The Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Mental Health Services (CMHS) is requesting approval for a revision from the Office of Management and Budget (OMB) to conduct the 2010 National Mental Health Services Survey (N-MHSS) (OMB No. 0930-0119), which expires on March 31, 2011. In previous survey cycles, this survey was entitled the National Survey of Mental Health Treatment Facilities (NSMHTF) and the Inventory of Mental Health Organizations (IMHO). The most recently completed survey was the 2008 NSMHTF. In this request, SAMHSA/CMHS is seeking OMB approval for a revised questionnaire (Attachment 1.0). The details of the revised questionnaire are described in Section B.
The N-MHSS is authorized by Section 505(b) [42 USC 290aa—4] of the Public Health Service Act, which mandates the collection of statistical data on mental health programs and persons who receive care from them. It also is authorized by Section 520(a) and (b)(13-14) [42 USC 290bb—31], which establishes the CMHS, provides for the conduct of surveys with respect to mental health services, and helps states improve their mental health data collection.
The 2010 N-MHSS differs from the previous version of the survey in the following ways: (a) to facilitate completing the survey online, definitions of terms and other survey information will be offered at the survey website; (b) the eligibility criteria for inclusion in the survey, previously outlined in a flyer accompanying the survey, have now been incorporated into the questionnaire as screening questions; and (c) the questionnaire has been reorganized for greater simplicity and shortened by eliminating several questions identified as no longer relevant. These changes were designed to improve data quality, reduce respondent burden, and bring the N-MHSS more in line with SAMHSA’s National Survey of Substance Abuse Treatment Services (N-SSATS).
The U.S. government has been collecting information on mental health services since 1840. From 1840 to 1946, the U.S. Bureau of the Census collected mental health services information. Following the creation of the National Institute of Mental Health (NIMH) in 1946, the present-day Department of Health and Human Services (DHHS) continued the collection of information on mental health services from 1947 through 1968. The current series of surveys to collect mental health services information, through the Inventory of Mental Health Organizations (IMHO), began in 1969 under the direction of NIMH. Responsibility for the IMHO was transferred to the CMHS with the creation of SAMHSA in 1992. Renamed the National Survey of Mental Health Treatment Facilities in 2008, and now the National Mental Health Services Survey, this series of specialty mental health provider surveys has existed, in one form or another, for the past 40 years. Since 1969, the goals and content of this data collection effort have been fairly consistent: obtaining basic trend data on the type of mental health services provided, caseloads, bed counts, and admissions for specialty mental health facilities and for mental health services provided by non-federal general hospitals and Department of Veterans Affairs medical centers. This data collection effort is part of the longest continuous series in American public health and is the only mechanism for obtaining national and state level data about the specialty mental health care delivery system described here.
In 2008, NSMHTF changed the respondent level from the organization to the facility to align the survey more closely with SAMHSA’s N-SSATS (OMB No. 0930-0106). Like its predecessor, the 2010 N-MHSS continues the emphasis on the providers’ point-of-service level (the facility level), as opposed to the organizational level. In order to provide continuity with the data collected in earlier NSMHTF and IMHO surveys, the 2010 N-MHSS is designed to permit aggregating data across facilities to produce organizational-level data.
This series of surveys also complements the Client/Patient Sample Survey (CPSS) (OMB No. 0930-0281), another survey sponsored by CMHS, which collects demographic, clinical, and service use data on probability samples of clients/patients in specific types of mental health facilities. The CPSS collects data at the client/patient level, whereas the N-MHSS collects information at the facility level.
The purpose of the survey continues to be the collection of information from mental health providers across the nation about the treatment services they provide to persons with mental illness. The survey targets the specialty mental health service delivery sector. Excluded are individual and small group mental health practices and facilities operated by the U.S. military or the Indian Health Service. It collects information on the actual mental health treatment services provided at a particular service location. This information is used by mental health professionals, researchers, and policymakers to track current trends in mental health care, such as service utilization and access to care. It also is used by CMHS to update the Mental Health Facility Locator, a component of SAMHSA’s Mental Health Services Locator, an online tool that matches local mental health services with the individuals who need them.
CMHS will use the information from the 2010 N-MHSS to (a) update mental health care databases and directories for the United States, (b) provide a sampling frame of facilities for other surveys (such as the CPSS), (c) provide summary data for state and national health care reform efforts and mental health parity, and (d) study trends in the utilization and client/patient characteristics of mental health facilities. Data derived from the 2010 N-MHSS will be published in special SAMHSA publications such as Data Highlights reports designed to update national trend data on mental health service utilization, in recurring CMHS publications such as Mental Health, United States, and in professional journals such as Psychiatric Services and The Social Science Journal. Data from the 2010 N-MHSS also will be included in the National Center for Health Statistics’ (NCHS) Health, United States and in the Department of Commerce’s Statistical Abstract, which is published biennially.
In addition to providing data on national trends in mental health care services, the 2010 N-MHSS will produce state-level tables that will be provided to each state mental health agency as part of a long-standing, in-kind federal-state partnership in mental health data collection and reporting. In conjunction with other surveys, results from the 2010 N-MHSS will be used to document selected characteristics of mental health treatment services nationwide and by state.
Another federal agency that uses these data is the National Institute of Mental Health (NIMH). It uses the name and address component to identify and mail questionnaires to mental health facilities in support of particular research studies. Other users include (a) state governments, which utilize the information from the N-MHSS in their procedures for licensing facilities, in budgeting and planning, and in research; (b) mental health facilities themselves, which use the data in their program-planning efforts; (c) evaluators supported by CMHS in state governments, universities, and corporations; (d) the U.S. Congress, which requests periodic special reports on mental health treatment services, such as services to elderly persons who have mental health conditions; and (e) the U.S. Bureau of the Census, which uses the names and addresses of facilities to help prepare the universe for the next decennial census.
