Substance Abuse And Mental Health Services Administration
Planning for Program Changes and Future Workforce Needs Is Incomplete Gao ID: GAO-04-683 June 4, 2004The 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.
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.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-04-683, Substance Abuse And Mental Health Services Administration: Planning for Program Changes and Future Workforce Needs Is Incomplete
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Report to the Chairman, Committee on Health, Education, Labor, and
Pensions, U.S. Senate:
United States General Accounting Office:
GAO:
June 2004:
Substance Abuse and Mental Health Services Administration:
Planning for Program Changes and Future Workforce Needs Is Incomplete:
GAO-04-683:
GAO Highlights:
Highlights of GAO-04-683, a report to the Chairman, Committee on
Health, Education, Labor, and Pensions, U.S. Senate:
Why GAO Did This Study:
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.
What GAO Found:
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.
What GAO Recommends:
We are recommending that the Administrator of SAMHSA: (1) develop a
detailed succession strategy, (2) ensure that the agency‘s workforce
has the appropriate expertise to implement the performance partnership
grants, (3) develop a procedure to allow applicants for discretionary
grants to correct administrative errors in applications and resubmit
them, and (4) expedite completion of the plan for the Congress
providing information on the performance partnership grants. SAMHSA
said that each recommendation addresses an area that the agency has
identified for further action or improvement.
www.gao.gov/cgi-bin/getrpt?GAO-04-683.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Leslie Aronovitz at (312)
220-7600 or aronovitzl@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
SAMHSA's Strategic Planning Efforts Are Incomplete:
SAMHSA's Efforts to Manage Its Workforce Lack Important Elements:
SAMHSA Is Taking Action to Improve Its Partnerships with Federal
Agencies and Departments:
SAMHSA Could More Effectively Manage Partnerships with State and Local
Grantees:
Conclusions:
Recommendations for Executive Action:
Agency Comments:
Appendix I: Scope and Methodology:
Appendix II: SAMHSA's Strategic Workforce Plan Goals and Strategies, by
Focus Area:
Appendix III: Comments from the Department of Health and Human
Services:
Tables:
Table 1: Purpose Statements of SAMHSA's Centers:
Table 2: SAMHSA's Priority Issues and Priority Principles:
Table 3: Selected Collaborative Initiatives between SAMHSA and Its
Federal Partners:
Table 4: Fiscal Year 2003 Interagency Agreements between SAMHSA and Its
Federal Partners:
Table 5: Information on Selected Discretionary Grant Programs:
Figures:
Figure 1: SAMHSA Organization Chart and Staffing Levels, Fiscal Year
2003:
Figure 2: SAMHSA's Budget Devoted to Block Grants and Other Activities,
Fiscal Year 2003:
Abbreviations:
HHS: Department of Health and Human Services:
SAMHSA: Substance Abuse and Mental Health Services Administration:
United States General Accounting Office:
Washington, DC 20548:
June 4, 2004:
The Honorable Judd Gregg:
Chairman:
Committee on Health, Education, Labor, and Pensions:
United States Senate:
Dear Mr. Chairman:
Mental illness and substance abuse are major national problems. It is
estimated that more than 44 million Americans have a mental
disorder,[Footnote 1] 22 million Americans have a substance abuse
problem,[Footnote 2] and 7 to 10 million Americans have co-occurring
mental health and substance abuse disorders.[Footnote 3] 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.[Footnote 4] 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.[Footnote
5] In response to a requirement in the Children's Health Act of
2000,[Footnote 6] 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.)
Results in Brief:
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. As part of
its strategic planning process, SAMHSA developed three long-term goals-
-promoting accountability, enhancing service capacity, and improving
the effectiveness of substance abuse and mental health services. SAMHSA
also developed a set of 11 priority issues--such as co-occurring mental
health and substance abuse disorders--to guide the agency's activities.
While the goals and priority issues provide some guidance to the
agency, they are not a substitute for a strategic plan. In particular,
they do not identify the approaches 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 its programs. SAMHSA is implementing a
strategic workforce plan that calls for the development of a skilled
workforce and efficient work processes, but 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. The proportion of SAMHSA's staff
eligible to retire is increasing--it is expected to be 25 percent in
fiscal year 2005--and future retirements and attrition could leave the
agency without leadership continuity and the appropriate workforce to
effectively carry out its programs. In addition, the agency has not
fully developed hiring and training plans to ensure that its workforce
will have the necessary expertise to administer the proposed
performance partnership grants. Finally, SAMHSA recently implemented a
performance management system that is intended to hold staff
accountable for results by linking staff expectations with the agency's
long-term goals. However, SAMHSA's system 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.
