institutions to develop and assess training on mental health preparedness  and response.
section_title: SAMHSA Has Assessed State Mental Health and Substance Abuse Disaster Plans
paragraphs: SAMHSA reviewed state mental health and substance abuse plans as part  of its disaster preparedness grant program. In 2007, the agency completed  a review of the disaster plans of 34 of the 35 states that received a  SAMHSA preparedness grant to, among other things, give SAMHSA  aggregated information about states’ disaster planning and technical  assistance needs. According to SAMHSA, the mental health and  substance abuse disaster plans of these 34 states showed improvement  over the plans the states had submitted in 2002 as part of their grant  applications. Areas SAMHSA identified as showing improvement included    stronger partnership for planning and response among state mental health  and substance abuse services agencies;   an increased number of unified plans that encompass both mental health  and substance abuse services issues;   stronger partnerships with key stakeholders such as emergency  management, public health agencies, and voluntary organizations that are  active in disasters; and    clearer identification and articulation of the disaster response role of state  mental health and substance abuse agencies.
SAMHSA also identified several ways in which the plans could be  improved. For example, it reported that while most plans indicated that  the state deploys disaster responders to provide mental health and  substance abuse services, about one-third of the plans needed to provide  more detailed information on the training, qualifications, and safe  deployment of these responders. SAMHSA also reported that although  states were more likely to incorporate substance abuse services into their  disaster planning, about half the plans still did not indicate specific  planning and response actions that substance abuse agencies should take.
In reviewing mental health and substance abuse disaster plans from five of  the six states in our study, we made observations that are consistent with  SAMHSA’s findings. For example, we found that the five states’ disaster  plans varied in their attention to substance abuse topics. Two states in our  review issued separate mental health and substance abuse plans. Each of  the other three states issued a unified disaster plan to cover both mental  health and substance abuse, but only one of the three plans specifically  discussed both types of services. The other two plans primarily discussed  mental health services and had few specific references to providing  substance abuse services following a disaster. For example, these plans  did not include specific information about providing methadone treatment  for people with a drug abuse disorder following a disaster—information  that was provided in the separate substance abuse plans. In addition, we  found that disaster plans of the states in our review did not always identify  specific actions or responsibilities related to serving the mental health and  substance abuse needs of certain special populations. Three state  disaster plans did not identify specific actions for preparing to work with  children, and two plans did not include provisions for specific cultural  minorities.
Mental health and substance abuse officials from the states in our review  told us that they recognized various gaps in their disaster preparedness.  For example, state officials discussed the need to provide additional  training to disaster responders and said they would like to collaborate  more extensively with state health, emergency management, and  education agencies. One observation that state mental health officials  made was that schools could be an important local resource for providing  postdisaster services to children but that relationships between state  mental health agencies and schools are sometimes not in place prior to a  disaster. Officials from several states described benefits from meeting  other states’ officials at SAMHSA’s regional training conferences, but told  us that resource limitations or the need to first plan within their own state  made it difficult to continue these relationships.
SAMHSA’s report recommended that the agency conduct state-specific  needs assessments to identify individual states’ technical assistance needs  for mental health and substance abuse disaster planning. SAMHSA  officials told us that the agency is exploring methods to conduct such  assessments and that the agency would need to determine the availability  of resources for the assessments.
section_title: HHS Is Taking Steps to Be Better Prepared to Send Federal Resources to Help States Address the Psychological Consequences of Disasters
paragraphs: To help states address the psychological consequences of disasters, HHS,  as the lead federal department for public health and medical preparedness,  is implementing several efforts to be better prepared to send federal  resources to help states. For example, HHS is increasing the capacity of  federal disaster response teams to provide mental health services to  disaster victims and responders. Based on lessons learned following  Hurricane Katrina, the White House Homeland Security Council  recommended that HHS organize, train, and equip medical and public  health professionals in preconfigured and deployable teams. In response,  HHS organized U.S. Public Health Service Commissioned Corps officers  into several teams—including five Rapid Deployment Force teams that  each include 4 mental health providers and five Mental Health Teams that  each include about 20 mental health providers. HHS created team rosters  and sponsored a large-scale training exercise from July 15, 2007, through  August 24, 2007, that allowed the team members, including the mental  health providers, to train together.
HHS also plans to recruit additional mental health providers into the  Commissioned Corps. HHS officials told us that there has been a shortage  of mental health providers in the Commissioned Corps and that  requirements for deployment on short notice made it difficult for agencies  to ensure that team members’ regular responsibilities are fulfilled while  the team member is deployed. For fiscal year 2008, HHS proposed to  recruit providers to staff full-time, dedicated Health and Medical Response  Teams. Two teams—each with 105 members, including at least 4 mental  health providers—would serve as the primary responders for the  Commissioned Corps and reduce the deployment burden placed on other  officers.
HHS has also taken steps to increase the supply of drugs indicated for  psychological disorders that should be available in the event of a disaster.  Prior to Hurricane Katrina, HHS began developing Federal Medical  Stations to provide mass casualty capability (i.e., equipment, material, and  pharmaceuticals) to augment local health care infrastructures  overwhelmed by a terrorist attack or natural disaster. These stations  included a cache of drugs focused on urgent and emergency care. Given  the large number of evacuees with special medical needs who required  care following the hurricane, HHS revised the cache in 2006 to increase  the types of drugs specifically indicated for mental health conditions from  20 to 33. For example, HHS increased the types of antidepressants and  antipsychotics and added five new classes of drugs, including drugs to  treat sleep disorders.
