Catastrophic Disasters
Federal Efforts Help States Prepare for and Respond to Psychological Consequences, but FEMA's Crisis Counseling Program Needs Improvements Gao ID: GAO-08-22 February 29, 2008Catastrophic disasters, such as Hurricane Katrina, may result in trauma and other psychological consequences for the people who experience them. The federal government provides states with funding and other support to help them prepare for and respond to disasters. Because of congressional interest in these issues, GAO examined (1) federal agencies' actions to help states prepare for the psychological consequences of catastrophic disasters and (2) states' experiences obtaining and using grants from the Crisis Counseling Assistance and Training Program (CCP) to respond to the psychological consequences of catastrophic disasters. CCP is a program of the Department of Homeland Security's (DHS) Federal Emergency Management Agency (FEMA). GAO reviewed documents and interviewed program officials from federal agencies and conducted additional work in six states with experience responding to catastrophic disasters: Florida, Louisiana, Mississippi, New York, Texas, and Washington.
Federal agencies have awarded grants and conducted other activities to help states prepare for the psychological consequences of catastrophic and other disasters. For example, in fiscal years 2003 and 2004, the Department of Health and Human Services' (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA) provided grants to mental health and substance abuse agencies in 35 states for disaster planning. In 2007, SAMHSA completed an assessment of mental health and substance abuse disaster plans developed by states that received a preparedness grant. SAMHSA found that, for the 34 states with plans available for review, these plans generally showed improvement over those that had been submitted by states as part of their application for its preparedness grant. The agency also identified several ways in which the plans could be improved. For example, about half the plans did not indicate specific planning and response actions that substance abuse agencies should take. Similarly, GAO's review of the plans available from six states found varying attention among the plans to covering substance abuse issues. SAMHSA officials said the agency is exploring methods of determining states' individual technical assistance needs. Other federal agencies--the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and DHS--have provided broader preparedness funding that states may use for mental health or substance abuse preparedness, but these agencies' data-reporting requirements do not produce information on the extent to which states used funds for this purpose. States in GAO's review experienced difficulties in applying for CCP funding and implementing their programs following catastrophic disasters. CCP, a key federal postdisaster response grant program to help states deliver crisis counseling services, is administered by FEMA in collaboration with SAMHSA. State officials said they had difficulty collecting information needed for their CCP applications and experienced lengthy application reviews. FEMA and SAMHSA officials said they have taken steps to improve the application submission and review process. State officials also said they experienced problems implementing their CCPs. For example, they said that FEMA's policy of not reimbursing states and their CCP service providers for indirect costs, such as certain administrative expenses, led to problems recruiting and retaining service providers. Other FEMA postdisaster response grant programs allow reimbursement for indirect costs. A FEMA official said the agency had been considering since 2006 whether to allow indirect cost reimbursement under CCP but did not know when a decision would be made. States also cited difficulties assisting people who needed more intensive crisis counseling services than those traditionally provided through state CCPs. FEMA and SAMHSA officials said they plan to consider options for adding other types of crisis counseling services to CCP, based in part on states' experiences with CCP pilot programs offering expanded crisis counseling services. The officials did not know when they would complete their review and reach a decision.
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Director: Team: Phone:GAO-08-22, Catastrophic Disasters: Federal Efforts Help States Prepare for and Respond to Psychological Consequences, but FEMA's Crisis Counseling Program Needs Improvements
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
February 2008:
Catastrophic Disasters:
Federal Efforts Help States Prepare for and Respond to Psychological
Consequences, but FEMA's Crisis Counseling Program Needs Improvements:
GAO-08-22:
GAO Highlights:
Highlights of GAO-08-22, a report to congressional requesters.
Why GAO Did This Study:
Catastrophic disasters, such as Hurricane Katrina, may result in trauma
and other psychological consequences for the people who experience
them. The federal government provides states with funding and other
support to help them prepare for and respond to disasters. Because of
congressional interest in these issues, GAO examined (1) federal
agencies‘ actions to help states prepare for the psychological
consequences of catastrophic disasters and
(2) states‘ experiences obtaining and using grants from the Crisis
Counseling Assistance and Training Program (CCP) to respond to the
psychological consequences of catastrophic disasters. CCP is a program
of the Department of Homeland Security‘s (DHS) Federal Emergency
Management Agency (FEMA). GAO reviewed documents and interviewed
program officials from federal agencies and conducted additional work
in six states with experience responding to catastrophic disasters:
Florida, Louisiana, Mississippi, New York, Texas, and Washington.
What GAO Found:
Federal agencies have awarded grants and conducted other activities to
help states prepare for the psychological consequences of catastrophic
and other disasters. For example, in fiscal years 2003 and 2004, the
Department of Health and Human Services‘ (HHS) Substance Abuse and
Mental Health Services Administration (SAMHSA) provided grants to
mental health and substance abuse agencies in 35 states for disaster
planning. In 2007, SAMHSA completed an assessment of mental health and
substance abuse disaster plans developed by states that received a
preparedness grant. SAMHSA found that, for the 34 states with plans
available for review, these plans generally showed improvement over
those that had been submitted by states as part of their application
for its preparedness grant. The agency also identified several ways in
which the plans could be improved. For example, about half the plans
did not indicate specific planning and response actions that substance
abuse agencies should take. Similarly, GAO‘s review of the plans
available from six states found varying attention among the plans to
covering substance abuse issues. SAMHSA officials said the agency is
exploring methods of determining states‘ individual technical
assistance needs. Other federal agencies”the Centers for Disease
Control and Prevention, the Health Resources and Services
Administration, and DHS”have provided broader preparedness funding that
states may use for mental health or substance abuse preparedness, but
these agencies‘ data-reporting requirements do not produce information
on the extent to which states used funds for this purpose.
States in GAO‘s review experienced difficulties in applying for CCP
funding and implementing their programs following catastrophic
disasters. CCP, a key federal postdisaster response grant program to
help states deliver crisis counseling services, is administered by FEMA
in collaboration with SAMHSA. State officials said they had difficulty
collecting information needed for their CCP applications and
experienced lengthy application reviews. FEMA and SAMHSA officials said
they have taken steps to improve the application submission and review
process. State officials also said they experienced problems
implementing their CCPs. For example, they said that FEMA‘s policy of
not reimbursing states and their CCP service providers for indirect
costs, such as certain administrative expenses, led to problems
recruiting and retaining service providers. Other FEMA postdisaster
response grant programs allow reimbursement for indirect costs. A FEMA
official said the agency had been considering since 2006 whether to
allow indirect cost reimbursement under CCP but did not know when a
decision would be made. States also cited difficulties assisting people
who needed more intensive crisis counseling services than those
traditionally provided through state CCPs. FEMA and SAMHSA officials
said they plan to consider options for adding other types of crisis
counseling services to CCP, based in part on states‘ experiences with
CCP pilot programs offering expanded crisis counseling services. The
officials did not know when they would complete their review and reach
a decision.
What GAO Recommends:
GAO recommends that DHS, in consultation with HHS, expeditiously (1)
revise CCP policy to allow reimbursement for indirect costs and (2)
determine what types of expanded crisis counseling services should be
incorporated into CCP. DHS and HHS generally concurred with these
recommendations, but did not indicate when they would complete these
activities.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-08-22]. For more information, contact
Cynthia A. Bascetta at (202) 512-7114 or bascettac@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Federal Agencies Have Awarded Grants to States to Support Preparation
for Psychological Consequences of Catastrophic Disasters, and SAMHSA
Has Assessed States' Disaster Plans:
States Experienced Several Difficulties in Applying for and
Implementing Their CCPs Following Catastrophic Disasters:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: Additional Federal Programs Used to Respond to
Psychological Consequences of Catastrophic Disasters:
Appendix III: Comments from the Department of Homeland Security:
Appendix IV: Comments from the Department of Health and Human Services:
Appendix V: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Number of Days for States' ISP and RSP Application Submission
and Federal Review for Selected Catastrophic Disasters:
Table 2: Amount of Claims for Deficit Reduction Act Funds Submitted by
Selected States to Serve People Affected by Hurricane Katrina, as of
June 27, 2007:
Abbreviations:
ASPR: Assistant Secretary for Preparedness and Response:
CCP: Crisis Counseling Assistance and Training Program:
CDC: Centers for Disease Control and Prevention:
CMS: Centers for Medicare & Medicaid Services:
DHS: Department of Homeland Security:
FDNY: New York City Fire Department:
FEMA: Federal Emergency Management Agency:
HHS: Department of Health and Human Services:
HRSA: Health Resources and Services Administration:
ISP: Immediate Services Program:
MBES: Medicaid Budget and Expenditure System:
NCPTSD: National Center for PTSD:
Project SERV: Project School Emergency Response to Violence:
PTSD: posttraumatic stress disorder:
RSP: Regular Services Program:
SAMHSA: Substance Abuse and Mental Health Services Administration:
SCHIP: State Children's Health Insurance Program:
SERG: SAMHSA Emergency Response Grant:
VA: Department of Veterans Affairs:
WTC: World Trade Center:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
February 29, 2008:
Congressional Requesters:
Hundreds of thousands of people nationwide have been exposed to
psychological trauma resulting from catastrophic disasters, such as the
terrorist attacks of September 11, 2001, and Hurricane Katrina in
August 2005.[Footnote 1] Traumatic experiences such as losing a loved
one, losing one's home, or witnessing disturbing scenes can affect the
residents, responders, and others involved in a catastrophic disaster
and its aftermath. These experiences have led to a variety of
psychological consequences, including depression, posttraumatic stress
disorder (PTSD),[Footnote 2] and increased use or abuse of tobacco or
alcohol. In addition, catastrophic disasters can affect a community's
ability to deliver mental health and substance abuse services. For
example, hospitals had problems meeting the demand for inpatient
psychiatric care after Hurricane Katrina because of disruption to the
health care infrastructure.[Footnote 3]
Effectively delivering mental health and substance abuse services to
address psychological consequences related to catastrophic and other
disasters requires that both predisaster preparedness efforts and
postdisaster response[Footnote 4] efforts be well planned and
coordinated among the multiple jurisdictions, agencies, and
nongovernmental organizations involved. In the aftermath of the
September 11 attacks, the Institute of Medicine reported that there
were gaps in the preparedness of the nation's mental health, public
health, medical, and emergency response systems to meet the
psychological needs that result from terrorism.[Footnote 5] It noted,
for example, that government agencies and service providers were not
well coordinated and mental health providers often did not have
disaster training.
For predisaster preparedness, the Department of Homeland Security (DHS)
is responsible for coordinating with federal, state,[Footnote 6] and
local agencies to develop plans, procedures, training, and other
activities. In coordination with DHS, the Department of Health and
Human Services (HHS) is responsible for helping the nation develop
public health--including mental health and substance abuse--systems
that are prepared to meet the surge in medical needs that may occur
following disasters. Within HHS the Substance Abuse and Mental Health
Services Administration (SAMHSA) helps integrate mental health and
substance abuse services into these federal efforts. Federal agencies
may carry out these responsibilities through a variety of efforts,
including the following activities: the provision of grants to states
for preparedness efforts,[Footnote 7] development of training and
guidance related to preparedness, assessment of state activities, and
development of plans for utilizing federal staff and medical supplies
to assist states.
For postdisaster response, DHS and HHS efforts may include providing
states with funding to assist their response to the psychological
consequences of the disaster. The primary long-standing federal
postdisaster grant program for helping states respond to short-term
crisis counseling needs following disasters is the Crisis Counseling
Assistance and Training Program (CCP),[Footnote 8] which is
administered by DHS's Federal Emergency Management Agency (FEMA) and
its federal partner, SAMHSA.[Footnote 9] A state's application for CCP
funds must demonstrate that the need for crisis counseling in the
affected area is beyond the capacity of state and local resources. If
awarded funds, states typically contract with community organizations
to provide the crisis counseling services, including outreach and
public education, individual and group counseling, and referral for
other services. We and others have reported on difficulties with CCP.
In 2005, for example, we reported that following the September 2001
attack on the World Trade Center (WTC), limited financial oversight of
New York's CCP by FEMA and SAMHSA made it difficult to determine
whether program funds were being used efficiently and effectively to
help alleviate psychological distress.[Footnote 10] In addition, other
federal agencies have reported on difficulties that states have
experienced implementing their CCPs.[Footnote 11]
Because of your interest in ensuring that our nation is prepared to
respond effectively to the psychological consequences of catastrophic
disasters, we examined the following questions: (1) What actions have
federal agencies taken to help states prepare for the psychological
consequences of catastrophic disasters? (2) What have been the states'
experiences in obtaining and using CCP grants to respond to the
psychological consequences of catastrophic disasters?
In general, to address our objectives, we obtained program documents
from federal agencies involved in disaster preparedness and response
activities--including DHS and HHS. We also interviewed officials from
these agencies, academic institutions, and national organizations that
focus on mental health, substance abuse, and emergency management. We
conducted additional work in six judgmentally selected states. We
included New York, Florida, Louisiana, and Mississippi because they
were directly affected by one of three catastrophic disasters that we
included in our scope: the WTC attack in 2001, Hurricane Charley in
2004, and Hurricane Katrina in 2005. We included Texas because it
hosted a large number of people displaced by Hurricane Katrina, and we
included Washington because it both hosted people displaced by
Hurricane Katrina and has features that make it vulnerable to natural
and man-made disasters, such as large ports. Results from this
nongeneralizable sample of states cannot be used to make inferences
about other states.
To examine actions by federal agencies to help states prepare for the
psychological consequences of catastrophic disasters, we identified
federal grants awarded and other activities that occurred during fiscal
year 2002 through fiscal year 2006 to help states prepare for the
psychological consequences of disasters. We also reviewed mental health
and substance abuse disaster plans from the six states in our review
and interviewed officials from these agencies. To examine states'
experiences in obtaining and using CCP grants to respond to the
psychological consequences of catastrophic disasters, we interviewed
mental health officials from the six states in our review concerning
their experiences in applying for CCP funding and implementing their
programs. We also reviewed CCP grant applications or other relevant
documentation submitted by the six states in our review. In addition,
we interviewed officials from FEMA and SAMHSA to obtain their
perspectives on the states' applications and the states' experiences
implementing programs using CCP funds. We also reviewed reports by GAO
and other entities and pertinent legislation. (For additional
information on our methodology, see app. I.) We conducted our work from
March 2006 through February 2008 in accordance with generally accepted
government auditing standards. Those standards require that we plan and
perform the audit to obtain sufficient, appropriate evidence to provide
a reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Results in Brief:
Federal agencies have awarded grants to help states prepare for the
psychological consequences of catastrophic and other disasters, and
SAMHSA has conducted an assessment of state mental health and substance
abuse disaster plans. In fiscal years 2003 and 2004, SAMHSA provided
preparedness grants to mental health and substance abuse agencies in 35
states for disaster planning. In addition, HHS's Centers for Disease
Control and Prevention (CDC), HHS's Health Resources and Services
Administration (HRSA), and DHS have also provided preparedness funding
that states may use for mental health or substance abuse preparedness,
but the agencies' data-reporting requirements do not produce
information on the extent to which states used funds for this purpose.
