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Healthy Transitions Initiative – Now you see it, now you don’t!

August 02, 2013

In 2009 the Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, funded seven states five-year cooperative agreements to participate in the Healthy Transitions Initiative (HTI). This initiative was designed to integrate services and supports for youth and young adults 16-25 with serious mental health conditions and their families. One of the unique aspects of the original HTI funding is that it only went to states and the states were asked to craft practice and policy. This combination of practice informing policy and policy impacting practice is critical to replication and sustainable change to create better outcomes and create supportive state-level policies.

Here are some excerpts from the cooperative agreement description:

  • “Young people with serious mental health conditions, particularly those involved with the public mental health system, often face a more difficult transition to adulthood and the successful assumption of adult roles and responsibilities compared to their peers with or without other disabilities. The Healthy Transitions Initiative will create developmentally-appropriate and effective youth-guided local systems of care to improve outcomes for youth and young adults with serious mental health conditions in areas such as education, employment, housing, mental health and co-occurring disorders, and decrease contacts with the juvenile and criminal justice system.  These local systems will be linked and integrated at the State/Tribal/Territorial levels in order to effect policy change and replication statewide.

    The unique service needs of these young adults extend beyond those of children and younger adolescents, and they differ from those of adults. While these youth have ongoing needs for clinical services, they also have significant needs for support services that facilitate independent living and the ability to make wise choices as young adults. Youth who age out of child-serving systems may have difficulty obtaining services in adult systems. They often encounter a reduction or elimination of services when services available to children and adolescents are no longer accessible to them. Support services that assist youth with independent living address needs for housing, employment, education, basic living skills, and social support.. To ensure that systems of care are youth-guided and support youth transition to adulthood, partners from family, youth, and adult consumer organizations or stakeholders must be included in the development of coordinated, quality services and systems of care.

Sounds impressive, right?
Exactly the kind of comprehensive, forward thinking that we have come to expect from SAMHSA. And we at the Children’s Mental Health Network have thoroughly enjoyed watching and learning from these seven state initiatives, especially with the growing important involvement of young adults participating in the design and delivery of services and supports that most effectively meet their needs. So we were thrilled, but by no means surprised, when we saw that proposed funding for the Healthy Transitions Initiative (HTI) was included in the President’s budget proposal to Congress.

Ah, but we celebrated too early. When the Senate Appropriations subcommittee on Labor-HHS turned in their markup the HTI, budgeted for $25 million, was no where to be found. Interestingly, there was a new addition to the Community Block Grant for just under $25 million to direct funds to ”evidence-based programs addressing the needs of individuals with the early signs of serious mental illness, including psychotic disorders, regardless of the age of the individual at onset.”

So let’s recap:

  • HTI to the tune of $25 million is out and Block Grant funding for ”evidence-based programs addressing the needs of individuals with the early signs of serious mental illness, including psychotic disorders, regardless of the age of the individual at onset” is in – to the tune of close to $25 million ($24,817,000 to be exact).
  • HTI which is focused on a comprehensive, community-based, youth and family driven initiative is out. 
  • Block Grant funding for evidence-based programs addressing the needs of a very small percentage of the overall population of focus (even though the population of focus in the Block Grant funding is vaguely defined), directs funding for specific treatment approaches that may be valuable in their own right, but in the larger context of preparing communities for what is needed to support young adults and their families and vice versa, not even close – is in.

Oh my, oh my, where should we begin with our dismay at this one? 