The general public uses the data via the Internet through the National Mental Health Information Center (NMHIC), a website component of the SAMHSA Health Information Network (SHIN), a service of CMHS which is accessible from SAMHSA’s homepage. The NMHIC provides the public with information about mental health via a toll-free telephone number (800-789-2647), an Internet site, and more than 200 publications, and was developed for mental health consumers, family members, service providers, the general public, policymakers, and the media. Using the NMHIC Internet site (http://mentalhealth.samhsa.gov/databases/), the public can search for mental health facilities by state, city, type of service setting offered, and facility name. The NMHIC also is used extensively by mental health professionals to locate referral locations for their clients/patients.
Perhaps most important, the data derived from the 2010 N-MHSS will be used to populate CMHS’ Mental Health Facility Locator available through SAMHSA’s Mental Health Services Locator, a free online tool that individuals across the country can use to locate mental health treatment facilities in their area that provide the particular type(s) of mental health treatment services the individuals are seeking. This database includes information on the type of facility, who operates it, different treatment approaches offered at the facility, supportive services and practices offered, types of payment accepted, specially designed programs offered, availability of a crisis intervention team, languages in which services are provided, availability of services for the hearing impaired, and basic contact information so that the individual can schedule an appointment.
The Office of the Assistant Secretary for Planning and Evaluation (ASPE) has reviewed this proposed data collection and had no comments.
The 2010 N-MHSS data collection will use multiple technologies and applications in order to minimize respondent burden and improve the quality of the data collected. These include a web-based, self-administered survey, computer-assisted telephone interviewing (CATI), an automated data entry program, and a centralized database application that maintains survey frame information and manages all data collection modes simultaneously.
The 2010 N-MHSS will use the latest technology for all data collection applications.
Facility Tracking and Data Editing System (F-TADES), a specially developed application that will store and organize facility information, manage and monitor survey progress, and field multiple data collection modes simultaneously for the 2010 N-MHSS
WebServ 2, an SQL 2005 ASP.NET application for developing the web survey
Visual Studio.Net 2005 for creation of the Internet pages
Blaise 4.8 to create computer-assisted telephone interviews
Viking, a full-featured data entry software that runs on Unix
SAS 9.3 for the production of all data files
The survey will be offered in multiple modes, including a web version that respondents can log onto using a unique user ID and password assigned to their facility. Based on results of the 2008 NSMHTF, it is expected that approximately 45 percent of all respondents will choose to complete the survey online. Facilities that choose to use the Internet will be assisted by range checks and data validations that are built into the WebServ2 program, as well as programmed skip patterns. Web respondents will be able to move back and forth in the survey and edit their responses, suspend the survey and come back to the same point in the questionnaire later, and also will have the benefit of pre-filled information from their prior completed NSMHTF survey questionnaire (e.g., name and address of the facility). The web version of the survey will comply with the requirements of Section 508 of the Rehabilitation Act to permit accessibility to people with disabilities.
The 2010 N-MHSS also will use Blaise CATI to collect data from non-respondents. In addition, Blaise will support the scheduling, monitoring, and documentation of all telephone calls made to the respondent. It is expected that more than 10 percent of respondents will complete the survey by phone, based on results of the 2008 NSMHTF.
The 2010 N-MHSS also will include an informational website for facilities, with restricted access areas for states and the SAMHSA/CMHS task order officer (TOO). For facilities, the site will contain the questionnaire, as well as all definitional and instructional material. It also will include links to related SAMHSA sites, a description of the study and its goals, and a link to view current response rates by state (a similar N-SSATS site had 1490 hits during the 2008 cycle). States and territories will use passwords to enter the restricted state area and access relevant project reports. The TOO will have a password providing entry to the state area as well as the restricted management section of the site. In the management section, the TOO will be able to view project materials and production reports during data collection.
The information on mental health facilities already available from other data collection efforts cannot be used because the scope of coverage is limited and available data typically are outdated and not standardized across types of facilities. For example, the American Hospital Association (AHA) collects limited information on psychiatric hospitals in its annual survey of hospitals. However, neither the scope of coverage nor the data collected are in the detail required by CMHS to facilitate mental health planning, evaluation, congressional reports, and other applications. No detailed data are collected by the AHA on ambulatory psychiatric services or on the availability of services in separate psychiatric inpatient units of non-federal general hospitals, the nature of these services, caseloads, and client/patient characteristics. With regard to coverage, the AHA survey excludes many state, county, and private psychiatric hospitals that are neither AHA members nor registered by the AHA. Although some basic information (for example, provision of psychiatric services) is collected on the AHA survey, the 2010 N-MHSS will collect more detailed and standardized information regarding hospitals with separate psychiatric inpatient units in comparison with other types of mental health facilities.
No other national organization or federal agency collects standardized information on mental health services across particular mental health facility types such as outpatient community mental health clinics, residential treatment centers for severely emotionally disturbed children, and multi-setting community mental health facilities.
The Office of Applied Studies (OAS) within SAMHSA collects data on substance abuse treatment services through the N-SSATS. These data are restricted to substance abuse services provided by substance abuse or mental health facilities. The 2010 N-MHSS will complement and not duplicate the data collected by OAS since it will collect information only for mental health services.