We found that, according to state officials, five of the six states in
our review used CDC or HRSA preparedness funds to support mental health
and substance abuse agencies at least once during fiscal years 2002
through 2006. In 2007, SAMHSA completed an assessment of mental health
and substance abuse disaster plans developed by states that received a
SAMHSA preparedness grant. The agency found that, for the 34 states
with plans available for review, these plans generally showed
improvement over those that had been submitted by states as part of
their application for SAMHSA's preparedness grant. The agency also
identified several ways in which the plans could be improved. For
example, about half the plans did not indicate specific planning and
response actions that substance abuse agencies should take. Similarly,
our review of plans available from the six states in our review found
varying attention among the plans to covering substance abuse issues.
SAMHSA officials told us that the agency was exploring methods of
determining states' individual technical assistance needs. HHS is also
taking steps to be better prepared to send federal resources to help
states address the psychological consequences of a catastrophic
disaster. For example, HHS is increasing its capacity to deploy teams
of trained providers who can provide mental health services following a
catastrophic disaster.
Officials from the six states in our review told us they experienced
difficulties in applying for CCP funding and implementing their
programs, particularly in response to catastrophic disasters. They
reported difficulty collecting information needed for their
applications, in part because the application guidance did not provide
sufficient detail. In addition, states sometimes experienced lengthy
application reviews by FEMA and SAMHSA after catastrophic disasters,
which contributed to delays in executing contracts with service
providers. FEMA and SAMHSA officials told us they had taken steps to
improve the application submission and review process. State officials
also identified problems in implementing CCPs after catastrophic
disasters. For example, they said that FEMA's policy of not reimbursing
states and service providers for indirect program costs, such as
certain administrative expenses, made it difficult for state CCPs to
recruit and retain providers. Other FEMA postdisaster response grant
programs allow reimbursement for indirect costs. A FEMA official told
us that the agency had been considering whether to allow reimbursement
for indirect costs under CCP since June 2006 but did not know when a
decision would be made. Including indirect costs in CCP and not
requiring service providers to absorb these costs could expand the pool
of providers willing to participate in this program, which could
strengthen states' ability to assist disaster victims in coping with
the psychological consequences of catastrophic disasters. State
officials also cited difficulties assisting people who could benefit
from expanded services, such as more intensive crisis counseling
services than those traditionally provided through state CCPs. FEMA and
SAMHSA officials told us they planned to examine whether certain
expanded services should be incorporated into CCP. These officials did
not know when they would complete their review. Promptly determining
what types of expanded crisis counseling services should become a
permanent part of CCP would enable states to more effectively develop
their CCP proposals and more effectively provide their populations with
needed crisis counseling services.
To improve the federal government's ability to help states respond to
the psychological consequences of catastrophic disasters, we are
recommending that the Secretary of Homeland Security direct the
Administrator of FEMA, in consultation with the Administrator of
SAMHSA, to expeditiously take the following two actions: (1) revise CCP
policy to allow states and service providers that receive CCP funds to
use them for indirect costs and (2) determine what types of expanded
crisis counseling services should be formally incorporated into CCP and
make any necessary revisions to program policy. We provided a draft of
this report to DHS and HHS for comment. Both DHS and HHS generally
concurred with both of our recommendations and stated that they had
taken or will take steps toward implementing them. However, they did
not provide specific timelines for completing these actions.
Background:
A catastrophic disaster exposes residents and responders to a variety
of traumatic experiences that put them at risk for adverse
psychological consequences. Preparedness at the federal, state, and
local levels is critical to the nation's ability to provide the
services needed to address these problems during response. In light of
the emergence of threats posed by terrorism and the complex issues
involved in responding to those threats, GAO has identified disaster
preparedness and response as a major challenge for the 21st
century.[Footnote 12]
Psychological Consequences of Catastrophic Disasters:
Research has shown that people who have experienced or witnessed
certain incidents during or after a catastrophic disaster--such as
serious physical injury, destruction of a home, or long-term
displacement from the community--can experience an array of
psychological consequences. For example, studies found that 1 to 2
months after the WTC attack, the rate of probable PTSD was 11.2 percent
among a sample of adults in the New York City metropolitan area,
compared with about 4 percent elsewhere in the United States,[Footnote
13] and Manhattan residents reported increases in smoking, alcohol
consumption, and marijuana use.[Footnote 14] Research has also shown
that psychological effects can persist or emerge months or years after
the event has occurred. For example, a 2006 study on the use of
counseling services by people affected by the WTC attack found that
some people first sought counseling services more than 2 years after
the event.[Footnote 15]
Certain populations may be especially vulnerable to psychological
consequences following a disaster. These include children and survivors
of past traumatic events. Others who may be especially vulnerable
include people who had a preexisting mental illness at the time of a
disaster. Research has also shown that disaster responders may be
especially vulnerable because of the direct and protracted nature of
their exposure to traumatic experiences, extended working hours, and
sleep deprivation. A CDC survey of New Orleans firefighters and police
officers about 2 to 3 months following Hurricane Katrina found that
about one-third of respondents reported symptoms of depression or PTSD,
or both.[Footnote 16]
Psychological responses can also be affected by the characteristics of
the particular disaster and its aftermath. Terrorism differs from
natural disasters in that it can create a general sense of fear in the
population outside the affected area. The Institute of Medicine noted
that although terrorism and other disasters may share important
characteristics, "the malicious intent and unpredictable nature of
terrorism may carry a particularly devastating impact for those
directly and indirectly affected."[Footnote 17] During the recovery
phase of a catastrophic natural disaster, ongoing stress due to the
perceived loss of support associated with large-scale dislocation of
the population can also affect mental health. In an assessment of
health-related needs for residents returning to the New Orleans area 7
weeks after Hurricane Katrina, researchers found that many respondents
had emotional concerns--such as feeling isolated or crowded--and about
half had levels of distress that indicated a possible need for mental
health services.[Footnote 18]
Federal Role in Public Health Preparedness and Response:
The Robert T. Stafford Disaster Relief and Emergency Assistance Act
(Stafford Act)[Footnote 19] is the principal federal statute governing
federal disaster assistance and relief. State and local governments
have the primary responsibility for disaster response, and the Stafford
Act established the process for states to request a presidential
disaster declaration for affected counties in order to obtain
supplemental assistance--such as physical assets, personnel, and
funding--from the federal government when a disaster exceeds state and
local capabilities and resources. The President may make a disaster
declaration for both catastrophic disasters and smaller-scale disasters
that exceed a state's ability to respond.
The Stafford Act and FEMA's regulations contain provisions related to
disaster preparedness. The act encourages each state to have a plan
that stipulates the state's overall responses in the event of an
emergency. FEMA regulations require that, as a condition of receiving
CCP funds to respond to a disaster, states agree to include mental
health disaster planning in their overall plans.[Footnote 20] The
regulations do not require that state mental health and substance abuse
agencies develop their own disaster plans, but such plans are
recommended by SAMHSA as important components of disaster preparedness.
In 2003, SAMHSA issued mental health disaster planning guidance to help
state and local mental health agencies create or revise disaster
plans.[Footnote 21] The agency recommends, for example, that plans
describe the specific responsibilities of state mental health agencies
and other organizations in responding to a disaster and
responsibilities for maintaining and revising a disaster plan. In 2004,
SAMHSA issued guidance recommending that state substance abuse agencies
develop all-hazard substance abuse disaster plans.[Footnote 22] The
guidance recommends, among other things, that these plans include
information on working with other agencies and providers and on
providing medications, such as methadone.[Footnote 23]
DHS created the National Response Plan in December 2004 to provide an
all-discipline, all-hazards approach for the management across
jurisdictions of domestic incidents such as catastrophic natural
disasters and terrorist attacks when federal involvement is necessary.
The National Response Plan details the missions, policies, structures,
and responsibilities of federal agencies for coordinating resource and
programmatic support to states, tribes, and other federal
agencies.[Footnote 24]
DHS has responsibility for coordinating the federal government's
response to disasters, including administering the provisions of the
Stafford Act. FEMA administers funding for disaster relief by
reimbursing federal, state, and local government agencies and certain
nongovernmental organizations for eligible disaster-related
expenditures.[Footnote 25] The National Response Plan also gives FEMA
responsibility to coordinate mass care, housing, and human services,
including coordinating the provision of immediate, short-term
assistance for people dealing with the anxieties, stress, and trauma
associated with a disaster. In addition, HHS is designated as the
primary agency for coordinating public health and hospital emergency
preparedness activities and coordinating the federal government's
public health and medical response.[Footnote 26] Depending on the
circumstances of a disaster, HHS's responsibilities may include
assessing mental health and substance abuse needs, providing disaster
mental health training materials, and providing expertise in long-term
mental health services. Other agencies--including the Departments of
Defense, Justice, Labor, and Veterans Affairs (VA)--support HHS's
preparedness and response efforts.[Footnote 27]
Primary Federal Response Program for Crisis Counseling Services:
For over 30 years, the federal government has used CCP to support
short-term crisis counseling and public education services to help
alleviate the psychological distress caused or aggravated by disasters
for which a presidential disaster declaration has been made.[Footnote
28] FEMA administers CCP in conjunction with SAMHSA, which provides
technical assistance, develops program guidance, and conducts oversight
on behalf of FEMA.
States seeking CCP funding following a presidentially declared disaster
can apply to FEMA for an immediate grant and, if necessary, a longer-
term grant.[Footnote 29] The Immediate Services Program (ISP) grant
funds CCP services for up to 60 days following a disaster declaration,
and states applying for the grant must do so within 14 days of the
declaration. The Regular Services Program (RSP) grant is designed to
help states meet a continuing need for crisis counseling services for
up to an additional 9 months.[Footnote 30] States applying for an RSP
grant must do so within 60 days of a disaster declaration. If a state
decides to apply for an RSP grant, the ISP grant can be extended until
the RSP application is reviewed and a funding decision has been made. A
state's CCP application must demonstrate that the need for crisis
counseling in the affected area is beyond the capacity of state and
local resources. A state must develop its needs assessment by using a
prescribed formula that, among other things, includes the estimated
numbers of deaths, persons injured, and damaged or destroyed homes
attributable to the disaster. This needs assessment is critical for
developing a state's program plan and budget request, which must also
be included in its application. FEMA reviews all ISP and RSP
applications and receives input from SAMHSA, which also reviews the
applications. FEMA has final authority for all funding decisions. Both
ISP and RSP grants are generally managed by state mental health
agencies, which typically contract with community organizations to
provide CCP services.
The CCP model was designed to meet the short-term mental health needs
of people affected by disasters through outreach that involves
education, individual and group counseling, and referral for other
services. The main focus of the model is to help people regain their
predisaster level of functioning by, among other things, providing
emotional support, mitigating additional stress, and providing
referrals to additional resources that may help them recover. CCP
services, which are to be provided anonymously and free of charge, are
primarily delivered through direct contact with disaster survivors in
familiar settings--such as homes, schools, community centers, and
places of religious worship. Services are designed to be delivered by
teams of mental health professionals and paraprofessionals from the
community affected by the disaster. The mental health professionals,
who have prior specialized mental health or counseling training and are
usually licensed by the state, typically coordinate and supervise
paraprofessionals who may not have had previous training as mental
health professionals. Paraprofessionals working as CCP crisis
counselors provide outreach, crisis counseling, and referrals. All
members of the teams are to be trained in the basics of crisis
counseling and CCP. States cannot use CCP funds to provide longer-term
services such as treatment for psychiatric disorders or substance
abuse, office-based therapy, or medications. The state programs are
expected to refer survivors who may need such services to an
appropriate agency or licensed mental health professional.
From fiscal year 2001 through fiscal year 2006, the majority of CCP
grant funding has been used to meet needs following catastrophic
disasters. According to FEMA, during this period, the agency obligated
a total of about $424 million in CCP funds, with about $289 million
(about 68 percent) obligated for states that responded to the three
catastrophic disasters in our review--the WTC attack, Hurricane
Charley, and Hurricane Katrina. According to FEMA, the agency obligated
about $167 million for New York and other states that responded to the
WTC attack;[Footnote 31] about $7 million for Florida to respond to
Hurricane Charley; and about $51 and $23 million in CCP funds for
Louisiana and Mississippi, respectively, to respond to Hurricane
Katrina.[Footnote 32] In addition, FEMA allowed 26 additional states,
commonly called "host states," to apply for CCP funding to assist
people displaced as a result of Hurricane Katrina. According to FEMA,
the agency obligated for these host states a total of about $37
million, ranging from about $13,000 to about $13 million each.[Footnote
33] For example, the agency obligated about $13 million and $129,000
for Texas and Washington, respectively.[Footnote 34]
At SAMHSA's request, VA's National Center for PTSD (NCPTSD) conducted
an evaluation of CCP and provided its report in June 2005.[Footnote 35]
NCPTSD researchers examined state CCPs that were for disasters
occurring from October 1996 through September 2001 and that concluded
by December 2003, which resulted in an examination of programs
implemented by 27 states to respond to 28 disasters. The evaluation
also included case studies of four specific disasters--the bombing of
the Murrah Federal Building in Oklahoma City, Oklahoma, in 1995;
Hurricane Floyd in 1999; the WTC attack in 2001; and the Rhode Island
nightclub fire in 2003. Although NCPTSD's evaluation found that CCP
performed well in certain respects, it identified a number of ways in
which states had difficulties implementing their CCPs, and it indicated
that drawing conclusions about some aspects of the program was
difficult because data were of poor quality and incomplete.
Federal Agencies Have Awarded Grants to States to Support Preparation
for Psychological Consequences of Catastrophic Disasters, and SAMHSA
Has Assessed States' Disaster Plans:
Federal grants have helped states prepare for the psychological
consequences of catastrophic and other disasters, and SAMHSA has
conducted an assessment of disaster plans from many state mental health
and substance abuse agencies. In fiscal years 2003 and 2004, SAMHSA
awarded grants to mental health and substance abuse agencies in 35
states specifically for disaster planning. CDC, HRSA, and DHS have also
provided preparedness funding that states may use for mental health or
substance abuse preparedness, but the agencies' data-reporting
requirements do not produce information on the extent to which states
used funds for this purpose. In 2007, SAMHSA completed an assessment of
mental health and substance abuse disaster plans developed by states
that received its preparedness grant. SAMHSA found that these plans
showed improvements over those that had been submitted by states as
part of their application for the preparedness grant. The agency also
identified several ways in which the plans could be improved. In
addition to assisting states with their preparedness, HHS is taking
steps to be better prepared to send federal resources to help states
respond to the psychological consequences of disasters.
