Substance Abuse And Mental Health Services Administration: Planning for Program Changes and Future Workforce Needs Is Incomplete
Published: 2004-06-04T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Substance Abuse and Mental Health Services Administration (SAMHSA) is the lead federal agency responsible for improving the quality and availability of prevention and treatment services for substance abuse and mental illness. The upcoming reauthorization review of SAMHSA will enable the Congress to examine the agency's management of its grant programs and plans for converting its block grants to performance partnership grants, which will hold states more accountable for results. GAO was asked to provide the Congress with information about SAMHSA's (1) strategic planning efforts, (2) efforts to manage its workforce, and (3) partnerships with state and community-based grantees.
section_title: What GAO Found
paragraphs: SAMHSA has not completed key planning efforts to ensure that it can effectively manage its programs. The agency has operated without a strategic plan since October 2002, and although SAMHSA officials are drafting a plan, they do not know when it will be completed. SAMHSA developed long-term goals and a set of priority issues that provide some guidance for the agency's activities, but they are not a substitute for a strategic plan. In particular, they do not identify the approaches and resources needed to achieve the agency's long-term goals and the desired results against which the agency's programs can be measured. SAMHSA also has not fully developed strategies to ensure it has the appropriate staff to manage the agency's programs. Although the proportion of SAMHSA's staff eligible to retire is increasing, the agency has not developed a detailed succession strategy to prepare for the loss of essential expertise and to ensure that the agency continues to have the ability to fill key positions. In addition, the proposed performance partnership grants will change the way SAMHSA administers its largest grant programs, but the agency has not completed hiring and training strategies to ensure that its workforce will have the skills needed to administer the grants. Finally, SAMHSA's system for evaluating staff performance does not distinguish between acceptable and outstanding performance, and the agency does not assess staff performance in relation to specific competencies--practices that would help reinforce individual accountability for results. SAMHSA has opportunities to improve its partnerships with state and community-based grantees. For example, grantees objected to SAMHSA's practice of rejecting discretionary grant applications that do not comply with administrative requirements--such as those that exceed page limitations--without reviewing them for merit. Rejecting applications solely on administrative grounds potentially prevents SAMHSA from supporting the most effective programs. SAMHSA's recent changes to the review process should reduce such rejections, but have not eliminated them. State officials are also concerned that SAMHSA has not finalized the performance data that states would be required to report under the proposed performance partnership grants. To comply, states will need to change their data systems, but they cannot complete these changes until SAMHSA finalizes the requirements. The Congress directed SAMHSA to submit a plan by October 2002 describing the final data reporting requirements and any legislative changes needed to implement the grants, but SAMHSA has not yet completed the plan. This delay could prevent the agency from meeting its current timetable for implementing the mental health and substance abuse performance partnership grants in fiscal years 2005 and 2006, respectively.

section_title: Letter
paragraphs: Mental illness and substance abuse are major national problems. It is  estimated that more than 44 million Americans have a mental disorder, 22  million Americans have a substance abuse problem, and 7 to 10 million  Americans have co-occurring mental health and substance abuse  disorders. Substance abuse and mental health disorders are treatable, and  services can help relieve people’s symptoms and reduce the likelihood of  their developing future problems.
The Department of Health and Human Services’ (HHS) Substance Abuse  and Mental Health Services Administration (SAMHSA) is the lead federal  agency responsible for improving the quality and availability of prevention  and treatment services for substance abuse and mental illness. In fiscal  year 2003, SAMHSA managed a budget of $3.1 billion; its staff of about 500  full-time-equivalent employees was one of the smallest among HHS  agencies. SAMHSA’s budget primarily supported grants to states and local  agencies to provide substance abuse and mental health services. The  agency largely depends on the work of these grantees to carry out its  mission—to help people recover from substance abuse and mental illness  and develop the resilience to cope with problems that can lead to them.
SAMHSA also carries out its mission through collaborations with other  federal agencies and departments.
The upcoming legislative reauthorization of SAMHSA provides the  Congress with an opportunity to review how the agency manages its grant  programs. Furthermore, examining SAMHSA’s relationships with state and  local partners is particularly important as SAMHSA and the Congress  prepare to change the way the agency administers its largest grant  programs, the substance abuse and mental health block grants. In  response to a requirement in the Children’s Health Act of 2000, SAMHSA  is developing plans to transform its current block grants. The new grants— performance partnership grants—would give states greater flexibility in  how they spend funds, while holding them more accountable for achieving  specific results. In preparation for SAMHSA’s legislative reauthorization,  you asked us to provide information on SAMHSA’s (1) strategic planning  efforts, (2) efforts to manage its workforce, (3) collaborations with federal  agencies and departments, and (4) partnerships with state and community- based grantees.
To conduct our work, we analyzed pertinent agency documents and  interviewed officials from SAMHSA. We also interviewed officials from  selected federal agencies and departments that are engaged in  collaborative efforts with SAMHSA. For information on SAMHSA’s  partnerships with state grantees, we interviewed officials from the mental  health or substance abuse agency in 10 states—California, Colorado,  Connecticut, Iowa, Massachusetts, Mississippi, Montana, South Dakota,  Texas, and Virginia. We selected these states on the basis of variation in  their geographic location, the size of their fiscal year 2003 mental health or  substance abuse block grant award, the number of other grant awards  they received in fiscal year 2002, and their involvement in SAMHSA  initiatives to improve states’ ability to report mental health and substance  abuse data. We also interviewed representatives of selected community- based organizations that received grants from SAMHSA. We conducted  our work from July 2003 through May 2004 in accordance with generally  accepted government auditing standards. (For additional information on  our methodology, see app. I.)
subsections: section_title: Background
paragraphs: In October 1992, the Congress established SAMHSA to strengthen the  nation’s health care delivery system for the prevention and treatment of  substance abuse and mental illnesses. SAMHSA has three centers that  carry out its programmatic activities: the Center for Mental Health  Services, the Center for Substance Abuse Prevention, and the Center for  Substance Abuse Treatment. (See table 1 for a description of each center’s  purpose.) The centers receive support from SAMHSA’s Office of the  Administrator; Office of Program Services; Office of Policy, Planning, and  Budget; and Office of Applied Studies. The Office of Program Services  oversees the grant review process and provides centralized administrative  services for the agency; the Office of Policy, Planning, and Budget  develops the agency’s policies, manages the agency’s budget formulation  and execution, and manages agencywide strategic and program planning  activities; and the Office of Applied Studies gathers, analyzes, and  disseminates data on substance abuse practices in the United States,  which includes administering the annual National Survey on Drug Use and  Health—a primary source of information on the prevalence, patterns, and  consequences of drug and alcohol use and abuse in the country.