section_title: States Experienced Several Difficulties in Applying for and Implementing Their CCPs Following Catastrophic Disasters
paragraphs: State officials told us they experienced difficulties in applying for CCP  funding and implementing their programs, particularly in the wake of  catastrophic disasters. States had problems collecting information needed  to prepare their ISP applications within FEMA’s application deadline and  preparing parts of their ISP and RSP applications, including estimating the  number of people who might need crisis counseling services. FEMA and  SAMHSA officials told us they had taken steps to revise the applications  and supporting guidance to help address these difficulties. States also  experienced lengthy application reviews, and FEMA and SAMHSA officials  said they had taken steps to improve the submission and review process.  In addition, state officials told us they experienced problems  implementing their CCPs, such as difficulties resulting from FEMA’s policy  of not reimbursing state CCPs for indirect program costs. Additional  problems that state officials cited were related to assisting people in need  of more intensive counseling services and making referrals for mental  health and substance abuse treatment. FEMA and SAMHSA are  considering options to address some of these concerns, but they do not  know when they will make these decisions.
subsections: section_title: States Encountered Difficulties in Preparing CCP Applications, and FEMA and SAMHSA Officials Cited Efforts to Clarify the Applications and Provide Training
paragraphs: Officials in the six states in our review told us they encountered  difficulties as they prepared their CCP applications following the  catastrophic disasters included in our review, including difficulties in  collecting the information required for their ISP applications within  established deadlines. Officials said that the amount of information  required for their applications was difficult to collect because of the scope  of the disasters and the necessity for responding on other fronts, such as  ensuring the safety of patients and personnel at state-run mental health  facilities. For example, Texas officials estimated that the state hosted  more than 400,000 Hurricane Katrina evacuees and that they had to collect  information for over 250 counties to estimate how many people might  need crisis counseling services. Furthermore, several state officials said  that some of the information required for the ISP application, such as that  on preliminary damages and the location of people who might need  services, was not always available or reliable immediately following a  catastrophic disaster. According to SAMHSA, because information from  traditional sources was lacking following Hurricane Katrina, states were  allowed to use other sources—such as newspaper reports and anecdotal  evidence—to complete their applications. However, Louisiana and  Mississippi officials told us that obtaining the information required by  SAMHSA to complete the application was difficult and was sometimes  unavailable in the immediate aftermath of the hurricane. Officials in three  states we contacted said that the difficulty of completing their applications  on time was exacerbated because multiple disasters affected the same  jurisdictions in close succession and they were required to submit a  separate application for each one. Louisiana, for example, had to submit  separate ISP applications following Hurricanes Katrina and Rita, even  though the hurricanes affected overlapping areas and occurred less than   1 month apart.
State officials also told us that the CCP application’s needs assessment  formula, which they are to use to estimate the number of people who  might need crisis counseling services, created problems in estimating  needs following catastrophic disasters in their states. The needs  assessment formula includes several categories of loss, including deaths,  hospitalizations, homes damaged or destroyed, and disaster-related  unemployment. State officials told us that the formula’s loss categories  did not capture data that they considered critical to assessing mental  health needs following a catastrophic disaster, such as estimates of  populations at increased risk for psychological distress, including children  and the elderly, or information on destroyed or damaged community  mental health centers. While states can include such information in a  narrative portion of their application, several state officials told us it was  not clear to them how this narrative information is factored into funding  decisions. NCPTSD’s evaluation of CCP for SAMHSA described concerns  similar to those noted by states in our review about the accuracy of the  results produced by using the formula. Moreover, NCPTSD concluded that  the formula could be a contributing factor in discrepancies it found  between states’ estimates of people in need and the numbers of people  actually served.
Preparing the sections of the application on plans for providing CCP  services and on program budgets also was difficult, according to state  officials. For example, state officials said the application guidance did not  provide sufficient detail to indicate what federal officials would consider  reasonable numbers of supervisors, outreach workers, and crisis  counselors to hire. Several officials also said it was difficult to use the  fiscal guidance to determine what agency officials would consider a  reasonable budget for various CCP activities, such as use of paid television  and radio advertisements for outreach. State officials said that having  more detailed guidance would help them develop better proposals and  minimize the need to revise their applications during the review process.
Federal program officials told us they have taken steps to address various  difficulties that states experienced in collecting information and preparing  their CCP applications. Agency officials told us that they recently made  changes intended to reduce the amount of information required in the ISP  and RSP applications, modified the needs assessment formula, and  clarified the applications and supporting guidance. For example, in the  revised needs assessment formula the weights assigned to most of the loss  categories have been adjusted for estimating the number of people who  could benefit from CCP services. According to SAMHSA, the revised ISP  and RSP applications were approved in September 2007; the agency made  these available to states in November 2007. In 2006, in response to  feedback from states regarding difficulties with the application process,  FEMA and SAMHSA revised their 4-day CCP basic training course for  states to increase its focus on preparing CCP applications. According to a  FEMA program official, the course was also revised in 2007 to reflect  recent changes to the applications and supporting guidance, and FEMA  program officials have requested that FEMA’s Emergency Management  Institute offer the course annually instead of every other year. This  program official also told us that a Web-based CCP orientation course was  developed and that it is required for all those who attend the basic training  course.
section_title: States Experienced Lengthy Application Reviews following Catastrophic Disasters, and FEMA and SAMHSA Have Taken Steps Intended to Shorten the Review Process
paragraphs: State officials told us that FEMA and SAMHSA’s CCP application review  process was lengthy after catastrophic disasters, especially for RSP  applications submitted following Hurricane Katrina. A FEMA official  estimated that for CCP applications submitted in 2002 through 2006 it had  generally taken the agencies about 14 days to review and make funding  decisions for ISP applications and about 28 to 70 days to review and make  funding decisions for RSP applications. Our analysis of CCP applications  for the catastrophic disasters in our review showed that it took FEMA and  SAMHSA from 5 to 39 days to review and make funding decisions for ISP  applications and 58 to 286 days to review and make funding decisions for  RSP applications. (See table 1.)