Federal Grants Have Supported States' Mental Health and Substance Abuse
Preparedness for Catastrophic and Other Disasters:
SAMHSA awarded $6.8 million over fiscal years 2003 and 2004
specifically to help state mental health and substance abuse agencies
prepare for the psychological consequences of catastrophic and other
disasters. The agency awarded 35 states;[Footnote 36] the total amount
awarded to each individual state ranged from about $105,000 to about
$200,000.[Footnote 37] Two of the six states in our review, New York
and Texas, received a SAMHSA grant. New York, which already had a
mental health disaster plan, used the funds to develop a plan for its
state substance abuse agency. Texas, which was already developing a
mental health disaster plan, used the grant to help fund a consortium
of state agencies with postdisaster mental health responsibilities--
including mental health, public safety, and victims' services--and to
increase the role of substance abuse providers in preparedness
activities. Mental health officials from one of the four states in our
review that did not apply for a SAMHSA grant told us their agency did
not apply because it was already engaged in planning with the state
public health agency, and officials from the other three states said
they did not apply due to competing demands on their time.
CDC, HRSA, and DHS public health and homeland security preparedness
grant funds can also be used by states to prepare for the psychological
consequences of disasters, and we found examples of states using CDC
and HRSA funds for this purpose. During fiscal years 2002 through 2006,
CDC and HRSA awarded about $6.1 billion in grants to states and
selected urban areas to improve public health and hospital
preparedness,[Footnote 38] and DHS provided about $12.1 billion in
grants to states and localities for broad preparedness
efforts.[Footnote 39] CDC and HRSA require that states document how
they plan to engage in certain mental health and substance abuse
preparedness activities,[Footnote 40] and although there is no
requirement that states spend their DHS grant funds to prepare for the
psychological consequences of disasters, a state may choose to do so.
These grant programs fund broader preparedness efforts, and their data-
reporting requirements do not produce information on the full extent to
which states used funds for mental health and substance abuse
preparedness activities. We found that, according to state officials,
public health agencies in five of the six states in our review--all but
Mississippi--used either CDC or HRSA preparedness funds to support
mental health and substance abuse agencies' activities at least once
during fiscal years 2002 through 2006.[Footnote 41] For example, in
Florida, Texas, and Washington, public health agencies allocated funds
to mental health and substance abuse agencies for the development of a
disaster plan or to pay the salaries of disaster planners. In
Louisiana, the mental health agency received funds to, among other
things, develop criteria for a registry of volunteer mental health
professionals and help mental health and substance abuse treatment
facilities develop disaster plans. Mental health or substance abuse
officials in the six states we reviewed told us their agencies were not
allocated funds from their state's DHS grant during fiscal years 2002
through 2006.
In addition to awarding grants to states, federal agencies have funded
training and developed guidance to enhance states' preparedness for the
psychological consequences of disasters. For example, SAMHSA
established its Disaster Technical Assistance Center[Footnote 42] in
fiscal year 2003 to provide training and technical assistance to state
mental health and substance abuse agencies. SAMHSA also distributes
various guidance documents, such as guidance to help prevent and manage
stress in disaster response workers before, during, and after a
disaster.[Footnote 43] In addition, CDC, HRSA, and DHS fund the
development of training activities that can benefit the preparedness of
states' mental health providers. For example, HRSA officials told us
that the agency's Bioterrorism Training and Curriculum Development
Program awarded a contract in 2006 to an accrediting body for
counseling programs to incorporate mental health disaster preparedness
into its educational standards,[Footnote 44] and CDC's Centers for
Public Health Preparedness Program awarded grants to academic
institutions to develop and assess training on mental health
preparedness and response.
SAMHSA Has Assessed State Mental Health and Substance Abuse Disaster
Plans:
SAMHSA reviewed state mental health and substance abuse plans as part
of its disaster preparedness grant program. In 2007, the agency
completed a review of the disaster plans of 34 of the 35 states that
received a SAMHSA preparedness grant to, among other things, give
SAMHSA aggregated information about states' disaster planning and
technical assistance needs.[Footnote 45] According to SAMHSA, the
mental health and substance abuse disaster plans of these 34 states
showed improvement over the plans the states had submitted in 2002 as
part of their grant applications. Areas SAMHSA identified as showing
improvement included:
* stronger partnership for planning and response among state mental
health and substance abuse services agencies;
* an increased number of unified plans that encompass both mental
health and substance abuse services issues;
* stronger partnerships with key stakeholders such as emergency
management, public health agencies, and voluntary organizations that
are active in disasters; and:
* clearer identification and articulation of the disaster response role
of state mental health and substance abuse agencies.
SAMHSA also identified several ways in which the plans could be
improved. For example, it reported that while most plans indicated that
the state deploys disaster responders to provide mental health and
substance abuse services, about one-third of the plans needed to
provide more detailed information on the training, qualifications, and
safe deployment of these responders. SAMHSA also reported that although
states were more likely to incorporate substance abuse services into
their disaster planning, about half the plans still did not indicate
specific planning and response actions that substance abuse agencies
should take.
In reviewing mental health and substance abuse disaster plans from five
of the six states in our study, we made observations that are
consistent with SAMHSA's findings.[Footnote 46] For example, we found
that the five states' disaster plans varied in their attention to
substance abuse topics. Two states in our review issued separate mental
health and substance abuse plans. Each of the other three states issued
a unified disaster plan to cover both mental health and substance
abuse, but only one of the three plans specifically discussed both
types of services. The other two plans primarily discussed mental
health services and had few specific references to providing substance
abuse services following a disaster. For example, these plans did not
include specific information about providing methadone treatment for
people with a drug abuse disorder following a disaster--information
that was provided in the separate substance abuse plans. In addition,
we found that disaster plans of the states in our review did not always
identify specific actions or responsibilities related to serving the
mental health and substance abuse needs of certain special
populations.[Footnote 47] Three state disaster plans did not identify
specific actions for preparing to work with children, and two plans did
not include provisions for specific cultural minorities.
Mental health and substance abuse officials from the states in our
review told us that they recognized various gaps in their disaster
preparedness. For example, state officials discussed the need to
provide additional training to disaster responders and said they would
like to collaborate more extensively with state health, emergency
management, and education agencies. One observation that state mental
health officials made was that schools could be an important local
resource for providing postdisaster services to children but that
relationships between state mental health agencies and schools are
sometimes not in place prior to a disaster. Officials from several
states described benefits from meeting other states' officials at
SAMHSA's regional training conferences, but told us that resource
limitations or the need to first plan within their own state made it
difficult to continue these relationships.
SAMHSA's report recommended that the agency conduct state-specific
needs assessments to identify individual states' technical assistance
needs for mental health and substance abuse disaster planning. SAMHSA
officials told us that the agency is exploring methods to conduct such
assessments and that the agency would need to determine the
availability of resources for the assessments.
HHS Is Taking Steps to Be Better Prepared to Send Federal Resources to
Help States Address the Psychological Consequences of Disasters:
To help states address the psychological consequences of disasters,
HHS, as the lead federal department for public health and medical
preparedness, is implementing several efforts to be better prepared to
send federal resources to help states. For example, HHS is increasing
the capacity of federal disaster response teams to provide mental
health services to disaster victims and responders. Based on lessons
learned following Hurricane Katrina, the White House Homeland Security
Council recommended that HHS organize, train, and equip medical and
public health professionals in preconfigured and deployable
teams.[Footnote 48] In response, HHS organized U.S. Public Health
Service Commissioned Corps officers[Footnote 49] into several teams--
including five Rapid Deployment Force teams that each include 4 mental
health providers and five Mental Health Teams that each include about
20 mental health providers.[Footnote 50] HHS created team rosters and
sponsored a large-scale training exercise from July 15, 2007, through
August 24, 2007, that allowed the team members, including the mental
health providers, to train together.
HHS also plans to recruit additional mental health providers into the
Commissioned Corps. HHS officials told us that there has been a
shortage of mental health providers in the Commissioned Corps and that
requirements for deployment on short notice made it difficult for
agencies to ensure that team members' regular responsibilities are
fulfilled while the team member is deployed. For fiscal year 2008, HHS
proposed to recruit providers to staff full-time, dedicated Health and
Medical Response Teams.[Footnote 51] Two teams--each with 105 members,
including at least 4 mental health providers--would serve as the
primary responders for the Commissioned Corps and reduce the deployment
burden placed on other officers.
HHS has also taken steps to increase the supply of drugs indicated for
psychological disorders that should be available in the event of a
disaster. Prior to Hurricane Katrina, HHS began developing Federal
Medical Stations to provide mass casualty capability (i.e., equipment,
material, and pharmaceuticals) to augment local health care
infrastructures overwhelmed by a terrorist attack or natural disaster.
These stations included a cache of drugs focused on urgent and
emergency care. Given the large number of evacuees with special medical
needs who required care following the hurricane, HHS revised the cache
in 2006 to increase the types of drugs specifically indicated for
mental health conditions from 20 to 33. For example, HHS increased the
types of antidepressants and antipsychotics and added five new classes
of drugs, including drugs to treat sleep disorders.
States Experienced Several Difficulties in Applying for and
Implementing Their CCPs Following Catastrophic Disasters:
State officials told us they experienced difficulties in applying for
CCP funding and implementing their programs, particularly in the wake
of catastrophic disasters. States had problems collecting information
needed to prepare their ISP applications within FEMA's application
deadline and preparing parts of their ISP and RSP applications,
including estimating the number of people who might need crisis
counseling services. FEMA and SAMHSA officials told us they had taken
steps to revise the applications and supporting guidance to help
address these difficulties. States also experienced lengthy application
reviews, and FEMA and SAMHSA officials said they had taken steps to
improve the submission and review process. In addition, state officials
told us they experienced problems implementing their CCPs, such as
difficulties resulting from FEMA's policy of not reimbursing state CCPs
for indirect program costs. Additional problems that state officials
cited were related to assisting people in need of more intensive
counseling services and making referrals for mental health and
substance abuse treatment. FEMA and SAMHSA are considering options to
address some of these concerns, but they do not know when they will
make these decisions.
States Encountered Difficulties in Preparing CCP Applications, and FEMA
and SAMHSA Officials Cited Efforts to Clarify the Applications and
Provide Training:
Officials in the six states in our review told us they encountered
difficulties as they prepared their CCP applications following the
catastrophic disasters included in our review, including difficulties
in collecting the information required for their ISP applications
within established deadlines.[Footnote 52] Officials said that the
amount of information required for their applications was difficult to
collect because of the scope of the disasters and the necessity for
responding on other fronts, such as ensuring the safety of patients and
personnel at state-run mental health facilities. For example, Texas
officials estimated that the state hosted more than 400,000 Hurricane
Katrina evacuees and that they had to collect information for over 250
counties to estimate how many people might need crisis counseling
services. Furthermore, several state officials said that some of the
information required for the ISP application, such as that on
preliminary damages and the location of people who might need services,
was not always available or reliable immediately following a
catastrophic disaster. According to SAMHSA, because information from
traditional sources was lacking following Hurricane Katrina, states
were allowed to use other sources--such as newspaper reports and
anecdotal evidence--to complete their applications. However, Louisiana
and Mississippi officials told us that obtaining the information
required by SAMHSA to complete the application was difficult and was
sometimes unavailable in the immediate aftermath of the hurricane.
Officials in three states we contacted said that the difficulty of
completing their applications on time was exacerbated because multiple
disasters affected the same jurisdictions in close succession and they
were required to submit a separate application for each one. Louisiana,
for example, had to submit separate ISP applications following
Hurricanes Katrina and Rita, even though the hurricanes affected
overlapping areas and occurred less than 1 month apart.[Footnote 53]
State officials also told us that the CCP application's needs
assessment formula, which they are to use to estimate the number of
people who might need crisis counseling services, created problems in
estimating needs following catastrophic disasters in their states. The
needs assessment formula includes several categories of loss, including
deaths, hospitalizations, homes damaged or destroyed, and disaster-
related unemployment.[Footnote 54] State officials told us that the
formula's loss categories did not capture data that they considered
critical to assessing mental health needs following a catastrophic
disaster, such as estimates of populations at increased risk for
psychological distress, including children and the elderly, or
information on destroyed or damaged community mental health centers.
While states can include such information in a narrative portion of
their application, several state officials told us it was not clear to
them how this narrative information is factored into funding decisions.
NCPTSD's evaluation of CCP for SAMHSA described concerns similar to
those noted by states in our review about the accuracy of the results
produced by using the formula. Moreover, NCPTSD concluded that the
formula could be a contributing factor in discrepancies it found
between states' estimates of people in need and the numbers of people
actually served.[Footnote 55]
Preparing the sections of the application on plans for providing CCP
services and on program budgets also was difficult, according to state
officials. For example, state officials said the application guidance
did not provide sufficient detail to indicate what federal officials
would consider reasonable numbers of supervisors, outreach workers, and
crisis counselors to hire. Several officials also said it was difficult
to use the fiscal guidance to determine what agency officials would
consider a reasonable budget for various CCP activities, such as use of
paid television and radio advertisements for outreach. State officials
said that having more detailed guidance would help them develop better
proposals and minimize the need to revise their applications during the
review process.
Federal program officials told us they have taken steps to address
various difficulties that states experienced in collecting information
and preparing their CCP applications. Agency officials told us that
they recently made changes intended to reduce the amount of information
required in the ISP and RSP applications, modified the needs assessment
formula, and clarified the applications and supporting guidance. For
example, in the revised needs assessment formula the weights assigned
to most of the loss categories have been adjusted for estimating the
number of people who could benefit from CCP services. According to
SAMHSA, the revised ISP and RSP applications were approved in September
2007; the agency made these available to states in November 2007. In
2006, in response to feedback from states regarding difficulties with
the application process, FEMA and SAMHSA revised their 4-day CCP basic
training course for states to increase its focus on preparing CCP
applications. According to a FEMA program official, the course was also
revised in 2007 to reflect recent changes to the applications and
supporting guidance, and FEMA program officials have requested that
FEMA's Emergency Management Institute offer the course annually instead
of every other year. This program official also told us that a Web-
based CCP orientation course was developed and that it is required for
all those who attend the basic training course.
States Experienced Lengthy Application Reviews following Catastrophic
Disasters, and FEMA and SAMHSA Have Taken Steps Intended to Shorten the
Review Process:
State officials told us that FEMA and SAMHSA's CCP application review
process was lengthy after catastrophic disasters, especially for RSP
applications submitted following Hurricane Katrina. A FEMA official
estimated that for CCP applications submitted in 2002 through 2006 it
had generally taken the agencies about 14 days to review and make
funding decisions for ISP applications and about 28 to 70 days to
review and make funding decisions for RSP applications. Our analysis of
CCP applications for the catastrophic disasters in our review showed
that it took FEMA and SAMHSA from 5 to 39 days to review and make
funding decisions for ISP applications and 58 to 286 days to review and
make funding decisions for RSP applications. (See table 1.)