In fiscal year 2003, SAMHSA’s staff totaled 504 full-time-equivalent  employees, a decrease from 563 in fiscal year 1999. Thirteen of the  employees were in the Senior Executive Service, and the average grade of  SAMHSA’s general schedule workforce was 12.5—up from 11.7 in fiscal  year 1999. In addition, 25 of the employees were members of the U.S.  Public Health Service Commissioned Corps. SAMHSA’s program staff are  almost evenly divided among its three centers (see fig. 1), and all are  located in the Washington, D.C., metropolitan area.
SAMHSA’s budget increased from about $2 billion in fiscal year 1992 to  about $3.1 billion in fiscal year 2003. SAMHSA uses most of its budget to  fund grant programs that are managed by its three centers. (See fig. 2.) In  fiscal year 2003, 68 percent of SAMHSA’s budget funded the Substance  Abuse Prevention and Treatment Block Grant ($1.7 billion) and the  Community Mental Health Services Block Grant ($437 million). The  remaining portion of SAMHSA’s budget primarily funded other grants;   $74 million (2.4 percent) of its fiscal year 2003 budget supported program  management.
subsections: section_title: Administration of SAMHSA’s Block and Discretionary Grants
paragraphs: SAMHSA’s major activity is to use its grant programs to help states and  other public and private organizations provide substance abuse and  mental health services. For example, the substance abuse block grant  program gives all states a funding source for planning, carrying out, and  evaluating substance abuse services. States use their substance abuse  block grants to fund more than 10,500 community-based organizations.  Similarly, the mental health block grant program supports a broad  spectrum of community mental health services for adults with serious  mental illness and children with serious emotional disorders.
In December 2002, SAMHSA released for public comment its initial  proposal for how it will transform the substance abuse and mental health  block grants into performance partnership grants. In administering the  block grants, the agency currently holds states accountable for complying  with administrative and financial requirements, such as spending a  specified percentage of funds on particular services or populations.  According to SAMHSA’s proposal, the new grants will give states more  flexibility to meet the needs of their population by removing certain  spending requirements. At the same time, the grants will hold states  accountable for achieving specific goals related to the availability and  effectiveness of mental health and substance abuse services. For example,  SAMHSA has proposed that it would waive the current requirement that a  state use a certain percentage of its substance abuse block grant funds for  HIV services if that state can show a reduction of HIV transmissions  among the population with a substance abuse problem. The Children’s  Health Act of 2000 required SAMHSA to submit a plan to the Congress by  October 2002 describing the flexibility the performance partnership grants  would give the states, the performance measures that SAMHSA would use  to hold states accountable, the data that SAMHSA would collect from  states, definitions of the data elements, obstacles to implementing the  grants and ways to resolve them, the resources needed to implement the  grants, and any federal legislative changes that would be necessary.
In addition to the block grants that SAMHSA awards to all states, the  agency awards grants on a competitive basis to a limited number of  eligible applicants. These discretionary grants help public and private  organizations develop, implement, and evaluate substance abuse and  mental health services. In fiscal year 2003, the agency funded 73  discretionary grant programs, the largest of which was the $98.1 million  Children’s Mental Health Services Program. This program helps grantees  integrate and manage various social and medical services needed by  children and adolescents with serious emotional disorders.
Discretionary grant applications submitted to SAMHSA go through several  stages of review. When SAMHSA initially receives grant applications, it  screens them for adherence to specific formatting and other  administrative requirements. Applications that are rejected—or screened  out—at this stage receive no further review. Applications that move on are  reviewed on the basis of their scientific and technical merit by an initial  review group and then by one of SAMHSA’s national advisory councils.  The councils, which ensure that the applications support the mission and  priorities defined by SAMHSA or the specific center, must concur with the  scores given to the applications by the initial review group. On the basis of  the ranking of these scores given by the peer reviewers and on other  criteria posted in the grant announcement, such as geographic location,  SAMHSA program staff decide which grant applications receive funding.  Center directors and grants management officers must approve award  decisions that differ from the ranking of priority scores, and SAMHSA’s  administrator approves all final award decisions.
SAMHSA’s oversight of its block and discretionary grants consists  primarily of reviews of independent audit reports, on-site reviews, and  reviews of grant applications. SAMHSA’s Division of Grants Management  provides grant oversight, which includes reviewing the results of grantees’  annual financial audits that are required by the Single Audit Act. In  general, these audits are designed to determine whether a grantee’s  financial statements are fairly presented and grant funds are managed in  accordance with applicable laws and program requirements. Furthermore,  SAMHSA is statutorily required to conduct on-site reviews to monitor  block grant expenditures in at least 10 states each fiscal year. The  reviews examine states’ fiscal monitoring of service providers and  compliance with block grant requirements, such as requirements to  maintain a certain level of state expenditures for drug abuse treatment and  community mental health services—referred to as maintenance of effort.  In addition, SAMHSA project officers—grantees’ main point of contact  with SAMHSA—monitor states’ compliance with block grant requirements  through their review of annual block grant applications. For example, in  the substance abuse block grant application, states report how they spent  funds made available during a previous fiscal year and how they intend to  obligate funds being made available in the current fiscal year; project  officers review this information to determine if states have complied with  statutory requirements. For discretionary grants, project officers monitor  grantees’ use of funds through several mechanisms, including quarterly  reports, site visits, conference calls, and regular meetings. The purpose of  monitoring both block and discretionary grants is to ensure that grantees  achieve program goals and receive any technical assistance needed to  improve their delivery of substance abuse and mental health services.