The NCHS conducts a continuing survey of patient discharges, the National Hospital Discharge Survey (NHDS) (OMB No. 0920-0212), based on inpatient data from short-stay hospitals, as well as the National Hospital Ambulatory Medical Care Survey (NHAMCS) (OMB No. 0920-0278) that surveys hospital-based ambulatory services. However, neither of these surveys provides information at the facility level on mental health services and the utilization of those services. In addition, NCHS collects information on patients seen by physicians, including psychiatrists, in private practice in its National Ambulatory Medical Care Survey (OMB No. 0920-0234). In contrast to NCHS surveys, the N-MHSS does not survey treatment providers in private practice (for example, psychiatrists and clinical psychologists). For these reasons, CMHS routinely has shared data from the precursors of the N-MHSS with NCHS.
The proposed 2010 N-MHSS does not duplicate other data collection efforts and is the only national survey that will provide data for precise estimates on the characteristics of specialty mental health facilities and their service utilization necessary to fulfill the minimal data needs of federal, state, and local agencies, as well as private sector organizations. Most importantly, the N-MHSS is the only national source that provides a current and comprehensive database of mental health facilities throughout the U.S. used to populate the Mental Health Facility Locator available through SAMHSA’s online Mental Health Services Locator, a vital resource for mental health consumers, family members, and mental health professionals searching for needed mental health services throughout the nation.
The 2010 N-MHSS involves small entities. The following methods will be used to minimize reporting burden for small entities in particular and for all respondents in general:
The survey is designed to collect the absolute minimal amount of information required for the intended use of the data.
The use of Internet technologies will increase the options available to the respondents to complete the survey (for example, mail, fax, or web) and will decrease the time between data collection and error resolution (for example, the Internet version will automatically check each response).
The facility name and address information will be included on the cover of the questionnaire. The facility will be asked to correct and update the items directly on the cover rather than completing these items on a blank questionnaire. In addition, in the web version, name and address information will be pre-filled on the first screen of the survey.
The facility is requested to report only on components that it operates directly and not on services that it purchases from other facilities through contracts or agreements.
All of the instructions for each question are included with the question rather than on a separate instruction page. This saves the respondent the time and trouble of turning pages between the questionnaire and an accompanying instruction manual.
An informational website that includes instructions and definitions of key terms will be set up for respondents. This will allow those responding on the Internet to have the survey and the definitions open simultaneously in their web browser.
Key terms in the web survey will be hyperlinked so that respondents can click on the term and be taken directly to that term on the informational website definitions page.
Contractor staff will be available, via a toll-free telephone line, to answer any questions that respondents may have regarding the 2010 N-MHSS.
If the requested information is not collected, federal program and policy activities will suffer in several ways. As part of its mission, the Center for Mental Health Services/SAMHSA leads national efforts to improve mental illness prevention, mental health treatment, and mental health recovery services for all Americans. CMHS pursues this mission by helping States improve the quality of their mental health programs and service delivery systems. Through development of data standards that provide the basis for uniform, comparable, high-quality statistics on the numbers and characteristics of mental health service providers throughout the nation and of persons served, CMHS surveys, specifically the N-MHSS, is vital to providing much needed and timely data that permit analyses of state and national trends in mental health service utilization important as the state level for program planning and resource allocation purposes.
As the only federal source with responsibility for the production and updating on a timely basis the mental health facility database used for the Mental Health Facility Locator available through SAMHSA’s online Mental Health Services Locator, the N-MHSS is critical for providing mental health consumers, their families, and mental health professionals with the most current information for locating appropriate services in their area. In addition, the N-MHSS further supports CMHS’ program efforts in response to “Goal 6 – Technology Is Used to Access Mental Health Care and Information” of the President’s New Freedom Commission on Mental Health, Achieving the Promise: Transforming MH Care in America (See: www.mentalhealthcommission.gov/reports/FinalReport/FullReport.htm). Among the Commission’s findings was that there exists unmet needs and that “more individuals could recover from even the most serious mental illnesses if they had access in their communities to treatment and supports that are tailored to their needs.” If the proposed N-MHSS is not conducted or conducted less frequently, critical information about mental health treatment services offered to consumers in need of such services will not be available to this segment of the U.S. population. Finally, as similar surveys have done previously, the information collected in the N-MHSS will provide the sampling frame for periodically conducted specialized surveys of mental health service providers and persons served.
The CMHS surveys have a tradition of being fielded approximately once every two years. Rare exceptions to this two-year survey cycle have occurred, such as in 2006 when there was a shift in survey focus from the organization as respondent to the facility as respondent and it was not possible to issue a contract for the survey to be conducted in that year. If the data collection were conducted less frequently, essential cross-sectional data, as well as trend data, would not be available for planning and research at the federal, state, and local levels. Because of the rapid pace of change in the mental health service delivery system, a two-year time frame is the minimum needed to document these changes. Finally, the 2010 N-MHSS will provide the most up-to-date information available to the public who depend on SAMHSA’s online Mental Health Services Locator for finding needed mental health care in their area.
This data collection complies fully with 5 CFR 1320.5(d)(2).
The notice soliciting public comment on this data collection required in 5CFR 1320.8(d) was published in the Federal Register on July 6, 2009 (Volume 74, number 127, page 31963). Comments were received from one source in response to this notice (See Attachment 2.0). The concern expressed was to request mental health facility respondents to provide information about their respective smoking policy and if they provide smoking cessation services. SAMHSA/CMHS recognizes that smoking is an important issue particularly as it concerns persons with mental illness. The revised N-MHSS questionnaire was modified and now includes a yes/no response category for “smoking cessation services” in Question A-10 that pertains to preventive/support services offered by mental health facilities. In addition, a new question (A-22) was added to the questionnaire that specifically acknowledges and addresses the public comment concern about the smoking policy of mental health facilities. Because of space limitations and to minimize respondent burden, this single question regarding smoking policy has been included and captures the essential intent of the suggestions offered through the public comment.