State officials told us that the lengthy reviews and the resulting delays in  obtaining RSP funding created difficulties for their CCPs. According to  state officials, delays in application approval contributed to delays in  executing contracts with service providers, delays in hiring staff, and  problems retaining staff. They told us they needed to obtain a decision on  their RSP application as quickly as possible so they could better plan and  implement their programs.
Federal program officials told us that several factors contributed to the  time it took to review applications following these catastrophic disasters.  These factors included an unanticipated high volume of CCP applications  following Hurricane Katrina. CCP applications submitted by states that  were directly affected by Hurricane Katrina, as well as by 26 states hosting  people who had evacuated after Hurricane Katrina, created unanticipated  demands that were well beyond the normal capacity of their CCP staff to  handle. FEMA officials told us that the two agencies typically reviewed  an average of 17 new ISP applications and 13 new RSP applications each  year from fiscal year 2002 through 2006, but that they reviewed 31 ISP  applications and 20 RSP applications in response to Hurricane Katrina  alone. According to SAMHSA officials, the agency had not planned for the  surge of applications created by FEMA’s decision to allow host states to  apply for CCP funding and had no policies in place at the time to enable  SAMHSA’s CCP and grants management staff to adapt quickly to the  submission of so many CCP applications within a few weeks. To respond,  some SAMHSA staff had to handle double the number of applications they  usually process, and the agency supplemented its six CCP reviewers by  using six staff from other parts of the agency to help review CCP grant  applications. FEMA hired three temporary staff to assist with the  application review process after Hurricane Katrina. However, a report  prepared for SAMHSA on its response to Hurricane Katrina noted that  some agency staff who assisted with the review of applications did not  have sufficient knowledge of CCP and the grant review process and  therefore required training.
SAMHSA and FEMA have taken actions to be prepared for such a surge in  applications in the future. A SAMHSA official told us that the agency sent  five staff from various parts of the agency to the August 2007 4-day CCP  basic training course to help them gain a better understanding of the CCP  application process. In December 2007, the agency hired a staff person,  whose position was funded by FEMA, in its grants management office to,  among other things, assist in the review of CCP applications and the fiscal  monitoring of CCP grants. They expect the addition of this employee to  help to shorten application review times for RSP grants.
SAMHSA officials told us that the need to obtain further information from  the states also contributed to the length of the reviews following  Hurricane Katrina. In examining various CCP applications submitted by  the states in our study after Hurricane Katrina and related  correspondence, we noted instances in which SAMHSA sent letters to  states informing them that their applications contained errors, were  incomplete, or required clarification for the agency to proceed with its  review. In some instances, the agency made multiple requests to a state to  clarify a specific part of its application. For example, SAMHSA found that  Louisiana did not provide complete information in its RSP application  related to the process the state planned to use to identify the local service  providers with which it would contract—a process that was different from  the one traditionally used to contract for CCP services. According to  federal officials, issues related to this process resulted in Louisiana not  submitting a complete application until 6 months after its initial  application, which in turn created enormous delays in the application  review process.
SAMHSA officials told us that another reason for the need to obtain  additional clarification was that the agency had established a more  stringent CCP application review process in July 2005. According to  SAMHSA officials, the revised CCP applications and guidance should help  reduce the need for states to revise their applications during the review  process. In addition, agency officials told us that the 2007 CCP basic  training course for applicants included information on the application  process and on the new review standards.
section_title: States Faced Difficulties in Implementing Their CCPs after Catastrophic Disasters, including Problems Related to Lack of Indirect-Cost Reimbursement and Need for Expanded Services
paragraphs: State officials said they faced difficulties in implementing their CCPs  following catastrophic disasters. For example, they told us that FEMA’s  policy of not reimbursing states and counseling service providers for  indirect costs caused difficulties for state CCPs. They also described the  need for expanded crisis counseling services and cited additional  concerns.
subsections: section_title: Obtaining Reimbursement for Indirect Costs
paragraphs: States told us that FEMA’s policy of precluding states and their CCP  service providers from obtaining reimbursement for indirect costs has  created difficulties in implementing their programs. Under CCP guidelines,  states and their CCP service providers cannot be reimbursed for indirect  costs related to managing and monitoring their programs that are not  directly itemized in their program budgets. However, state officials told us  that it can be difficult for their agencies and service providers to determine  what proportion of their overall administrative costs is attributable to CCP  activities. In addition, several state officials also told us that CCP service  providers often have limited capacity in their overall agency budgets to  redirect funds from other services to cover the indirect costs associated  with their CCP work.
State officials told us that the inability to obtain reimbursement for  indirect costs contributed to difficulties in recruiting and retaining service  providers. According to Louisiana officials, for example, that inability  contributed to the decision of one of its largest Hurricane Katrina CCP  contractors providing services in New Orleans to withdraw from the  state’s program in 2007. While CCP guidance precluded reimbursement for  indirect costs, the provider decided to request reimbursement. In a June  2006 letter to the state mental health office, the provider stated that  participating in the state’s CCP had created a financial burden that  included moving funds from other services to its CCP contract. In July  2006, FEMA declined the provider’s request to include indirect costs in its  budget, stating that under CCP guidelines all budget charges must be  direct and that the provider should work with the state to see whether any  of these costs could be reclassified as direct costs in the provider’s budget.
Officials in FEMA’s grants management office told us that although CCP  policy prohibits reimbursement for indirect costs, they were unaware of  statutory or regulatory prohibitions on the reimbursement of such costs.  Furthermore, they told us that other FEMA disaster response grant  programs do allow indirect cost reimbursement. For example, grantees  can be reimbursed for indirect costs under FEMA’s Public Assistance  Program and Hazard Mitigation Grant Program. Other federal  postdisaster response grant programs also allow grantees to be  reimbursed for indirect costs, including the SAMHSA Emergency  Response Grant (SERG) program and the Department of Education’s  Project School Emergency Response to Violence (Project SERV) program.