section_title: Selected Federal Agencies and Departments That Collaborate with SAMHSA
paragraphs: SAMHSA has partnerships with every HHS agency and 12 federal  departments and independent agencies that fund substance abuse and  mental health programs and activities. For example, within HHS, the  Centers for Disease Control and Prevention and the Health Resources and  Services Administration have responsibility for improving the accessibility  and delivery of mental health and substance abuse services, and the  National Institutes of Health funds research on numerous topics related to  substance abuse and mental health. The Departments of Education,  Housing and Urban Development, Justice, and Veterans Affairs fund  substance abuse and mental health initiatives to help specific populations,  such as children and homeless people. In addition, the White House  Office of National Drug Control Policy is responsible for overseeing and  coordinating federal, state, and local drug control activities. Specifically,  the office gives federal agencies guidance for preparing their annual  budgets for activities related to reducing illicit drug use. It also develops  substance abuse profiles of states and large cities, which contain statistics  related to drug use and information on federal substance abuse prevention  and treatment grants awarded to that state or city.
section_title: SAMHSA’s Strategic Planning Efforts Are Incomplete
paragraphs: SAMHSA has operated without a strategic plan since October 2002.  Although agency officials are in the process of drafting a plan that covers  fiscal years 2004 through 2009 and expect to have it ready for public  comment in the fall of 2004, they do not know when they will issue a final  strategic plan.
As part of its strategic planning process, which began in fiscal year 2002,  SAMHSA developed three long-term goals for the agency—promoting  accountability, enhancing service capacity, and improving the  effectiveness of substance abuse and mental health services. SAMHSA’s  management has also identified 11 priority issues to guide the agency’s  activities and resource allocation and 10 priority principles that agency  officials are to consider when they develop policies and programs related  to these issues. (See table 2 for a list of SAMHSA’s priority issues and  priority principles.) For example, when SAMHSA develops grant programs  to increase substance abuse treatment capacity—a priority issue—staff  are to consider the priority principle of how the programs can be  implemented in rural settings. To ensure that the priority issues play a  central role in the work of its three centers, SAMHSA established work  groups for all the priority issues that include representation from at least  two centers. The work groups are to make recommendations to SAMHSA’s  leadership about funding for specific programs and to develop cross- center initiatives.
Although SAMHSA officials consider the agency’s set of priority issues and  priority principles a valuable planning and management tool, it lacks  important elements that a strategic plan would provide. For example,  SAMHSA’s priorities do not identify the approaches and resources needed  to achieve the long-term goals; the results expected from the agency’s  grant programs and a timetable for achieving those results; and an  assessment of key external factors, such as the actions of other federal  agencies, that could affect SAMHSA’s ability to achieve its goals. Without a  strategic plan that includes the expected results against which the  agency’s efforts can be measured, it is unclear how the agency or the  Congress will be able to assess the agency’s progress toward achieving its  long-term goals or the adequacy and appropriateness of SAMHSA’s grant  programs. Such assessments would help SAMHSA determine whether it  needs to eliminate, create, or restructure any grant programs or activities.  The priority issue work groups are developing multiyear action plans that  could support SAMHSA’s strategic planning efforts, because the plans are  expected to include measurable performance goals, action steps to meet  those goals, and a description of external factors that could affect program  results. SAMHSA officials expect to approve the action plans by June 30,  2004, and include them as a component of the draft strategic plan.
section_title: SAMHSA’s Efforts to Manage Its Workforce Lack Important Elements
paragraphs: SAMHSA’s strategic workforce planning efforts lack key strategies to  ensure appropriate staff will be available to manage the agency’s  programs. Specifically, SAMHSA has not developed a detailed succession  strategy to prepare for the loss of essential expertise and to ensure that  the agency can continue to fill key positions. In addition, the agency has  not fully developed hiring and training strategies to ensure that its project  officers can administer the proposed performance partnership grants.  SAMHSA has, however, taken steps to improve project officers’ expertise  for managing the current block grants and to increase staff effectiveness  by improving the efficiency of its work processes. While SAMHSA recently  implemented a performance management system that links staff  expectations with the agency’s long-term goals, other aspects of the  system do not reinforce individual accountability.
subsections: section_title: SAMHSA Has Not Fully Planned for Future Workforce Needs, but Has Taken Steps to Improve Staff Effectiveness
paragraphs: SAMHSA’s strategic workforce planning lacks key elements to ensure that  the agency has staff with the appropriate expertise to manage its  programs. The goal of strategic workforce planning is to develop long-term  strategies for acquiring, developing, and retaining staff needed to achieve  an organization’s mission and programmatic goals. SAMHSA is  implementing a strategic workforce plan—developed for fiscal years 2001  through 2005—that identifies the need to strategically and systematically  recruit, hire, develop, and retain a workforce with the capacity and  knowledge to achieve the agency’s mission. SAMHSA developed the plan  to improve organizational effectiveness and make the agency an “employer  of choice,” and the plan calls for development of an adequately skilled  workforce and efficient work processes. (See app. II for additional  information on SAMHSA’s strategic workforce plan.) The plan specifically  outlines the need to engage in succession planning to prepare for the loss  of essential expertise and to implement strategies to obtain and develop  the competencies that the agency needs.
SAMHSA did not include a succession strategy in its strategic workforce  plan, and the agency has not yet developed such a strategy. As we have  previously reported, succession planning is important for strengthening an  agency’s workforce by ensuring an ongoing supply of successors for  leadership and other key positions. SAMHSA officials told us the agency  has begun to engage in succession planning. They also noted that recent  retirement and attrition rates have been moderate—about 5 percent and 10  percent, respectively, in fiscal year 2003—and that the agency’s small size  allows them to identify those likely to retire and to fill key vacancies as  they occur. However, the proportion of SAMHSA’s workforce eligible to  retire is expected to rise from 19 percent in fiscal year 2003 to 25 percent  in fiscal year 2005, and careful planning could help SAMHSA prepare for  the loss of essential expertise.