SAMHSA has taken steps to improve its collaborations with other federal
agencies and departments. To jointly fund grant programs with its
federal partners, SAMHSA frequently uses interagency agreements, which
allow funds to be transferred between agencies. While interagency
agreements can streamline the grantmaking process by enabling a single
agency to administer a jointly funded grant program, SAMHSA's process
for approving the agreements has been lengthy and has delayed the
awarding of grants. To improve this process, SAMHSA recently
implemented new procedures for reviewing and approving interagency
agreements. It is too early to know how SAMHSA's new policies will
affect the efficiency of its approval process. SAMHSA is also taking
steps to better coordinate with its federal partners to provide states
and community-based organizations with information on effective mental
health and substance abuse practices. For example, SAMHSA recently
initiated the Science to Service partnership to better integrate the
National Institutes of Health's research on effective practices with
the services funded by SAMHSA.
SAMHSA also 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 applications that
exceed the specified page limitation--without reviewing them for merit.
These grants are awarded on a competitive basis to a limited number of
eligible applicants, and rejecting applications solely on
administrative grounds potentially prevents SAMHSA from supporting the
most effective programs. SAMHSA recently changed its review process,
which agency officials believe will reduce the number of such
rejections. However, some applications continue to be rejected for
administrative reasons. In addition, state officials are concerned that
SAMHSA has not finalized the performance data that states would report
under the proposed performance partnership grants. To comply with the
proposed grant requirements, states will need to change their data
systems, but they cannot complete these changes until SAMHSA finalizes
the requirements. In 2000, the Congress directed SAMHSA to submit a
plan by October 2002 describing any legislative changes needed to
transform the block grants into performance partnership grants and the
final data reporting requirements. SAMHSA has not yet completed the
plan, and this delay could prevent the agency from meeting its current
timetable for implementing the mental health and substance abuse
grants--in fiscal years 2005 and 2006, respectively.
We are recommending that the Administrator of SAMHSA (1) develop a
detailed succession strategy, (2) ensure that the agency's workforce
has the appropriate expertise to implement the performance partnership
grants, (3) develop a procedure to allow applicants for discretionary
grants to correct administrative errors in applications and resubmit
them, and (4) expedite completion of the plan for the Congress
providing information on the performance partnership grants.
In commenting on a draft of this report, SAMHSA said that overall, it
generally agrees with the report's findings and that each
recommendation addresses an area that the agency has identified for
further action or improvement.
Background:
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.[Footnote 7] 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[Footnote 8].
Table 1: Purpose Statements of SAMHSA's Centers:
Center: Center for Mental Health Services;
Purpose: To improve the availability and accessibility of high-quality
community-based services for people with, or at risk for, mental
illnesses.
Center: Center for Substance Abuse Prevention;
Purpose: To bring effective substance abuse prevention to every
community, nationwide.
Center: Center for Substance Abuse Treatment;
Purpose: To promote the availability and quality of community-based
substance abuse treatment services for individuals and families who
need them.
Source: GAO analysis of SAMHSA documents.
[End of table]
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.[Footnote 9] 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.
Figure 1: SAMHSA Organization Chart and Staffing Levels, Fiscal Year
2003:
[See PDF for image]
Note: "Staff" refers to full-time-equivalent employees.
[End of figure]
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.[Footnote 10]
Figure 2: SAMHSA's Budget Devoted to Block Grants and Other Activities,
Fiscal Year 2003:
[See PDF for image]
Note: In addition to these funds, SAMHSA received $74.2 million from
HHS to help pay for its national surveys and its data, technical
assistance, and evaluation activities.
[End of figure]
Administration of SAMHSA's Block and Discretionary Grants:
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.[Footnote 11]
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.[Footnote 12] 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.[Footnote 13]
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[Footnote 14] and then by one
of SAMHSA's national advisory councils.[Footnote 15] 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[Footnote 16] provides grant oversight, which includes
reviewing the results of grantees' annual financial audits that are
required by the Single Audit Act.[Footnote 17] 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.[Footnote 18] 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.[Footnote 19] 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.
Selected Federal Agencies and Departments That Collaborate with SAMHSA:
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.[Footnote
20] 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.[Footnote 21] 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.
SAMHSA's Strategic Planning Efforts Are Incomplete:
SAMHSA has operated without a strategic plan since October
2002.[Footnote 22] 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,[Footnote 23] 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[Footnote 24] 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.