In February 2009, SAMHSA/CMHS convened a day-long expert panel meeting in Washington, D.C. This panel included representatives from national mental health consumer and specialty mental health organizations, mental health professionals and service providers, as well as representatives from academia, federal agencies, and the SAMHSA government contractors with responsibility for the development and maintenance of the online Mental Health Services Locator and customer feedback. The panel was charged with considering expansion of the survey frame. In addition, all aspects of the survey were discussed extensively, including the content of the survey questionnaire and related instructional material. Recommendations from the expert panel regarding improvements to the N-MHSS included the inclusion of eligibility criteria built into the survey questionnaire; a reorganization of questions asking about treatments, therapies, support services, and practices; and additional questions that would provide useful information for inclusion in the Mental Health Facility Locator.
Members of the expert panel include the following individuals:
Stephanie Adams, Vice President for Integrative Strategies, IQ
Solutions, Inc.
(240) 221-4353
Michael Ahmadi, Public Health Analyst, Office of Communications, SAMHSA
(240) 276-2125
Sarah Baron, Program Manager, IQ Solutions, Inc. (301) 984-1471 ext. 4312
Mark Covall, Executive Director, National Association of Psychiatric Health Systems (202) 393-6700
Will Ferris, Public Health Analyst, Strategic Planning and Evaluation Branch, OSPFM, NIAID, NIH, DHHS (301) 827-0057
Michael Gilmore, Director, Alexandria Community Services Board (703) 838-4455 ext. 206
Darcy Gruttadaro, Director, National Association of the Mentally Ill
(NAMI),
Child and Adolescent Action Center (703) 516-7965
Chuck Ingoglia, Vice President, National Council for Community Behavioral Healthcare (202) 684-7457
Ted Lutterman, Director of Research Analysis, Research Institute, National Association of State Mental Health Program Directors (703) 739-9333 ext. 121
Joy Midman, Director, National Association for Children's Behavioral
Health
(202) 857-9735
Aileen Rothbard, Research Professor, University of Pennsylvania School of Social Policy & Practice (215) 898-5588
Deborah Trunzo, Project Officer, National Survey of Substance Abuse Treatment Services, Office of Applied Studies, SAMHSA (240) 276-1267
Ashutosh Vyas, President/CEO, Vesta, Inc. (301) 459-9840 ext. 511
In addition, a pretest was conducted with representatives from nine mental health facilities that had responded to the 2008 NSMHTF. These respondents were mailed a pretest version of the questionnaire, completed the survey on paper, and then were interviewed by telephone using a structured debriefing guide. The debriefing focused on the clarity of concepts, questions, and skip instructions, as well as the overall burden to respondents. In response to pretest feedback, the questionnaire was edited to improve clarity and reduce burden. Discussion of the pretest for the 2010 N-MHSS is provided in Section B.4. A list of survey pretest participants is included in Attachment 3.0.
No payment or gifts are provided to respondents to participate.
No assurance of confidentiality is pledged to the respondents completing the survey questionnaires because the questions on the survey instrument pertain to their professional roles as representatives of the mental health facility with knowledge of this information. The 2010 N-MHSS does not involve the collection of confidential information. As a public health data request, the 2010 N-MHSS is in full compliance with HIPPA privacy regulations regarding client confidentiality. No personally-identifiable information is requested to be provided in this survey. All data collected on client characteristics are to be reported in aggregate form, only.
There are no questions of a sensitive nature in the 2010 N-MHSS.
The response burden and hourly wage were estimated by consulting with the nine-member survey pretest group who assessed the validity of the response burden and an average of $40 hourly wage plus fringe cost estimate (See Section B.4).
Estimates of the response burden are shown in Table 1. The estimated time for response to the questionnaire is one hour. Each facility will be asked to respond to one questionnaire. The N-MHSS will involve approximately 13,000 facilities. The total national hourly cost will be approximately $520,000 using $40 as the average wage plus fringe hourly estimate. Unlike the previous organization-level IMHO surveys, respondent burden variation across facilities is expected to be small given the change in the type of data to be collected. However, when seen from an organizational perspective, mental health organizations with many facilities will have a higher additive response burden.
TABLE 1
RESPONSE BURDEN FOR THE 2010 NATIONAL MENTAL HEALTH SURVEY
(N-MHSS)
Facility Type
|
Number of Respondents |
Responses per Respondent |
Total Responses |
Hours per Response |
Total Hour Burden |
Wage Rate |
Total Hourly Cost |
Public Psychiatric Hospitals
|
305 |
1 |
305 |
1 |
305 |
$40 |
$12,200 |
Private Psychiatric Hospitals
|
536 |
1 |
536 |
1 |
536 |
$40 |
$21,440 |
General Hospitals with Separate Psychiatric Units
|
1,719 |
1 |
1,719 |
1 |
1,719 |
$40 |
$68,760 |
Residential Treatment Centers for Adults
|
833 |
1 |
833 |
1 |
833 |
$40 |
$33,320 |
Residential Treatment Centers for Children
|
1,191 |
1 |
1,191 |
1 |
1,191 |
$40 |
$47,640 |
Outpatient Clinics (including Hospital-Based)
|
6,292 |
1 |
6,292 |
1 |
6,292 |
$40 |
$251,680 |
Multi-Setting Community Facilities
|
2,124 |
1 |
2,124 |
1 |
2,124 |
$40 |
$84,960 |
Total
|
13,000 |
|
13,000 |
|
13,000 |
|
$520,000 |
There are no capital, start-up, operations, or maintenance costs to respondents associated with this project.