Another shortcoming in SAMHSA’s strategic workforce planning is that  the agency has not fully developed hiring and training strategies to ensure  that its project officers will have the appropriate expertise to manage the  proposed performance partnership grants. The changes in the block grant  will alter the relationship between SAMHSA and the states, requiring  project officers to negotiate specific performance goals and monitor  states’ progress towards these goals. SAMHSA’s block grant reengineering  team found that, to carry out these responsibilities, project officers will  need training in performance management; elementary statistics; and  negotiation, advocacy, and mediation. SAMHSA expected to have a  training plan by late May 2004, but has not established a firm date by  which the training will be provided. As SAMHSA develops the training  plan, it will be important for the agency to consider how it will implement  and evaluate the training, including how it will assess the effect of the  training on staff’s development of needed skills and competencies.
In addition, the reengineering team recommended that the agency use  individualized staff development plans for project officers to ensure that  they acquire necessary skills. SAMHSA expects to have the individual  development plans in place by the end of fiscal year 2004. The team also  recommended that the agency develop new job descriptions to recruit new  staff. SAMHSA has developed job descriptions that identify the  responsibilities all project officers will have to meet and is using those  descriptions in its recruitment efforts.
SAMHSA has initiated efforts to improve the ability of project officers to  assist grantees with the current block grants. For example, SAMHSA  officials told us that the agency has made an effort to hire more project  officers with experience working in state mental health and substance  abuse systems. The agency is also expanding project officers’ training on  administrative policies and procedures and is planning to add a discussion  of block grant procedures to its on-line policy manual. These efforts  should help respond to the block grant reengineering team’s finding that  project officers require additional training in substance abuse prevention  and treatment and block grant program requirements. They should also  help address the concerns of state officials who told us that project  officers for the block grants have not always had sufficient background in  mental health or substance abuse services or have provided confusing or  incorrect information on grant requirements. For example, one state  received conflicting information from its project officer about the  percentage of its substance abuse block grant that it was required to spend  for HIV/AIDS services. Similarly, according to another state official, a  project officer provided unclear guidance on how to submit a request to  waive the mental health block grant’s maintenance of effort requirement,  which resulted in the state having to resubmit the request.
To meet the goal in its workforce plan of increasing staff effectiveness,  SAMHSA is taking steps to improve the agency’s work processes. For  example, agency officials expect to reduce the amount of time and effort  that staff devote to preparing grant announcements by issuing 4 standard  grant announcements for its discretionary grant programs, instead of the  30 to 40 issued annually in previous years. SAMHSA officials estimate that  the 4 standard announcements will encompass 75 to 80 percent of the  agency’s discretionary grants and believe they will improve the efficiency  of the grant award process. In addition, SAMHSA officials told us that  while most new award decisions have been made at the end of the fiscal  year, they expect that this consolidation will allow the agency to issue  some awards earlier in the year.
section_title: SAMHSA’s Performance Management System Does Not Sufficiently Recognize Differences in Employee Achievement
paragraphs: SAMHSA has adopted a new performance management system for its  employees that is intended to hold staff accountable for results by  aligning individual performance expectations with the agency’s goals—a  practice that we have identified as key for effective performance  management. SAMHSA is aligning the performance expectations of its  administrator and senior executives with the agency’s long-term goals and  priority issues and then linking those expectations with expectations for  staff at lower levels. As a result, SAMHSA’s senior executives’  performance expectations are linked directly to the administrator’s  objectives, and all other employees have at least one performance  objective that can be linked to the administrator’s objectives. For example,  objectives related to implementing the four new discretionary grant  announcements are included in the 2003 performance plans of the  appropriate center directors, branch chiefs, and project officers.
In contrast, other aspects of SAMHSA’s performance management system  do not reinforce individual accountability for results. SAMHSA’s  performance management system does not make meaningful distinctions  between acceptable and outstanding performance—an important practice  in a results-oriented performance management system. Instead, staff  ratings are limited to two categories, “meets or exceeds expectations” or  “unacceptable.” SAMHSA managers told us that few staff receive an  unacceptable rating and that using a pass/fail system can make it difficult  to hold staff accountable for their performance. Moreover, this type of  system may not give employees useful feedback to help them improve  their performance, and it does not recognize employees who are  performing at higher levels.
In addition, SAMHSA’s performance management system does not assess  staff performance in relation to specific competencies. Competencies  define the skills and supporting behaviors that individuals are expected to  exhibit in carrying out their work, and they can provide a fuller picture of  an individual’s contributions to achieving the agency’s goals. SAMHSA’s  strategic workforce plan includes a description of the competencies that  staff need, including technical competencies related to data collection and  analysis, co-occurring disorders, and service delivery. However, these  competencies have not been incorporated into the agency’s performance  management system to help reinforce behaviors and actions that support  the agency’s goals.
section_title: SAMHSA Is Taking Action to Improve Its Partnerships with Federal Agencies and Departments
paragraphs: SAMHSA jointly funds grant programs with other federal agencies and  departments, often through agreements that enable funds to be transferred  between agencies. While these interagency agreements can streamline the  grant-making process, SAMHSA’s lengthy procedures for approving them  have delayed the awarding of grants. SAMHSA officials told us that they  recently implemented policies to expedite the approval process. In  addition to jointly funding programs, SAMHSA shares mental health and  substance abuse expertise and information with other federal agencies  and departments. Grantees with whom we spoke identified opportunities  for SAMHSA to better coordinate with its federal partners to disseminate  information about effective practices to states and community-based  organizations.
subsections: section_title: SAMHSA Is Taking Steps to Expedite Approval of Joint Funding Arrangements
paragraphs: SAMHSA frequently collaborates with other federal agencies and  departments to jointly fund grant programs that support a range of  substance abuse and mental health services. (See table 3 for examples of  jointly funded programs.) For example, for the $34.4 million Collaborative  Initiative to Help End Chronic Homelessness, SAMHSA, the Health  Resources and Services Administration, the Department of Housing and  Urban Development, and the Department of Veterans Affairs provide funds  or other resources related to their own programs and the populations they  generally serve. SAMHSA’s funds are directed toward the provision of  substance abuse and mental health services for homeless people.
