Attachment D - Response to Comments

Attachment D: SAMHSA’s Response to Comments on 60 Day Federal Register Notice

Commenter	Comment	Paraphrased Comment	Response
Reporting on All Persons Served
Marin County Community Mental Health- San Rafael, CA	Full reporting on all persons served (not just the federal percentage as we have been reporting) will require additional resources. With shrinking resources and shrinking funding, providers are not in a position to take on much in the way of increased workload and if the optional questions are not things that providers are already collecting/monitoring, then it will entail more administrative time, taking away from the clinical.	SAMHSA should not collect data on all clients served as is will increase the burden on States and providers.	The intent of the proposed change is strictly to simplify the counting methodologies on clients served by programs supported by PATH funding. PATH providers must already collect data on all clients served in order to complete the calculation for determining the federal percentage, to report services delivered, and to provide client counts within demographics. Under the proposed changes, the PATH program would no longer have to complete the additional calculation, instead reporting all clients served by the program. This proposed change is anticipated to decrease provider burden by simplifying reporting requirements and would achieve the added benefit of acknowledging the overall impact of the program whose effectiveness may be decreased without PATH funding. For example, a program serving 100 clients in a program that is supported by PATH funding, but the PATH funding is one of multiple funding sources for the program; and where the PATH funding may be equivalent to 10% of the total funding for the program: Under the current counting methodology, the PATH program could only report 10 out of the 100 clients on the PATH Annual Survey (10% of 100 clients served by the program), understating the overall impact of the program. Under the proposed changes, the PATH program would report all 100 clients served by the program rather than the % of clients served based on the % of PATH funding supporting the program.
Episcopal Community Services, San Diego, CA	I…am deeply alarmed by, intended changes to the PATH data reporting requirements for 2009, in particular the "full reporting on all persons served".
Cumberland County Guidance Center	Reporting on all persons served with PATH Federal and matching State funds: No additional burden	SAMHSA should collect data on all clients served with PATH funding including leveraged state and local funding. Reporting on all persons served will not pose a burden.	This comment reflects the reasons why this change was proposed. The intent of the proposed change is strictly to simplify the counting methodologies on clients served by programs supported by PATH funding. PATH providers must already collect data on all clients served in order to complete the calculation for determining the federal percentage, to report services delivered, and to provide client counts within demographics.
Southeast Recovery and Mental Health Care Services- Columbus, OH	We would appreciate being able to report on all consumers served. Local funds are leveraged because of the Federal dollars and might not be available for these purposes without the federal funding. Therefore, we believe that reports of the program's impact should reflect the use of all resources. Since there is no way to separate services paid for by local versus Federal dollars, it is easier and more reflective of the program's impact to report on all consumers served.
Ohio Department of Mental Health	Reporting on All Clients Served: We support this change as it will provide a more accurate and illustrative picture of the scope of services performance not only by Ohio's PATH programs, but all PATH programs. This will allow for more objective comparative for assessing PATH programs with the State and across the country. Under the current methodology where programs only report on what they do with the federal PATH dollars, programs not get credit for those services they provide that are paid for by State match. Finally, there is an increased administrative burden on PATH providers when they are asked to separate services paid for by federal PATH dollars, versus State match dollars.

Reporting on Peer Providers
Cumberland County Guidance Center	The number of staff persons who are consumers, peer providers, or prosumers supported by PATH Federal and State matching funds. (Table A): No additional burden	Reporting on peer providers will not pose a burden. SAMHSA should collect data on former consumers that are currently employed by the PATH Agency.	This comment reflects that the provider anticipates no additional burden. This comment reflects the reasons why this change was proposed.
Southeast Recovery and Mental Health Care Services- Columbus, OH; Ohio Department of Mental Health- Columbus OH	It would be simple to track the number of consumer FTEs employed by the program. SAMHSA will reinforce the importance of peers for successful PATH programs by requiring tracking of this data.
Housing
Cumberland County Guidance Center	The number of enrolled consumers placed into housing (Transitional, Supportive, or Permanent). (Table C): No additional burden		This comment reflects that this provider does not anticipate additional burden.
Southeast Recovery and Mental Health Care Services- Columbus, OH	Our program already tracks the number of enrolled consumers who enter housing and the number of enrolled consumers who obtain mainstream benefits such as SSI/SSDI or Medicaid/Medicare. These are important steps on the path to achieving stability and our staff tracks this data for each consumer.	SAMHSA should collect data on enrolled consumers who enter housing. Reporting housing data will not pose a burden.	This comment reflects the reasons why this change was proposed. This comment reflects that some PATH providers are already collecting and analyzing data on the indicators of stability.
Ohio Department of Mental Health	We support the tracking of persons "enrolled" into the PATH program placed into housing. Housing is vital to a homeless person's recovery, in as much as connection to treatment.

