Testimony from Elinore F. McCance-Katz, M.D., Ph.D. on 21st Century Cure Implementation: Examining Mental Health Initiatives before Committee on Energy and Commerce

Chairman Burgess, Ranking Member Green, and members of the Subcommittee, thank you for inviting me to testify at this important hearing.

In December 2016, the 21^st Century Cures Act (Cures Act) was signed into law, and the Substance Abuse and Mental Health Services Administration (SAMHSA) has been actively implementing many of the provisions in coordination with our colleagues at the Department of Health and Human Services (HHS), other Federal agencies, state and local governments, tribal entities, and other key stakeholders.

The Cures Act addresses many critical issues including leadership and accountability for behavioral health at the federal level, the importance of evidence-based programs for the treatment and prevention of mental and substance use disorders, and the imperative need to coordinate efforts across government. We at SAMHSA appreciate your leadership and dedication in enacting new authorities to reduce the impact of substance abuse and mental illness on America’s communities.

In my testimony, I will highlight key ways in which SAMHSA is implementing Cures Act provisions and how this implementation is benefiting individuals, families, and communities across the country.

Strengthening Leadership and Accountability

The Cures Act established the position of Assistant Secretary for Mental Health and Substance Use. I am humbled and honored to be the first person to serve in this position and bring my experience as a psychiatrist and researcher to this important role. As the Assistant Secretary for Mental Health and Substance Use, I take seriously my duties as outlined in the Cures Act such as maintaining a system to disseminate research findings and evidence-based programs to improve prevention, treatment, and recovery support services; ensuring that grants are subject to performance and outcome evaluations; consulting with stakeholders to improve community-based and other mental health services including for adults with serious mental illness (SMI) and children with serious emotional disturbances (SED); collaborating with other departments (such as the Departments of Veterans Affairs, Defense, Housing and Urban Development, and Labor); and working with stakeholders to improve the recruitment and retention of mental health and addiction professionals. SAMHSA has a very important mission and we focus on using our resources wisely and addressing the most pressing issues.

Strengthening leadership and accountability at SAMHSA includes ensuring a strong clinical perspective at the agency. The Cures Act codifies the role of the Chief Medical Officer (CMO). I believe a clinical perspective at the national level is imperative to sound stewardship and implementation of high quality, effective services. As such, I have built upon the codification of the CMO in the Cures Act by expanding the Office of the Chief Medical Officer (OCMO) to include two additional psychiatrists, a psychologist, and a nurse practitioner. Further, to ensure the elevation of OCMO within SAMHSA, I have placed it strategically in the Office of the Assistant Secretary (OAS).

OCMO responsibilities include serving as a liaison between SAMHSA and providers, assisting the Assistant Secretary in evaluation, organization, integration, and coordination of SAMHSA programs; promoting evidence-based and promising practices; and coordinating internally and externally to assess the use and ensure the utilization of appropriate performance metrics.

The Cures Act also codified the Center for Behavioral Health Statistics and Quality (CBHSQ), which serves as the federal government’s lead agency for behavioral health statistics. CBHSQ conducts national surveys tracking population-level behavioral health issues. These surveys, including the National Survey on Drug Use and Health, serve as the national standard for behavioral health statistics. The Cures Act places a particular emphasis on program evaluation. As such, I have created a new Office of Evaluation, within CBHSQ, which will be responsible for conducting SAMHSA’s program evaluations. CBHSQ also is responsible for collecting standardized performance data from grantees. The Center is currently in the process of implementing an innovative, real-time, client-based data-entry and reporting system for the streamlined collection of these data.

The Interdepartmental Serious Mental Illness Coordinating Committee (ISMICC) was required by the Cures Act to ensure better coordination across the entire Federal Government related to addressing the needs of individuals with SMI and SED and their families. The Committee represents collaboration across multiple Departments including: HHS, Justice, Labor, Housing and Urban Development, Defense, Veterans Affairs, Education, and the Social Security Administration. Fourteen non-federal members representing treatment providers, researchers, patients, families, criminal justice systems, and others also participate in the ISMICC.

Last December, as required in the Cures Act, we released the first ISMICC Report to Congress, which was followed by the second public meeting of the ISMICC. The report included recommendations from the non-federal members to focus on the following five areas:

1. Strengthening federal coordination to improve care;
2. Closing the gap between what works and what is offered;
3. Reducing justice involvement and improving care for those who are justice involved;
4. Making it easier to obtain evidence-based behavioral healthcare services; and
5. Developing finance strategies to increase availability and affordability of care.