Concern about the exclusion of indirect costs from CCP reimbursement  has been a long-standing issue. In 1995, FEMA’s Inspector General issued a  report on CCP that said that the reimbursement of indirect costs appeared  allowable under applicable federal law and regulations. The Inspector  General recommended that FEMA review its policy on reimbursement for  indirect costs. FEMA and SAMHSA officials told us that reimbursement  for indirect costs was a recurring concern for states and service providers  and that states have advocated for a change in this policy. SAMHSA  officials said that allowing indirect cost reimbursement would promote  participation of a broader array of local service providers.
A FEMA official told us that the agency had been considering whether to  develop a new CCP policy to allow reimbursement for such costs.  According to this official, FEMA had been examining this issue since June  2006, when it received the letter from the Louisiana CCP service provider.
This official also told us that SAMHSA provided recommendations in  March 2007 on potential modifications to CCP guidance and application  materials to allow reimbursement for indirect costs. According to this  official, however, FEMA still needed to examine various implementation  issues, including which types of indirect costs might be reimbursed and  what changes to the application review process might be needed. As of  October 2007, this official did not know when the agency would make a  decision about whether to allow reimbursement for indirect costs.
section_title: Providing Expanded Crisis Counseling Services
paragraphs: State officials told us that after catastrophic disasters they faced the  challenge of how to assist people who were experiencing more serious  postdisaster distress than traditional CCP services could resolve.  According to New York, Louisiana, and Mississippi officials, some CCP  clients who did not display symptoms suggesting they needed a referral for  mental health or substance abuse treatment nevertheless could have  benefited from more intensive crisis counseling than was provided in the  CCP model. Furthermore, in the case of Hurricane Katrina, Mississippi  officials told us that they wanted to able to serve as many people as  possible within their CCPs because the devastation resulted in fewer  mental health and substance abuse providers being available to accept  referrals for treatment.
To assist these people, officials in New York, Louisiana, and Mississippi  asked FEMA and SAMHSA to allow their state CCPs to offer expanded  types of services after catastrophic disasters in their states. In response to  the states’ requests, FEMA and SAMHSA officials allowed the existing  state CCPs to develop pilot programs offering expanded crisis counseling  services consistent with the nonclinical, short-term focus of the CCP  model. New York’s expanded services, known as “enhanced services,”  were offered through the New York City Fire Department (FDNY) and  through community-based providers for both adults and children. FDNY’s  services started in September 2002, about 12 months after the WTC attack.  The community-based services started in spring 2003. Provided by mental  health professionals, these expanded services were based on cognitive  behavioral approaches. These services included helping clients recognize  symptoms of postdisaster distress and develop skills to cope with anxiety,  depression, or other symptoms. Individuals referred for expanded services  were offered a series of up to 12 counseling sessions. New York’s  community-based expanded services for adults ended in December 2003;  its community-based services for children ended in December 2004, as did  the FDNY’s services.
In November 2006, FEMA and SAMHSA allowed Louisiana and Mississippi  to plan for providing expanded crisis counseling services, known as  “specialized crisis counseling services,” to supplement CCP services  offered to people affected by Hurricane Katrina. Each state developed and  implemented expanded services based on operating principles developed  by SAMHSA and tailored to the needs of its population. Louisiana and  Mississippi began offering their expanded services in January 2007, about  17 months after the hurricane. In contrast to New York’s series of up to 12  sessions, the expanded services offered by Louisiana and Mississippi were  designed to be delivered in a single stand-alone session by mental health  professionals, although clients could obtain additional sessions. The  states’ CCPs used a standardized assessment and referral process to  determine whether to refer people for expanded services, such as stress  management. Louisiana and Mississippi used providers with prior mental  health training to refer expanded services clients for mental health and  substance abuse treatment services. In addition, the states used  paraprofessionals to link clients with other disaster-related services and  resources, such as financial services, housing, transportation, and child  care. According to a SAMHSA official, Louisiana’s CCP is scheduled to  stop providing expanded services to adults and children in February   2008. Mississippi, which focused on providing expanded services to  adults, stopped providing services in April 2007.
Several state officials said that it would be beneficial if the CCP model  could be expanded to include more intensive crisis counseling services  and if states could make these types of services available sooner. For  example, several officials told us that if expanded services were a  permanent part of CCP it would enable states responding to catastrophic  disasters to incorporate expanded services at an earlier stage in their CCP  service plans, training programs, and budgets. A New York official told us  that after the state received approval for the general concept of expanded  services, it took the state a few additional months to prepare a proposal,  obtain federal approval, and contract with and train the providers.  Because the state did not begin offering expanded services until it started  phasing down its delivery of traditional CCP services, fewer crisis  counselors were available to refer clients from traditional services to  expanded services. NCPTSD’s 2005 evaluation of CCP for SAMHSA  recommended that, at least on a trial basis, expanded services should  become a well-integrated part of state CCPs that is implemented relatively  early in state programs. NCPTSD also recommended evaluating the  efficacy of such services. FEMA and SAMHSA officials told us that after  completion of Louisiana’s program they planned to examine which  elements of Louisiana’s, Mississippi’s, and New York’s expanded services  programs might be beneficial to incorporate into CCP. FEMA and  SAMHSA officials also said that NCPTSD has begun to develop an  additional approach to providing postdisaster counseling services that  they would also like to examine after it has been developed. FEMA and  SAMHSA officials said they also planned to try to determine the most  opportune time to start offering expanded services to disaster survivors.  These officials did not know when the review would be completed.
section_title: Additional CCP Implementation Difficulties
paragraphs: Officials we interviewed in three of the states in our review expressed  concerns about the ability of state CCPs to appropriately refer people  needing mental health or substance abuse treatment services. Several state  officials said that the paraprofessional crisis counselors who generally  identify people for referral are not always able to properly identify people  who have more serious psychological problems. Officials said there was a  constant need to provide staff with training on CCP assessment and  referral techniques to ensure that they could identify people who needed a  referral. In its evaluation of CCP for SAMHSA, NCPTSD also reported  concerns by states related to the ability of paraprofessionals to identify  people needing a referral. According to SAMHSA, a CCP trainer’s toolkit  that was completed in August 2007 includes information on proper  techniques for conducting CCP assessments and referrals. The agency is  planning to distribute the toolkit to states in spring 2008 when it holds a  planned training.