Six months in the life (and potential demise) of the Healthy Transitions Initiative
First, let’s look at the Fiscal year 2014: Budget in Brief: Strengthening Health and Opportunity for All Americans document prepared by the U.S. Department of Health & Human Services. You will note that in the table on page 39 the Community Mental Health Services Block Grant shows no increase and the Healthy Transitions Initiative shows a recommended increase of $25 million:
 samhsabudgetclose

And then on page 41 of the same document there is specific language supporting the Healthy Transitions Initiative (highlights are ours):

  • Consistent with the President’s “Now is the Time” proposal, the Budget will begin to address these issues by investing $130 million in new SAMHSA funding to make sure students and young adults get treatment for mental health issues. These efforts will reach 750,000 young people every year through programs to promote mental health, prevent violence, identify mental illness early and create a clear pathway to treatment for those in need. This objective will be accomplished by providing:
    • $55 million for Project AWARE (Advancing Wellness and Resilience in Education) composed of: $40 million for State grants to help states and communities keep schools safe and get students with behavioral health issues referred to the services they need and $15 million for Mental Health First Aid training for teachers and other adults who work with youth to detect and respond to mental illness, including how to encourage adolescents and families to seek treatment.
    • $50 million to train 5,000 new social workers, counselors, psychologists, peer professionals and other mental health professionals to serve students and young adults, $35 million of which will be co-administered with HRSA.
    • $25 million for Healthy Transitions, innovative state-based strategies supporting young people ages 16 to 25 and their families to access and navigate the behavioral health treatment systems.
      *Our note – You can also see Healthy Transitions Initiative referenced on page 95 in the Fiscal year 2014 Budget of the U.S. Government.

But then on July 11, 2013, our puzzlement began:
From the Appropriations Bill (S. 1284) for the Departments of Labor, Health and Human Services, and Education, and related agencies for the fiscal year ending September 30, 2014
Page 65 – Provided further, That States shall expend at least 5 percent of the amount each receives for carrying out section 1911 of the PHS Act to support evidence based programs that address the needs of individuals with early serious mental illness, including psychotic disorders, regardless of the age of the individual at onset. 

No mention of the Healthy Transitions Initiative anywhere in this document that we could find.

And then the press release on the same day pretty much sealed the deal. In this excerpt from the Press Release by the U.S. Senate Committee on Appropriations regarding the Fiscal Year 2014 Labor, Health and Human Services, and Education, and Related Agencies Appropriations Bill – Full Committee Mark we have included the section related to mental health services.

  • Strengthening Our Mental Health System and Reducing Violence—Now Is the Time 
    The mass shootings last year at an Aurora, Colorado, movie theater and at Sandy Hook Elementary School in Newtown, Connecticut, raised public awareness about the problems of violence and mental illness in our communities as perhaps never before. 

    There are approximately 30,000 firearm-related homicides and suicides in the United States each year, and almost one-quarter of 14- to 17-year-olds have witnessed a shooting in their lifetime. Research shows that exposure to community violence can impact children’s mental health and development and can substantially increase the likelihood that these children will later commit violent acts themselves. Unfortunately, less than half of children and adults with diagnosable mental health problems receive the treatment they need. Addressing these challenges will require complex, comprehensive solutions that are beyond the scope of any single school, community, state, or set of laws. But funding provided in this bill to prevent violence, increase access to mental health treatment, and improve school safety can play an important role. 

    Mental Health Services: The bill includes $119 million in new funding to increase access to mental health services. This includes a total of $95 million for the administration’s Now is the Time initiative: $15 million for Mental Health First Aid programs that teach individuals to identify and respond to the signs of mental illness; $40 million for Project AWARE State grants, which will focus on making schools safer and connecting young people with mental health services; and $40 million in new funding to address shortages in the behavioral health workforce. In addition, the bill includes a new 5 percent set-aside within the Community Mental Health Services Block Grant that will allocate $24 million to evidence-based programs addressing the needs of individuals with the early signs of serious mental illness. 

No mention of $25 million for Healthy Transitions Initiative but a new addition of close to $25 million to the Community Mental Health Services Block Grant for “evidence-based programs addressing the needs of individuals with the early signs of serious mental illness.” Note that the press release leaves out the last part of the descriptor – “including psychotic disorders, regardless of the age of the individual at onset.”

What is hard to fathom is that the first two paragraphs of this section of the press release actually reinforce the need for focused attention on emerging adults – those specifically identified in the Healthy Transitions Initiative. What is unfortunate is that the opening paragraphs continue to perpetuate the myth that mental illness and violence go together like ham and cheese when there is overwhelming epidemiological evidence that the vast majority of people with psychiatric disorders do not commit violent acts. Only about 4 percent of violence in the United States can be attributed to people with mental illness. Since the press release chose to lead with the linking of the horrific tragedies in Colorado and Connecticut with violence and mental illness we would be remiss if we did not counter with the comments of Dr. Michael Stone, professor of clinical psychiatry at Columbia and an expert on mass murderers, who said in an interview with the New York Times that “Most of these killers are young men who are not floridly psychotic. They tend to be paranoid loners who hold a grudge and are full of rage.”… “Even though we know from large-scale epidemiologic studies like the E.C.A. study that a young psychotic male who is intoxicated with alcohol and has a history of involuntary commitment is at a high risk of violence, most individuals who fit this profile are harmless.”

This distinction is so important for understanding what is happening to children’s mental health right before our very eyes. It is being marginalized, subsumed and over-simplified into sound bites that have a level of complexity that is surface-level at best. When decisions are being made about what to fund with Federal dollars we should expect the most comprehensive approaches possible. With the removal of the HTI from the Appropriations budget we are witnessing the further dismantling of the piloting of approaches that are not just treatment based, but are equally focused on system level policy change backed by solid research at the local, state and national level. That is how we move the learning forward. In this instance, it appears we are moving backward.

The next fascinating document worthy of a closer look is the report that accompanies the Appropriations Bill (S. 1284). This report provides rational for the increase in mental health services block grant (MHBG) funding. It should be noted that we were unable to find any reference in this report regarding the decision to remove the Healthy Transitions Initiative from the budget.
Excerpt (page 114) from the report that accompanies S. 1284 providing rationale for increase in block grant funding (highlights are ours):

  • The MHBG distributes funds to 59 eligible States and territories through a formula based on specified economic and demographic factors. Grant applications must include an annual plan for providing comprehensive community mental health services to adults with a serious mental illness and children with a serious emotional disturbance.

    The Committee does not include bill language requested by the administration requiring States to set aside 5 percent of MHBG funds for effective mental health prevention and treatment programs. The Committee is concerned that this language is too broad to target early treatment services to those who need it most: individuals with serious mental illness. Instead, the Committee bill requires States to set aside 5 percent of their MHBG funds for evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders.

    The Committee notes that the majority of individuals with severe mental illness experience their first symptoms during adolescence or early adulthood. Despite the existence of effective treatments, there are often long delays—years, and sometimes decades—between the first onset of symptoms and when people receive help. The consequences of delayed treatment can include loss of family and social supports, disruption of employment, substance abuse, increased hospitalizations, and reduced prospects for long-term recovery.

    One promising model that seeks to address serious mental illness at an early stage is called First Episode Psychosis [FEP], currently being used in Canada, the United Kingdom, and Australia. This early treatment model may help reduce symptoms, reduce relapse rates, and prevent deterioration of cognitive function in individuals suffering from psychotic illness. The 5 percent set-aside will provide $24,817,000 to programs such as FEP. The Committee provides an increase to the block grant over the fiscal year 2013 level to help States meet this new requirement without losing funding for existing services. The Committee directs SAMHSA to collaborate with NIMH in developing guidelines to States regarding effective programs funded by this set-aside.

I can’t decide when reading the third and fourth paragraph if I am experiencing vertigo or cognitive dissonance. Maybe a bit of both. Let’s start with the third paragraph:

  • The Committee notes that the majority of individuals with severe mental illness experience their first symptoms during adolescence or early adulthood. Despite the existence of effective treatments, there are often long delays—years, and sometimes decades—between the first onset of symptoms and when people receive help. The consequences of delayed treatment can include loss of family and social supports, disruption of employment, substance abuse, increased hospitalizations, and reduced prospects for long-term recovery.