Many of SAMHSA’s joint funding arrangements use interagency  agreements to transfer funds between agencies, which allow grantees to  receive all of their grant funds from a single federal agency or department  (see table 4). For example, Safe Schools, Healthy Students grantees  receive all of their funds from the Department of Education, even though  SAMHSA also supports this program. SAMHSA officials told us that  interagency transfers create fewer funding streams and make the process  less confusing to grantees.
While transferring funds can streamline the grant process, SAMHSA’s  system for approving interagency agreements has been inefficient. Before  the funds are transferred, the agencies involved must approve an  interagency agreement describing the amount of money being transferred  and how it will be used. Officials from the Departments of Justice and  Education told us that SAMHSA’s approval process was lengthy and  resulted in agreements being completed at the last minute. The  Department of Education found that it took SAMHSA more than 70 days to  approve the 2003 Safe Schools, Healthy Students interagency agreement— a period that SAMHSA estimated was about 40 days longer than in  previous years. SAMHSA officials told us that the approval process was  complicated by the lack of a clear policy identifying the SAMHSA  management officials who needed to review and approve the agreements.  In March 2004, SAMHSA implemented new policies that clarify the process  for reviewing and approving agreements and the responsibilities of  specific SAMHSA officials. At that time, SAMHSA also began to track the  time it takes for the agency to review and approve interagency  agreements. It is too early to know how SAMHSA’s new policies will affect  the efficiency of the approval process.
section_title: SAMHSA Has Efforts Under Way to Better Coordinate with Other Agencies to Share Information on Effective Practices
paragraphs: SAMHSA provides its expertise and information on substance abuse and  mental health to other federal agencies and departments and collaborates  with them to share information with states and community-based  organizations. For example, officials from the Health Resources and  Services Administration told us that in coordinating health care and  mental health services for people who are homeless, they use SAMHSA’s  knowledge of community-based substance abuse and mental health  providers who can work with primary care providers. Also, the Office of  National Drug Control Policy uses data from SAMHSA’s National Survey  on Drug Use and Health to determine the extent to which it has achieved  its goals and objectives. This survey also provides data to support HHS’s  Healthy People 2010’s substance abuse focus area.
Several grantees told us that SAMHSA and the National Institutes of  Health could better collaborate to ensure that providers have information  about the most effective ways to deliver substance abuse and mental  health services. Recognizing the importance of such a partnership, the two  agencies recently initiated the Science to Service initiative, which is  designed to better integrate the National Institutes of Health’s research on  effective practices with the services funded by SAMHSA. For example, in  fiscal year 2003, SAMHSA and the National Institutes of Health funded a  grant to help states more readily integrate effective mental health  practices into service delivery in their states.
In addition, grantees recommended that SAMHSA better coordinate with  the Departments of Education and Justice to disseminate information  about effective practices to states and community-based organizations.  For example, a state official told us that SAMHSA and the Department of  Education do not ensure that their processes for evaluating substance  abuse prevention programs result in comparable sets of model programs.  The two agencies evaluate programs using different criteria and rate some  prevention programs differently. SAMHSA reported that it may be  appropriate for agencies to have different criteria because each agency  must have the ability to tailor its criteria to meet the specific goals of its  grant programs. A SAMHSA official acknowledged, however, that  SAMHSA and the Departments of Education and Justice are discussing  how they can refine their criteria for evaluating prevention programs and  better communicate the results to grantees.
section_title: SAMHSA Could More Effectively Manage Partnerships with State and Local Grantees
paragraphs: Officials from state mental health and substance abuse agencies and  community-based organizations identified opportunities for SAMHSA to  better manage its block and discretionary grant programs. They cited  concerns with SAMHSA’s grant application processes, site visits, and the  availability of information on technical assistance. SAMHSA plans to  transform its block grants into performance partnership grants in fiscal  years 2005 and 2006, and the agency, along with the states, is preparing for  the change. However, state officials are concerned that SAMHSA has not  finalized the performance data that states would report under the  proposed performance partnership grants. In addition, SAMHSA has not  completed the plan it must send to the Congress identifying the data  reporting requirements for the states and any legislative changes needed to  implement the performance partnership grants.
subsections: section_title: Grantees Have Raised Concerns about SAMHSA’s Grant Processes
paragraphs: Officials from states and community-based organizations told us that  SAMHSA could improve administration of its grant programs, citing  concerns related to the agency’s grant application review processes, site  visits to review states’ compliance with block grant requirements, and the  availability of information on technical assistance opportunities. In some  instances, SAMHSA has begun to respond to these issues.
subsections: section_title: Discretionary Grant Applications
paragraphs: Grantees we talked to expressed concern that SAMHSA rejects  discretionary grant applications without reviewing them for merit if they  do not comply with administrative requirements. SAMHSA told us that of  the 2,054 fiscal year 2003 applications it received after January 3, 2003,  393—19 percent—were rejected in this initial screening process. Of the  14 grantees we interviewed, 4 told us that SAMHSA rejected 1 of their 2003  grant applications without review and a fifth had 5 applications rejected.  Grantees told us that this practice does not enable applicants to obtain  substantive feedback on the content of their applications. They also said  that SAMHSA’s practice of waiting to notify applicants of the rejection  until it notifies all applicants of funding decisions—near the start of the  next fiscal year—impedes their fiscal planning.