Officials we spoke to in all six states in our review told us that their CCPs  were constrained by FEMA’s policy of not allowing CCP funds to be used  to provide some case management services. According to CCP guidance,  case management is not typically an allowable program service. Several  state officials told us that it would be beneficial if state CCPs could  provide some form of case management after catastrophic disasters, when  many survivors are likely to have numerous needs and may require  additional support to obtain services necessary for their recovery. State  officials said that Hurricane Katrina highlighted the difficulties that  disaster survivors can have negotiating complex service and support  systems. Louisiana officials said, for example, that many people who  experienced extraordinary levels of stress because of the hurricane had  low literacy skills and clearly needed support to make connections to  additional services and resources. One state official also told us that  because the practical difficulties of meeting needs involving housing can  often be a cause of the emotional distress that CCPs are trying to alleviate,  they would like CCP crisis counselors to be able to more directly help  people connect with disaster-related services to meet these needs.
State officials also told us that it was difficult to identify people in need of  crisis counseling services because FEMA does not give state CCPs access  to specific information on the location of people registered for federal  disaster assistance. NCPTSD’s evaluation of CCP also noted that the  unavailability of this information made it difficult for state CCPs to locate  people who might need services. Several state officials told us that FEMA  had provided them with some counts of disaster registrants at the state,  county, or Zip Code levels but that they also needed information on the  specific locations of disaster survivors to conduct effective outreach.  FEMA officials told us that the agency stopped providing information on  the specific location of registrants in the 1990s. They also told us that it  was their understanding that FEMA stopped providing this information  due to concerns about the privacy of registrants.
section_title: Conclusions
paragraphs: The scope and magnitude of catastrophic disasters can result in acute and  sustained psychological trauma that can be debilitating for extended  periods of time. While CCP is a key component of the federal  government’s response to the psychological consequences of disasters, we  have identified two important limitations that can affect states’ ability to  use CCP to respond to the special circumstances of catastrophic disasters.  First, state officials responding to the WTC attack and Hurricane Katrina  identified the need to provide expanded crisis counseling services through  CCP. FEMA and SAMHSA recognized such a need when they permitted  three state CCPs to expand their programs to provide more intensive  short-term crisis counseling than the CCP model generally allows. FEMA  and SAMHSA officials told us they intended to consider incorporating  certain types of expanded services into CCP. Promptly determining what  types of expanded services should become a permanent part of CCP  would enable states to more effectively develop their CCP proposals and  provide their populations with needed counseling services in the event of  future catastrophic disasters.
Second, FEMA’s policy of precluding states and their CCP service  providers from obtaining reimbursement for indirect costs associated with  managing and monitoring their CCPs has made it difficult for states to  effectively administer their CCPs. State officials reported that the lack of  reimbursement for indirect costs made it more difficult to recruit and  retain service providers and contributed to a major contractor’s  withdrawal from Louisiana’s Hurricane Katrina CCP. Other FEMA disaster  response grant programs allow reimbursement for such costs. Although  FEMA had been examining this issue for over a year, an agency official did  not know when the agency would reach a decision on whether to revise  CCP policy to allow coverage of indirect costs. Including indirect costs in  CCP and not requiring service providers to absorb these costs could  expand the pool of providers willing to participate in this program. This  could strengthen states’ ability to assist disaster victims in coping with the  psychological consequences of catastrophic disasters.
section_title: Recommendations for Executive Action
paragraphs: To address gaps identified by federal and state officials in the federal  government’s ability to help states respond to the psychological  consequences of catastrophic disasters, we recommend that the Secretary  of Homeland Security direct the Administrator of FEMA, in consultation  with the Administrator of SAMHSA, to expeditiously take the following  two actions:    determine what types of expanded crisis counseling services should be  formally incorporated into CCP and make any necessary revisions to  program policy, and revise CCP policy to allow states and service providers that receive CCP  funds to use them for indirect costs.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to DHS and HHS for comment. Both  DHS and HHS generally concurred with both of our recommendations and  stated that they had taken or will take steps toward implementing them.  However, they did not provide specific timelines for completing these  actions. (DHS’s comments are reprinted in app. III; HHS’s comments are  reprinted in app. IV).
In response to our recommendation to expeditiously allow reimbursement  for indirect costs within CCP, both departments commented that allowing  reimbursement for such costs will promote broader participation of local  service providers. In its comments, DHS also said that the inclusion of  indirect costs will help expedite the application review process and that  FEMA has been working with SAMHSA to revise CCP policy to allow  reimbursement for indirect costs. HHS stated that the draft report  accurately reflected concerns regarding the exclusion of indirect costs and  that SAMHSA had previously given FEMA a recommendation supporting a  change in this policy. Although DHS and HHS indicated that they are  working on a revision of the policy to allow reimbursement of such costs,  they did not provide a timeline for completing this activity. As our report  notes, FEMA has been examining this issue since 2006, and it is important  to complete this work expeditiously so that in the event of a future  disaster, state CCPs could be in a better position to attract the  participation of a broad array of service providers.