Table 1: Number of Days for States' ISP and RSP Application Submission
and Federal Review for Selected Catastrophic Disasters:
ISP Application: Days from disaster declaration to state submission of
application;
WTC attack, New York: 8;
Hurricane Charley, Florida: 14;
Hurricane Katrina: Louisiana: 14;
Hurricane Katrina: Mississippi: 14;
Hurricane Katrina: Texas: 10[A];
Hurricane Katrina: Washington: 26[A].
ISP Application: Days from state submission of application to
completion of federal review;
WTC attack, New York: 5;
Hurricane Charley, Florida: 5;
Hurricane Katrina: Louisiana: 24;
Hurricane Katrina: Mississippi: 22;
Hurricane Katrina: Texas: 39;
Hurricane Katrina: Washington: 14.
RSP Application: Days from disaster declaration to state submission of
application;
WTC attack, New York: 63[B];
Hurricane Charley, Florida: 59;
Hurricane Katrina: Louisiana: 59;
Hurricane Katrina: Mississippi: 60;
Hurricane Katrina: Texas: 55;
Hurricane Katrina: Washington: [C].
RSP Application: Days from state submission of application to
completion of federal review;
WTC attack, New York: 213;
Hurricane Charley, Florida: 58;
Hurricane Katrina: Louisiana: 286;
Hurricane Katrina: Mississippi: 110;
Hurricane Katrina: Texas: 125;
Hurricane Katrina: Washington: [C].
Source: GAO analysis based on information provided by FEMA, SAMHSA, and
states.
[A] Texas and Washington applied for CCP funding as host states to
serve persons displaced from states directly affected by Hurricane
Katrina. Host states were not required to abide by the standard 14-day
application deadline. Once FEMA determined that 100 or more disaster
survivors had registered with FEMA for federal disaster assistance in a
state, the state was notified that it was eligible to submit an
application for ISP funding and that if the state wanted to apply it
had 10 days from the date of notification to do so.
[B] According to a FEMA official, the agency allowed New York to submit
its RSP application after the 60-day application deadline.
[C] Washington did not apply for RSP funding.
[End of table]
State officials told us that the lengthy reviews and the resulting
delays in obtaining RSP funding created difficulties for their CCPs.
According to state officials, delays in application approval
contributed to delays in executing contracts with service providers,
delays in hiring staff, and problems retaining staff. They told us they
needed to obtain a decision on their RSP application as quickly as
possible so they could better plan and implement their programs.
Federal program officials told us that several factors contributed to
the time it took to review applications following these catastrophic
disasters. These factors included an unanticipated high volume of CCP
applications following Hurricane Katrina. CCP applications submitted by
states that were directly affected by Hurricane Katrina, as well as by
26 states hosting people who had evacuated after Hurricane Katrina,
created unanticipated demands that were well beyond the normal capacity
of their CCP staff to handle.[Footnote 56] FEMA officials told us that
the two agencies typically reviewed an average of 17 new ISP
applications and 13 new RSP applications each year from fiscal year
2002 through 2006, but that they reviewed 31 ISP applications and 20
RSP applications in response to Hurricane Katrina alone. According to
SAMHSA officials, the agency had not planned for the surge of
applications created by FEMA's decision to allow host states to apply
for CCP funding and had no policies in place at the time to enable
SAMHSA's CCP and grants management staff to adapt quickly to the
submission of so many CCP applications within a few weeks. To respond,
some SAMHSA staff had to handle double the number of applications they
usually process, and the agency supplemented its six CCP reviewers by
using six staff from other parts of the agency to help review CCP grant
applications. FEMA hired three temporary staff to assist with the
application review process after Hurricane Katrina. However, a report
prepared for SAMHSA on its response to Hurricane Katrina noted that
some agency staff who assisted with the review of applications did not
have sufficient knowledge of CCP and the grant review process and
therefore required training.[Footnote 57]
SAMHSA and FEMA have taken actions to be prepared for such a surge in
applications in the future. A SAMHSA official told us that the agency
sent five staff from various parts of the agency to the August 2007 4-
day CCP basic training course to help them gain a better understanding
of the CCP application process. In December 2007, the agency hired a
staff person, whose position was funded by FEMA, in its grants
management office to, among other things, assist in the review of CCP
applications and the fiscal monitoring of CCP grants. They expect the
addition of this employee to help to shorten application review times
for RSP grants.
SAMHSA officials told us that the need to obtain further information
from the states also contributed to the length of the reviews following
Hurricane Katrina. In examining various CCP applications submitted by
the states in our study after Hurricane Katrina and related
correspondence, we noted instances in which SAMHSA sent letters to
states informing them that their applications contained errors, were
incomplete, or required clarification for the agency to proceed with
its review. In some instances, the agency made multiple requests to a
state to clarify a specific part of its application. For example,
SAMHSA found that Louisiana did not provide complete information in its
RSP application related to the process the state planned to use to
identify the local service providers with which it would contract--a
process that was different from the one traditionally used to contract
for CCP services. According to federal officials, issues related to
this process resulted in Louisiana not submitting a complete
application until 6 months after its initial application, which in turn
created enormous delays in the application review process.
SAMHSA officials told us that another reason for the need to obtain
additional clarification was that the agency had established a more
stringent CCP application review process in July 2005.[Footnote 58]
According to SAMHSA officials, the revised CCP applications and
guidance should help reduce the need for states to revise their
applications during the review process. In addition, agency officials
told us that the 2007 CCP basic training course for applicants included
information on the application process and on the new review standards.
States Faced Difficulties in Implementing Their CCPs after Catastrophic
Disasters, including Problems Related to Lack of Indirect-Cost
Reimbursement and Need for Expanded Services:
State officials said they faced difficulties in implementing their CCPs
following catastrophic disasters. For example, they told us that FEMA's
policy of not reimbursing states and counseling service providers for
indirect costs[Footnote 59] caused difficulties for state CCPs. They
also described the need for expanded crisis counseling services and
cited additional concerns.
Obtaining Reimbursement for Indirect Costs:
States told us that FEMA's policy of precluding states and their CCP
service providers from obtaining reimbursement for indirect costs has
created difficulties in implementing their programs. Under CCP
guidelines, states and their CCP service providers cannot be reimbursed
for indirect costs related to managing and monitoring their programs
that are not directly itemized in their program budgets. However, state
officials told us that it can be difficult for their agencies and
service providers to determine what proportion of their overall
administrative costs is attributable to CCP activities. In addition,
several state officials also told us that CCP service providers often
have limited capacity in their overall agency budgets to redirect funds
from other services to cover the indirect costs associated with their
CCP work.
State officials told us that the inability to obtain reimbursement for
indirect costs contributed to difficulties in recruiting and retaining
service providers. According to Louisiana officials, for example, that
inability contributed to the decision of one of its largest Hurricane
Katrina CCP contractors providing services in New Orleans to withdraw
from the state's program in 2007. While CCP guidance precluded
reimbursement for indirect costs, the provider decided to request
reimbursement. In a June 2006 letter to the state mental health office,
the provider stated that participating in the state's CCP had created a
financial burden that included moving funds from other services to its
CCP contract. In July 2006, FEMA declined the provider's request to
include indirect costs in its budget, stating that under CCP guidelines
all budget charges must be direct and that the provider should work
with the state to see whether any of these costs could be reclassified
as direct costs in the provider's budget.
Officials in FEMA's grants management office told us that although CCP
policy prohibits reimbursement for indirect costs, they were unaware of
statutory or regulatory prohibitions on the reimbursement of such
costs.[Footnote 60] Furthermore, they told us that other FEMA disaster
response grant programs do allow indirect cost reimbursement. For
example, grantees can be reimbursed for indirect costs under FEMA's
Public Assistance Program[Footnote 61] and Hazard Mitigation Grant
Program.[Footnote 62] Other federal postdisaster response grant
programs also allow grantees to be reimbursed for indirect costs,
including the SAMHSA Emergency Response Grant (SERG) program and the
Department of Education's Project School Emergency Response to Violence
(Project SERV) program.
Concern about the exclusion of indirect costs from CCP reimbursement
has been a long-standing issue. In 1995, FEMA's Inspector General
issued a report on CCP that said that the reimbursement of indirect
costs appeared allowable under applicable federal law and
regulations.[Footnote 63] The Inspector General recommended that FEMA
review its policy on reimbursement for indirect costs.[Footnote 64]
FEMA and SAMHSA officials told us that reimbursement for indirect costs
was a recurring concern for states and service providers and that
states have advocated for a change in this policy. SAMHSA officials
said that allowing indirect cost reimbursement would promote
participation of a broader array of local service providers.
A FEMA official told us that the agency had been considering whether to
develop a new CCP policy to allow reimbursement for such costs.
According to this official, FEMA had been examining this issue since
June 2006, when it received the letter from the Louisiana CCP service
provider. This official also told us that SAMHSA provided
recommendations in March 2007 on potential modifications to CCP
guidance and application materials to allow reimbursement for indirect
costs. According to this official, however, FEMA still needed to
examine various implementation issues, including which types of
indirect costs might be reimbursed and what changes to the application
review process might be needed. As of October 2007, this official did
not know when the agency would make a decision about whether to allow
reimbursement for indirect costs.
Providing Expanded Crisis Counseling Services:
State officials told us that after catastrophic disasters they faced
the challenge of how to assist people who were experiencing more
serious postdisaster distress than traditional CCP services could
resolve. According to New York, Louisiana, and Mississippi officials,
some CCP clients who did not display symptoms suggesting they needed a
referral for mental health or substance abuse treatment nevertheless
could have benefited from more intensive crisis counseling than was
provided in the CCP model. Furthermore, in the case of Hurricane
Katrina, Mississippi officials told us that they wanted to able to
serve as many people as possible within their CCPs because the
devastation resulted in fewer mental health and substance abuse
providers being available to accept referrals for treatment.
To assist these people, officials in New York, Louisiana, and
Mississippi asked FEMA and SAMHSA to allow their state CCPs to offer
expanded types of services after catastrophic disasters in their
states. In response to the states' requests, FEMA and SAMHSA officials
allowed the existing state CCPs to develop pilot programs offering
expanded crisis counseling services consistent with the nonclinical,
short-term focus of the CCP model.[Footnote 65] New York's expanded
services, known as "enhanced services," were offered through the New
York City Fire Department (FDNY) and through community-based providers
for both adults and children. FDNY's services started in September
2002, about 12 months after the WTC attack. The community-based
services started in spring 2003. Provided by mental health
professionals, these expanded services were based on cognitive
behavioral approaches. These services included helping clients
recognize symptoms of postdisaster distress and develop skills to cope
with anxiety, depression, or other symptoms. Individuals referred for
expanded services were offered a series of up to 12 counseling
sessions. New York's community-based expanded services for adults ended
in December 2003; its community-based services for children ended in
December 2004, as did the FDNY's services.
In November 2006, FEMA and SAMHSA allowed Louisiana and Mississippi to
plan for providing expanded crisis counseling services, known as
"specialized crisis counseling services," to supplement CCP services
offered to people affected by Hurricane Katrina. Each state developed
and implemented expanded services based on operating principles
developed by SAMHSA[Footnote 66] and tailored to the needs of its
population. Louisiana and Mississippi began offering their expanded
services in January 2007, about 17 months after the hurricane. In
contrast to New York's series of up to 12 sessions, the expanded
services offered by Louisiana and Mississippi were designed to be
delivered in a single stand-alone session by mental health
professionals, although clients could obtain additional sessions. The
states' CCPs used a standardized assessment and referral process to
determine whether to refer people for expanded services, such as stress
management. Louisiana and Mississippi used providers with prior mental
health training to refer expanded services clients for mental health
and substance abuse treatment services. In addition, the states used
paraprofessionals to link clients with other disaster-related services
and resources, such as financial services, housing, transportation, and
child care. According to a SAMHSA official, Louisiana's CCP is
scheduled to stop providing expanded services to adults and children in
February 2008.[Footnote 67] Mississippi, which focused on providing
expanded services to adults,[Footnote 68] stopped providing services in
April 2007.
Several state officials said that it would be beneficial if the CCP
model could be expanded to include more intensive crisis counseling
services and if states could make these types of services available
sooner. For example, several officials told us that if expanded
services were a permanent part of CCP it would enable states responding
to catastrophic disasters to incorporate expanded services at an
earlier stage in their CCP service plans, training programs, and
budgets. A New York official told us that after the state received
approval for the general concept of expanded services, it took the
state a few additional months to prepare a proposal, obtain federal
approval, and contract with and train the providers. Because the state
did not begin offering expanded services until it started phasing down
its delivery of traditional CCP services, fewer crisis counselors were
available to refer clients from traditional services to expanded
services. NCPTSD's 2005 evaluation of CCP for SAMHSA recommended that,
at least on a trial basis, expanded services should become a well-
integrated part of state CCPs that is implemented relatively early in
state programs.[Footnote 69] NCPTSD also recommended evaluating the
efficacy of such services. FEMA and SAMHSA officials told us that after
completion of Louisiana's program they planned to examine which
elements of Louisiana's, Mississippi's, and New York's expanded
services programs might be beneficial to incorporate into CCP. FEMA and
SAMHSA officials also said that NCPTSD has begun to develop an
additional approach to providing postdisaster counseling services that
they would also like to examine after it has been developed. FEMA and
SAMHSA officials said they also planned to try to determine the most
opportune time to start offering expanded services to disaster
survivors. These officials did not know when the review would be
completed.
Additional CCP Implementation Difficulties:
Officials we interviewed in three of the states in our review expressed
concerns about the ability of state CCPs to appropriately refer people
needing mental health or substance abuse treatment services. Several
state officials said that the paraprofessional crisis counselors who
generally identify people for referral are not always able to properly
identify people who have more serious psychological problems. Officials
said there was a constant need to provide staff with training on CCP
assessment and referral techniques to ensure that they could identify
people who needed a referral. In its evaluation of CCP for SAMHSA,
NCPTSD also reported concerns by states related to the ability of
paraprofessionals to identify people needing a referral.[Footnote 70]
According to SAMHSA, a CCP trainer's toolkit that was completed in
August 2007 includes information on proper techniques for conducting
CCP assessments and referrals. The agency is planning to distribute the
toolkit to states in spring 2008 when it holds a planned training.