Table 2: SAMHSA's Priority Issues and Priority Principles:
Issues:
Co-occurring mental health and substance abuse disorders;
Substance abuse treatment capacity;
Seclusion and restraint;
Strategic prevention framework;
Children and families;
Mental health system transformation;
Disaster readiness and response;
Homelessness;
Aging;
HIV/AIDS and hepatitis;
Criminal justice;
Principles:
Science to services/evidence-based practices;
Data for performance measurement and management;
Collaboration with public and private partners;
Recovery/reducing stigma and barriers to services;
Cultural competency/eliminating disparities;
Community and faith-based approaches;
Trauma and violence;
Financing strategies and cost effectiveness;
Rural and other specific settings;
Workforce development.
Source: GAO analysis of SAMHSA documents.
[End of table]
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.[Footnote
25] 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.
SAMHSA's Efforts to Manage Its Workforce Lack Important Elements:
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.
SAMHSA Has Not Fully Planned for Future Workforce Needs, but Has Taken
Steps to Improve Staff Effectiveness:
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.[Footnote 26]
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.[Footnote 27] 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[Footnote 28] 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.[Footnote 29] 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.[Footnote 30]
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,[Footnote 31] 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.[Footnote 32]
SAMHSA's Performance Management System Does Not Sufficiently Recognize
Differences in Employee Achievement:
SAMHSA has adopted a new performance management system for its
employees[Footnote 33] 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.[Footnote 34] 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.[Footnote 35]
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.[Footnote 36] 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.
SAMHSA Is Taking Action to Improve Its Partnerships with Federal
Agencies and Departments:
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.
SAMHSA Is Taking Steps to Expedite Approval of Joint Funding
Arrangements:
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.
Table 3: Selected Collaborative Initiatives between SAMHSA and Its
Federal Partners:
Grant program: Safe Schools, Healthy Students Initiative;
Federal partner(s): Department of Education, Department of Justice;
SAMHSA funding (fiscal year 2003): $71.0 million;
Purpose: To implement and enhance comprehensive communitywide
strategies for creating safe and drug-free schools and promoting
healthy childhood development.
Grant program: Serious and Violent Offenders Re-entry Initiative;
Federal partner(s): Department of Education, Department of Housing and
Urban Development, Department of Justice, Department of Labor;
SAMHSA funding (fiscal year 2003): $8.0 million;
Purpose: To prepare offenders to successfully return to their
communities after having served a significant period of confinement.
Grant program: Collaborative Initiative to Help End Chronic
Homelessness;
Federal partner(s): Health Resources and Services Administration,
Department of Housing and Urban Development, Department of Veterans
Affairs;
SAMHSA funding (fiscal year 2003): $7.4 million;
Purpose: To end chronic homelessness by seeking to create a
collaborative and comprehensive approach to addressing homelessness.
Grant program: Science to Service: State Implementation of Evidence-
based Programs;
Federal partner(s): National Institutes of Health;
SAMHSA funding (fiscal year 2003): $2.8 million;
Purpose: To promote and support implementation of evidence-based
mental health treatment practices in state systems.
Grant program: Collaboration to Link Health Care for the Homeless
Programs and Community Mental Health Agencies;
Federal partner(s): Health Resources and Services Administration;
SAMHSA funding (fiscal year 2003): $1.2 million;
Purpose: To develop partnerships between community mental health and
homeless health care systems.
Source: GAO analysis of HHS and Departments of Education, Housing and
Urban Development, and Justice documents.
[End of table]
Many of SAMHSA's joint funding arrangements use interagency agreements
to transfer funds between agencies,[Footnote 37] 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.[Footnote 38]
Table 4: Fiscal Year 2003 Interagency Agreements between SAMHSA and
Its Federal Partners:
Center: Center for Mental Health Services;
Funds transferred from the center: Number of agreements: 24;
Funds transferred from the center: Funds: $80,536,775;
Funds transferred to the center: Number of agreements: 24;
Funds transferred to the center: Funds: $87,096,930.
Center: Center for Substance Abuse Prevention;
Funds transferred from the center: Number of agreements: 19;
Funds transferred from the center: Funds: $1,839,787;
Funds transferred to the center: Number of agreements: 9;
Funds transferred to the center: Funds: $7,445,505.
Center: Center for Substance Abuse Treatment;
Funds transferred from the center: Number of agreements: 10;
Funds transferred from the center: Funds: $8,482,000;
Funds transferred to the center: Number of agreements: 3;
Funds transferred to the center: Funds: $2,140,000.
Center: Total;
Funds transferred from the center: Number of agreements: 53;
Funds transferred from the center: Funds: $90,858,562;
Funds transferred to the center: Number of agreements: 36;
Funds transferred to the center: Funds: $96,682,435.
Source: GAO analysis of SAMHSA documents.
[End of table]
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.