In response to concerns over the number of grant applications it rejected  on administrative grounds in fiscal year 2003, SAMHSA has changed the  way it will screen fiscal year 2004 applications. On March 4, 2004,  SAMHSA announced revised requirements that are intended to simplify  and expedite the initial screening process for discretionary grants. For  example, SAMHSA will no longer automatically screen out applicants  because their application is missing a section, such as the table of  contents. Instead, the agency will consider whether the application  contains sufficient information for reviewers to consider the application’s  merit. In addition, SAMHSA will allow applicants more flexibility in the  format of their application. Instead of focusing exclusively on specific  margin sizes or page limits, SAMHSA will consider the total amount of  space used by the applicant to complete the narrative portion of the  application. SAMHSA expects that under the new procedures it will  screen out significantly fewer applications. However, some applications  continue to be rejected for administrative reasons and will not receive a  merit review. In another change, a SAMHSA official told us that it would  begin to notify applicants within 30 days of the decision if their application  is rejected.
section_title: Block Grant Applications
paragraphs: State officials told us that the length and complexity of the mental health  and substance abuse block grant applications create difficulties for both  states and project officers. They described the block grant applications as  confusing, repetitive, and difficult to complete. Furthermore, officials in  five states told us that SAMHSA project officers may not be using the  information states provide in the block grant application as well as they  could, especially the narrative portion. For example, one state official  received questions from the project officer about the state’s substance  abuse activities for women and children that could have been answered by  reading the narrative section of the application. State officials suggested  that project officers could more easily use the information states provided  if the application were streamlined and included only the information  most important to SAMHSA. They suggested that SAMHSA make these  changes when it converts the block grants to performance partnership  grants. SAMHSA officials told us they will not know whether the  applications can be streamlined until they finalize the format of the  performance partnership grants.
To allow center staff to retrieve information more quickly from the current  substance abuse block grant application, the Center for Substance Abuse  Prevention and the Center for Substance Abuse Treatment began to use a  Web-based application in spring 2003. The Web-based application allows  the centers to retrieve information collected from the substance abuse  block grant applications and more quickly develop reports analyzing data  across states, such as the number of states in compliance with specific  block grant requirements.
section_title: Site Visits
paragraphs: State officials told us that SAMHSA’s site visits to review states’  compliance with block grant requirements do not always allow the agency  to adequately review their programs. For example, officials in three states  told us that the length of these visits—often 3 to 5 days—is too short for  SAMHSA to fully understand conditions in the state that affect the  provision of services. Officials in two of these states said 3-day site visits  did not provide reviewers with enough time to visit mental health care  providers in the more remote parts of the state and observe how they  respond to local service delivery challenges. A SAMHSA official told us  that 3-day site visits are generally adequate for most states, but states are  able to request a longer visit. The official acknowledged that SAMHSA  could better communicate this flexibility to states.
section_title: Technical Assistance
paragraphs: Officials from eight states said the technical assistance they received from  SAMHSA and its contractors was helpful; officials from five states told  us that the agency could improve its dissemination of information about  what assistance is available to grantees. For example, one state official  suggested that SAMHSA provide more information on its Web site about  what assistance is available or has been requested by other states. He said  that making this information available is especially important because  there is high staff turnover at the state level, and relatively new staff may  have little knowledge about what SAMHSA offers. Several state mental  health officials commented that SAMHSA’s substance abuse block grant  has a more structured technical assistance program than the mental health  block grant and is able to offer more assistance opportunities. SAMHSA  officials noted that the substance abuse block grant program has more  funds and staff to devote to the provision of technical assistance.  SAMHSA’s Center for Substance Abuse Treatment, for example, has a  separate program branch to manage technical assistance contracts. This  center is in the process of creating a list of documents that grantees  developed with the help of technical assistance contractors—such as a  state strategic plan for providing substance abuse services—so that other  states can use them as models.
section_title: SAMHSA Is Preparing States for Performance Partnership Grants, but Has Not Finalized States’ Reporting Requirements
paragraphs: To prepare for the mental health and substance abuse performance  partnership grants—which SAMHSA plans to implement in fiscal years  2005 and 2006, respectively—SAMHSA has worked with states to develop  performance measures and improve states’ ability to report performance  data. Specifically, SAMHSA identified outcomes for which states would be  required to report performance data. SAMHSA asked states to voluntarily  report on performance measures related to these outcomes in their fiscal  year 2004 block grant applications and the agency provided states with  funding to help them make needed changes to their data collection and  reporting systems. Over fiscal years 2001 and 2002, SAMHSA awarded 3- year discretionary grants of about $100,000 per year to state mental health  and substance abuse agencies to develop systems for collecting and  reporting performance data. State officials told us they used the grants in  a variety of ways, such as to train service providers to report performance  data.
Substance abuse and mental health agency officials we talked to told us  that their states have made progress in preparing to report on performance  measures, but that their states would need to make additional data system  changes before they could report all of the data that SAMHSA has  proposed for the performance partnership grants. For example, officials  from three states told us that they were still unprepared to report data that  would come from other state agencies—such as information on school  attendance obtained from the state’s education system. In addition, several  state officials told us they have been unable to complete their preparations  because they are waiting for SAMHSA to finalize the data it will require  states to report. For example, a state mental health director told us that  the lack of final reporting requirements has contributed to a delay in the  implementation of the state’s new information management system.  Similarly, officials from a state substance abuse agency told us that  without SAMHSA’s final requirements, the state agency is limited in its  ability to require substance abuse treatment providers to change the way  they report performance data.
In addition, the Congress may need to make statutory changes before  SAMHSA can implement the performance partnership grants, but SAMHSA  has not given the Congress the information it sought on what changes are  needed or on how the agency proposes to implement the grants— including the final data reporting requirements for the states. In 2000, the  Congress directed SAMHSA to submit a plan containing this information  by October 2002. SAMHSA submitted this plan to HHS for internal review  on April 12, 2004, after which the plan must receive clearance from the  Office of Management and Budget. SAMHSA could not tell us when it  expects to submit the plan to the Congress.
section_title: Conclusions
paragraphs: SAMHSA’s leaders are taking steps to improve the management of the  agency, but key planning tools are not fully in place. SAMHSA has been  slow to issue a strategic plan, which is essential to guide the agency’s  efforts to increase program accountability and direct resources toward  accomplishing its goals. Furthermore, while SAMHSA is in the process of  implementing its strategic workforce plan, the agency’s workforce  planning efforts lack important elements—such as a detailed succession  strategy—to help SAMHSA prepare for future workforce needs. Because  future retirements and attrition could leave the agency without the  appropriate workforce to effectively carry out its programs, it would be  prudent for SAMHSA to have a succession strategy to help it retain  institutional knowledge, expertise, and leadership continuity.
