Last month SAMHSA released their FY 2018 budget justification to be considered by Appropriations Committees in the House and Senate. We all know these are tough times, and cuts will be forthcoming, but one item in the SAMHSA budget justification stood out for me. SAMHSA is recommending ending the Healthy Transitions program a year early, in effect, discontinuing funding before grantees can complete a full and comprehensive evaluation.
These grants were designed to test out strategies for ensuring that young adults with mental health challenges do not progress to more serious forms of mental illness. Young adults at risk of developing a serious mental illness are precisely the target audience that has garnered so much attention over the past few years as a motivating force for the creation of the Helping Families in Mental Health Crisis Act (see 21st Century Cures Act, beginning on page 18). Why then, would SAMHSA propose ending the grants a year early?
Given all of the conversation in Congress and the national press over the past few years about the need for evaluating the effectiveness of treatment approaches for young adults at risk of developing a serious mental illness, the idea of not completing an evaluation that is in the final, most important stage, seemed unthinkable to me. That was until I read in the budget justification that SAMHSA was recommending just that. Here is their justification as written in the budget document submitted to Congress:
SAMHSA has developed significant knowledge and evidence for states to begin implementing and bringing to scale these efforts. SAMHSA will continue to ensure this knowledge is disseminated. (SAMHSA Justification of Estimates for Appropriations Committees)
The problem with SAMHSA's justification is that they have not "developed significant knowledge and evidence for states to begin implementing and bringing to scale these efforts." With this budget justification, SAMHSA appears to be throwing in the towel and prematurely pulling the plug on a grant program in which they have invested a considerable amount of money ($79 million dollars). A grant program that gets to the heart of what politicians have been railing about for several years about not enough attention being focused on developing strategies to address the needs of individuals at risk of developing a serious mental illness.
Brief History of Healthy Transitions
It is true that SAMHSA has developed knowledge about how to support community efforts to engage and serve youth and young adults experiencing mental illness. However, the knowledge-based evidence is extremely limited due to the minimal investment in rigorous evaluation of prior young adult oriented SAMHSA grant programs. The limited evaluations of these prior programs also lacked sufficient funding to examine outcomes in young adults who dropped out of treatment, or what types of interventions led to better or worse outcomes for which individuals.
SAMHSA’s first grant investment focused on young adults (Partnerships for Youth Transition) only served 562 individuals across grantees. The limited outcome evaluation focused only on the 34% of participants who stayed enrolled in the program for 12 months. This evaluation did not include any information on the quality or type of services delivered. (Haber, Karpur, Deschenes, & Clark, 2008).
SAMHSA’s 2nd comparable grant investment (the Healthy Transitions Initiative) supported services for 1542 individuals across ten communities. SAMHSA funded no evaluation of the Healthy Transition Initiative (HTI). An independently funded study showed improvements in HTI communities’ capacity to serve young adults (Walker, Koroloff, & Mehess, 2014); however, this study did not examine program impacts on young adult participants.
SAMHSA implemented the current Healthy Transitions grant program back In the fall of 2014. At that time, SAMHSA awarded 16 Healthy Transitions grants to 13 States (Connecticut, Delaware, Florida, Kentucky, Maryland, Massachusetts, New Mexico, Oklahoma, Pennsylvania, Rhode Island, Tennessee, Utah, and Wisconsin), the Research Foundation for Mental Hygiene in New York, the District of Columbia, and the Fairbanks Native Association in Alaska. Each grantee was awarded up to $1,000,000 per year for up to 5 years.
In March of 2015, SAMHSA began a national evaluation of the Healthy Transition grant programs to expand the limited knowledge base about what works to engage young adults in mental health services and improve young adults’ socio-emotional well-being. The Healthy Transitions grant program and the accompanying national evaluation is SAMHSA’s first large scale effort to learn how to address the many challenges to providing services to young adults at risk for or experiencing serious mental illness.
What Will Be Lost with This Proposed Cut
The SAMHSA FY18 budget proposes to eliminate funding for the Healthy Transitions grant communities, resulting in the loss of the grantees’ 5th and final year of funding—the year originally intended to focus on program sustainability. Without FY18 funding, the national evaluation will not adequately capture changes in systems or program participants resulting from SAMHSA’s extensive grant program investments made to date. The recommendation to cut the final year of funding makes little sense to me, and my guess is that when you share this post with your representatives in Congress, it will make little sense to them.
Secretary Price Calls for Continued Investment in High-Priority Mental Health Programs
In March of this year, HHS Secretary Price provided testimony before the House Appropriations Committee. He said, "Many Americans struggling with substance abuse also suffer from serious mental illness. Although the Department has made significant strides in helping individuals battling with mental illness and substance abuse, less than half of American children and adults with diagnosable mental health issues receive the treatment they need. To continue the Department’s efforts in these areas, the Administration requests continued investment in high-priority mental health programs that address suicide prevention, serious mental illness, and children’s mental health."
The Healthy Transitions grant program embodies the spirit and approach of Secretary Price's comments. As well, comprehensive evaluation data is precisely the type of information Congress has asked for with the creation of the SAMHSA Interdepartmental Serious Mental Illness Coordinating Committee. This committee will be making recommendations to the new Assistant Secretary of SAMHSA, and through that position, to Secretary Price, about what to continue to fund and what to let go. Strangely, there appears to be a disconnect between SAMHSA' proposal to end the Healthy Transitions program prematurely, resulting in an incomplete national evaluation, and the Secretary's call for investing in high-priority mental health programs. For a SAMHSA grant program that is on the cusp of being able to evaluate, with extensive data, strategies for addressing serious mental illness in young adults, discontinuing the final year of funding, the most important year for learning through evaluation what works, is most short-sighted.
Evaluation of Treatment and Cost Associated with Transition-Age Youth Is of Paramount Importance
We know that young adults with untreated mental illness are at disproportionately higher risk than those without mental illness to experience many costly, negative outcomes including involvement in the criminal justice system, inpatient psychiatric hospitalizations, as well as lower rates of high school and college completion. A principal goal of the Healthy Transitions program is to decrease the prevalence of these costly outcomes among young adult program participants. If successful, this could have large fiscal implications. For example, a typical week long felony trial can cost more than $5000/week. It has been estimated that preventing just one young offender from entering a lifetime of crime could save society between $1.7-$2.3 million dollars. In a 2012 study, it was estimated that the average cost of a typical psychiatric hospital stay was $6,700 (AHRQ, 2015). The median earnings of young adult high school completers were 22 percent higher than those of young adults who did not complete high school ($25,000) (McFarland, et al. The Condition of Education 2017).
The current Healthy Transitions program, and its independent, rigorous evaluation methods, presents the first large-scale opportunity to learn critical information about successful strategies to engage young adults in effective interventions to improve their well-being. For the first time in the history of federal funding for grants that focus on transition-age youth, the evaluation component includes a process evaluation that will allow the field to understand more about which types of services improve outcomes more and for which youth. The evaluation also has a comparison group, which will help us better understand how similar youth fare in the absence of these types of innovative services. The individual outcome evaluation captures outcomes for youth even after they leave services, which will allow for an evaluation of the changes in the entire sample of youth served. Finally, the current evaluation also includes a system outcomes evaluation so that grantee activities that produce positive system change can be identified. Conversely, grantee activities that are unproductive can be identified. This level of knowledge-based evidence is not available from the previous transition-age youth grant programs.
Without FY18 funding, the national evaluation will not adequately capture changes in program participants’ mental health and well-being, substance abuse behaviors, employment and education outcomes, housing stability, use of costly inpatient or residential treatment services, or criminal justice involvement. After already investing $79 million dollars into Healthy Transitions, one would think SAMHSA would want to complete the job and accurately judge the impact the grant program has made.
21st Century Cures Act Underscores the Importance of Healthy Transitions
The passage of the 21st Century Cures Act makes it clear that Congress is calling for a comprehensive focus on young adults who are either at risk of or have developed a serious mental illness. And that must include the rigorous evaluation of efforts to intervene before young adults with serious mental illness get to such extreme crisis points that would require interventions like Assisted Outpatient Treatment and hospitalization.
Your representatives in Congress, who likely championed mental health reform on the backs of stories of young adults with serious mental illness not getting appropriate services, need to be made aware that discontinuing the Healthy Transitions program with an incomplete evaluation is akin to throwing away the 79 million dollars already invested.
What You Can Do
I am encouraging you to contact your representatives in the House and Senate and tell them this is one program worth finishing. The data that will be gained in the final year of funding will be invaluable in learning how to sustain innovative treatment and support efforts for young adults with serious mental illness.
It is of particular importance for Network readers in the following states with Healthy Transition grants to share your voice. These states have representatives who are sitting members of the House and Senate Appropriations committees. Their opinions will go a long way when the time comes for final decision-making about what stays and what goes.
Remember, members of Congress in all states should be contacted. Here is a great website for easily finding your representative's contact information.
* * * * * * * * *
President & CEO
Children's Mental Health Network