SAMHSA Has Efforts Under Way to Better Coordinate with Other Agencies
to Share Information on Effective Practices:
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.[Footnote 39]
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.[Footnote 40] 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.[Footnote 41]
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.[Footnote 42] 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.
SAMHSA Could More Effectively Manage Partnerships with State and Local
Grantees:
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.
Grantees Have Raised Concerns about SAMHSA's Grant Processes:
Officials from states and community-based organizations[Footnote 43]
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.
Discretionary Grant Applications:
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.[Footnote 44]
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.[Footnote 45] 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.[Footnote 46] 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.[Footnote 47] 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.[Footnote 48] 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.[Footnote 49]
Block Grant Applications:
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.[Footnote 50]
Site Visits:
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.
Technical Assistance:
Officials from eight states said the technical assistance they received
from SAMHSA and its contractors[Footnote 51] was helpful;[Footnote 52]
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.
SAMHSA Is Preparing States for Performance Partnership Grants, but Has
Not Finalized States' Reporting Requirements:
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.[Footnote 53] 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.[Footnote 54]
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.
Conclusions:
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.
Recommendations for Executive Action:
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.
Agency Comments:
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.
Sincerely yours,
Signed by:
Leslie G. Aronovitz:
Director, Health Care--Program Administration and Integrity Issues:
[End of section]
Appendix I: Scope and Methodology:
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,[Footnote 55] 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.[Footnote 56] 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.
Table 5: Information on Selected Discretionary Grant Programs:
Grant: Targeted Capacity Expansion: HIV;
Sponsoring center: Center for Substance Abuse Treatment;
Priority issue: HIV/AIDS and hepatitis;
Funding (fiscal year 2003): $61.5 million.
Grant: Child Traumatic Stress Initiative;
Sponsoring center: Center for Mental Health Services;
Priority issue: Children and families;
Funding (fiscal year 2003): $29.8 million.
Grant: Best Practices: Community-Initiated Prevention Intervention
Studies;
Sponsoring center: Center for Substance Abuse Prevention;
Priority issue: Strategic prevention framework;
Funding (fiscal year 2003): $9.8 million.
Grant: Collaboration to Link Health Care for the Homeless Programs and
Community Mental Health Agencies;
Sponsoring center: Center for Mental Health Services;
Priority issue: Homelessness;
Funding (fiscal year 2003): $1.2 million.
Source: GAO analysis of SAMHSA documents.
[End of table]
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.
[End of section]
Appendix II: SAMHSA's Strategic Workforce Plan Goals and Strategies, by
Focus Area:
Goals;
Focus areas: Clarifying organizational purpose: 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;
Focus areas: Creating effective work processes: SAMHSA has effective
and efficient processes and methods for accomplishing its mission and
optimizing its workforce;
Focus areas: Valuing our most critical asset--people: 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;
Focus areas: Clarifying organizational purpose: Ensure that SAMHSA has
a cross-functional executive leadership team that works together to
guide the organization toward achieving its mission;
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;
Create an organizational structure that maintains the strengths of the
current system, focuses on quality, and increases flexibility and
capacity;
Focus areas: Creating effective work processes: Improve the
development, review, and management of discretionary grants;
Improve the publication clearance process;
Examine the block and formula grants process to create a more
efficient and streamlined process;
Establish a new system for responding to external requests;
Continue to enhance customer-focused and effective infrastructure at
SAMHSA;
Focus areas: Valuing our most critical asset--people: Change the size,
scope, and distribution of the workforce of SAMHSA;
Anticipate competency needs and strategically close competency gaps
where needed;
Continue to enhance a systematic approach to recruiting skilled talent
in a tight labor market;
Continue to enhance a systematic approach to retaining existing
expertise;
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.
Source: GAO analysis of SAMHSA's Strategic Workforce Plan 2001-2005.
[End of table]
[End of section]
Appendix III: Comments from the Department of Health and Human
Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Substance Abuse and Mental Health Services Administration:
Center for Mental Health Services:
Center for Substance Abuse Prevention:
Center for Substance Abuse Treatment:
Rockville MD 20857:
MAY 14 2004:
Ms. Leslie G. Aronovitz:
Director, Health Care - Program Administration and Integrity Issues:
General Accounting Office:
Washington, D.C. 20548:
Dear Ms. Aronovitz:
Thank you for the opportunity to provide comments on your draft report
entitled SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION:
Planning for Program Changes and Future Workforce Needs is Incomplete
(GAO-04-683).