Officials we spoke to in all six states in our review told us that
their CCPs were constrained by FEMA's policy of not allowing CCP funds
to be used to provide some case management services. According to CCP
guidance, case management is not typically an allowable program
service.[Footnote 71] Several state officials told us that it would be
beneficial if state CCPs could provide some form of case management
after catastrophic disasters, when many survivors are likely to have
numerous needs and may require additional support to obtain services
necessary for their recovery. State officials said that Hurricane
Katrina highlighted the difficulties that disaster survivors can have
negotiating complex service and support systems. Louisiana officials
said, for example, that many people who experienced extraordinary
levels of stress because of the hurricane had low literacy skills and
clearly needed support to make connections to additional services and
resources. One state official also told us that because the practical
difficulties of meeting needs involving housing can often be a cause of
the emotional distress that CCPs are trying to alleviate, they would
like CCP crisis counselors to be able to more directly help people
connect with disaster-related services to meet these needs.
State officials also told us that it was difficult to identify people
in need of crisis counseling services because FEMA does not give state
CCPs access to specific information on the location of people
registered for federal disaster assistance. NCPTSD's evaluation of CCP
also noted that the unavailability of this information made it
difficult for state CCPs to locate people who might need
services.[Footnote 72] Several state officials told us that FEMA had
provided them with some counts of disaster registrants at the state,
county, or Zip Code levels but that they also needed information on the
specific locations of disaster survivors to conduct effective outreach.
FEMA officials told us that the agency stopped providing information on
the specific location of registrants in the 1990s. They also told us
that it was their understanding that FEMA stopped providing this
information due to concerns about the privacy of registrants.
Conclusions:
The scope and magnitude of catastrophic disasters can result in acute
and sustained psychological trauma that can be debilitating for
extended periods of time. While CCP is a key component of the federal
government's response to the psychological consequences of disasters,
we have identified two important limitations that can affect states'
ability to use CCP to respond to the special circumstances of
catastrophic disasters. First, state officials responding to the WTC
attack and Hurricane Katrina identified the need to provide expanded
crisis counseling services through CCP. FEMA and SAMHSA recognized such
a need when they permitted three state CCPs to expand their programs to
provide more intensive short-term crisis counseling than the CCP model
generally allows. FEMA and SAMHSA officials told us they intended to
consider incorporating certain types of expanded services into CCP.
Promptly determining what types of expanded services should become a
permanent part of CCP would enable states to more effectively develop
their CCP proposals and provide their populations with needed
counseling services in the event of future catastrophic disasters.
Second, FEMA's policy of precluding states and their CCP service
providers from obtaining reimbursement for indirect costs associated
with managing and monitoring their CCPs has made it difficult for
states to effectively administer their CCPs. State officials reported
that the lack of reimbursement for indirect costs made it more
difficult to recruit and retain service providers and contributed to a
major contractor's withdrawal from Louisiana's Hurricane Katrina CCP.
Other FEMA disaster response grant programs allow reimbursement for
such costs. Although FEMA had been examining this issue for over a
year, an agency official did not know when the agency would reach a
decision on whether to revise CCP policy to allow coverage of indirect
costs. Including indirect costs in CCP and not requiring service
providers to absorb these costs could expand the pool of providers
willing to participate in this program. This could strengthen states'
ability to assist disaster victims in coping with the psychological
consequences of catastrophic disasters.
Recommendations for Executive Action:
To address gaps identified by federal and state officials in the
federal government's ability to help states respond to the
psychological consequences of catastrophic disasters, we recommend that
the Secretary of Homeland Security direct the Administrator of FEMA, in
consultation with the Administrator of SAMHSA, to expeditiously take
the following two actions:
* determine what types of expanded crisis counseling services should be
formally incorporated into CCP and make any necessary revisions to
program policy, and:
* revise CCP policy to allow states and service providers that receive
CCP funds to use them for indirect costs.
Agency Comments and Our Evaluation:
We provided a draft of this report to DHS and HHS for comment. Both DHS
and HHS generally concurred with both of our recommendations and stated
that they had taken or will take steps toward implementing them.
However, they did not provide specific timelines for completing these
actions. (DHS's comments are reprinted in app. III; HHS's comments are
reprinted in app. IV).
In response to our recommendation to expeditiously allow reimbursement
for indirect costs within CCP, both departments commented that allowing
reimbursement for such costs will promote broader participation of
local service providers. In its comments, DHS also said that the
inclusion of indirect costs will help expedite the application review
process and that FEMA has been working with SAMHSA to revise CCP policy
to allow reimbursement for indirect costs. HHS stated that the draft
report accurately reflected concerns regarding the exclusion of
indirect costs and that SAMHSA had previously given FEMA a
recommendation supporting a change in this policy. Although DHS and HHS
indicated that they are working on a revision of the policy to allow
reimbursement of such costs, they did not provide a timeline for
completing this activity. As our report notes, FEMA has been examining
this issue since 2006, and it is important to complete this work
expeditiously so that in the event of a future disaster, state CCPs
could be in a better position to attract the participation of a broad
array of service providers.
In response to our recommendation to expeditiously determine what types
of expanded crisis counseling services should be formally incorporated
into CCP, HHS and DHS commented that, as our draft report indicated,
they plan to wait until Louisiana has completed its pilot expanded
services program before making this determination. They said that
because Louisiana had applied for an extension of its CCP, they cannot
provide a timeline for completion of their reviews of expanded services
pilots. We believe, however, that federal program officials already
have a considerable amount of information about these pilots--New York
and Mississippi have completed their programs and Louisiana has been
providing information on an ongoing basis. We believe that it is
important for FEMA and SAMHSA to expeditiously review the experience of
the pilot programs and other relevant information so they can
expeditiously determine which expanded services should be formally
incorporated into CCP. This will help ensure that states responding to
a disaster will be able to provide the appropriate range of CCP
services to assist people who are in need of crisis counseling
services. In addition, HHS commented that SAMHSA has initiated a
workgroup to ensure that the CCP model reflects current best practices.
However, we have learned that, as of January 2008, the workgroup had
not yet begun to conduct its work.
HHS and DHS commented on our discussion of states' reports on
difficulties they had experienced in preparing their CCP applications.
DHS stated that FEMA, in consultation with SAMHSA, took action to
expedite the submission, review, and approval of ISP applications
submitted after Hurricane Katrina, including allowing the use of
shorter applications by states hosting Hurricane Katrina evacuees. We
clarified our discussion of host states' ability to apply for CCP funds
to note that FEMA allowed them to submit an abbreviated ISP
application. DHS also commented that it is not feasible to have one
grant application or one grant for two separate disasters because FEMA
must separately account for and report on funds for specific disasters.
We attempted to obtain further clarification from DHS about why FEMA
separately accounts for funds for each disaster, but DHS did not
provide this information.
In addition, HHS and DHS commented that the draft report's description
of the needs assessment process failed to capture the degree to which
they had provided states flexibility in quantifying survivor needs
after Hurricane Katrina. DHS said that FEMA and SAMHSA did not rely
primarily on damage assessments, as few had been completed. Rather,
FEMA registration numbers, newspaper reports, and anecdotal data were
relied on to estimate need. Our draft report described action taken by
FEMA to help states collect information needed to prepare their ISP
applications after Hurricane Katrina, and we have revised the final
report to make it clear that states were allowed to use other sources
of information.
In commenting on the CCP application review process, HHS and DHS said
that the data in our report showing that it took up to 286 days to
review applications were misleading because only Louisiana's
application took that long to review and the state's proposed use of a
different procedure for identifying the local service providers with
which it would contract caused enormous delays in the review process.
However, the review of New York's RSP after the WTC disaster also took
over 200 days, and the reviews for four of the five states in our study
took longer than FEMA's estimated average review period. The draft
report contained information on several factors that contributed to
longer review times, and we added to the final report information on
Louisiana's proposal to use an alternative procedure and its effect on
the length of the review of Louisiana's RSP application.
HHS also commented on our discussion of states' concerns that lengthy
reviews and resulting delays in obtaining funding created difficulties
for CCPs in executing contracts with service providers and implementing
their programs. HHS said that the report should note that these
challenges were the result of state fiscal and contracting practices
that do not relate to the availability of federal funds. Although state
practices may contribute to delays, extended federal reviews also may
contribute to delays in states' ability to implement their CCPs.
DHS commented on our description of states' discussion of the
importance of case management services for CCP clients and mentioned
the Post-Katrina Emergency Management Reform Act of 2006,[Footnote 73]
which amended the Stafford Act to allow for the provision of case
management services to meet the needs of survivors of major disasters.
These services could include financial assistance to help state or
local government agencies or qualified private organizations to provide
case management services. In its comments, DHS also stated that FEMA
has entered into an interagency agreement with HHS to collaborate
closely on the development and implementation of a case management
program; this agreement is for the development of a pilot program to
determine the best methods of providing case management services. FEMA
provided additional information indicating that its case management
program will coordinate with CCP.
In its comments, HHS made observations about the importance of
recognizing culture and language issues as barriers to effective
responses to catastrophic disasters, incorporating behavioral health
into all grantee planning and response activities, and requiring grant
recipients to report on how funds were used to address the
psychological consequences of a disaster. These are important points,
and we would encourage HHS agencies to consider them in their disaster
preparedness and response programs. HHS noted that HRSA's National
Bioterrorism Hospital Preparedness Program, Emergency System for
Advance Registration of Volunteer Healthcare Professionals, and
Bioterrorism Training and Curriculum Development Program have been
transferred to ASPR; we added this information to the final report
where appropriate. HHS also identified actions it had taken in response
to GAO's May 2005 report on the CCP, including improving the fiscal
monitoring of grants.[Footnote 74] In addition, HHS noted that the
grants management position funded by FEMA that we discussed in our
draft report was filled in December 2007. Our final report reflects
this development.
In its comments, HHS said that instead of referring to 35 states that
received disaster preparedness grants, our report should refer to 34
states and the District of Columbia; the draft report noted that our
use of the word "state" included states, territories, Puerto Rico, and
the District of Columbia. In addition, HHS suggested that we revise the
title of the report by removing the reference to CCP needing
improvements. In light of our findings and recommendations, we believe
the need for expeditious action supports the original title. HHS also
provided technical comments, which we incorporated where appropriate.
We are sending a copy of this report to the Secretaries of Health and
Human Services and Homeland Security. We will make copies available to
others on request. In addition, the report will be available at no
charge on the GAO Web site at [hypertext, http://www.gao.gov].
If you have any questions about this report, please contact me at (202)
512-7114 or bascettac@gao.gov. Contacts for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this
report are listed in appendix V.
Signed by:
Cynthia A. Bascetta:
Director, Health Care:
List of Requesters:
The Honorable Joseph I. Lieberman:
Chairman:
Committee on Homeland Security and Governmental Affairs:
United States Senate:
The Honorable Bennie G. Thompson:
Chairman:
Committee on Homeland Security:
House of Representatives:
The Honorable Mike Michaud:
Chairman:
Subcommittee on Health:
Committee on Veterans' Affairs:
House of Representatives:
The Honorable Carolyn B. Maloney:
House of Representatives:
[End of section]
Appendix I: Scope and Methodology:
To do our work, we obtained program documents and interviewed officials
from the Department of Health and Human Services (HHS), including the
Administration for Children and Families, Centers for Disease Control
and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS),
Health Resources and Services Administration (HRSA), National
Institutes of Health, Office of the Assistant Secretary for
Preparedness and Response,[Footnote 75] and Substance Abuse and Mental
Health Services Administration (SAMHSA); the Department of Education;
the Department of Homeland Security (DHS), including the Federal
Emergency Management Agency (FEMA); the Department of Justice; and the
Department of Veterans Affairs (VA), including the National Center for
Posttraumatic Stress Disorder (NCPTSD). We spoke with researchers from
the National Center for Child Traumatic Stress at the University of
California, Los Angeles, and the National Center for Disaster
Preparedness at Columbia University. We also interviewed officials from
national organizations, including the American Red Cross, National
Alliance on Mental Illness, National Association of State Mental Health
Program Directors, National Association of State Alcohol and Drug Abuse
Directors, and National Emergency Management Association. In addition,
we reviewed relevant literature.
We conducted additional work in six judgmentally selected states that
had experience responding to the psychological consequences of three
catastrophic disasters during fiscal years 2002 through 2006 that we
included in our scope: the World Trade Center (WTC) attack in 2001,
Hurricane Charley in 2004, and Hurricane Katrina in 2005. We included
New York because it responded to the WTC attack;[Footnote 76] Florida
because it responded to Hurricane Charley; and Louisiana and
Mississippi because they responded to Hurricane Katrina. We included
Texas in our review because it hosted a large number of people
displaced by Hurricane Katrina, and we included Washington because it
hosted people displaced by Hurricane Katrina and has features, such as
large ports, that make it vulnerable to natural and man-made disasters.
Results from this nongeneralizable sample of six states cannot be used
to make inferences about other states.
To examine actions by federal agencies to help states prepare for the
psychological consequences of catastrophic disasters, we reviewed key
federal preparedness and response documents--such as the National
Response Plan, the Interim National Preparedness Goal, and FEMA's Guide
for All-Hazard Emergency Operations Planning--and recent reports on the
federal government's response to Hurricane Katrina.[Footnote 77] We
identified federal grant programs and other activities that were
related to disaster preparedness and were funded during fiscal year
2002 through fiscal year 2006 by reviewing relevant documents and
through discussions with federal and state officials. For key HHS and
DHS preparedness grant programs, we reviewed relevant documentation,
such as application guidance, and interviewed federal program
officials. We obtained disaster plans for the mental health and
substance abuse agencies in the six states included in our review and
examined the plans we received. We also interviewed mental health and
substance abuse officials from these six states about their
preparedness activities. In addition, we examined SAMHSA's 2007 report
on mental health and substance abuse disaster plans developed by states
that received its preparedness grant.[Footnote 78]
To examine states' experiences in obtaining and using federal Crisis
Counseling Assistance and Training Program (CCP) grants to respond to
the psychological consequences of catastrophic disasters, we reviewed
program documentation, including the applicable statute, regulations,
guidance, and grantee reports. We also reviewed CCP applications or
other relevant documentation that the six states submitted to FEMA for
declared counties[Footnote 79] in response to one of the three
catastrophic disasters in our review. We reviewed documentation to
obtain information on states' experiences in applying for CCP funding
and on FEMA's and SAMHSA's processes for reviewing applications,
including examining the length of time it took the agencies to review
applications and make funding decisions for the selected catastrophic
disasters. In addition, we interviewed state mental health officials
from the six states to obtain additional information on their
experiences applying for CCP funding and implementing their CCPs
following these three disasters. We interviewed FEMA and SAMHSA
officials to obtain their perspectives on states' applications and
states' experiences implementing their CCPs to respond to catastrophic
disasters and to obtain information pertaining to FEMA's and SAMHSA's
administration of the program. Furthermore, we examined the 2005 report
on CCP prepared for SAMHSA by NCPTSD.[Footnote 80]
To identify other federal programs that have supported mental health
and substance abuse services in response to catastrophic disasters, we
reviewed GAO reports,[Footnote 81] Congressional Research Service
reports,[Footnote 82] the Catalog of Federal Domestic Assistance, and
pertinent legislation and program regulations. We interviewed federal
program officials about these programs and obtained available
information, including grantee applications, award data, and reports,
to determine how the programs were used to respond to mental health or
substance abuse needs following the three catastrophic disasters
included in our review. We present information on the use of various
federal programs to respond to needs following the catastrophic
disasters in our review; the list we present is not exhaustive. To
determine the amount of Deficit Reduction Act of 2005 funds used by the
32 states that had been approved by CMS for demonstration projects
following Hurricane Katrina, we analyzed data in CMS's Medicaid Budget
and Expenditure System (MBES), which includes claims data for health
care services, including inpatient mental health care services. We
analyzed MBES claims data available as of June 27, 2007, for services
provided August 24, 2005, or later to eligible people affected by
Hurricane Katrina. To assess the reliability of the MBES data, we
discussed the database with an agency official and conducted electronic
testing of the data for obvious errors in completeness. States submit
all claims data to the system electronically and must attest to the
completeness and accuracy of the data. These data are preliminary in
nature, in that they are subject to further review by CMS and are
likely to be updated as states continue to submit claims for Deficit
Reduction Act funding. We determined that these data were sufficiently
reliable for the purpose of our report.