In response to our recommendation to expeditiously determine what types  of expanded crisis counseling services should be formally incorporated  into CCP, HHS and DHS commented that, as our draft report indicated,  they plan to wait until Louisiana has completed its pilot expanded services  program before making this determination. They said that because  Louisiana had applied for an extension of its CCP, they cannot provide a  timeline for completion of their reviews of expanded services pilots. We  believe, however, that federal program officials already have a  considerable amount of information about these pilots—New York and  Mississippi have completed their programs and Louisiana has been  providing information on an ongoing basis. We believe that it is important  for FEMA and SAMHSA to expeditiously review the experience of the pilot  programs and other relevant information so they can expeditiously  determine which expanded services should be formally incorporated into  CCP. This will help ensure that states responding to a disaster will be able  to provide the appropriate range of CCP services to assist people who are  in need of crisis counseling services. In addition, HHS commented that  SAMHSA has initiated a workgroup to ensure that the CCP model reflects  current best practices. However, we have learned that, as of January 2008,  the workgroup had not yet begun to conduct its work.
HHS and DHS commented on our discussion of states’ reports on  difficulties they had experienced in preparing their CCP applications. DHS  stated that FEMA, in consultation with SAMHSA, took action to expedite  the submission, review, and approval of ISP applications submitted after  Hurricane Katrina, including allowing the use of shorter applications by  states hosting Hurricane Katrina evacuees. We clarified our discussion of  host states’ ability to apply for CCP funds to note that FEMA allowed them  to submit an abbreviated ISP application. DHS also commented that it is  not feasible to have one grant application or one grant for two separate  disasters because FEMA must separately account for and report on funds  for specific disasters. We attempted to obtain further clarification from  DHS about why FEMA separately accounts for funds for each disaster, but  DHS did not provide this information.
In addition, HHS and DHS commented that the draft report’s description of  the needs assessment process failed to capture the degree to which they  had provided states flexibility in quantifying survivor needs after  Hurricane Katrina. DHS said that FEMA and SAMHSA did not rely  primarily on damage assessments, as few had been completed. Rather,  FEMA registration numbers, newspaper reports, and anecdotal data were  relied on to estimate need. Our draft report described action taken by  FEMA to help states collect information needed to prepare their ISP  applications after Hurricane Katrina, and we have revised the final report  to make it clear that states were allowed to use other sources of  information.
In commenting on the CCP application review process, HHS and DHS said  that the data in our report showing that it took up to 286 days to review  applications were misleading because only Louisiana’s application took  that long to review and the state’s proposed use of a different procedure  for identifying the local service providers with which it would contract  caused enormous delays in the review process. However, the review of  New York’s RSP after the WTC disaster also took over 200 days, and the  reviews for four of the five states in our study took longer than FEMA’s  estimated average review period. The draft report contained information  on several factors that contributed to longer review times, and we added  to the final report information on Louisiana’s proposal to use an  alternative procedure and its effect on the length of the review of  Louisiana’s RSP application.
HHS also commented on our discussion of states’ concerns that lengthy  reviews and resulting delays in obtaining funding created difficulties for  CCPs in executing contracts with service providers and implementing  their programs. HHS said that the report should note that these challenges  were the result of state fiscal and contracting practices that do not relate  to the availability of federal funds. Although state practices may contribute  to delays, extended federal reviews also may contribute to delays in states’  ability to implement their CCPs.
DHS commented on our description of states’ discussion of the  importance of case management services for CCP clients and mentioned  the Post-Katrina Emergency Management Reform Act of 2006, which  amended the Stafford Act to allow for the provision of case management  services to meet the needs of survivors of major disasters. These services  could include financial assistance to help state or local government  agencies or qualified private organizations to provide case management  services. In its comments, DHS also stated that FEMA has entered into an  interagency agreement with HHS to collaborate closely on the  development and implementation of a case management program; this  agreement is for the development of a pilot program to determine the best  methods of providing case management services. FEMA provided  additional information indicating that its case management program will  coordinate with CCP.
In its comments, HHS made observations about the importance of  recognizing culture and language issues as barriers to effective responses  to catastrophic disasters, incorporating behavioral health into all grantee  planning and response activities, and requiring grant recipients to report  on how funds were used to address the psychological consequences of a  disaster. These are important points, and we would encourage HHS  agencies to consider them in their disaster preparedness and response  programs. HHS noted that HRSA’s National Bioterrorism Hospital  Preparedness Program, Emergency System for Advance Registration of  Volunteer Healthcare Professionals, and Bioterrorism Training and  Curriculum Development Program have been transferred to ASPR; we  added this information to the final report where appropriate. HHS also  identified actions it had taken in response to GAO’s May 2005 report on  the CCP, including improving the fiscal monitoring of grants. In addition,  HHS noted that the grants management position funded by FEMA that we  discussed in our draft report was filled in December 2007. Our final report  reflects this development.
In its comments, HHS said that instead of referring to 35 states that  received disaster preparedness grants, our report should refer to 34 states  and the District of Columbia; the draft report noted that our use of the  word “state” included states, territories, Puerto Rico, and the District of  Columbia. In addition, HHS suggested that we revise the title of the report  by removing the reference to CCP needing improvements. In light of our  findings and recommendations, we believe the need for expeditious action  supports the original title. HHS also provided technical comments, which  we incorporated where appropriate.
We are sending a copy of this report to the Secretaries of Health and  Human Services and Homeland Security. We will make copies available to  others on request. In addition, the report will be available at no charge on  the GAO Web site at http://www.gao.gov.