Income Benefits
Cumberland County Guidance Center	The number of Enrolled consumers who were assisted with successfully obtaining income benefits (SSI, SSDI, VA, etc.) (Table C): 10 Hours Burden	Reporting income benefits data will impose an additional burden	SAMHSA acknowledges that for providers choosing to participate in the optional measures there may be an increase in burden. Income is a building block to client stability and enhances the success rate of treatment services. Data collection is limited to the activities performed by the program via an assisted referral to the client in completing an application for benefits. PATH providers are encouraged to assess the additional burden of data collection requirements for other programs administered by the provider or partner service providers where income data may already be collected (i.e. SOAR) and leverage those other data collection processes to minimize burden.
Southeast Recovery and Mental Health Care Services- Columbus, OH	Our program already tracks the number of enrolled consumers who enter housing and the number of enrolled consumers who obtain mainstream benefits such as SSI/SSDI or Medicaid/Medicare. These are important steps on the path to achieving stability and our staff tracks this data for each consumer.	SAMHSA should collect data on enrolled consumers who obtain mainstream benefits.	This comment reflects that some PATH providers are already collecting and analyzing data on the indicators of stability. This comment reflects the reasons why this change was proposed.
Ohio Department of Mental Health	We support the decision to track outcomes for individuals who are linked to income benefits, including SSI and SSDI, as we believe that access to benefits is an integral part of stabilizing PATH clients.