Since that time, the ISMICC formed working groups to address each of these recommendations. The groups are working to ensure that recommendations lead to practical and actionable activities, which will ultimately benefit those living with mental disorders. For example, the development of guidance to communities on universal mental health screening for youth in schools is underway. Another key example is the development of a pilot survey to better assess the prevalence of mental disorders across America’s communities.

We have also engaged subject matter experts across the country, from academia, hospitals, insurers, community providers, state government, consumers, and family members to inform SAMHSA and its partners on complex problems such as civil commitment implementation, workforce challenges, improving crisis response systems, coordinating federal research agendas, screening and treatment of serious emotional disturbance among children, and partnering with the faith community. We provide monthly updates to ISMICC members and they have been strong advocates to address issues related to serious mental illness in our nation. HHS leadership and staff look forward to continued work with the other Federal departments and non-federal public members represented on the Committee.

Ensuring Mental and Substance Use Disorders Prevention, Treatment and Recovery Programs Keep Pace with Science and Technology

The Cures Act created the National Mental Health and Substance Use Policy Laboratory (Policy Lab). The Policy Lab is working to promote evidence-based practices and service delivery models through evaluating models that would benefit from further development and expansion. In particular, the Policy Lab is focusing on schizophrenia and schizoaffective disorder, as well as other SMI. It is also focusing on evidence-based practices and services for substance use disorders with an emphasis on opioids.

The responsibilities of the Policy Lab outlined in Cures are: to identify, coordinate, and facilitate the implementation of policy changes likely to have a significant effect on mental health and mental illness; to work with the Center for Behavioral Health Statistics and Quality to collect information from grantees under programs operated by the Administration in order to evaluate and disseminate information on evidence-based practices, including culturally and linguistically appropriate services and service delivery models; to provide leadership in identifying and coordinating policies and programs, including evidence-based programs related to mental illness and addiction; to periodically review programs and activities operated by the Administration relating to the diagnosis or prevention of, treatment for, and recovery from, mental illness and substance use disorders, including identifying any such programs or activities that are duplicative and are not evidence-based, effective, or efficient.

To provide communities, clinicians, policy-makers and others in the field with the information and tools they need to incorporate evidence-based practices into their practice, the Policy Lab launched an Evidence-Based Practices Resource Center (Resource Center) in April 2018. The Resource Center, at www.samhsa.gov/ebp-resource-center, contains a collection of science-based resources, including Treatment Improvement Protocols, toolkits, resource guides, and clinical practice guidelines, for a broad range of audiences. Moving forward, SAMHSA plans to develop and to disseminate additional resources, such as new or updated Treatment Improvement Protocols, guidance documents, clinical practice policies, toolkits, and other actionable materials that incorporate the latest scientific evidence on mental health and substance use.

Supporting State Activities and Responses to Mental Health and Addiction Needs

The Cures Act reauthorized the Community Mental Health Services Block Grant and codified a set-aside for first episode psychosis. This set-aside is vitally important to ensuring that people with SMI receive appropriate treatment. If we can intervene early and provide needed treatment and psychosocial services, people are able to manage their SMI and live full, productive lives.

Through this set-aside, states have been able to address the critical need to intervene as quickly and early as possible. States have developed and implemented strategies and programs including: statewide coordinated specialty care models, training of peer support specialists, expansion of treatment capacity through existing treatment teams, and establishment of quality assurance systems.

Since the enactment of the set-aside in 2015, SAMHSA, in coordination with our colleagues at the National Institute of Mental Health (NIMH), a component of the National Institutes of Health, has established 250 of these life-saving programs in every state and the District of Columbia.

Promoting Access to Mental Health and Substance Use Disorder Care

The Cures Act reauthorized many critical programs at SAMHSA. SAMHSA’s Programs of Regional and National Significance (PRNS) focus on providing high quality services to myriad populations including those involved with the criminal justice system, those living with HIV, individuals who are homeless, pregnant and postpartum women, and adolescents.

The Cures Act particularly heightened emphasis on serving those living with serious mental illness. For example, the Act reauthorized the Assisted Outpatient Treatment program. Assisted outpatient treatment programs are court-supervised treatment that take place in the community, sometimes referred to as “(involuntary) outpatient commitment.” In FY 2016, SAMHSA implemented an Assisted Outpatient Treatment grant program and awarded 17 grants through the program. A variety of program types receive these grants, including, county and city mental health systems, mental health courts, and any other entities with authority under the law of the state in which the grantee is located to mandate Assisted Outpatient Treatment. This four-year program is intended to implement and evaluate new Assisted Outpatient Treatment programs and identify evidence-based practices in order to reduce the incidence and duration of psychiatric hospitalization, homelessness, incarceration, and interactions with the criminal justice system, while improving the health and social outcomes of individuals living with SMI. This program is designed to work with families and courts to allow these individuals to obtain treatment while continuing to live in the community and in their homes within those communities. SAMHSA has partnered with the Assistant Secretary for Planning and Evaluation and NIMH to implement a cross-site evaluation that will assess the effectiveness and impact of the Assisted Outpatient Treatment grant program.