The 2010 N-MHSS will be executed under a three-year contract (the third year is an option year) for which the total cost is $2,499,747. Year one concentrates on survey frame and questionnaire development. The second year focuses on the development of survey applications and data collection, followed by a third year directed toward data cleaning, summarizing, and publishing. Additional costs will be incurred indirectly by the government in personnel costs of staff involved in oversight of the survey. It is estimated that one CMHS employee will be involved for approximately 50 percent of time at a salary of $55.00 per hour. Costs of CMHS staff time will approximate $57,000 annually, for a total of $171,000 for the three-year contract period.
The total government cost estimate for the contract amount and government personnel costs is $2,670,747, with an annualized cost of $890,249.
Currently, there are 4,610 burden hours in the OMB inventory. When preparing this submission, it has come to SAMHSA’s attention that the hours were incorrectly recorded on the 2008 Notice of Action. The burden should have been recorded as 13,831 hours, as the 2008 NSMHTF supporting statement and 30-day Federal Register notice reported. SAMHSA is now requesting 13,000 hours. The decrease of 831 hours is due to an adjustment in that there are currently less specialty mental health facilities in operation than in previous years.
Table 2 shows the time schedule for the 2010 N-MHSS. The survey mailing is scheduled for one month after OMB approval. The generation of tables from the 2010 N-MHSS is scheduled for 14 months following OMB approval.
TABLE 2
PROPOSED SCHEDULE
Activity |
Planned Start Time |
Printing of questionnaires, letters, and instructional materials |
OMB approval |
Mailing |
OMB approval + 1 month |
Data collection |
OMB approval + 2 months |
Anomaly production |
OMB approval + 3 months |
Non-response prompting calls |
OMB approval + 5 months |
Core and missing data CATI |
OMB approval + 6 months |
Data collection cutoff date |
OMB approval + 9 months |
Production of unimputed file |
OMB approval + 10 months |
Production of imputed file |
OMB approval + 11 months |
Table production |
OMB approval + 14 months |
Final file delivery |
OMB approval + 18 months |
Submission of project documentation |
OMB approval + 19 months |
The planned data analysis is designed for the following purposes:
To develop national tables for use in the CMHS publication series, Mental Health, United States, in special SAMHSA Data Highlights reports, and to answer information requests.
To develop state-level tables, including national totals, for distribution to the states and for posting on the restricted access areas for states on the N-MHSS website.
To provide detailed facility-level utilization data by type of mental health organization (e.g., state psychiatric hospitals, private psychiatric hospitals) and type of service setting (i.e., inpatient, residential, and outpatient) at both the national and state levels to answer information requests and for use in CMHS publications.
Tables for a planned Mental Health, United States, 2010 will include all mental health organizations in the United States aggregated from the facility to the organization level. Tables will include:
Number of mental health organizations, by type of organization: United States, selected years, 1970–2010
Number, percent distribution, and rate of 24-hour hospital and residential treatment beds, by type of mental health organization: United States, selected years, 1970–2010
Number, percent distribution, and rate of 24-hour hospital and residential treatment admissions, by type of mental health organization: United States, selected years, 1969–2010
Number, percent distribution, and rate of less than 24-hour care admissions, by type of mental health organization: United States, selected years, 1969–2010
An example of a Mental Health, United States, 2004 table is presented in Attachment 4.0.
State Tables, 2010 will include all mental health organizations in the United States aggregated from the facility to the organization level. Specific tables will include:
a. Number of Mental Health Organizations by State According to Organizational Type: 2010 N-MHSS
b. Patient Census in 24-Hour Hospital or Residential Care Settings by State, According to Patient Census Indicators: 2010 N-MHSS
c. Number and Rate per 100,000 U.S. Population in a 24-Hour Hospital or Residential Setting by State, and According to Caseload Statistics: 2010 N-MHSS
An example of a table from 2004 State Tables is presented in Attachment 5.0. The State Tables, 2010 will be distributed to the states and made available to the public in response to information requests through the National Mental Health Information Center (NMHIC) site.
An exemption for the requirement to display the expiration date is not requested.
This collection of information involves no exceptions to the Certification for Paperwork Reduction Act Submissions.
The 2010 National Mental Health Services Survey (N-MHSS) is a multimode (web, paper, and CATI) survey of all eligible mental health treatment facilities currently operating in the United States, its territories, and the District of Columbia. As in the 2008 NSMHTF, the 2010 survey will collect information at the facility or point-of-service level, while at the same time retaining the relationship of the service location to the organizational level. The survey defines a mental health facility as one that (a) is formally established by law, regulation, charter, license, or agreement; (b) has an established organizational structure, including a staffing structure; (c) has a primary goal for all or part of the facility of improving the mental health of its clientele; (d) has a clientele with psychiatric, psychological, or associated social adjustment impairments; and (e) provides mental health treatment services. In addition, eligible facilities must have a primary treatment focus of providing mental health, or an equal mix of mental health and substance abuse, treatment services. Facilities are excluded if they are: a jail, prison, or other organization that provides treatment solely for incarcerated persons; administered by the Indian Health Service (IHS) or tribally-operated; a Department of Defense (DoD) military treatment facility (MTF) or; an individual or small group mental health practice.
The resulting survey frame includes facilities that provide hospital inpatient services; residential services; and outpatient, day treatment, or partial hospitalization services. It includes psychiatric hospitals, general hospitals with separate psychiatric units, outpatient clinics, residential treatment centers for both adults and children, and multi-setting (nonhospital) mental health facilities.
A full enumeration of all eligible mental health facilities is planned; therefore, no formal sampling plan is needed. A census survey is the preferred method for the 2010 N-MHSS because the data are meant to measure trends in service utilization and also to populate SAMHSA’s online Mental Health Facility Locator. The estimated number of mental health facilities by type is presented in column 1 of Table 1 of Section A.12.