Primary Medical Care
Cumberland County Guidance Center	The number of Enrolled consumers who were assisted with successfully obtaining primary medical care. (Table C): 10 hours burden	Reporting primary medical care data will impose an additional burden.	SAMHSA acknowledges that for providers choosing to participate in the optional measures there may be an increase in burden. Primary healthcare is a building block to client stability and often leads to diagnosis and treatment services for mental health and substance abuse. The outcome does not require the documentation of medical services the client receives. Data collection is limited to the activities performed by the program via an assisted referral to the client in completing application for services and a follow up to document attainment status. PATH providers are encouraged to assess the additional burden in terms of data collection requirements for other programs administered by the provider or service partners where data procurement may already be occur, and leverage those other data collection processes to minimize burden.
Southeast Recovery and Mental Health Care Services- Columbus, OH	If SAMSHA requires programs to track linkage to primary care, it will be important to define if tracking this is for informational purposes or if SAMHSA is adding linkage to primary care as a program goal. Our current program goal is to link each consumer to housing and ongoing mental health care. If SAMHSA adds linkage to primary care as a program goal, that may affect the number of consumers who can be served with existing resources. If SAMSHA is tracking linkage to primary care for informational purposes, perhaps this would best be tracked in the client demographic data rather than program outputs/outcomes.	SAMHSA should not collect data on linking PATH clients to primary medical care without explaining the intent of the data and how it impacts the program in a meaningful way. Collecting data on linking PATH clients to primary medical care is more appropriate for client demographics than in program outcome measurement.	A primary function and use of the PATH funding is the delivery of outreach services to identify and engage consumers who are homeless/at-risk of homelessness, and who are also suffering from serious mental illness or mental illness combined with substance abuse. Along with survival services, the primary purpose of outreach services is linking consumers to services. Lack of primary health care services is a barrier to consumer stability that directly affects the consumer's ability to become and maintain stability during subsequent housing and treatment. The intent of this proposed change is to assess the program's success at linking consumers to this necessary service component, but not to assess the consumer's success in completing the services. Since the focus of this proposed change is the linkage of consumers to services, a function the program is already conducting and documenting, it is not anticipated that the documentation of the linkage to primary health care will impose additional provider burden.
State of Montana, Department of Public Health and Human Services, Addictive and Mental Disorders Division	Montana PATH providers and State Office have some concerns re: requests for: "The number of Enrolled consumers who were assisted with successfully obtaining primary medical care" …reporting request are part of comprehensive case management services. What will this data be used for? Once the data is collected how will it affect the program in a useful way?
Ohio Department of MH	As the objective of PATH is to connect people with mental health services, ODMN is unclear of the intent behind collecting primary healthcare linkage…
Mental Health Care
Colorado Coalition for the Homeless	I would suggest one addition: the number of enrolled consumers who were assisted with successfully obtaining mental health care. This is a primary focus of our work with many of our clients who either deny mental illness or decline psychiatric medication on first contact or who have gone with adequate medication for many years.	SAMHSA should collect data on the number of enrolled consumers who were assisted with successfully obtaining mental health care.	It is agreed that the primary focus of the PATH program is the identification and linkage of eligible consumers to mental health services. This is already tracked in the current PATH report.
Employment
Cumberland County Guidance Center	The number of Enrolled consumers who were assisted with successfully obtaining or increasing their earned income (employment). (Table C).: 5 hours burden	Reporting earned income data will impose an additional burden	SAMHSA acknowledges that for providers choosing to participate in the optional measures there may be an increase in burden. Income is a building block to client stability and enhances the success rate of treatment services. Data collection is limited to the activities performed by the program via an assisted referral to the client in completing application for income and a follow up to document attainment status. PATH providers are encouraged to assess the additional burden in terms of data collection requirements for other programs administered by the provider or service partners where data procurement may already be occur, and leverage those other data collection processes to minimize burden.
Southeast Recovery and Mental Health Care Services- Columbus, OH	The issue of tracking employment is somewhat complicated. Historically, tracking income for homeless people is a challenge. Most tracking methodologies use two point-in-time counts: income at entry and income at exit. We know that employment for homeless people can be sporadic...Our program works with consumers for a few weeks to a few months, and we do not currently have the staffing capacity (in number or training) to focus on consumer employment. Adding this as a program goal could negatively affect the number of consumers served, unless additional resources are obtained. It will be important for SAMSHA to define their intent in tracking employment and to clear define how to track this outcome...	SAMHSA should not collect data on the number of clients that are connected to employment as it will increase the burden of States and providers.	A primary function and use of the PATH funding is the delivery of outreach services to identify and engage consumers who are homeless/at-risk of homelessness, and who are also suffering from serious mental illness or mental illness combined with substance abuse. Along with survival services, the primary purpose of outreach services is linking consumers to services. Lack of ongoing income is a barrier to consumer stability that directly affects the consumer's ability to become and maintain stability during subsequent housing and treatment. The intent of this proposed change is to assess the program's success at linking consumers to this necessary service component, but not to assess the consumer's success in completing the services. Since the focus of this proposed change is the linkage of consumers to services, a function the program is already conducting and documenting, it is not anticipated that the documentation of the linkage to employment services will impose additional provider burden.

