Attachment 3

Comments from the 60- Day FRN

FY 2008-2010 MHBG Guidance & Instructions

May 29, 2007

Themes	Summary of Comments	Recommendation
Integration of Transformation as a Guiding Principle in the MHBG Plan	States that did not get the SAMHSA T-SIG should not be held accountable for or penalized in any way (such as delay in approving the block grant application) for failure to show substantial progress in its transformation efforts. SAMHSA should be pleased with States that are making substantial leap forward without benefit of federal funding support or federal technical assistance as the states that were funded. Unfunded states should not be held to the same standard as states who received an infusion of funding and TA for this effort. The Guidance lacks instruction on how CMHS will hold states accountable for transformation. (Florida) Eliminate the requirement to describe mental health transformation under each criterion. Nebraska will not report on this item. (Nebraska) Oklahoma has included transformation within the scope of planning, including the MHBG Plan, for the past several years. As a Transformation State Incentive Grant state we certainly have work products that exemplify this. However, it is in unclear in the proposed Guidance as to how guiding principles or lack thereof may be a specific compliance issue in terms of approved Block Grant applications. (Oklahoma) This is an activity Arizona can easily report on. Transformation is a broad definition that encompasses many initiatives that the state is currently involved in. (Arizona) This requirement presents a significant challenge. True transformation efforts should include ways in which the multiple state agencies with mental health related services and funding are collaborating and coordinating activities and this is not always possible in states that do have the infrastructure development grants and the staffing that is designated to facilitate these activities. (Georgia) The FY 2008 to FY 2010 Block Grant Guidance incorporates requirements to report on transformation activities within the specific block grant criterion to which they relate. This in itself is not problematic as the Illinois Division of Mental Health is engaged in many transformative activities, and as such welcomes the opportunity to highlight these activities. (Illinois)	The purpose of asking States for this information is to provide information to CMHS on the level of transformation activities across all States nationally. States would not be penalized during the BG review process. This information will not be used to address accountability for individual States or to compare States against each other.
Table 4: Transformation Expenditure Reporting	No added value for Table 4. Nebraska will not report on this item. The Nebraska accounting system does not track funds in this manner and would mean that Division staff would be forced to guess where funds should be classified. Such an exercise would not produce accurate data. (Nebraska) It would be extremely difficult and burdensome for the Department of Mental Health to report each state transformation activity listed in Table 4. Additionally, the DMH does not feel that Table 4 is necessary or practical for a state like South Dakota where there is no additional money to be utilized for direct funding of transformational activities. While DMH cannot quantify in expenditures the funding for each area listed in Table 4, our current State Plan performance indicators do show progress in many areas related to transformation activities (supporting individual plans of care, improving coordination of care among multiple systems, provision of evidence based practices, improving consumer access to employment and affordable housing, etc). DMH does not feel Table 4 provides a true representation of efforts towards transformation in the planning and delivery of community mental health services in South Dakota. (South Dakota) The reporting of state and Block Grant expenditures for transformation activities – this table may be challenging to states to report as funding and expenditures are not likely to be captured in state accounting systems in a way that will readily conform to the table. (Georgia) Data is not currently available to report on all of the 19 transformation activities as they are listed in Table 4 on p.33. Mississippi can continue to report how CMHS Block Grant funds are expended, as in previous years and as called for in Criterion 5 in federal state plan requirements; however, we would have significant difficulty reporting expenditures for all of the activities as presented in Table 4 format. Although a few of the activities listed reflect the same topics addressed in the URS/NOMS measures, most would involve additional data definitions and information management system changes to report. (Mississippi) The funding aspect of this may be hard to quantify from the State's perspective to meet the intent of this change. The proposed Guidance does include a Table 4 on page 33 which provides some categories for consideration. We would anticipate times when it may be difficult to arbitrarily assign specific funding to the categories as proposed. The approach in proposed Guidance may present a burden that will not be offset by the benefit of completing this work to be in compliance with the application requirements. (Oklahoma) Overwhelming consensus among state agency