Overall, we accept the findings of the report. Each of its key findings
and recommendations focuses on an area already identified by the
Substance Abuse and Mental Health Services Administration (SAMHSA) as
needing further action or improvement, and I am pleased to say that
efforts are already well underway to address each of these issues. We
fully endorse the value the report places on strategic planning,
workforce planning, and collaboration with our Federal, State, and
community partners. Our comments below are designed to clarify some of
SAMHSA's accomplishments in these areas.
Strategic Planning:
SAMHSA will continue its active engagement in an ongoing and dynamic
strategic planning process. Our matrix of priorities and cross-cutting
principles is central to this process. The mission, vision, goals, and
objectives resulting from the strategic planning process were contained
in our fiscal year (FY) 2004 and FY 2005 budget submissions, and are
forming the basis for full integration of budget and performance in our
FY 2006 budget submission. Our FY 2004 and FY 2005 budget requests were
organized by strategic goal and matrix priority area. SAMHSA has
approved action plans for some of the matrix priority areas, to guide
program development. The remainder are to be completed and approved by
June 30. Once the action plans are completed, the draft SAMHSA
strategic plan will be updated, and summaries of the action plans will
be appended. The plan will then be disseminated for public comment,
submitted to the Department of Health and Human Services (DHHS) for
clearance, and published. As the DHHS strategic plan was sent to
Congress in early April and is now publicly available, the timing of
its publication no longer affects the schedule for SAMHSA's strategic
plan.
Workforce Planning:
The report recommends that SAMHSA "implement workforce succession
planning," and indicates SAMHSA is not developing a succession plan. To
the contrary, SAMHSA has already begun to address this issue, and we
place a high priority on our development of a succession plan. In FY
2005, 25 percent of SAMHSA staff will be eligible for voluntary
retirement. Despite a moderate attrition rate of 10 percent in FY 2003,
SAMHSA is making preparations for an anticipated increase in this rate
over the coming years. We are reviewing the pool of staff eligible to
retire within the next several years to identify skills and expertise
that could be lost to the organization. These competencies will be
integrated, as appropriate, into the curriculum of our ongoing
management development program. When staff in key positions notify us
of anticipated retirement, we immediately begin recruitment planning.
Staff capabilities and training needs are assessed on an ongoing basis
to guide recruitment plans, and to re-tool our current workforce.
SAMHSA aggressively recruits outstanding scholars and other highly
qualified job candidates, to offset the anticipated retirement trends.
Such recruitment is frequently conducted nationwide.
The report recommends that SAMHSA "ensure the agency's workforce has
the appropriate expertise to implement the performance partnership
grants." We have already taken several steps to address this need.
SAMHSA has identified a number of areas in which the project officers
require further professional development to adequately address their
future responsibilities. Current project officers are being reassigned
to updated position descriptions that reflect the new responsibilities,
and their performance will be assessed on those responsibilities.
Recruitment for new project officers uses the updated position
descriptions, and job candidates are assessed against the new skill set
requirements. A workgroup has been convened to develop prioritized,
individual staff development plans, and to identify and schedule
necessary training for affected staff.
Discretionary grant applications:
The report recommends that SAMHSA "develop a procedure to allow
applicants for discretionary grants to correct administrative errors in
applications and resubmit them." In FY 2004, SAMHSA improved its
procedures to ensure applications are subjected to peer review whenever
possible. Criteria that exclude applications from review are only those
necessary to ensure a fair and competent review, and are similar to the
requirements of other Federal agencies. The criteria include:
programmatic eligibility criteria (such as appropriate licensure);
compliance with application deadlines; legibility; and adherence to
space limitations to ensure an equal playing field. The new procedures
have yielded a substantial increase in the percentage of applications
submitted to peer review. Given the recent implementation of these
improvements, we view the report's recommendation to be premature.
SAMHSA plans to evaluate the success of the changes in FY 2004 before
determining whether additional changes are needed and what they would
be.
Performance Partnership Grants:
The report recommends that SAMHSA "expedite completion of the plan for
the Congress providing information on the performance partnership
grants." SAMHSA will continue on its path to increase accountability in
its block grant and discretionary programs. We have identified seven
domains of client outcomes, in which we anticipate data would be
collected to monitor grant performance. These outcome measures have
been publicized in the proposed FY 2005 applications for both the
mental health and substance abuse block grants, and in the Requests for
Applications for both the Access to Recovery program and the Strategic
Prevention Framework State Incentive Grants. By unifying data
collection efforts in these seven domains, we anticipate reducing
multiple reporting burden on the States and other grantees, and
aggregating data across programs to assess performance. We look forward
to submitting the Report to Congress, and to implementing the changes
necessary to ensure the highest quality of services are provided
through this critical funding source.
Thank you again for the chance to provide clarification on these
issues. If you have any further questions, please feel free to contact
me on 301-443-4795.