If you have any questions about this report, please contact me at   (202) 512-7114 or bascettac@gao.gov. Contacts for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this report. GAO staff who made major contributions to this report are  listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: To do our work, we obtained program documents and interviewed  officials from the Department of Health and Human Services (HHS),  including the Administration for Children and Families, Centers for  Disease Control and Prevention (CDC), Centers for Medicare & Medicaid  Services (CMS), Health Resources and Services Administration (HRSA),  National Institutes of Health, Office of the Assistant Secretary for  Preparedness and Response, and Substance Abuse and Mental Health  Services Administration (SAMHSA); the Department of Education; the  Department of Homeland Security (DHS), including the Federal  Emergency Management Agency (FEMA); the Department of Justice; and  the Department of Veterans Affairs (VA), including the National Center for  Posttraumatic Stress Disorder (NCPTSD). We spoke with researchers  from the National Center for Child Traumatic Stress at the University of  California, Los Angeles, and the National Center for Disaster Preparedness  at Columbia University. We also interviewed officials from national  organizations, including the American Red Cross, National Alliance on  Mental Illness, National Association of State Mental Health Program  Directors, National Association of State Alcohol and Drug Abuse  Directors, and National Emergency Management Association. In addition,  we reviewed relevant literature.
We conducted additional work in six judgmentally selected states that had  experience responding to the psychological consequences of three  catastrophic disasters during fiscal years 2002 through 2006 that we  included in our scope: the World Trade Center (WTC) attack in 2001,  Hurricane Charley in 2004, and Hurricane Katrina in 2005. We included  New York because it responded to the WTC attack; Florida because it  responded to Hurricane Charley; and Louisiana and Mississippi because  they responded to Hurricane Katrina. We included Texas in our review  because it hosted a large number of people displaced by Hurricane  Katrina, and we included Washington because it hosted people displaced  by Hurricane Katrina and has features, such as large ports, that make it  vulnerable to natural and man-made disasters. Results from this  nongeneralizable sample of six states cannot be used to make inferences  about other states.
To examine actions by federal agencies to help states prepare for the  psychological consequences of catastrophic disasters, we reviewed key  federal preparedness and response documents—such as the National  Response Plan, the Interim National Preparedness Goal, and FEMA’s  Guide for All-Hazard Emergency Operations Planning—and recent reports  on the federal government’s response to Hurricane Katrina. We identified  federal grant programs and other activities that were related to disaster  preparedness and were funded during fiscal year 2002 through fiscal year  2006 by reviewing relevant documents and through discussions with  federal and state officials. For key HHS and DHS preparedness grant  programs, we reviewed relevant documentation, such as application  guidance, and interviewed federal program officials. We obtained disaster  plans for the mental health and substance abuse agencies in the six states  included in our review and examined the plans we received. We also  interviewed mental health and substance abuse officials from these six  states about their preparedness activities. In addition, we examined  SAMHSA’s 2007 report on mental health and substance abuse disaster  plans developed by states that received its preparedness grant.
To examine states’ experiences in obtaining and using federal Crisis  Counseling Assistance and Training Program (CCP) grants to respond to  the psychological consequences of catastrophic disasters, we reviewed  program documentation, including the applicable statute, regulations,  guidance, and grantee reports. We also reviewed CCP applications or  other relevant documentation that the six states submitted to FEMA for  declared counties in response to one of the three catastrophic disasters in  our review. We reviewed documentation to obtain information on states’  experiences in applying for CCP funding and on FEMA’s and SAMHSA’s  processes for reviewing applications, including examining the length of  time it took the agencies to review applications and make funding  decisions for the selected catastrophic disasters. In addition, we  interviewed state mental health officials from the six states to obtain  additional information on their experiences applying for CCP funding and  implementing their CCPs following these three disasters. We interviewed  FEMA and SAMHSA officials to obtain their perspectives on states’  applications and states’ experiences implementing their CCPs to respond  to catastrophic disasters and to obtain information pertaining to FEMA’s  and SAMHSA’s administration of the program. Furthermore, we examined  the 2005 report on CCP prepared for SAMHSA by NCPTSD.
To identify other federal programs that have supported mental health and  substance abuse services in response to catastrophic disasters, we  reviewed GAO reports, Congressional Research Service reports, the  Catalog of Federal Domestic Assistance, and pertinent legislation and  program regulations. We interviewed federal program officials about these  programs and obtained available information, including grantee  applications, award data, and reports, to determine how the programs  were used to respond to mental health or substance abuse needs following  the three catastrophic disasters included in our review. We present  information on the use of various federal programs to respond to needs  following the catastrophic disasters in our review; the list we present is  not exhaustive. To determine the amount of Deficit Reduction Act of 2005  funds used by the 32 states that had been approved by CMS for  demonstration projects following Hurricane Katrina, we analyzed data in  CMS’s Medicaid Budget and Expenditure System (MBES), which includes  claims data for health care services, including inpatient mental health care  services. We analyzed MBES claims data available as of June 27, 2007, for  services provided August 24, 2005, or later to eligible people affected by  Hurricane Katrina. To assess the reliability of the MBES data, we  discussed the database with an agency official and conducted electronic  testing of the data for obvious errors in completeness. States submit all  claims data to the system electronically and must attest to the  completeness and accuracy of the data. These data are preliminary in  nature, in that they are subject to further review by CMS and are likely to  be updated as states continue to submit claims for Deficit Reduction Act  funding. We determined that these data were sufficiently reliable for the  purpose of our report.
We conducted our work from March 2006 through February 2008 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
section_title: Appendix II: Additional Federal Programs Used to Respond to Psychological Consequences of Catastrophic Disasters
paragraphs: In addition to CCP, federal agencies have used other programs following  catastrophic disasters to help states and localities provide mental health  and substance abuse services to disaster survivors. The following list  presents information on the use of various federal programs to respond to  needs following the catastrophic disasters in our review; it is not an  exhaustive list.
Federal agencies have used established grant programs to help states  respond to the psychological consequences of catastrophic disasters,  some of which are generally intended to be used following smaller-scale  emergencies.