In addition, SAMHSA has not completed plans to ensure that its workforce  has the appropriate expertise to manage the proposed performance  partnership grants, which would represent a significant change in the way  SAMHSA holds states accountable for achieving results. These grants  would require new skills from SAMHSA’s workforce. Therefore, it is  important for SAMHSA to complete hiring and training strategies to ensure  that its workforce can effectively implement the grants.
SAMHSA cannot convert the block grants to performance partnership  grants until it gives the Congress its implementation plan, which was due  in October 2002. The Congress needs the information in SAMHSA’s plan  for its deliberations about legislative changes that may be needed to allow  SAMHSA to implement the performance partnership grants. In addition,  the plan’s information on the performance measures SAMHSA will use to  hold states accountable is needed by the states as they prepare to report  required performance data. If SAMHSA does not promptly submit this  plan, states may not be ready to submit all needed data by the time  SAMHSA has planned to implement the grants—in fiscal years 2005 and  2006—and SAMHSA may not have the legislative authority needed to make  the mental health and substance abuse prevention and treatment block  grant programs more accountable and flexible.
Finally, as SAMHSA makes efforts to increase program accountability, it is  in the agency’s interest to fund state and local programs that show the  most promise for improving the quality and availability of prevention and  treatment services. Although SAMHSA has made changes that should  reduce the number of discretionary grant applications rejected solely for  administrative reasons—such as exceeding the specified page limitation— some applications are still not reviewed for merit because of  administrative errors. Allowing applicants to correct such errors and  resubmit their application within an established time frame could help  ensure that reviewers are able to assess the merits of the widest possible  pool of applications and could increase the likelihood of SAMHSA’s  funding the most effective mental health and substance abuse programs.
section_title: Recommendations for Executive Action
paragraphs: We recommend that, to improve SAMHSA’s management of its programs,  promote the effective use of its resources, and increase program  accountability, the Administrator of SAMHSA take the following four  actions:    Develop a detailed succession strategy to ensure SAMHSA has the  appropriate workforce to carry out the agency’s mission.
Complete hiring and training strategies, and assess the results, to ensure  that the agency’s workforce has the appropriate expertise to implement  performance partnership grants.
Expedite completion of its plan for the Congress providing information on  the agency’s proposal for implementing the performance partnership  grants and any legislative changes that must precede their implementation.
Develop a procedure that gives applicants whose discretionary grant  application contains administrative errors an opportunity to revise and  resubmit their application within an established time frame.
section_title: Agency Comments
paragraphs: We provided a draft of this report to SAMHSA for comment. Overall,  SAMHSA generally agreed with the findings of the report. (SAMHSA’s  comments are reprinted in app. III.) SAMHSA said that it already has  efforts under way to address each of the report’s key findings and  recommendations, and that it endorses the value the report places on  strategic planning, workforce planning, and collaboration with federal,  state, and community partners.
SAMHSA indicated that it will continue to engage in a strategic planning  process and said that its priority issues and principles are central to this  process. As we had noted in the draft report, SAMHSA commented that it  expects to complete and approve the action plans developed by each of its  priority issue work groups by June 30, 2004. SAMHSA also said that it  would update its draft strategic plan to include summaries of the action  plans, and then disseminate the draft for public comment, submit it to HHS  for clearance, and publish the final plan. Our draft report stated that  SAMHSA did not want to issue its strategic plan before HHS issued the  new departmental strategic plan. In its comments, SAMHSA noted that  HHS published its strategic plan in April 2004 and that this was no longer  an issue affecting SAMHSA’s schedule for publishing its plan.
In its comments, SAMHSA also stated that it places a high priority on the  development of a succession plan. SAMHSA said that it is preparing for an  anticipated increase in the agency’s attrition rate over the next several  years and is reviewing the pool of staff eligible to retire to identify the  skills and expertise that could be lost to the organization. While SAMHSA  is beginning to engage in succession planning, it has not developed a  detailed succession strategy. We have made our recommendation more  specific to communicate the need for SAMHSA to develop such a strategy.
In response to our recommendation that SAMHSA complete hiring and  training strategies to ensure that the agency’s workforce has the  appropriate expertise to implement performance partnership grants,  SAMHSA said that it is addressing the need for its workforce to have the  appropriate expertise. For example, SAMHSA indicated that it has initiated  efforts to identify training needed by current staff and to ensure that new  staff have needed skills. However, we believe it is important for SAMHSA  to fully develop both hiring and training strategies to ensure that it has the  appropriate workforce in place when it implements performance  partnership grants.
In response to our recommendation to develop a procedure to allow  applicants to correct administrative errors in discretionary grant  applications, SAMHSA commented that its new screening procedures have  yielded a substantial increase in the percentage of applications that will be  reviewed for merit. As a result, SAMHSA believes our recommendation is  premature and said that it plans to evaluate the results of the revised  procedures before making any additional changes. While early evidence  indicates that the new procedures are reducing the proportion of  applications rejected for administrative reasons, these procedures have  not eliminated such rejections. Because it is important for reviewers to be  able to assess the merits of the widest possible pool of applications, we  believe it would be beneficial for SAMHSA to develop the procedure we  are recommending without delay.
Finally, in response to the report’s discussion of the performance  partnership grants, SAMHSA commented that it will continue its efforts to  increase accountability in its block grant and discretionary grant  programs. SAMHSA said that the proposed fiscal year 2005 mental health  and substance abuse block grant applications contain outcome measures  that the agency expects to use to monitor grant performance. However,  these applications have not been finalized, and the draft applications  indicate that several of the performance measures are still being  developed. It is important for SAMHSA to give the Congress its plan for  implementing the performance partnership grants so that the Congress  can consider any legislative changes that might be necessary to implement  the grants and SAMHSA can more fully hold states accountable for  achieving specific results.
SAMHSA also provided technical comments. We revised our report to  reflect SAMHSA’s comments where appropriate.
As arranged with your office, unless you publicly announce its contents  earlier, we plan no further distribution of this report until 30 days after its  issue date. We are sending copies of this report to the Secretary of Health  and Human Services, the Administrator of SAMHSA, appropriate  congressional committees, and other interested parties. We will also make  copies available to others who are interested upon request. In addition, the  report will be available at no charge on the GAO Web site at  http://www.gao.gov.