SAMHSA is also grateful that the Cures Act recognized and authorized another critical program for individuals living with SMI, Assertive Community Treatment (ACT). ACT is an evidence-based practice considered one of the most effective approaches to delivering services to people with SMI and has been disseminated by SAMHSA for widespread use through its Evidence-Based Toolkit series beginning in 2008. ACT is designed as a coordinated care approach to provide a comprehensive array of services, including medication management and other supportive services, directly via a multi-disciplinary team of professionals, rather than through referrals. An ACT team is composed of 10-12 transdisciplinary behavioral health staff – including psychiatrists, nurses, case managers, peer specialists and others – working together to deliver a mix of individualized, recovery oriented services to a caseload of approximately 100 people with SMI to help them with integration into the community. The services are provided 24 hours, seven days a week and as long as needed, wherever they are needed. ACT was developed to reduce re-hospitalization and improve outcomes on discharge. I am very pleased that Congress appropriated $5 million for SAMHSA’s first ever ACT program to be awarded in September 2018.

Suicide prevention is another critical component of mental health care which is highlighted in the Cures Act. Recent data from the Centers for Disease Control and Prevention (CDC) show that suicide deaths tragically continue to rise across the nation in virtually every state and across nearly every age group. According to CDC, in 2016, 44,965 Americans died by suicide; according to the National Survey on Drug Use and Health, there were an estimated 1.3 million suicide attempts in the United States. The Cures Act authorized SAMHSA’s existing National Suicide Prevention Lifeline (Lifeline). In 2017, the Lifeline answered over two million calls, far surpassing those recorded for 2016, with over 90 percent of callers reporting that calling the crisis hotline helped stop them from completing suicide.

Suicide remains the second leading cause of death for individuals 15-24 years old. The Cures Act reauthorized the Garrett Lee Smith Memorial Act, which provides grants to states and tribes to reduce youth suicide and suicide attempts. At the same time, the highest rate of suicide in America is among adults 45-64 years old. Prior to the Cures Act, there was no authorized suicide prevention program for adults at SAMHSA. SAMHSA is grateful for the authorization of the adult suicide prevention program in the Cures Act and for Congress’ funding of the first program in FY 2017. In FY 2017, SAMHSA awarded three grants for the Zero Suicide program. The purpose of this program is to implement suicide prevention and intervention programs within health systems for people who are 25 years of age or older. The comprehensive, multi-setting approach will raise awareness of suicide, establish referral processes, and improve care and outcomes for individuals who are at risk for suicide. Fourteen additional Zero Suicide grants are being awarded in FY 2018. SAMHSA also provided five grants under the Cooperative Agreements to Implement the National Strategy for Suicide Prevention program. The purpose of this program is to support states in implementing the 2012 National Strategy for Suicide Prevention goals and objectives focused on preventing suicide and suicide attempts among adults, ages 25 and older, to reduce the overall suicide rate and number of suicides in the United States.

Strengthening Mental and Substance Use Disorder Care for Children and Adolescents

The Cures Act also addresses the needs of children with mental and substance use disorders through reauthorization of the National Child Traumatic Stress Initiative. As one example of the work undertaken, the National Child Traumatic Stress Initiative conducted a Psychological First Aid Train the Trainer course for the State of Texas in response to Hurricane Harvey. Participants were selected from HHS-contracted behavioral health providers, giving priority to those regions most impacted by Hurricane Harvey.

It is estimated that over 7.4 million children and youth in the United States have a serious mental disorder. Unfortunately, only 41 percent of those in need of mental health services actually receive treatment. Created in 1992, SAMHSA's Children's Mental Health Initiative addresses this gap by supporting "systems of care" for children and youth with serious emotional disturbance (SED) and their families in order to increase their access to evidence-based treatment and supports. The Cures Act reauthorized the Children's Mental Health Initiative which provides grants to assist states, local governments, tribes, and territories in their efforts to deliver services and supports to meet the needs of children and youth with SED.