We conducted our work from March 2006 through February 2008 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
[End of section]
Appendix II: Additional Federal Programs Used to Respond to
Psychological Consequences of Catastrophic Disasters:
In addition to CCP, federal agencies have used other programs following
catastrophic disasters to help states and localities provide mental
health and substance abuse services to disaster survivors. The
following list presents information on the use of various federal
programs to respond to needs following the catastrophic disasters in
our review; it is not an exhaustive list.
Federal agencies have used established grant programs to help states
respond to the psychological consequences of catastrophic disasters,
some of which are generally intended to be used following smaller-scale
emergencies.
* SAMHSA awarded funds through its Emergency Response Grant (SERG)
program following Hurricane Katrina.[Footnote 83] The agency provided a
total of $900,000 to Alabama, Louisiana, Mississippi, and Texas to help
meet the overwhelming need for assistance. For example, Texas was
awarded $150,000 and helped evacuees in the Houston Astrodome and other
shelters who needed methadone medication because of opiate addiction.
* The Department of Education awarded funds through its Project School
Emergency Response to Violence (Project SERV) program following the
2001 terrorist attacks and Hurricanes Katrina and Rita. The agency
provided about $14 million and $7 million following these respective
disasters to help local education agencies respond by providing
services that could include crisis counseling, mental health
assessments, and referrals.[Footnote 84] For example, following the
2001 terrorist attacks, New York used Project SERV funds to provide
counseling and after-school mental health services.
* The Department of Justice provided funds through its Antiterrorism
and Emergency Assistance Program to help states and localities respond
to victims' mental health needs following mass violence and acts of
terrorism. Following the WTC attack, for example, New York used $5
million of its grant award from the Department of Justice to provide
additional funding to 15 service providers providing crisis counseling
services through the state CCP.
HHS has also temporarily modified or expanded ongoing federal health
care and social service programs to help states provide mental health
and substance abuse services after specific catastrophic disasters.
* CMS allowed states to temporarily cover certain health care costs
associated with catastrophic disasters through Medicaid and the State
Children's Health Insurance Program (SCHIP). For example, following
Hurricane Katrina, the Congress appropriated $2 billion to cover
certain health care costs related to Hurricane Katrina through Medicaid
and SCHIP.[Footnote 85] CMS allowed 32 states that either were directly
affected by the hurricane or had hosted evacuees to temporarily expand
the availability of coverage for certain people affected by the
hurricane.[Footnote 86] CMS allowed states to submit claims for
reimbursement for health care services that were provided August 24,
2005, or later. As of June 27, 2007, these states had submitted claims
to CMS for health care services totaling about $1.7 billion, of which
about $15.7 million was for mental health services provided in
inpatient facilities--such as hospitals, nursing homes, and psychiatric
facilities.[Footnote 87] (See table 2 for information on the amount of
claims submitted by states, including four states that were in our
review.)[Footnote 88]
Table 2: Amount of Claims for Deficit Reduction Act Funds Submitted by
Selected States to Serve People Affected by Hurricane Katrina, as of
June 27, 2007:
State: Florida;
Total claims: $1,232,069;
Claims for mental health services provided in inpatient facilities[A]:
0.
State: Louisiana;
Total claims: $961,645,567;
Claims for mental health services provided in inpatient facilities[A]:
$2,344,421.
State: Mississippi;
Total claims: $491,425,133;
Claims for mental health services provided in inpatient facilities[A]:
$8,812,012.
State: Texas;
Total claims: $12,380,827;
Claims for mental health services provided in inpatient facilities[A]:
$566.
State: Other states;
Total claims: $243,103,398;
Claims for mental health services provided in inpatient facilities[A]:
$4,571,568.
Dollars: State: Total;
Total claims: $1,709,786,994;
Claims for mental health services provided in inpatient facilities[A]:
$15,728,567.
Source: GAO analysis of CMS data.
[A] These amounts do not include claims for mental health services that
states may have reported to CMS within other categories--such as
physician services and outpatient services--for which claims specific
to mental health services could not be identified.
[End of table]
* HHS's Administration for Children and Families awarded $550 million
in supplemental Social Services Block Grant funds following the 2005
Gulf Coast hurricanes to temporarily expand the program to help 50
states and the District of Columbia meet social and health care service
needs.[Footnote 89] The funds could be used for providing case
management and counseling, mental health, and substance abuse services,
including medications. States could also use the funds for the repair,
renovation, or construction of community mental health centers and
other health care facilities damaged by the hurricanes. For example,
Mississippi was awarded about $128 million in supplemental funding and
used about $10 million of the funding in part to restore services to
mental health treatment facilities for adults and children and provide
transportation to mental health services.
Federal agencies also awarded funding outside of these established
programs to help states provide disaster-related mental health and
substance abuse services after specific catastrophic disasters in our
review. Some of these programs focused on specific at-risk groups, such
as disaster responders, while others were established to meet the
mental health needs of broader populations.
* HHS is coordinating federally funded programs for responders to the
WTC disaster--including firefighters, police, other workers or
volunteers, and federal responders--that provide free screening,
monitoring, or treatment services for physical illnesses and
psychological problems related to the disaster.[Footnote 90] We have
previously reported on the progress of these programs.[Footnote 91]
* SAMHSA provided $28 million to nine states most directly affected by
the September 11 attacks to provide various substance abuse and mental
health services for people directly affected by the attacks.[Footnote
92] These services included assessments, individual counseling, group
therapy, specialized substance abuse treatment, and case management.
[End of section]
Appendix III: Comments from the Department of Homeland Security:
U.S. Department of Homeland Security:
Washington, DC 20528:
[hyperlink, http://www.dhs.gov]:
January 24, 2008:
Ms. Cynthia Bascetta:
Director:
Health Care:
U.S. Government Accountability Office:
441 G St, NW:
Washington, DC 20548:
Dear Cynthia Bascetta:
The Department of Homeland Security (DHS) appreciates the opportunity
to review and comment on the Government Accountability Office's (GAO)
draft report GAO-08-22 entitled Catastrophic Disasters: Federal Efforts
Help States Prepare for and Respond to Psychological Consequences, but
FEMA's Crisis Counseling Program Needs Improvements (GAO Job Code
290506).
DHS generally concurs with both recommendations that state "GAO
recommends that FEMA, with the Substance Abuse and Mental Health
Services Administration (SAMSHA), expeditiously (1) revise CCP policy
to allow reimbursement for indirect costs and (2) determine what types
of expanded crisis counseling services should be incorporated into the
CCP."
Inclusion of indirect cost recovery within the Crisis Counseling
Assistance and Training program (CCP) will facilitate an expedited
application review process, as well as, promote participation of a
broader array of local service providers resulting in a more accessible
and effective program. Federal Emergency Management Agency (FEMA) is
working with SAMHSA and internal agency partners to implement this
change to current policy.
In regards to expanding crisis counseling services, an expansion of CCP
services has been piloted in three states affected by catastrophic
disasters: New York, Louisiana and Mississippi. As the draft report
correctly states, a full review of each expanded program is planned in
order to determine which elements of each program should be utilized in
the development of an appropriate, effective and responsible
augmentation to the CCP. The Louisiana pilot program remains open and
has recently requested a program extension to continue the provision of
services. It is not possible for program staff to provide a timeline
for completion of the reviews until program services are completed in
Louisiana.
In an effort to ensure that the CCP model reflects the most up-to-date
and best practices available, FEMA will continue to work with our
partners at SAMHSA, as well as, state, academic, non-profit and
government experts in disaster mental health throughout the country.
Even prior to the GAO report, FEMA staff was working closely with
SAMHSA staff on the revision of CCP policy to allow reimbursement for
indirect costs, as well as reviewing the types of expanded crisis
counseling services to be incorporated within the CCP model. FEMA and
SAMHSA are collaborating through workgroups charged with developing
guidelines to implement these changes.
CCP Implementation Difficulties Encountered By States:
Information Collection:
According to the draft report, state officials indicated that the
"States had problems collecting information needed to prepare their
Immediate Services Crisis Counseling Program (ISP) applications within
FEMA' s application deadline and preparing parts of their ISP and
Regular Services Crisis Counseling Program (RSP) applications." FEMA
recognized that Hurricane Katrina was a catastrophic incident that
called for extraordinary measures and solutions. Victims were
evacuated, or traveled on their own, to at least forty-four states. In
order to address the crisis counseling needs of the people displaced as
a result of Hurricane Katrina, FEMA made the decision to allow "host"
states the opportunity to apply for CCP funds. To expedite the
submission, review and approval of ISP applications for undeclared
counties and states receiving evacuees affected by Hurricane Katrina,
FEMA, in consultation with SAMHSA, developed a simplified ISP
application that states were encouraged to use. In lieu of the
traditional application, the revised format asked for brief, but
informative, information with the recommendation that the application
be no longer than five pages. Application submission expectations were
clearly identified in a guidance document provided as part of the
simplified application.
The description of the needs assessment process fails to capture the
degree to which flexibility was given the states in quantifying
survivor needs. FEMA and SAMHSA reviewers did not rely primarily on
damage assessments, as few had been completed. Rather, FEMA
registration numbers, newspaper reports and anecdotal data were relied
upon to estimate need and to scale initial programs.
According to the draft report, state officials indicated that "problems
were exacerbated because multiple disasters affected the same
jurisdiction in close succession and they were required to submit a
separate application for each one." One program application, or one
grant for two separate disasters, is not feasible as FEMA must account
for and report on disaster specific funds separately. However, when
situations like this occur, staff from FEMA and SAMHSA work closely
with the state to ensure that program implementation for both disasters
is seamless to the disaster victim, planned program efforts are adhered
to and separate program reports are submitted timely and accurately.
Application Review:
The draft report indicates that a state's RSP application is primarily
reviewed by SAMHSA. This statement is incorrect and should be changed.
All ISPs and RSPs are reviewed, in detail, by both FEMA and SAMHSA
program staff.
The report suggests that the application review process, post
catastrophic disaster, can be lengthy; taking up to 286 days prior to a
funding decision. The report indicates that these funding delays
created difficulties for states in "executing contracts with service
providers, delays in hiring staff and problems retaining staff." The
report should clarify that the only application that required 286 days
prior to a funding decision was the application submitted by the State
of Louisiana. Louisiana chose to utilize a Request for Proposal (RFP)
process to determine which providers they would contract with for the
provision of CCP services. Using a RFP process is atypical for the CCP.
The initial grant application submitted by the State was incomplete as
the document simply outlined their plan for the RFP. The completed
grant application was submitted six months later. This caused the
enormous delays in the review and funding of this State's grant
application.
Case Management:
State officials advised the GAO that it "would be beneficial if state
CCPs could provide some form of case management after catastrophic
disasters." It is important to note that as a result of the recognized
need for comprehensive case management services following Hurricane
Katrina, Congress passed the Post Katrina Emergency Management Reform
Act of 2006 allowing for the provision of "case management services,
including financial assistance, to state and local government agencies
or qualified private organizations to provide such services to victims
of major disasters to identify and address unmet needs." FEMA has
entered into an interagency agreement with the U.S. Department of
Health and Human Services to collaborate closely on the development and
implementation of a Case Management Program.
We thank you again for the opportunity to offer comments on this draft
report and look forward to working with you on future homeland security
issues.
Sincerely,
Signed by:
Steven J. Pecinovsky:
Director:
DHS Departmental GAO/OIG Liaison Office:
[End of section]
Appendix IV Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office of the Assistant Secretary for Legislation
Washington, D.C. 20201:
January 15, 2008:
Ms. Cynthia A. Bascetta:
Director, Health Care:
U.S. Government Accountability Office 441 G Street, NW
Washington, DC 20548
Dear Ms. Bascetta:
Enclosed are the Department's comments on the Government Accountability
Office (GAO) draft report on Catastrophic Disasters: Federal Efforts
Help States Prepare for and Respond to Psychological Consequences, but
FEMA's Crisis Counseling Program Needs Improvements (GAO-08-22).
The Department appreciates the opportunity to review and comment on
this draft before its publication.
Sincerely,
Signed by:
Vincent J. Ventimiglia:
Assistant Secretary for Legislation:
General Comments Of The U.S. Department Of Health And Human Services
(HHS) On The U.S. Government Accountability Office's (GAO) Draft
Report: Catastrophic Disasters: Federal Efforts Help States Prepare For
And Respond To Psychological Consequences, But FEMA's Crisis Counseling
Program Needs Improvements (GAO 08-22):
The GAO report contains several references to what was formerly HRSA's
National Bioterrorism Hospital Preparedness Program (NBHPP), the
Emergency System for Advance Registration of Volunteer Healthcare
Professionals, and the Bioterrorism Training and Curriculum Development
Program. However, with the passage of the Pandemic and All-Hazards
Preparedness Act (Public Law 109-417), these programs were transferred
to the Office of the Assistant Secretary for Preparedness and Response
(ASPR). Our specific comments include suggestions for acknowledging
these realignments in the draft report.
With respect to disaster response, health literacy is an important
factor in effective disaster response. However, health literacy was
only mentioned once in the draft report (Page 34) [Now on p. 31] with
respect to a comment made by Louisiana health officials that many
people experienced extraordinary levels of stress due to limited
literacy skills, and these people needed support to make connections to
additional services. GAO's report should also more fully address the
issue of culture and language as barriers to effective responses to
catastrophic disasters. Additionally, implementing post-disaster
response readiness, with practice drills and mock sessions would be
helpful for eliminating future errors in disaster responses.