If you or your staff have any questions, please contact me at (312) 220-7600  or Helene Toiv, Assistant Director, at (202) 512-7162. Janina Austin,  William Hadley, and Krister Friday also made major contributions to this  report.
section_title: Appendix I: Scope and Methodology
paragraphs: In performing our work, we obtained documents and interviewed officials  from the Substance Abuse and Mental Health Services Administration  (SAMHSA). While we reviewed documents related to SAMHSA’s strategic  planning and to its performance management system, we did not perform  a comprehensive evaluation of SAMHSA’s management practices. We also  reviewed the policies and procedures the agency uses to oversee states’  and other grantees’ use of block and discretionary grant funds. We  interviewed officials from SAMHSA’s Office of the Administrator; Office of  Policy, Planning, and Budget; Office of Program Services; Office of  Applied Studies; Center for Mental Health Services; Center for Substance  Abuse Prevention; and Center for Substance Abuse Treatment.
To determine how SAMHSA collaborates with other federal agencies and  departments, we interviewed officials from the Department of Education,  the Department of Justice, and the Department of Health and Human  Services’ Centers for Disease Control and Prevention, Health Resources  and Services Administration, and National Institutes of Health. After  reviewing lists of collaborative efforts provided by SAMHSA’s centers, we  selected these agencies because each one is involved in a collaborative  effort with each of SAMHSA’s three centers. Within these agencies, we  identified collaborative initiatives that involve interagency committees,  data sharing, interagency agreements, and other joint funding  arrangements. We interviewed and obtained documentation related to  these initiatives from federal agency officials who were directly involved  in them. We also interviewed officials from the Centers for Medicare &  Medicaid Services because Medicaid is the largest public payer of mental  health services and officials from the Indian Health Service, which  provides substance abuse and mental health services to tribal  communities. We interviewed officials from the White House Office of  National Drug Control Policy, which coordinates federal antidrug efforts.
To determine how SAMHSA collaborates with state grantees, we  interviewed officials from state mental health and substance abuse  agencies. We interviewed mental health agency officials in California,  Colorado, Connecticut, Mississippi, and South Dakota, and substance  abuse agency officials in Iowa, Massachusetts, Montana, Texas, and  Virginia. We selected these states on the basis of variation in their  geographic location, the size of their fiscal year 2003 mental health or  substance abuse block grant award, the number of discretionary grant  awards they received in fiscal year 2002, and their involvement in  SAMHSA initiatives to improve states’ ability to report mental health and  substance abuse data.
To gain a better understanding of SAMHSA’s collaborative efforts, we  interviewed officials from community-based organizations that received  discretionary grants from each of SAMHSA’s centers. We selected the  largest discretionary grant programs available to community-based  organizations from the Center for Substance Abuse Treatment (the  Targeted Capacity Expansion: HIV Program) and the Center for Mental  Health Services (the Child Traumatic Stress Initiative). We selected the  Center for Substance Abuse Prevention’s Best Practices: Community- Initiated Prevention Intervention Studies—the center’s second largest  discretionary grant program available to community-based  organizations—to provide a variety of SAMHSA’s priority issues. We also  selected one grant that was jointly funded by SAMHSA and the Health  Resources and Services Administration (the Collaboration to Link Health  Care for the Homeless Programs and Community Mental Health Agencies).  (See table 5.) For each of the four grant programs, we selected one  community-based organization that received grant funds in fiscal year 2001  or 2002 and that was located in 1 of the 10 states we selected.
To obtain additional information about SAMHSA’s collaboration with state  agencies and other grantees, we interviewed representatives of the  National Association of State Alcohol and Drug Abuse Directors, the  National Association of State Mental Health Program Directors, and the  Community Anti-Drug Coalitions of America. These organizations  represent, respectively, state substance abuse agencies, state mental  health agencies, and community-based substance abuse prevention  organizations. We also interviewed representatives of the National  Alliance for the Mentally Ill and the National Council on Alcoholism and  Drug Dependence, because those organizations represent consumers of  mental health services and substance abuse services, respectively. We  conducted our work from July 2003 through May 2004 in accordance with  generally accepted government auditing standards.
section_title: Appendix II: SAMHSA’s Strategic Workforce Plan Goals and Strategies, by Focus Area
subsections: section_title: Clarifying organizational purpose Creating effective work processes Valuing our most critical asset—people
paragraphs: SAMHSA has a strong leadership  and management capacity, a clearly  defined role as a national leader in  substance abuse and mental health  services, and a well-structured  organization to support its mission.
SAMHSA has effective and efficient  processes and methods for  accomplishing its mission and  optimizing its workforce.
SAMHSA strategically invests in its  workforce by putting the right people in  the right place at the right time. SAMHSA  systematically recruits, selects, and hires  talented employees and continuously re- recruits them by creating a great place to  work and by developing the competencies  needed to achieve its mission.
Strategies  Ensure that SAMHSA has a cross- functional executive leadership team  that works together to guide the  organization toward achieving its  mission.
Improve the development, review,  and management of discretionary  grants.
Change the size, scope, and distribution  of the workforce of SAMHSA.
Improve the publication clearance  process.
Anticipate competency needs and  strategically close competency gaps  where needed.
Develop a clear and compelling  multiyear strategy that is dynamic,  aligned with the organizational  mission, and linked to the  performance of each organizational  component and employee.
Examine the block and formula  grants process to create a more  efficient and streamlined process.
Continue to enhance a systematic  approach to recruiting skilled talent in a  tight labor market.
Establish a new system for  responding to external requests.
Continue to enhance a systematic  approach to retaining existing expertise.
Create an organizational structure  that maintains the strengths of the  current system, focuses on quality,  and increases flexibility and capacity.
Continue to enhance customer- focused and effective infrastructure  at SAMHSA.
Enhance the design and implementation  of a systematic approach to developing  the workforce.
Develop a systematic performance  management system to align individual  effort with strategic imperatives.
Implement a technology tool to provide  SAMHSA with workforce profile data for  managing its workforce.
section_title: Appendix III: Comments from the Department of Health and Human Services