The Children's Mental Health Initiative supports the development, implementation, expansion, and sustainability of comprehensive, community-based services that use the systems of care approach. Systems of care is a strategic approach to the delivery of services and supports that incorporates family-driven, strength-based, and culturally and linguistically competent care in order to meet the physical, intellectual, emotional, cultural, and social needs of children and youth throughout the United States. The systems of care approach helps prepare children and youth for successful transition to adulthood and assumption of adult roles and responsibilities. Services are delivered in the least restrictive environment with evidence-supported treatments and interventions. Individualized care management ensures that planned services and supports are delivered with an appropriate, effective, and youth-guided approach. This approach has demonstrated improved outcomes for children at home, at school, and in their communities. For example, Children's Mental Health Initiative grantee data show that suicide attempt rates fell over 38 percent within 12 months after children and youth accessed Children's Mental Health Initiative -related systems of care services. In addition, school suspensions/expulsions fell over 42 percent and unlawful behavior fell over 40 percent within 18 months of children and youth beginning systems of care related services and supports.

As directed in the FY 2018 appropriations, SAMHSA is funding a demonstration within the Children’s Mental Health Initiative for the first time in FY 2018. The Community Programs for Outreach and Intervention with Youth and Young Adults at Clinical High Risk for Psychosis will identify youth and young adults, not more than 25 years old, at clinical high risk for psychosis and provide evidence-based interventions to prevent the onset of psychosis or lessen the severity of psychotic disorder. It is expected that this program will: (1) improve symptomatic and behavioral functioning; (2) enable youth and young adults to resume age-appropriate social, academic, and/or vocational activities; (3) delay or prevent the onset of psychosis; and (4) minimize the duration of untreated psychosis for those who develop psychotic symptoms.

Other Key Priority Implementation Activities

As discussed in the hearing held by this Committee on October 5, 2017 regarding the federal response to the opioid crisis, SAMHSA continues to work closely with states on their implementation of the $1 billion State Targeted Response (STR) program authorized by section 1003 of the Cures Act, which enables states to build comprehensive approaches to opioid use disorder prevention, treatment, and recovery programs. These funds are supporting state efforts to reduce opioid overdose deaths and increase access to treatment. Building on this program, the Omnibus Budget for 2018 included an additional $1 billion for the State Opioid Response program distributed to states through a formula that considered the number of opioid overdose deaths and the treatment gap for those living with opioid use disorders within each state.

One of SAMHSA’s roles is to oversee implementation of 42 CFR part 2, the regulation governing confidentiality of substance use disorder patient records. SAMHSA made substantive updates to these regulations in 2017 and 2018; the first such major revisions since 1987. In compliance with the Cures Act, SAMHSA held a listening session in January 2018 to obtain input about how Part 2 impacts patient care, health outcomes, and patient privacy. More than 1200 people participated in-person or online and SAMHSA received several written comments as well. Major themes included the need to align 42 CFR Part 2 and HIPAA, the need for technical assistance and training, and the importance of integrated care and use of Electronic Health Records. SAMHSA will continue to diligently review these issues and work to ensure that individuals living with substance use disorders have access to practitioners who are fully equipped with the knowledge they need to provide the best care possible. Individuals living with substance use disorders have a right to privacy; but, we must also not forget their right to high quality, effective care for substance use disorders, mental disorders and physical illnesses.

Congress also recognized the critical role behavioral health parity plays in ensuring equitable, high-quality health and behavioral healthcare for all Americans. Section 13002 called for the convening of a public listening session and the creation of a parity action plan for increased enforcement of behavioral health parity. The listening session was held on July 27, 2017. More than fifteen groups provided public comment in person and a total of 40 comments were received via email or in writing. Comments were received from various stakeholder groups including insurance representatives, employers, behavioral health providers, and patients or their advocates. The most common concerns cited by commenters were the need for more guidance from Federal agencies, transparency from insurance companies as to parity analysis and coverage decisions, and enforcement of parity protections. The Action Plan includes strategies and action steps to address these comments.

I feel strongly that we need to ensure that the direction provided by Congress in Cures is followed with fidelity and the highest quality service delivery possible. In order to achieve this goal, I have re-configured SAMHSA’s Technical Assistance (TA) approach from a grantee-based TA approach to one which supports a robust national and regional strategy that emphasizes training on evidence-based and effective practices to communities across the country.

Conclusion

I am thankful for the clear and meaningful direction and goals that Congress articulated in the Cures Act. I believe that it is my responsibility to ensure that the vision identified in the Cures Act is realized. SAMHSA has made great strides in our programming and policies but there is more work to do. There are many more people and their families struggling with mental illness and addiction that need help. I look forward to continuing a strong partnership with Congress to help these Americans. With the Cures Act, Congress has provided an instrumental blueprint for addressing these needs, and we at SAMHSA greatly appreciate your efforts.