mental health planners is that reporting Table 4 is untenable, impractical and unnecessary. We strongly recommend dropping Table 4. This recommendation in no way represents a lack of support for the principles of mental health transformation. Opposition to Table 4 is based on the fact that states do not budget expenditures in a manner that would allow data for this table to be extracted in an accurate and meaningful way. The categories of transformation simply do not correlate with state budgeting practices. Without expensive time studies that go beyond the scope of state accountability requirements, states would be forced to make educated guesses about expenditures which could be harmful and misleading. (NASMHPD) The only major problem noted is Table 4. We don’t and would not be able to meaningfully account for cost by many of these 19 (plus “other”) activities. The transformation activities listed are largely underlying expectations of many services we provide. Many of them overlap within services and just cannot be broken out as proposed in the draft table. In summary, expenditures are not planned or tracked by most of these categories and the state would not be able to provide meaningful dollar amounts for Table 4, although we are supporting the activities throughout the system. (Michigan) I have great concern that the chart on page 33 (Table 4), goes beyond the scope here to ask states to report on all their state funding. It is also a pretty impossible reporting format, since I find it unlikely that most states keep their budgets/expenditure in this format and you will get a bunch of apples and oranges without any clear definitions, etc. (Maryland) The Alabama Department of Mental Health and Mental Retardation has undertaken a number of transformation activities that can be incorporated into the narrative and goals of the application as indicated in the revised guidance. However, reporting State as well as Block Grant expenditures for each transformation activity exceeds the scope of the Block grant requirements and represents an undue reporting burden on States. We especially request that the language regarding expenditures be stricken from the final guidance. (Alabama) The aspect of reporting that is problematic is the additional requirement to complete Table 4 which is entitled: FY2008 – FY 2010 MHBG Transformation Expenditure Reporting Form. Table 4 would require that Illinois track expenditures for up to twenty (20) specific activity categories. The Illinois DMH does not currently track the allocation of block grant dollars at this level of specificity, and to do so would place an undue burden on state fiscal staff. We therefore request that Table 4 be eliminated from the reporting requirements for the Mental Health Block Grant. (llinois)	Although NASMHPD and  several States are expressing difficulty in   providing the information in Table 4 and resistance to providing such data because of the additional burden, Table 4 will provide useful information of national transformation expenditures, expenditures across transformation activities, and changes in expenditures over time and is consistent with the language that had been included at one time in the President’s FY 07 Budget regarding State MHBG expenditures for transformation. CMHS will work in partnership with the States to obtain this important information and will allow flexibility in the way in which expenditure data may be reported given the structure of the table. Completion of Table 4 is optional.
Report One Mental Health Transformation Outcome Measure	Certainly the State will be able to address this requirement and this should not represent a notable increase in burden on completing the application. The proposed Guidance appears to provide latitude on the part of the State to define and quantify transformation-related measures. We would encourage CMHS to be supportive of this latitude and not overly arbitrate the extent to which a measure is considered to adequately address transformation as a MHBG compliance issue. (Oklahoma)
Describe Community-Based Services Provided to Older Adults	This will be especially challenging for states that have not developed specialized programs for older adults and serve them only through the standard adult service arrays. (Georgia) The American Association of Geriatric Psychiatry (AAGP) supports SAMHSA’s requirement to include a description of services provided to older adults under Criterion 4 of the State plan. (AAGP)	States are asked to describe those services available to older adults in the State’s system of care.
Report Additional NOMS	Additional guidance is needed for Maryland to be able to report the new NOMS for Living Situation, Employment, Criminal/Juvenile Justice, and School Attendance. It is unclear in the Guidance what information States should use to construct performance indicator tables and to determine FY targets. (Maryland) At least two of the additional NOMS are still under development and, therefore, it is difficult for states to collect and report data on these ill-defined measures. It is recommended that states be held accountable only for measures that are well defined and developed. (Florida) Arizona has been able to report on the required four NOMS as well as three optional NOMS in its past applications. (Arizona) The requirement to report all 9 NOMS, even though NOMS 8 & 9 are still in development, will be difficult to