SAMHSA awarded funds through its Emergency Response Grant (SERG)  program following Hurricane Katrina. The agency provided a total of  $900,000 to Alabama, Louisiana, Mississippi, and Texas to help meet the  overwhelming need for assistance. For example, Texas was awarded  $150,000 and helped evacuees in the Houston Astrodome and other  shelters who needed methadone medication because of opiate addiction.
The Department of Education awarded funds through its Project School  Emergency Response to Violence (Project SERV) program following the  2001 terrorist attacks and Hurricanes Katrina and Rita. The agency  provided about $14 million and $7 million following these respective  disasters to help local education agencies respond by providing services  that could include crisis counseling, mental health assessments, and  referrals. For example, following the 2001 terrorist attacks, New York  used Project SERV funds to provide counseling and after-school mental  health services.
The Department of Justice provided funds through its Antiterrorism and  Emergency Assistance Program to help states and localities respond to  victims’ mental health needs following mass violence and acts of  terrorism. Following the WTC attack, for example, New York used   $5 million of its grant award from the Department of Justice to provide  additional funding to 15 service providers providing crisis counseling  services through the state CCP.
HHS has also temporarily modified or expanded ongoing federal health  care and social service programs to help states provide mental health and  substance abuse services after specific catastrophic disasters.
CMS allowed states to temporarily cover certain health care costs  associated with catastrophic disasters through Medicaid and the State  Children’s Health Insurance Program (SCHIP). For example, following  Hurricane Katrina, the Congress appropriated $2 billion to cover certain  health care costs related to Hurricane Katrina through Medicaid and  SCHIP. CMS allowed 32 states that either were directly affected by the  hurricane or had hosted evacuees to temporarily expand the availability of  coverage for certain people affected by the hurricane. CMS allowed states  to submit claims for reimbursement for health care services that were  provided August 24, 2005, or later. As of June 27, 2007, these states had  submitted claims to CMS for health care services totaling about   $1.7 billion, of which about $15.7 million was for mental health services  provided in inpatient facilities—such as hospitals, nursing homes, and  psychiatric facilities. (See table 2 for information on the amount of claims  submitted by states, including four states that were in our review.)
HHS’s Administration for Children and Families awarded $550 million in  supplemental Social Services Block Grant funds following the 2005 Gulf  Coast hurricanes to temporarily expand the program to help 50 states and  the District of Columbia meet social and health care service needs. The  funds could be used for providing case management and counseling,  mental health, and substance abuse services, including medications. States  could also use the funds for the repair, renovation, or construction of  community mental health centers and other health care facilities damaged  by the hurricanes. For example, Mississippi was awarded about   $128 million in supplemental funding and used about $10 million of the  funding in part to restore services to mental health treatment facilities for  adults and children and provide transportation to mental health services.
Federal agencies also awarded funding outside of these established  programs to help states provide disaster-related mental health and  substance abuse services after specific catastrophic disasters in our  review. Some of these programs focused on specific at-risk groups, such  as disaster responders, while others were established to meet the mental  health needs of broader populations.
HHS is coordinating federally funded programs for responders to the WTC  disaster—including firefighters, police, other workers or volunteers, and  federal responders—that provide free screening, monitoring, or treatment  services for physical illnesses and psychological problems related to the  disaster. We have previously reported on the progress of these programs.
SAMHSA provided $28 million to nine states most directly affected by the  September 11 attacks to provide various substance abuse and mental  health services for people directly affected by the attacks. These services  included assessments, individual counseling, group therapy, specialized  substance abuse treatment, and case management.
section_title: Appendix III: Comments from the Department of Homeland Security
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: GAO Contact and Staff Acknowledgments
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Helene F. Toiv, Assistant Director;  William Hadley; Alice L. London; and Roseanne Price made major  contributions to this report.
section_title: Related GAO Products
paragraphs: September 11: Problems Remain in Planning for and Providing Health  Screening and Monitoring Services for Responders. GAO-07-1253T.  Washington, D.C.: September 20, 2007.
Homeland Security: Observations on DHS and FEMA Efforts to Prepare  for and Respond to Major and Catastrophic Disasters and Address  Related Recommendations and Legislation. GAO-07-1142T. Washington,  D.C.: July 31, 2007.
September 11: HHS Needs to Ensure the Availability of Health Screening  and Monitoring for All Responders. GAO-07-892. Washington, D.C.:   July 23, 2007.
Emergency Management: Most School Districts Have Developed  Emergency Management Plans, but Would Benefit from Additional  Federal Guidance. GAO-07-609. Washington, D.C.: June 12, 2007.
Disaster Preparedness: Better Planning Would Improve OSHA’s Efforts  to Protect Workers’ Safety and Health in Disasters. GAO-07-193.  Washington, D.C.: March 28, 2007.
Public Health and Hospital Emergency Preparedness Programs:  Evolution of Performance Measurement Systems to Measure Progress.  GAO-07-485R. Washington, D.C.: March 23, 2007.
Catastrophic Disasters: Enhanced Leadership, Capabilities, and  Accountability Controls Will Improve the Effectiveness of the Nation’s  Preparedness, Response, and Recovery System. GAO-06-618. Washington,  D.C.: September 6, 2006.
Federal Emergency Management Agency: Crisis Counseling Grants  Awarded to the State of New York after the September 11 Terrorist  Attacks. GAO-05-514. Washington, D.C.: May 31, 2005.
Hurricane Katrina: Status of Hospital Inpatient and Emergency  Departments in the Greater New Orleans Area. GAO-06-1003.  Washington, D.C.: September 29, 2006.
Mental Health Services: Effectiveness of Insurance Coverage and Federal  Programs for Children Who Have Experienced Trauma Largely  Unknown. GAO-02-813. Washington, D.C.: August 22, 2002.