The survey will continue to be a 100 percent enumeration of all known specialty mental health treatment facilities. Respondents to the 2010 N-MHSS will have a choice of (a) responding to the questionnaire on paper and mailing it in, (b) completing the questionnaire on paper and faxing it in, or (c) responding on the Internet. Non-respondents will be contacted by telephone and offered the option of completing the questionnaire by telephone (CATI). Facilities whose completed questionnaires are missing critical information also will be contacted by telephone in an effort to collect missing information. Instructional material and definitions of key terms will be available on an informational section of the survey website and as part of a paper insert in the mailed survey packets. The cover letter, definitions packet, and questionnaire for the 2010 N-MHSS are included in Attachments 6.0-6.3.
The 2010 N-MHSS will use a single questionnaire that is designed to collect, from a cross-section of mental health facilities, information about the various types of services provided to persons with mental illness. The N-MHSS will also collect information about the facility’s caseload, accreditation, and service programs for specialized client/patient populations. This purpose and the necessity to produce the database for SAMHSA’s online Mental Health Facility Locator require a full and current enumeration of mental health facilities throughout the United States and its territories.
In preparation for fielding the 2010 N-MHSS, the survey frame was updated through careful and thorough enhancement procedures that included contacting the state mental health agency (SMHA) in each state and territory to request a list of all eligible mental health facilities that they currently operate. These state and territory lists of eligible facilities were then combined with lists of facilities obtained from the following national associations and federal agencies: American Association of Children’s Residential Facilities, Alliance for Children and Families, American Hospital Association, American Residential Treatment Association, National Association of County Behavioral Health Directors, National Association of State Mental Health Program Directors, National Council for Community Behavioral Healthcare, and National Association of Psychiatric Health Systems. In addition, a list of mental health facilities was obtained from the Centers for Medicare and Medicaid Services (CMS).
Before the questionnaire is fielded, contact will be made with the SMHA in each state and territory to request a letter of endorsement for the survey. Letters of endorsement also will be requested from relevant national associations, who will be asked to post a statement of endorsement or notice about the upcoming 2010 N-MHSS on their websites to encourage facility participation. During the survey pretest of the N-MHSS, it was learned that facilities would be encouraged to respond to the survey if it were accompanied by endorsements.
It is anticipated that there will be four mailings for the 2010 N-MHSS: (a) an advance letter, (b) the initial survey packet, (c) a reminder letter, and (4) a second survey packet. The advance letter will alert facilities to the upcoming survey, and it will serve as a locating tool. Envelopes will be marked as “Return Service Requested” and undeliverable mail will be returned with new address information noted. The N-MHSS database will be updated with the new address and the advance letter will be resent. This will ensure that the majority of addresses in the database are current prior to mailing the initial survey packet.
The initial survey packet will be mailed approximately six weeks following the advance letter. It will contain a cover letter from SAMHSA/CMHS that includes information about the Mental Health Facility Locator, the survey website, and the toll-free telephone helpline; a copy of the respective state endorsement letter; an endorsement letter from a relevant national association; the N-MHSS questionnaire; a frequently asked questions (FAQ) 0page; a web flyer with the facility’s user ID and password; brief packet of definitions; and a postage-paid business reply envelope. The survey packet also will include a fact sheet with information about SAMHSA, the purpose of the survey, facility selection and data collection procedures, confidentiality, and how the survey results will be used. The fact sheet was added to the survey following feedback from facilities that participated in the survey pretest. Survey packet materials can be found as Attachments 6.0-6.3.
Approximately three weeks after the initial survey packet mailing, a reminder letter will be sent to all facilities that were mailed the survey packet. This letter will contain the facility’s user ID, facility password for accessing the survey online, and the telephone number for the survey helpline. Approximately four weeks following the reminder letter, a second survey packet will be mailed to facilities that have not yet responded. The packet will contain a slightly revised cover letter, along with all of the same survey-related materials that were included in the initial packet.
For respondents who have not returned the questionnaire 10 weeks after the initial mailing, reminder calls will be made through a CATI system, in which facilities will be encouraged to log on to the survey website and complete the survey online. If the opportunity arises during this call, interviewers will be trained to complete the full CATI interview if that is the facility’s preference. Once reminder calls have been completed, interview calls will be made to the facility director or the person designated by the director to schedule a time to complete the full CATI interview. Calls will be scheduled using an automated scheduler, and a message will be left after two attempts to contact the facility director. That message will include the survey helpline telephone number and a survey ID reference number for the facility director to use when returning the call.
Two weeks before the end of the field data collection period, a final round of reminder faxes will be sent requesting that facilities complete a number of critical core data items from Sections A and B of the questionnaire.
Throughout this process, the survey frame will be managed through a centralized application, Facility Tracking and Data Editing System (F-TADES), a specially developed application that will store and organize facility information, manage and monitor survey progress, and field multiple data collection modes simultaneously for the 2010 N-MHSS. WebServ2 (the web survey application), Blaise (the CATI application), and Viking (the data entry application) all interface with F-TADES, which tracks case status and stores contact information for each mental health facility in the survey frame file. F-TADES issues records to Blaise and WebServ2 for the CATI and web surveys and disables records in these modes when a case is complete. Through F-TADES, it is possible to put a case or set of cases on hold and re-field them at a later time based on status code, survey progress, or re-contact strategy. Also through F-TADES, the status of each facility is constantly recorded and monitored. This eliminates the possibility that facilities that have completed the survey will be contacted again, unless there are missing data that need to be collected or inconsistencies in need of error resolution.