establish indicators and targets when the measures are yet to be determined. (Georgia) Oklahoma expects to be able to provide the required data for these measures with only moderate revisions to current data collection systems. The State is supportive of the partnership approach utilized by the Center for Mental Health Services through the Data Infrastructure Grant program which permits states to assist and guide in the development of measurement systems. (Oklahoma) Request clarification of reporting measures on Table 6 marked with an asterisk (*) and whether the noted requirement for states to respond if they do not have data available to construct NOMS indicators at the time of the report. (Mississippi) In addition to a review of the timelines, the definitions for the NOMS need further delineation. It is important to provide service definitions that are clear and detailed but not so precise as to limit flexibility in achieving share goals. (NASMHPD) The addition of questions regarding consumers’ criminal justice involvement, level of functioning, school attendance, etc., radically changes the role of the consumer from the person evaluating services to the person being evaluated. We believe this change will have substantial and detrimental impact on consumers’ willingness to participate in consumer surveys. Vermont has already seen a significant reduction in adult consumer survey response rates from 53% in 1997 to 36% in 2006. Much of the decease is contributed to SAMHSA’s requirement that consumers be surveyed on an annual basis. The addition of new questions that do not relate to consumer satisfaction could further reduce response rates and reduce utility of consumer surveys to help guide state mental health policy. Vermont	States are encouraged to report as many NOMS as possible. The two NOMS in development will need to be further refined by CMHS. If a State cannot report on the added NOMS, the State is asked to complete the State Level Data Capacity Checklist. Clarification is provided in the Guidance. The asterisk (*) applies to all NOMS in the table.
Reporting Time Frame and Availability of Data	It appears that states will need to complete many of the URS tables prior to December 1 in order to get to the NOMS while completing the block grant application. This means that the data will be incomplete because some data runs that are based on claims are submitted as late as 9 months from the date of service. This also makes it difficult to set targets. All of these processes take time and could attribute to increased burden to include the consumer survey and involvement by the mental health planning council. (Maryland) May have to include new ways to capture the data through the Independent Case File Review, Consumer Satisfaction Survey, etc. (Arizona) NASMHPD is requesting that CMHS examine the reporting timelines in light of the proposed requirement for reporting on additional National Outcome Measures (NOMS). On September 1, 2007, state plans for FY 08 (which include 2007 actuals and 2008 targets) are due as well as the annual consumer surveys as part of the NOMS. Three months later on December 1, the Implementation Reports are due. Because states have extensive public review processes of the block grant submissions and approval requirements by state planning councils and their Governors, the deadlines require the states to develop “actuals” before the end of the service year. Therefore, these “actuals” are really estimates or projections based on partial year data for many states. The workload involved with developing these ‘temporary data’ is quite costly to the states and has nominal utility. In fact, the introduction of inaccurate data produces results which may be misleading. It would be more advantageous for the states if the due dates for the Plans were pushed back so that accurate data is available for planning purposes. (NASMHPD)	Submission dates for the MHBG plan and Implementation report are statutorily set and cannot be changed. States are only required to report “Projected “data for FY 2007 in the FY 2008 plan on September 1. This correction will be made in the Guidance for the FY 2008 plan.
6).Use of WebBGAS to Submit State Plans	Should pages requiring signatures be scanned into WebBGAS and submitted separately? (Florida) WebBGAS will not present an issue for submission of the plan. (Arizona) Oklahoma has utilized the WebBGAS system for the past two fiscal years. The system provides for some efficiency. However, the actual work product does not provide a written document which can be easily utilized by state and local level stakeholders. Oklahoma will continue to be supportive of the web-based application but will likely continue to prepare a parallel document more suitable for use by the Mental Health Planning and Advisory Council and the public in general. (Oklahoma) WebBGAS will not reduce the burden since the paperwork still has to be signed by the Director and Governor. In fact, WebBGAS will increase the time spent on submission since one has to learn to use the system and enter the data in the tables. (Hawaii)	The Guidance instructs States to mail an original and two copies of Part B to SAMHSA’s Grants Management Office. Part B includes parts of the application requiring original signatures. SAMHSA does not accept electronic signatures for applications and State plans.

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