HHS Response to the Recommendations in the Draft Report:
The draft report recommends that FEMA, with SAMHSA expeditiously:
1. Revise CCP policy to allow reimbursement for indirect costs; and
2. Determine what types of expanded crisis counseling services should
be incorporated into the CCP.
HHS has no objections to these recommendations. The draft report
accurately reflects concerns regarding the exclusion of indirect costs
from allowable CCP expenses, recognizing that allowing indirect cost
reimbursement for such costs will promote broader participation of
local service providers. As mentioned in the report, SAMHSA has
provided a recommendation supporting a change in this policy to FEMA
and FEMA is working toward implementation.
Regarding expansion of crisis counseling services, an expansion of CCP
services has been pilot tested in three States, New York, Louisiana,
and Mississippi. As the report indicates, FEMA and SAMHSA have
indicated that a full review of the three pilots will need to be
conducted to make clinically responsible recommendations for increasing
the types of services provided by the CCP as well as clear guidance on
how to do so. Since one of the pilots has not concluded at this time
and an extension request from this State is under review, it is not
possible for officials to give a timeline for final review and
conclusion.
Moreover, routine inclusion of additional crisis counseling services
should be appropriately considered to ensure optimal, ethical treatment
of disaster survivors and to further ensure that these services can be
provided in a way that does not incur harm. In addition, it should be
noted that SAMHSA has initiated a workgroup whose goal is to ensure
that the CCP model reflects the most up to date and best practices
available. The workgroup is charged with developing a set of strategies
to achieve this goal and will monitor progress through a tracking
chart.
Response to GAO Concerns Regarding FEMA Funded Grants Management
Position:
The FEMA funded Grants Management position referenced in the draft
report was filled in December 2007. In addition to grants management,
this individual will assist Project Officers with fiscal monitoring of
CCP grants. The addition of this employee should contribute to shorter
award times for RSP grants.
HHS Responses to Improvements Made Since May 2005 GAO Report:
It is important to note that several actions were taken in response to
the May 2005 GAO Report. Major improvements have been made in fiscal
monitoring of grants by SAMHSA and FEMA, including the use of
standardized budget tables across all programs, development and
implementation of a budget adjustment request form with close
monitoring procedures, and encouraging States/providers to hire
financial professionals to monitor fiscal activities for large grants.
ISP and RSP applications and supplemental instructions have been
revised, providing much clearer guidance. Revised instructions were
made available to States in November 2007 and can be found on the
SAMHSA website.
Data Collection and evaluation continue to improve. A data collection
toolkit has been developed with the assistance of the National Center
for Post Traumatic Stress Disorder (NCPTSD). The Toolkit includes
standardized data collection forms, surveys, and instructions.
Efforts have been made to elicit feedback from our stakeholders through
a cross site evaluation conducted by NCPTSD. In addition, a lessons-
learned meeting about Katrina, Wilma, and Rita was held in New Orleans
in May 2007 during which grantees provided information and
recommendations about their crisis counseling programs. Throughout the
report, reference is made to 35 States receiving disaster preparedness
grants. To be accurate, the report should refer to 34 States and the
District of Columbia.
Difficulties States Have Encountered Implementing Their CCPs:
On page 24 [Now on p. 23], reference is made to RSP applications taking
up to 286 days to review. This statement is misleading and should be
revised to reflect that the only application that took this long to
complete was the application from the State of Louisiana.
The report should also note that Louisiana made the decision to utilize
a Request for Proposal (RFP) process to determine which providers they
would contract with to provide CCP services and that utilizing this
process is atypical for the CCP and took many months, causing enormous
delays in the review process.
In the discussion of delays in "executing contracts with service
providers" on page 6 [Now n p. 5] it should be noted that the
challenges described are the result of State fiscal and contracting
practices that do not relate to the availability of Federal funds nor
does the Federal government have any influence over these kinds of
State practices.
Page 12 [Now on p. 11] of the draft report gives the impression that a
State's RSP application is primarily reviewed by SAMHSA. This is
incorrect. All ISP's and RSP's are reviewed by both FEMA and SAMHSA,
with FEMA having the final funding approval authority. Also, SAMHSA
plays a more direct role in monitoring the activities of an RSP, once
it is awarded, than it does monitoring an ISP. RSP grants are awarded
through SAMHSA and are assigned a SAMHSA project officer and grants
management specialist. ISP grants are awarded through FEMA and are
monitored by FEMA staff with consultation from SAMHSA staff.
The description of the needs assessment process following Katrina does
not capture the degree to which flexibility was given the States in
quantifying survivor needs. Reviewers did not rely primarily on damage
assessments, as few had been completed. Rather, FEMA registration
numbers, newspaper reports and anecdotal evidence were relied upon to
estimate need and scale initial programs. As more data became
available, it was incorporated into revised ISP and RSP applications.
With regard to CCP budgets, as stated in the draft report, Federal
officials have addressed concerns by extensively revising program
guidance materials.
Overall Comments:
GAO may want to address the limited access State mental health and
substance abuse authorities have to other types of disaster
preparedness and response funding. Many State mental health and
substance abuse officials have commented that most of these kinds of
funds are provided to public health departments which often do not
include behavioral health agencies in their planning and activities to
any significant degree. Clear language and expectations should be
attached to all disaster related funding mandating that recipients
partner with and incorporate behavioral health into all planning and
response activities. Furthermore, funding agencies should require all
recipients of funding to quantify and report on how funds were used to
address the psychological consequences of disaster.
GAO Language (Report Title):
Since many of the items discussed as concerns have been addressed or
are in the process of being addressed, we recommend a revision in the
title to read, "Catastrophic Disasters: Federal Efforts Help States
Prepare for and Respond to The Psychological Consequences of
Disasters."
[End of section]
Appendix V: GAO Contact and Staff Acknowledgments:
GAO Contact:
Cynthia A. Bascetta, (202) 512-7114 or bascettac@gao.gov:
Acknowledgments:
In addition to the contact named above, Helene F. Toiv, Assistant
Director; William Hadley; Alice L. London; and Roseanne Price made
major contributions to this report.
[End of section]
Related GAO Products:
September 11: Problems Remain in Planning for and Providing Health
Screening and Monitoring Services for Responders. GAO-07-1253T.
Washington, D.C.: September 20, 2007.
Homeland Security: Observations on DHS and FEMA Efforts to Prepare for
and Respond to Major and Catastrophic Disasters and Address Related
Recommendations and Legislation. GAO-07-1142T. Washington, D.C.: July
31, 2007.
September 11: HHS Needs to Ensure the Availability of Health Screening
and Monitoring for All Responders. GAO-07-892. Washington, D.C.: July
23, 2007.
Emergency Management: Most School Districts Have Developed Emergency
Management Plans, but Would Benefit from Additional Federal Guidance.
GAO-07-609. Washington, D.C.: June 12, 2007.
Disaster Preparedness: Better Planning Would Improve OSHA's Efforts to
Protect Workers' Safety and Health in Disasters. GAO-07-193.
Washington, D.C.: March 28, 2007.
Public Health and Hospital Emergency Preparedness Programs: Evolution
of Performance Measurement Systems to Measure Progress. GAO-07-485R.
Washington, D.C.: March 23, 2007.
Catastrophic Disasters: Enhanced Leadership, Capabilities, and
Accountability Controls Will Improve the Effectiveness of the Nation's
Preparedness, Response, and Recovery System. GAO-06-618. Washington,
D.C.: September 6, 2006.
Federal Emergency Management Agency: Crisis Counseling Grants Awarded
to the State of New York after the September 11 Terrorist Attacks. GAO-
05-514. Washington, D.C.: May 31, 2005.
Hurricane Katrina: Status of Hospital Inpatient and Emergency
Departments in the Greater New Orleans Area. GAO-06-1003. Washington,
D.C.: September 29, 2006.
Mental Health Services: Effectiveness of Insurance Coverage and Federal
Programs for Children Who Have Experienced Trauma Largely Unknown. GAO-
02-813. Washington, D.C.: August 22, 2002.
[End of section]
Footnotes:
[1] In this report, we consider disasters that are unusually
devastating and require extensive federal support to be catastrophic.
[2] PTSD is an often debilitating and potentially chronic disorder that
can develop after experiencing or witnessing a traumatic event and
includes such symptoms as distressing dreams and intrusive memories.
[3] GAO, Hurricane Katrina: Status of Hospital Inpatient and Emergency
Departments in the Greater New Orleans Area, GAO-06-1003 (Washington,
D.C.: Sept. 29, 2006), 13. A list of additional GAO products related to
mental health and catastrophic disasters is included at the end of this
report.
[4] For the purposes of this report, we are defining response to
include both short-term response after a disaster occurs and long-term
recovery.
[5] Institute of Medicine, Preparing for the Psychological Consequences
of Terrorism: A Public Health Strategy (Washington, D.C., 2003), 1.
[6] For the purposes of this report, "state" includes states,
territories, Puerto Rico, and the District of Columbia.
[7] For the purposes of this report, "grant" includes grants and
cooperative agreements. Cooperative agreements are used when
substantial interaction is expected between the federal agency and the
funding recipient.
[8] In this report, the program administered by the federal government
is referred to as "CCP," and individual programs administered by states
through CCP grants are referred to as "state CCPs."
[9] FEMA administers CCP through an annual interagency agreement with
SAMHSA.
[10] GAO, Federal Emergency Management Agency: Crisis Counseling Grants
Awarded to the State of New York after the September 11 Terrorist
Attacks, GAO-05-514 (Washington, D.C.: May 31, 2005), 29.
[11] See National Center for PTSD, "Retrospective 5-Year Evaluation of
the Crisis Counseling Assistance and Training Program," unpublished
report requested by SAMHSA (White River Junction, Vt., June 2005); and
Congressional Research Service, Gulf Coast Hurricanes: Addressing
Survivors' Mental Health and Substance Abuse Treatment Needs, RL33738
(Washington, D.C., Nov. 29, 2006).
[12] GAO, 21st Century Challenges: Reexamining the Base of the Federal
Government, GAO-05-325SP (Washington, D.C.: February 2005), 39-43.
[13] W.E. Schlenger et al., "Psychological Reactions to Terrorist
Attacks: Findings from the National Study of Americans' Reactions to
September 11," Journal of the American Medical Association, vol. 288,
no. 5 (2002), 581-588.
[14] D. Vlahov et al., "Increased Use of Cigarettes, Alcohol, and
Marijuana among Manhattan, New York, Residents after the September 11th
Terrorist Attacks," American Journal of Epidemiology, vol. 155, no. 11
(2002), 988-996.
[15] N.H. Covell et al., "Use of Project Liberty Counseling Services
over Time by Individuals in Various Risk Categories," Psychiatric
Services, vol. 57, no. 9 (2006), 1268-1270.
[16] CDC, "Health Hazard Evaluation of Police Officers and Firefighters
after Hurricane Katrina--New Orleans, Louisiana, October 17-28 and
November 30-December 5, 2005," Morbidity and Mortality Weekly Report,
vol. 55, no. 16 (2006), 456-458.
[17] Institute of Medicine, Psychological Consequences of Terrorism, 4.
[18] CDC, "Assessment of Health-Related Needs after Hurricanes Katrina
and Rita--Orleans and Jefferson Parishes, New Orleans Area, Louisiana,
October 17-22, 2005," Morbidity and Mortality Weekly Report, vol. 55,
no. 2 (2006), 38-41.
[19] Pub. L. No. 93-288, 88 Stat.143 (1974) (codified as amended at 42
U.S.C. §5121 et seq.)
[20] 44 C.F.R. §206.171(f)(1) and (g)(1)(iv).
[21] See SAMHSA, Mental Health All-Hazards Disaster Planning Guidance
(Rockville, Md., 2003). SAMHSA's mental health disaster planning
guidance is intended to be a companion to the emergency operations
planning guidance published by FEMA in 1996, which recommends that
state and local emergency management organizations have emergency
operations plans that include a health and medical annex with
provisions for responding to the mental health needs of people affected
by disasters.
[22] An all-hazards approach recognizes that some aspects of response
to terrorism, such as providing emergency medical services and managing
mass casualties, can be the same as for response to other emergencies,
such as natural disasters and epidemics.
[23] See SAMHSA, All Hazards Response Planning for State Substance
Abuse Service Systems, July 2004, [hyperlink,
http://www.samhsa.gov/csatdisasterrecovery/toc.htm] (accessed Nov. 6,
2007).
[24] In January 2008, DHS issued a National Response Framework to
supersede the National Response Plan. The framework is effective as of
March 22, 2008.
[25] The Congress appropriates funds for disaster relief on a no-year
basis; that is, they remain available without fiscal year limitation.
[26] Within HHS, the Office of the Assistant Secretary for Preparedness
and Response (ASPR) coordinates and directs the department's emergency
preparedness and response program.
[27] In the National Response Framework, FEMA continues to have
responsibility to coordinate mass care, housing, and human services and
HHS continues to be designated as the primary agency for coordinating
public health and hospital emergency preparedness activities.
[28] See app. II for information on other federal programs that have
been used to help states and localities respond to mental health and
substance abuse needs following catastrophic disasters.
[29] Generally, only states that have received a presidential major
disaster declaration are eligible to request CCP funding. However,
following Hurricane Katrina, FEMA allowed states that did not receive a
presidential major disaster declaration to apply for CCP funding to
assist people who had evacuated from the affected areas to their
jurisdictions.
[30] In some cases, FEMA may extend a state's RSP for an additional 90
days in response to a documented need. In limited circumstances, such
as disasters of a catastrophic nature, FEMA can extend a state's RSP
beyond the additional 90 days.
[31] According to a FEMA official, RSP obligations could not be
provided separately for each state that received CCP funding related to
the WTC attack. The $167 million includes funds that FEMA obligated to
New York as well as Connecticut, Massachusetts, New Jersey, and
Pennsylvania.
[32] As of October 2007, Louisiana was still providing CCP services and
FEMA had obligated about $47.6 million for the state to serve persons
in counties directly affected by Hurricane Katrina, which were covered
by the disaster declaration, and an additional $3.3 million to serve
people in counties not covered by the disaster declaration. FEMA also
obligated about $4 million in CCP funding for Alabama to respond to
Hurricane Katrina.
[33] Fifteen of the host states received both ISP and RSP funding.
[34] According to FEMA, CCP obligation data are as of October 8, 2007.
[35] NCPTSD, Retrospective 5-Year Evaluation of the Crisis Counseling
Program.