Sincerely,
Signed by:
Charles G. Curie, M.A., A.C.S.W.
Administrator:
[End of section]
FOOTNOTES
[1] U.S. Department of Health and Human Services, Mental Health: A
Report of the Surgeon General (Rockville, Md.: 1999).
[2] Substance Abuse and Mental Health Services Administration, Results
from the 2002 National Survey on Drug Use and Health: National Findings
(Rockville, Md.: 2003).
[3] Substance Abuse and Mental Health Services Administration, Report
to Congress on the Prevention and Treatment of Co-Occurring Substance
Abuse Disorders and Mental Disorders (Rockville, Md.: 2002).
[4] Unless otherwise noted, in this report, "states" refers to the 50
states, the territories, and the District of Columbia.
[5] SAMHSA awards block grants to all states and territories and the
District of Columbia; awards are allocated according to statutory
formulas that take into account specific characteristics of each state,
such as population size and the cost of providing services.
[6] Pub. L. No. 106-310, § 3403, 114 Stat. 1101, 1219 (codified at 42
U.S.C. § 300x-59 (2000)).
[7] Pub. L. No. 102-321, 106 Stat. 324 (codified at 42 U.S.C. § 290aa
et seq. (2000)).
[8] The National Survey on Drug Use and Health was formerly called the
National Household Survey on Drug Abuse.
[9] The U.S. Public Health Service Commissioned Corps is one of the
seven Uniformed Services of the United States. The Commissioned Corps
provides a variety of services to help promote the health of the
nation, such as delivering health care services to medically
underserved populations and providing health expertise during national
emergencies.
[10] SAMHSA's program management budget covers the salaries of 486 of
the agency's 504 full-time-equivalent employees. The salaries of the
remaining 48 employees are funded by portions of the substance abuse
and mental health block grants retained by SAMHSA for administrative
purposes.
[11] Five percent of the substance abuse and mental health block grants
is retained at SAMHSA; in fiscal year 2003, this amounted to almost
$110 million, of which SAMHSA used 47 percent for the collection of
national substance abuse data, 39 percent for technical assistance
activities, 12 percent for state data systems, and 2 percent for
program evaluation.
[12] States with an AIDS case rate of greater than 10 per 100,000
population are currently required to spend 2 percent to 5 percent of
their substance abuse block grant allocation on HIV/AIDS-related
substance abuse programs. The specific percentage is related to the
change in the state's block grant allocation since 1990, and, in
practice, all states affected by the requirement are now required to
spend 5 percent. 42 U.S.C. § 300x-24(b)(2), 4(A) and (B) (2000).
[13] 42 U.S.C. § 300x-59 (2000).
[14] The initial review group consists of mental health and substance
abuse experts, primarily from outside the federal government, and
people who have received substance abuse or mental health services.
[15] SAMHSA and the individual centers each have an advisory council
composed of professionals from relevant scientific and health fields
and individuals representing the interests of the public. The councils
were established by the Congress to advise, consult with, and make
recommendations to SAMHSA on substance abuse and mental health issues.
The national advisory councils do not review applications for grants
that are required by the Congress or are less than $100,000.
[16] The Division of Grants Management is within SAMHSA's Office of
Program Services.
[17] Under the Single Audit Act, nonfederal entities that expend
$300,000 ($500,000 for fiscal years ending after December 31, 2003) are
required to obtain an independent audit of all federal awards. The
audit includes a review of internal controls, compliance with laws and
regulations, and costs charged to federal programs. 31 U.S.C. §
7502(a)(1)(A), (3), and (e)(1) - (4) (2000).
[18] 42 U.S.C. § 300x-55(g)(1) (2000).
[19] The Public Health Service Act requires states to maintain state
expenditures for community mental health services and drug abuse
treatment at a level that is not less than the average level of state
expenditures for the previous 2 years. 42 U.S.C. §§ 300x-4(b)(1) and
300x-30(a) (2000).
[20] Prior to the 1992 legislation that created SAMHSA, HHS's Alcohol,
Drug Abuse, and Mental Health Administration was responsible for major
federal substance abuse and mental health activities related to both
services and research. In the 1992 legislation, the Congress
transferred research responsibilities to the National Institutes of
Health, to be carried out by the National Institute on Alcohol Abuse
and Alcoholism, National Institute on Drug Abuse, and National
Institute of Mental Health.
[21] SAMHSA also has partnerships with the Department of Defense,
Department of Homeland Security, Department of Labor, Department of
Transportation, Nuclear Regulatory Commission, Small Business
Administration, Social Security Administration, and Corporation for
National and Community Service.
[22] SAMHSA's previous strategic plan covered the period from May 1996
through fiscal year 2002.