Mailed questionnaires will be received by reading their barcodes into the F-TADES application. Faxed questionnaires will be received and read into F-TADES manually using the ID on the first page of the questionnaire. The Paperless Online Edit Tracking system (POET), which was developed for N-SSATS and modified for N-MHSS, will be used to track hard-copy edits and callbacks by staff. This F-TADES module is used by phone center staff during the initial quality control review of the paper questionnaires to record data quality problems. All problems and resolutions are recorded, and all calls to facilities are entered into the F-TADES history file. Paper questionnaires are then data entered using Viking, a full-featured data entry software that runs on Unix. The software features 100 percent double-key verification; skip, range, and consistency checks; and field flagging for error resolution. The data from Viking, the web and CATI will all be saved directly into the master data file in F-TADES.
All questionnaires, regardless of the response mode, will be reviewed for consistency using a uniform set of rules. Questionnaires returned in the mail and those that are faxed will receive a 100 percent manual review. The web and CATI instruments will prevent and identify errors through the programming of edit specifications; thus, web and CATI errors are resolved as the respondent completes the survey.
For responses that are still missing after these data collection methods have been concluded, appropriate imputation techniques will be employed similar to those used in previous rounds of the survey. It is expected that the same approach will be applied to the N-MHSS imputation for critical core data items. Imputation will involve deductive procedures combined with either hot-deck or regression-based approaches. Imputing missing items will focus on selected variables based on their importance to the study and the availability of historic data to make quality imputations feasible. The final approach will be based on the type and extent of missing data, analysis objectives, and availability of auxiliary data for use in imputation. The expectation is that deductive and hot-deck methods will be used.
Historically, response rates for the precursor to the N-MHSS, the Inventory of Mental Health Organizations (IMHO) have been in the 80 percent to 90 percent range. However, since 1998, the response rates have declined to the 70 percent to 80 percent range. The response rate for the 2008 NSMHTF was 74 percent. The 2010 N‑MHSS questionnaire format and data collection procedures have been revised to be more closely aligned with those used by
N-SSATS. Because the N-SSATS survey has been successfully fielded for many years with an average 95 percent response rate, it is expected that response rate for the 2010 N-MHSS will closely approximate that achieved in the latest rounds of SAMHSA’s N-SSATS.
It is critical in the 2010 N-MHSS to emphasize to facilities the importance of the survey and the value of their participation. It also is critical to make communication between the facilities and the government contractor conducting the N-MHSS for SAMHSA/CMHS as fluid and easy as possible. The following methods have been developed to ensure a high response rate.
The first method used to maximize the response rate will be to handle undelivered mail. On the mail out of the advance letter, a return address service will be requested of the U.S. Postal Service. This service instructs the Postal Service to return undeliverable mail with a sticker showing the correct address. The facility’s contact information will then be corrected in the F-TADES database prior to mailing out the initial survey packet. For other returned mail, the contractor will attempt to determine the correct address (by use of the telephone and the Internet) and if found, update the database and send a survey packet to the correct location.
A second method of maximizing response rate is to pre-fill some responses for the facility, such as facility name and address. Only factual information that changes little from year to year will be pre-filled in an effort to ease respondent burden and encourage the facility to continue with the survey.
The third method to encourage higher response rates is incorporating the facility eligibility criteria as screening questions on the survey questionnaire. In the 2008 NSMHTF, eligibility criteria were detailed in a separate flyer in the survey packet, and facilities were required to read the criteria and determine for themselves if they were eligible to participate in the survey. In the 2010 N-MHSS, every facility that receives the survey packet will be instructed to respond to the questionnaire, and a series of clear screening questions at the beginning of the survey instrument will screen out those facilities that are ineligible.
The fourth method to encourage higher response rates is the use of business-reply mail envelopes, which will be included in the packet so that the respondent will be able to return the questionnaire without paying for postage. A fax number will be included in the instructions so that respondents may elect to use this method for returning the completed questionnaires if they prefer. In addition, a web version of the questionnaire and all supporting materials will be available to respondents on the survey website, accessed with the facility’s unique user ID and password. The survey packet will include a brightly-colored web flyer, highlighting the web address and the facility’s user ID and password, so that respondents are immediately aware of the web option. Respondents will have three modes available for responding to the 2010 N-MHSS: mail, fax and web. Offering different modes of return is expected to help improve the response rate. Throughout the field period, the contractor will continually encourage facilities to respond to the survey in the mode of their preference, through a reminder letter, a second survey packet mailing, and reminder faxes.
A fifth method of maximizing response rate will be through the use of CATI for facilities that do not return a completed questionnaire. The software package Blaise will be used to create the CATI, and the calls will be made from the contractor’s telephone center. It is expected that most facilities that do not complete a paper or web questionnaire will complete the CATI. CATI initially will be used to make reminder calls to facilities asking them to complete the survey on paper or on the web. These modes are preferable, as facilities that respond by paper and web tend to provide more accurate client counts than do those that complete the survey by telephone. Following the reminder calls, if a facility still has not responded, it will be contacted again in an attempt to complete the full survey by telephone. For remaining non-responders near the end of the data collection period, the CATI will include only the core questions (from Sections A and B of the questionnaire). Based on results on the 2008 NSMHTF, it is expected that approximately 45 percent of respondents will complete the survey by web, 40 percent will complete/return by mail, 10 percent will complete by CATI, and another 5 percent will complete/return by fax.