[36] SAMHSA awarded grants for disaster planning to the following
states: Alabama, Alaska, California, Colorado, Connecticut, the
District of Columbia, Hawaii, Illinois, Indiana, Iowa, Kentucky, Maine,
Maryland, Massachusetts, Minnesota, Missouri, Nebraska, Nevada, New
Hampshire, New Jersey, New Mexico, New York, North Carolina, Ohio,
Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South
Dakota, Tennessee, Texas, Virginia, West Virginia, and Wisconsin.
[37] State activities funded by these grants were completed by the end
of 2006. SAMHSA has not allocated funds to make any additional
preparedness grants to states.
[38] The grant programs are CDC's Public Health Emergency Preparedness
Program and HRSA's National Bioterrorism Hospital Preparedness Program.
These funds were awarded annually to public health agencies in states
and three urban areas--Chicago, Los Angeles, and New York City. In
March 2007, the National Bioterrorism Hospital Preparedness Program was
transferred from HRSA to ASPR and was renamed the Hospital Preparedness
Program.
[39] In fiscal year 2006, DHS integrated five preparedness grant
programs into the Homeland Security Grant Program.
[40] For example, CDC's program required in fiscal years 2005 and 2006
that states document how they planned to increase the availability of
crisis counseling, mental health, and substance abuse support for
public health responders. In addition, HRSA's program encouraged states
to allocate a portion of their funds to develop registries of volunteer
mental health care providers who could provide services following a
disaster. In middle to late 2006, CDC and HRSA began developing formal
data analysis programs that could be used to generate standardized
reports. GAO, Public Health and Hospital Emergency Preparedness
Programs: Evolution of Performance Measurement Systems to Measure
Progress, GAO-07-485R (Washington, D.C.: Mar. 23, 2007), 15.
[41] According to state officials, from fiscal year 2002 through fiscal
year 2006, state public health agencies allocated CDC and HRSA grant
funds to state mental health agencies as follows: Florida ($140,000),
Louisiana ($500,000), New York ($400,000), Texas ($172,000), and
Washington ($70,000).
[42] The Disaster Technical Assistance Center is operated by
Educational Services, Inc., under contract with SAMHSA.
[43] SAMHSA, A Guide to Managing Stress in Crisis Response Professions
(Rockville, Md., 2005).
[44] The Bioterrorism Training and Curriculum Development Program was
transferred from HRSA to ASPR in March 2007.
[45] SAMHSA did not review one state's disaster plan because it was not
available at the time of SAMHSA's review. SAMHSA, "State Behavioral
Health All-Hazards Disaster Plan Review Report," unpublished report
(Rockville, Md., June 2007).
[46] Of the six states we included in our review of disaster plans, New
York and Texas were also included in SAMHSA's review. We did not review
a disaster plan from Washington. An official from Washington told us
that the state began developing a unified mental health and substance
abuse disaster plan in 2005 and was scheduled to complete that plan by
January 1, 2008.
[47] Experts have observed that some people--including children, those
with preexisting mental illness, disaster response workers, frail
elderly, and cultural minorities--may warrant specialized approaches
when states plan for the psychological consequences of disasters.
[48] White House Homeland Security Council, The Federal Response to
Hurricane Katrina: Lessons Learned (Washington, D.C., Feb. 23, 2006),
105.
[49] 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. At the time of Hurricane Katrina, U.S. Public Health
Service Commissioned Corps officers were not assigned to preexisting
teams; rather, teams were formed as they were needed.
[50] HHS officials told us that the teams were configured primarily to
provide mental health support, although elements of the training
related to substance abuse. For example, training materials list
alcohol abuse as a symptom of psychological problems and note that
people in recovery for substance abuse may relapse following a
disaster.
[51] When not deployed in response to an emergency, the Health and
Medical Response Team members would obtain training, provide training
to other Commissioned Corps and Medical Reserve Corps members, and
provide clinical and public health services to underserved communities.
[52] According to an agency official, following Hurricane Katrina the
agency did not require host states to abide by the 14-day application
deadline. Once FEMA determined that 100 or more disaster survivors had
registered with FEMA for federal disaster assistance in a state, the
state was notified that it was eligible to submit an abbreviated
version of the application for ISP funding and that it had 10 days from
the date of notification to apply.
[53] In addition, Louisiana had to administer each CCP separately,
which included, for example, submitting separate quarterly reports for
each program.
[54] The CCP needs assessment formula did not include a specific
category for estimating crisis counseling needs in situations, such as
Hurricane Katrina, in which a state was hosting disaster evacuees and
did not itself experience casualties or property destruction.
Therefore, according to a FEMA official, the agency made an ad hoc
decision after Hurricane Katrina to allow states hosting evacuees to
develop their ISP needs assessments based solely on the number of
evacuees in their state who had registered for federal disaster
assistance.
[55] The researchers found both overestimation and underestimation of
people needing crisis mental health services, with some state CCPs
reporting that they served 3 to 10 times more people than had been
estimated to need CCP services and others reporting that they served
one-half to one-fourteenth the number of people that had been
estimated. See NCPTSD, Retrospective 5-Year Evaluation of the Crisis
Counseling Program, B27-B28, E12.
[56] Louisiana, for example, submitted ISP and RSP applications to
provide services in parishes that received a presidential disaster
declaration for Hurricane Katrina. The state also submitted an
abbreviated ISP application and RSP application to provide CCP services
in parishes that did not receive a presidential disaster declaration
but that hosted evacuees. According to SAMHSA officials, the state also
submitted an RSP application to provide services to people affected by
Hurricane Rita.
[57] Educational Services, Inc., "Beyond Katrina: An After-Action
Report on Improving Substance Abuse and Mental Health Response to
Future Disasters," unpublished report, prepared at the request of
SAMHSA (Bethesda, Md., May 8, 2006), 39.
[58] SAMHSA officials told us they made changes in the application
review process based in part on our 2005 report on New York's CCP,
known as Project Liberty, which was established after the 2001 WTC
attack. We reported, among other things, that FEMA and SAMHSA had not
obtained realistic budget information during the CCP application
process that they could use to effectively assess how New York was
planning to spend Project Liberty grant funds. See GAO-05-514.
[59] Indirect costs are those incurred by an organization that are not
readily identified with a particular project but are necessary to the
operation of the organization and the performance of the project.
Typical examples of indirect costs include the cost of operating and
maintaining facilities, accounting and personnel services, and
depreciation.
[60] A FEMA official responsible for CCP told us that it was unclear
why CCP policy does not allow for the reimbursement of indirect costs.
[61] The Public Assistance Program can provide financial assistance to
state governments, local governments, Indian tribes or authorized
tribal organizations, Alaskan Native villages, and certain nonprofit
organizations to help them recover from disasters.
[62] The Hazard Mitigation Grant Program provides assistance to states,
local governments, Indian tribes, and private nonprofit organizations
for long-term hazard mitigation projects following a major disaster
declaration to reduce the loss of life and property after a natural
disaster.
[63] FEMA Office of Inspector General, Inspection of FEMA's Crisis
Counseling Assistance and Training Program, I-01-95 (Washington, D.C.,
June 1995), 25.
[64] FEMA Office of Inspector General, Inspection of FEMA's Crisis
Counseling Assistance and Training Program, 25.
[65] In the past, SAMHSA had provided Florida with supplemental
financial assistance to fund services outside the state's CCP.
Following Hurricane Charley and the three other hurricanes that
affected Florida in 2004, state officials found that some people
required services that went beyond the scope of the state's CCP, and so
officials requested federal funds to provide additional services. In
response, SAMHSA awarded an $11 million grant to help the state provide
services not included in the state's CCP, such as mental health
treatment, case management, substance abuse treatment, and other
services.
[66] SAMHSA's six operating principles are (1) disaster-trained
clinical professionals are a key component of specialized crisis
counseling teams; (2) an active outreach must be maintained; (3)
appropriate assessment and referral techniques will be utilized; (4)
specialized techniques must be appropriate to the short-term, temporary
nature of CCP and phases of disaster recovery; (5) specialized
techniques must focus on immediate practical needs and priorities of
survivors; and (6) training, supervision, and oversight are critical to
successful implementation and operation.
[67] According to SAMHSA, Louisiana's entire Hurricane Katrina CCP was
scheduled to end February 28, 2008. However, as of November 2007,
SAMHSA and FEMA were reviewing a request from Louisiana to extend the
state's CCP through December 31, 2008.
[68] Mississippi did not include children in its expanded program
because it was already involved in two other initiatives related to the
mental health needs of children affected by the hurricane.
[69] NCPTSD, Retrospective 5-Year Evaluation of the Crisis Counseling
Program, D148.
[70] NCPTSD, Retrospective 5-Year Evaluation of the Crisis Counseling
Program, E19.
[71] Case management involves a range of services to help people
recover from a disaster, such as helping them obtain health, social,
and financial services. According to CCP guidance, providers may give
survivors information about other FEMA disaster assistance programs and
information on other resources. However, the guidance states that it is
beyond the scope of CCP for crisis counselors to serve as advocates for
disaster survivors in obtaining services or resolving disputes or
function in a way that might create dependence on CCP staff and
programs that will not exist following the end of CCP.
[72] NCPTSD, Retrospective 5-Year Evaluation of the Crisis Counseling
Program, C60.
[73] Pub. L. No. 109-295, Title VI, §689f, 120 Stat. 1355, 1452 October
4, 2006.
[74] GAO, Federal Emergency Management Agency: Crisis Counseling Grants
Awarded to the State of New York after the September 11 Terrorist
Attacks, GAO-05-514 (Washington, D.C.: May 31, 2005).
[75] The Office of the Assistant Secretary for Preparedness and
Response coordinates and directs HHS's emergency preparedness and
response program. In December 2006 the Office of Public Health
Emergency Preparedness became the Office of the Assistant Secretary for
Preparedness and Response.
[76] Although the September 11, 2001, WTC attack occurred in fiscal
year 2001, we included this event in our review because the response
primarily occurred during the time period we examined.
[77] These reports included U.S. House of Representatives, Select
Bipartisan Committee to Investigate the Preparation for and Response to
Hurricane Katrina, A Failure of Initiative: Final Report of the Select
Bipartisan Committee to Investigate the Preparation for and Response to
Hurricane Katrina (Washington, D.C., Feb. 15, 2006); White House
Homeland Security Council, The Federal Response to Hurricane Katrina:
Lessons Learned (Washington, D.C., Feb. 23, 2006); U.S. Senate
Committee on Homeland Security and Governmental Affairs, Hurricane
Katrina: A Nation Still Unprepared (Washington, D.C., May 2006); and
Educational Services, Inc., "Beyond Katrina: An After-Action Report on
Improving Substance Abuse and Mental Health Response to Future
Disasters," unpublished report, prepared at the request of SAMHSA
(Bethesda, Md., May 8, 2006).
[78] SAMHSA, "State Behavioral Health All-Hazards Disaster Plan Review
Report," unpublished report (Rockville, Md., June 2007).
[79] Generally, only states that have received a presidential disaster
declaration are eligible to request CCP funding. These presidential
declarations are county-specific.
[80] NCPTSD, "Retrospective 5-Year Evaluation of the Crisis Counseling
Assistance and Training Program," unpublished report requested by
SAMHSA (White River Junction, Vt., June 2005).
[81] See, for example, GAO, Mental Health Services: Effectiveness of
Insurance Coverage and Federal Programs for Children Who Have
Experienced Trauma Largely Unknown, GAO-02-813 (Washington, D.C.: Aug.
22, 2002).
[82] See, for example, Congressional Research Service, Federal Stafford
Act Disaster Assistance: Presidential Declarations, Eligible
Activities, and Funding, RL33053 (Washington, D.C., Mar. 6, 2007); and
Congressional Research Service, Gulf Coast Hurricanes: Addressing
Survivors' Mental Health and Substance Abuse Treatment Needs, RL33738
(Washington, D.C., Nov. 29, 2006).
[83] SERG can be used to support mental health and substance abuse
services after smaller-scale emergencies that have not received a
presidential disaster declaration. SERG typically does not fund long-
term mental health or substance abuse treatment, medications,
hospitalization, or services that may be provided through CCP.
[84] Project SERV is generally used following smaller-scale
emergencies, such as school shootings and suicides, that have not
received a presidential disaster declaration. Grant funds may not be
used for medical services, drug treatment, or rehabilitation, except
for pupil services or referral to treatment for students who are
victims of, or witnesses to, a crime, or who illegally use drugs. See
20 U.S.C. §7164 (2).
[85] The Deficit Reduction Act of 2005, Pub. L. No. 109-171, §6201, 120
Stat. 4, 132 (2006).
[86] GAO, Hurricane Katrina: Allocation and Use of $2 Billion for
Medicaid and Other Health Care Needs, GAO-07-67 (Washington, D.C.: Feb.
28, 2007).
[87] This total does not include mental health claims that states may
have reported to CMS within other reportable categories--such as
physician services or outpatient services--for which claims specific to
mental health services could not be identified.
[88] New York and Washington did not participate in this temporarily
expanded program.
[89] The Department of Defense Appropriations Act, 2006, Pub. L. 109-
148, Division B, 119 Stat. 2680, 2745, 2768 (2005).
[90] The WTC health programs are (1) the New York City Fire Department
WTC Medical Monitoring and Treatment Program; (2) the New York/New
Jersey WTC Consortium; (3) the WTC Federal Responder Screening Program;
(4) the WTC Health Registry; (5) the Police Organization Providing Peer
Assistance program; and (6) Project COPE. The WTC Health Registry also
includes people living or attending school in the area of the WTC, or
working or present in the vicinity on September 11, 2001. In addition
to these six programs, a New York State responder screening program
received federal funding for screening New York State employees and
National Guard personnel who responded to the WTC attack in an official
capacity. This program ended its screening examinations in November
2003.
[91] For information on the progress of these programs and difficulties
they have experienced, see, for example, GAO, September 11: HHS Needs
to Ensure the Availability of Health Screening and Monitoring for All
Responders, GAO-07-892 (Washington, D.C.: July 23, 2007); GAO,
September 11: HHS Has Screened Additional Federal Responders for World
Trade Center Health Effects, but Plans for Awarding Funds for Treatment
Are Incomplete, GAO-06-1092T (Washington, D.C.: Sept. 8, 2006); and
GAO, September 11: Monitoring of World Trade Center Health Effects Has
Progressed, but Program for Federal Responders Lags Behind, GAO-06-481T
(Washington, D.C.: Feb. 28, 2006).
[92] Grantees were Connecticut, Maryland, Massachusetts, New Jersey,
New York, Pennsylvania, Rhode Island, Virginia, and the District of
Columbia. States received funds through one or more of SAMHSA's three
centers: the Center for Mental Health Services, the Center for
Substance Abuse Prevention, and the Center for Substance Abuse
Treatment.
[End of section]
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