[23] Promoting accountability involves measuring and reporting program
performance; enhancing capacity involves increasing the availability of
substance abuse and mental health services.
[24] SAMHSA officials told us that the priorities are evolving, and the
agency is not precluded from focusing on other emerging areas.
[25] The Government Performance and Results Act requires federal
agencies' strategic plans to include six components: (1) a
comprehensive agency mission statement; (2) agencywide long-term goals
and objectives for all major functions and operations; (3) approaches
(or strategies) to achieve the goals and objectives and the various
resources needed; (4) the relationship between the long-term goals/
objectives and the annual performance goals; (5) an identification of
key factors, external to the agency and beyond its control, that could
significantly affect achievement of the strategic goals; and (6) a
description of how program evaluations were used to establish or revise
strategic goals and a schedule for future program evaluations. 5 U.S.C.
§ 306(a) (2000). HHS is required to comply with the Government
Performance and Results Act, and it is good practice for its component
agencies to follow the same guidelines in developing their strategic
plans.
[26] In addition to developing strategies to address long-term staffing
needs and determine the critical skills and competencies needed to
carry out programs, other important principles of strategic workforce
planning are building the capacity to implement the strategies;
monitoring and evaluating the agency's progress toward achieving its
workforce goals; and involving top management, employees, and other
stakeholders in developing, communicating, and implementing the
strategic workforce plan. For additional information on these
principles, see U.S. General Accounting Office, Human Capital: Key
Principles for Effective Workforce Planning, GAO-04-39 (Washington,
D.C.: Dec. 11, 2003).
[27] See U.S. General Accounting Office, Human Capital: Insights for
U.S. Agencies from Other Countries' Succession Planning and Management
Initiatives, GAO-03-914 (Washington, D.C.: Sept. 15, 2003).
[28] To help create effective work processes, SAMHSA's strategic
workforce plan called for the development of a team to streamline the
process for administering the block grants. As a result, SAMHSA
established a block grant reengineering team to examine the processes,
policies, and procedures that govern the administration of the
Substance Abuse Prevention and Treatment Block Grant. The team
presented its final report to SAMHSA's administrator on September 26,
2003.
[29] SAMHSA has indicated that the training will be either provided or
arranged for by the fall of 2005.
[30] For additional information on key components of strategic
workforce training and development efforts, see U.S. General Accounting
Office, Human Capital: A Guide for Assessing Strategic Training and
Development Efforts in the Federal Government, GAO-04-546G (Washington,
D.C.: March 2004).
[31] The announcements describe the general design of the four types of
grants and provide application instructions. The four types of grants
are: (1) services grants to implement evidence-based approaches, (2)
infrastructure grants to support activities such as coordinating
funding streams and developing performance measures, (3) best practices
planning and implementation grants to help communities test and
evaluate best practices for providing services, and (4) service-to-
science grants to document and evaluate innovative practices.
[32] In fiscal year 2003, 76 percent of SAMHSA's new grants were
awarded in the fourth quarter, with 65 percent awarded in September,
the last month of the fiscal year. A SAMHSA official told us that
grants receiving second and third year funding are usually made earlier
in the fiscal year.
[33] Performance management is a system for setting expectations for
employees and evaluating their performance.
[34] Other key practices are (1) connecting performance expectations to
crosscutting goals; (2) providing and routinely using performance
information to track organizational goals; (3) requiring follow-up
actions, based on performance information, to address organizational
priorities; (4) using competencies to provide a fuller assessment of
performance; (5) linking pay to individual and organizational
performance; (6) making meaningful distinctions in performance; (7)
involving employees and stakeholders to gain ownership of performance
management systems; and (8) maintaining continuity during transitions.
See U.S. General Accounting Office, Results Oriented Cultures: Creating
a Clear Linkage between Individual Performance and Organizational
Success, GAO-03-488 (Washington, D.C.: Mar. 14, 2003).
[35] See GAO-03-488.
[36] In addition to technical competencies, SAMHSA also identified
leadership, management, interpersonal and organizational, and human
resource competencies.
[37] Interagency agreements allow an agency to enter into an
arrangement in which it pays another agency for goods and services it
receives or is paid by another agency for goods and services it
provides. 31 U.S.C. § 1535 (2000).
[38] In contrast, the Collaborative Initiative to Help End Chronic
Homelessness, in which SAMHSA participates with three other federal
agencies, does not use interagency agreements, and grantees had to
complete four separate applications and receive their grant funds from
each agency. The President's fiscal year 2004 and 2005 budgets proposed
a similar grant program involving these four agencies--the Samaritan
Initiative--that would use interagency transfers of funds, but the
Congress has not authorized this initiative.