This paragraph speaks to the strength of the Healthy Transitions Initiative – the most comprehensive and targeted approach to addressing the needs of young adults with emotional challenges.

And then the fourth paragraph:

  • One promising model that seeks to address serious mental illness at an early stage is called First Episode Psychosis [FEP], currently being used in Canada, the United Kingdom, and Australia. This early treatment model may help reduce symptoms, reduce relapse rates, and prevent deterioration of cognitive function in individuals suffering from psychotic illness. The 5 percent set-aside will provide $24,817,000 to programs such as FEP. The Committee provides an increase to the block grant over the fiscal year 2013 level to help States meet this new requirement without losing funding for existing services. The Committee directs SAMHSA to collaborate with NIMH in developing guidelines to States regarding effective programs funded by this set-aside.

This paragraph is focused on a treatment model that apparently has great success with individuals suffering from a psychotic illness, which we have noted above is a small percentage of young adults with serious emotional challenges. Where is the complexity inherent in the HTI that shines a bright light on not just practice, but needed policy and system collaboration strategies and long term sustainable change in community health practice to ensure that young adults are getting what they need to be successful? 

Okay, so how did this happen?
Well, we actually don’t know and really need the help of Network faithful to find out. We have prepared a few questions that we will be sending to the Senate subcommittee members and encourage you to send your questions as well.

But first, an important note for all of us to remember. Elected officials rely on the information provided to them to be able to make fully-informed decisions, which means it is incumbent upon us to do our job as educators to speak up and let them know what is working well and making a difference for youth with serious emotional challenges and their families. Ultimately, the responsibility lies with us as citizens of this great country to make some noise. If we don’t let our voices be heard then we might as well be playin’ jacks.

Here are the questions we will be asking the Senate subcommittee in a letter to be sent out early next week. Answers to these questions will help us both understand how this happened, and maybe more important, ready us to be better prepared in the future.

The Senate committee proposal calls for a new 5 percent set-aside within the Community Mental Health Services Block Grant that will allocate $24 million to States. The specific language reads “Provided further, That States shall expend at least 5 percent of the amount each receives for carrying out section 1911 of the PHS Act to support evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders, regardless of the age of the individual at onset. Since the $25 million in the President’s budget for the Healthy Transitions Initiative does not appear in the Senate Bill it leads us to conclude that the funds identified for HTI were moved over to the Block Grant.

Here are the questions we are asking:

  • How was the decision made to remove HTI funding? What was the rationale to support this decision? Who was involved in making this decision?
  • How was the decision made to add funding to the Community Mental Health Services Block Grant? What was the rationale to support this decision? Who was involved in making this decision?
  • In the descriptive language concerning the addition of funds to the Community Mental Health Services Block Grant it reads in part “support evidence-based programs that address the needs of individuals with early serious mental illness, including psychotic disorders, regardless of the age of the individual at onset…” What is the age range considered to fit this population of focus?
  • What is the rationale for spreading these additional $24,817,000 across 50 states? From our perspective effective and lasting change takes a concentrated effort. Diluting funds across all 50 states through the Block Grant provides for a lukewarm effort at best. Concentrating efforts on a finite number of grants with more robust funding allows for system transformation efforts to take hold – a much more effective use of federal funds.
  • In the report that accompanies S. 1284 it is noted that “The Committee directs SAMHSA to collaborate with NIMH in developing guidelines to States regarding effective programs funded by this set-aside.” What will be the criteria for these guidelines? How will lessons learned from the effective SAMHSA funded Healthy Transitions Initiative programs, currently operating in 7 states, be incorporated?  
  • Beyond developing guidelines, what type of technical assistance and oversight will be provided? Who will provide such oversight and assistance?

 If you have actually read through this very long post then congratulations, you only have one more thing to do – get involved! 

  • Click here to learn how you can add your voice to the growing education campaign on the importance of the Healthy Transitions Initiative.

Scott Bryant-Comstock
President & CEO
Children’s Mental Health Network

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