A sixth method of maximizing the response rate is including in the advance and initial survey cover letters from SAMHSA/CMHS (that introduces the survey and explains its purpose), a clear emphasis on the importance of having accurate facility information listed in SAMHSA’s online Mental Health Facility Locator. Facilities that do not respond to the survey may have inaccurate or incomplete information in the locator, which impedes their ability to provide help to those mental health consumers, family members, and professionals in search of needed mental health treatment services in their communities. Other important survey-related materials to maximize survey response rate include the fact sheet which provides details about the purpose of the survey and the many important uses of the resulting data, as well as endorsement letters from each facility’s state mental health agency (SMHA) and the appropriate national association of which the facility is an affiliate or member. Select associations will provide a letter of endorsement to be included in the survey packet or will post either a notice about the upcoming N-MHSS or a statement of endorsement of the survey on their website. The use of endorsement letters has been an effective method demonstrating support for the importance and value of the survey to the mental health field. Used most recently in the 2008 NSMHTF, endorsements letters are a significant factor in encouraging survey participation. In the survey pretest, most respondents stated that such endorsements and the addition of a fact sheet would encourage their participation in the survey.
A seventh method for improving response rates will be the availability of a toll-free telephone helpline number that will be included in all correspondence to facilities. In the 2008 NSMHTF, facilities called the helpline to report a change in director or contact person for the survey, an additional service site location, a change of address, or to change answers submitted in response to the questionnaire. In their survey packets, facilities will be provided with a frequently asked questions (FAQ) flyer that will summarize those questions that might otherwise cause a respondent to decline to participate in the survey. Definitions of key terms and concepts will be included in the survey packets to facilitate responses to questions about treatment approaches and services offered at each facility.
Finally, an informational section on the survey website will be developed for facilities and states that will contain the questionnaire, all instructional material and definitions, and other supporting materials including the FAQ flyer, survey fact sheet and copies of endorsement letters and web notices. Based on feedback obtained from the survey pretest, the presence on the website of easily retrievable definitions for key terms used in the survey and answers to FAQs will help to ensure response. Obstacles to successfully completing the survey will be minimized so that respondent time and effort will be used efficiently resulting in a high completion rate. In addition to the posting of endorsement letters/web notices from national associations to help garner support and enthusiasm for the N-MHSS, and as an added incentive to participate, the informational site also will be used during the field data collection period to post weekly reports with response rates for all 50 states, the District of Columbia, and the U.S. territories.
To test the revisions made to the 2010 N-MHSS questionnaire and accompanying instructional material based on recommendations from the expert panel (See Section A.8), and to test data collection procedures, a survey pretest was conducted with 9 representative mental health facilities that had been systematically selected from among the respondents that completed the 2008 NSMHTF. Following initial contact with the directors of the selected sites, a survey packet that included the draft questionnaire and instructional material was mailed to each facility director for review prior to conducting the pretest debriefing. These debriefings focused on a variety of survey-related issues including, for example, organizational/facility structure; point-of-contact roles and responsibilities for completing the questionnaire; Internet access; detailed questionnaire review for clarity of data items, categories, and skip patterns; mail out procedures; motivation regarding facility participation including being listed on SAMHSA’s online Mental Health Facility Locator; respondent burden; and usability features of a survey website.
The majority of directors reported that their facility had the necessary technical capabilities for entering data onto a password-protected survey website. Directors recommended that the inclusion of a fact sheet in the survey packet of materials would be a helpful tool by provided a brief overview of survey sponsorship, purpose of survey, selection of facilities for participation, data collection procedures, and use of survey results. They also had recommendations for clarifying the wording of several data items on the questionnaire, and suggestions for changes to survey procedures and instructions to improve data collection and reduce burden.
These recommendations were incorporated into revisions made to the data collection procedures, the survey instructional material, and the questionnaire (See Attachments 6.0-6.3). The 9 representative mental health facilities that participated in the survey pretest can be found as Attachment 3.0.
Mathematica Policy Research (Mathematica) is the primary government contractor with overall responsibility for the implementation through execution phases of the project—development of the survey frame, conducting the fieldwork for the 2010 N-MHSS for SAMHSA/CMHS, development of imputation procedures, and the creation of a final imputed data file. Mathematica is also responsible for the production of statistical tables derived from data obtained through the N-MHSS and for analysis of survey results that will be published in a SAMHSA Data Highlights report.
The primary contractor for this project is:
Barbara Rogers, Project Director
Mathematica Policy Research
600 Alexander Road
Princeton, NJ 08540
(609) 275-2249
The statistical consultant regarding this project’s imputation procedures:
Eric Grau
Mathematica Policy Research
600 Alexander Road
Princeton, NJ 08540
(609) 275-2249
The government project officer/task order officer (TOO) for this project is:
Laura Milazzo-Sayre
Survey Statistician
Survey, Analysis and Financing Branch
Division of State and Community Systems Development
Center for Mental Health Services, SAMHSA
1 Choke Cherry Road, Room 2-1098
Rockville, MD 20857
(240) 276-1764
List of Attachments
Attachment 1.0— 2010 N-MHSS Revised Questionnaire
Attachment 2.0— Public
Comment, 60-Day FRN Regarding the 2010 N-MHSS; Federal
Register/Vol. 74, No. 127, Pg. 31963/Monday, July 6, 2009
Attachment 3.0— 2010 N-MHSS Pretest Participants
Attachment 4.0— Example Table from Mental Health, United States, 2004
Attachment 5.0— Example Table from 2004 State Tables
Attachment 6.0— 2010 N-MHSS Cover Letter from SAMHSA/CMHS
Attachment 6.1— 2010 N-MHSS Bi-Fold Fact Sheet
Attachment 6.2— 2010 N-MHSS Web Flyer
Attachment 6.3— 2010 N-MHSS Definitions Packet
| File Type | application/msword |
| File Title | OMB Package |
| Author | Barbara Roders |
| Last Modified By | USER |
| File Modified | 2009-12-02 |
| File Created | 2009-12-02 |