Medical Insurance
State of Montana, Department of Public Health and Human Services, Addictive and Mental Disorders Division	Montana PATH providers and State Office have some concerns re: requests for: "The number of Enrolled consumers who were assisted with successfully obtaining medical insurance or coverage plans (Medicaid, Medicare, and/or state/local plans)" …reporting request are part of comprehensive case management services. What will this data be used for? Once the data is collected how will it affect the program in a useful way?	SAMHSA should clarify why collecting data on linking clients to medical insurance or coverage plans is important to the PATH program.	A barrier to the receipt of mental health, substance abuse, and primary health care services is the lack of resources to pay for the services. Most medical insurance plans cover the cost of these services. Lack of mental health, substance abuse, and primary healthcare services is a barrier to consumer stability that directly affects the consumer's ability to become and maintain stability during subsequent housing and treatment. The intent of this proposed change is to assess the program's success at linking consumers to this necessary service component, but not to assess the consumer's success in completing the services.
Ohio Department of Mental Health	ODMN supports the tracking of those linked to a medical insurance plan in light of its inextricable link to their ongoing mental health treatment.	SAMHSA should collect data on linking clients to medical insurance or coverage plans.	This comment reflects the reasons why this change was proposed.
Cumberland County Guidance Center	The number of Enrolled consumers who were assisted with successfully obtaining medical insurance or coverage plans (Medicaid, Medicare, and/or state/local plans). (Table C): 5 hours burden	Reporting medical insurance data will impose an additional burden	SAMHSA acknowledges that for providers choosing to participate in optional measures there may be an increase in burden. A barrier to the receipt of mental health, substance abuse, and primary health care services is the lack of resources to pay for the services. Most medical insurance plans cover the cost of these services. Lack of mental health, substance abuse, and primary healthcare services is a barrier to consumer stability that directly affects the consumer's ability to become and maintain stability during subsequent housing and treatment. The intent of this proposed change is to assess the program's success at linking consumers to this necessary service component, but not to assess the consumer's success in completing the services. PATH providers are encouraged to assess the additional burden in terms of data collection requirements for other programs administered by the provider or service partners where data procurement may already be occur, and leverage those other data collection processes to minimize burden.

Outcome Measures Overall
Colorado Coalition for the Homeless	I strongly endorse the changes to be incorporated into next year's report, particularly the outcome questions. I know they are voluntary but I hope they become mandatory. We already track these data internally; they are important measures to the success of our collective efforts.	SAMHSA should make the optional outcome measures mandatory.	This comment reflects that some PATH providers are already collecting and analyzing data on the indicators of stability.
Marin County Community Mental Health	We request to indeed keep the optional elements optional for 2009 and beyond. With shrinking resources and shrinking funding, providers are not in a position to take on much in the way of increased workload and if the optional questions are not things that providers are already collecting/monitoring, then it will entail more administrative time, taking away from the clinical.	SAMHSA should keep the optional outcome measures optional.	Congress is moving towards performance-based funding and transparency in fund activities and uses. It is imperative that the PATH program implement data collection and reporting that clearly showcases the program's usefulness and worthiness.
Cameron Elk County MHMR, Ridgway, PA	I believe the five questions are good and will provide good data to have when evaluating the PATH programs. We already do keep track of numbers placed in housing, numbers who are successful in obtaining income, and employment just for our own records. It would not be difficult to track clients who obtain medical insurance or primary medical care.	SAMHSA should collect the outcome measures.	This comment reflects that some PATH providers are already collecting and analyzing data on the indicators of stability.
Episcopal Community Services, San Diego, CA	The questions would be perceived as intrusive and an immediate "turnoff" for most of the people we approach on the streets and in community-based sites. Such an informational imposition would serious compromise our ability to establish trust and build effective, positive rapport, which is critical to our ability to engage this population in services, helping them to transition off the streets and into recovery.	SAMHSA should not collect the optional outcome measures so that PATH employees can spend the majority of their time with clients not on data collection and reporting.	A primary function and use of the PATH funding is the delivery of outreach services to identify and engage consumers who are homeless/at-risk of homelessness, and who are also suffering from serious mental illness or mental illness combined with substance abuse. Along with survival services, the primary purpose of outreach services is linking consumers to services. The documentation of the efforts of the program to successfully link the consumer to needed resources is not a function of data collection from the client; rather it is an internal operational function of the program itself. The intent of this proposed change is to assess the program's success at linking consumers to this necessary service, but not to assess the consumer's success in completing the services. Since the focus of this proposed change is the linkage of consumers to services, a function the program is already conducting and documenting, it is not anticipated that the documentation of the linkage to services will impose additional provider burden or impact program client engagement rates.
Transitional Living, Inc., Hamilton, OH	I would express my concern that additional tracking of detailed outcomes that are often not in control of the PATH Team could result in staff being more office based vs out in the community outreaching and engaging consumers into services. Oftentimes the successful acquisition of the of areas such as benefits do not come to fruition until after a consumer is not longer with PATH and is successfully engaged with mainstream mental health services and case management.
State of Montana, Department of Public Health and Human Services, Addictive and Mental Disorders Division	Increased reporting can be burdensome and take valuable time from client care/services