[39] HHS's Healthy People 2010 is a set of disease prevention and
health promotion objectives. These objectives are arranged into 28
focus areas, including 1 on substance abuse and 1 on mental health and
mental disorders. Using its National Survey on Drug Use and Health,
SAMHSA is responsible for reporting baseline data and data measuring
progress toward the 2010 targets.
[40] The Science to Service initiative is a collaboration among
SAMHSA's three centers and the National Institutes of Health's National
Institute of Mental Health, National Institute on Alcohol Abuse and
Alcoholism, and National Institute on Drug Abuse.
[41] SAMHSA also coordinates with the National Institutes of Health to
disseminate effective substance abuse treatment practices identified by
National Institutes of Health researchers through SAMHSA's 14 regional
addiction technology transfer centers.
[42] SAMHSA's National Registry of Effective Programs and Practices
provides a list of programs that have met SAMHSA's criteria for
effectiveness and are ready to be disseminated as model programs. The
Department of Education's Safe and Drug-Free Schools program also has a
list of best practices, some of which are part of SAMHSA's National
Registry of Effective Programs and Practices.
[43] We interviewed officials from five state mental health agencies,
five state substance abuse agencies, and four community-based
organizations.
[44] In fiscal year 2003, SAMHSA rejected applications without review
if the applications did not meet specific format requirements, such as
font or margin specifications or page limitations; were received after
the due date; did not contain required documentation; did not respond
to the grant's guidelines and review criteria; or had excessive funding
requests.
[45] SAMHSA officials told us that of the 1,661 applications that were
reviewed for merit, 300 were awarded grants. SAMHSA was unable to
provide data on the number of applications rejected without review for
fiscal year 2003 applications received through January 3, 2003, or for
applications received in previous years.
[46] 69 Fed. Reg. 10,254 (Mar. 4, 2004).
[47] SAMHSA will require that the total area of the project narrative
(excluding margins, but including charts, tables, graphs, and
footnotes) not exceed 58.5 square inches--the total area available on
the page--multiplied by the page limit reported in the grant
announcement.
[48] A SAMHSA official told us that as of April 29, 2004, SAMHSA had
screened 100 fiscal year 2004 applications and rejected 11 for
administrative reasons.
[49] HHS released a grant application manual--HHS Awarding Agency
Grants Administration Manual--on October 1, 2003; section 2.04.104C-8
requires SAMHSA and other HHS agencies to notify applicants within 30
days if their grant application has been rejected.
[50] The Center for Mental Health Services does not use a Web-based
application, but it has created tables that enable states to enter
performance data for the mental health block grant online.
[51] SAMHSA may contract with a mental health or substance abuse expert
to provide technical assistance targeted to a state's specific needs.
[52] In addition, officials from one state told us that the technical
assistance they received from SAMHSA did not meet their needs and an
official from a second state told us that he had not requested or
received any technical assistance from SAMHSA within the past year.
[53] SAMHSA officials told us that they are working with the states to
measure and report on the following outcomes: (1) abstinence from
alcohol abuse or drug use and decreased symptoms of mental illness, (2)
increased or retained employment and school enrollment, (3) decreased
involvement with the criminal justice system, (4) increased stability
in family and living conditions, (5) increased access to services, (6)
increased retention in substance abuse treatment and reduced
utilization of psychiatric inpatient beds, (7) increased social
supports and social connectedness, (8) client perception of care, (9)
cost effectiveness, and (10) use of evidence-based practices. The
outcomes will also be the basis for performance data that SAMHSA
requires for other grants it awards to states.
[54] The Center for Mental Health Services awarded grants of about
$100,000 to mental health agencies in 49 states and the District of
Columbia; Ohio and Micronesia did not receive funds and the other
territories received $50,000 each. The Center for Substance Abuse
Treatment awarded $100,000 grants to the substance abuse agencies in 32
states, the District of Columbia, and Puerto Rico; the U.S. Virgin
Islands received $50,000.
[55] Fiscal year 2002 was the most recent year for which this
information was available.
[56] The Center for Substance Abuse Prevention's largest discretionary
grant program is the Targeted Capacity Expansion: Substance Abuse
Prevention and HIV Prevention in Minority Communities Initiative,
which, like the Targeted Capacity Expansion: HIV Program, falls within
SAMHSA's HIV/AIDS and hepatitis priority issue.
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Web site: www.gao.gov/fraudnet/fraudnet.htm E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director, NelliganJ@gao.gov (202) 512-4800 U.S.
General Accounting Office, 441 G Street NW, Room 7149 Washington, D.C.
20548:
