SAMHSA Update: Phoenix Area IHS Behavioral Health Conference

August 16th, 2016Jon Perez

SAMHSA Regional Administrator

DHHS Region IX

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Total Federal Behavioral Health Spending 2015

$168.1 Billion

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Top Federal Funding 2015

Social Security Administration:

$87.2 billion is the largest, representing 51.9% of

the federal budget for mental health

DHHS:

HHS budgets $66.8 billion, or 39.8% of the

federal budget, for behavioral health.

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Overall Federal Spending

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US Department of Health and Human Services Funding 2015

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Behavioral Health Spending in Millions of Dollars by Agency,* FY 2015

* Excludes the Department of Health and Human Services and the Social Security

Administration

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US Department of Health and Human Services

– 11 DHHS Grant making agencies

–Administers more than 100 programs across its operating divisions

– Approximately 80,000 employees

– FY 16 Budget approximately $1 trillion

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DHHS Organizational Chart

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FY 2016 President’s Budget for HHS(Dollars in millions)

2014 2015 2016 /1

Budget Authority 961,166 1,048,237 1,092,992

Total Outlays 936,223 1,013,051 1,093,041

Fulltime Equivalents (FTE) 74,947 77,865 80,418

http://www.hhs.gov/about/budget/fy2016/budget-in-brief/index.html

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SAMHSA Grant Funding: Tribally Related Programs FY 2015-16

http://www.samhsa.gov/grants-awards-by-state/details/Arizona

http://www.samhsa.gov/grants-awards-by-state/details/California

http://www.samhsa.gov/grants-awards-by-state/details/Nevada

Arizona: $2,975,614

California: $9,275,040

Nevada: $500,000

Total

$12,750,654

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Quick Update: TBHG

• FY16 Tribal Behavioral Health Grant Program– Also Known as Native Connections

– Application deadline: June 2, 2016

– Funding: $94.8 Million over 5 years

– Number of Awards: About 94 new tribal grants

– Purpose: (1) Prevent and reduce suicidal behavior and substance abuse; (2) reduce the impact of trauma; (3) promote mental health

– Population: Young people up to/including age 24

– Eligibility: Tribes, tribal organizations, consortia of tribes or tribal organizations

Indian Health Service

Division of Behavioral Health

Overview:

Convergent Service Approach

Of Theories, Maps, and Compasses

How we understand something depends, in no small measure, on our worldview:

where we are from

what we have learned

what our life experiences have been

what we hold to be true and of great value

Overview

CAVALRY PICTURE

INTEGRATION NOT SEGREGATION

If you do not touch the

heart, you will never heal

the soul...

INTEGRATION NOT SEGREGATION

The spirit must be healed

as well as the mind.

U.S. Senate: First Session of the 52nd Congress, Congressional

Serial Set 2892

1891

Ziewie Davis No 2 F Very bright girl eldest daughter of an ambitious

father who made a great effort to have things as she had learned to

want them. He owned a small store and wishing to be very civilized had

his name translated into English (Don t Know How) and printed on his

sign DK How. Ziewie was his clerk and bookkeeper for about a year but

unexpectedly developed consumption and died in a few months. Her

influence was such that her sister and cousins were at once sent off to

school

I would sit right in front of the examining table and

then people would just come and drop by and talk to

me.

But what they wanted to talk about was dreams…

Eduardo Duran, Ph.D.

2010 Advances in Indian Health Conference DHHS Indian Health Service

Western Understanding, Traditional Understanding

WESTERN DATA AS UNIVERSAL “REALITY”

“For generations, Native Peoples have been objects of study, financial gain, or publishing potential, more victimized than helped by ‘data’ and data based inquiry. Such inquiry is performed almost exclusively by researchers from worlds Native Peoples do not understand; nor do the researchers, in turn, really understand their Native subjects.

They just believe they do because they have numbers that say so.”

Jon Perez, Ph.D.

Director of Behavioral Health, IHS

NIMH Conference on Collaborative Research 2004

FOCUS ON FUNDING AND DATA

Knowledge without

application is

meaningless…

OF CIRCLES AND P

pCircle of

Traditions

OF CIRCLES AND P

• Areas of convergence between

• theory and practice

• traditional and non-traditional

• experimental and time honored

• The area between the circles that take the best from both worlds to serve the people who live in both worlds.

CONVERGENT SERVICES…

• Integrate:

• Heart, Mind, Body, Spirit

• Professions, approaches, worldviews

• Mobilize:

• Understanding and action

• A person’s strengths

• A family’s and community’s strengths

• Sustain:

• the changes when they are still new and tenuous

• Habituate:

• Make a new home

CONVERGENT PRACTICES ARE

CHARACTERIZED BY…

• Problem focus not discipline focus

• Mutual respect for divergent worldviews,

training and approaches--windows to

understanding, allies in the fight

• Using Strengths to fight Problems

• Bringing many weapons to bear on problems

• Including individual, family, and community.

• Being sustainable

• Integrated evaluation of the programs themselves

CONVERGENT SERVICES

• Technology is a tool not a cultural value

• Information is power

• It will be a central weapon to support your

programs and services

• Use it to support your people and programs

• Passivity or rejection of it will equal

programmatic demise

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Tribal Behavioral Health Agenda

• Collaboration

• Cooperation

• Engagement

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The Power of the TBHA

• Based on tribal voices and priorities

• Opportunity to shape policies and programs

– Supports wisdom of cultural/traditional practices alongside Western approaches

– Garners appropriate attention to priorities that address outstanding challenges

– mobilizes collaborators to act together

• Uses existing platforms (i.e., strategic plans, etc.) to “work differently”

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6

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What the TBHA is

• A document that provides a clear, national statement about the extent and need for prioritizing behavioral health problems

• A tool for improving collaboration on common issues across different entities/sectors

• A blueprint that harmonizes efforts and creates a unified approach for funding, programs, and policy activities—no single entity changes outcomes alone

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What the TBHA is Not

• Not a silver bullet—will not fix problems, compounded over decades, overnight

• Not a strategic plan—nor a replacement for existing strategic plans (existing plans have a purpose and legal and/or policy directives)

• Not a list of prescribed actions that tribal, federal, state, and local governments or other stakeholders must take

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TBHA Components

Strategies

Priorities

Foundational Elements

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Moving Toward Integration: Strategic Prevention Framework

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2010

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Bending the Cost Curve, Lowering Health Care Growth: Must Address Behavioral Health

Pay for Outcomes, Not Units

Better Integrated

Care

Expanded Coverage to Uninsured Prevention

& Wellness

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ACA and Arizona(2016)

• 205,666 individuals selected a Marketplace plan

• 280,546 Arizonans enrolled in Medicaid and CHIP

• 487,212 Total new beneficiaries

• expands mental health and substance use disorder benefits and federal parity protections for:

• 1,269,319 Arizonans

http://www.hhs.gov/healthcare/facts/bystate/az.html

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ESSENTIAL HEALTH BENEFITS (EHB) 10 BENEFIT CATEGORIES

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care

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SAMHSA’s Strategic Initiatives

1. Prevention of Substance Abuse and Mental Illness

2. Trauma and Justice

3. Recovery Support

4. Health Care and Health Systems Integration

5. Health Information Technology

6. Workforce Development

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Substance Abuse

Substance Abuse—American Indians and Alaska Natives

National Survey on Drug Use and

Health 2013

age AI-AN Nat’l Comparison

Alcohol

alcohol use (current) 12+ 37.3 52.2 ↓

binge alcohol use 12+ 23.5 22.9 ↑

heavy alcohol use 12+ 5.8 6.3 ↓

Tobacco

tobacco use (current) 12+ 40.1 25.5 ↑

cigarette use (current) 12+ 36.5 21.3 ↑

cigar use (current) 12+ 6.1 4.7 ↑

smokeless tobacco (current) 12+ 5.3 3.4 ↑

Illicits/Substance Abuse/SUD

illicit drug use (current) 12+ 12.3 9.4 ↑

substance abuse or dependence 12+ 14.9 6.6 ↑

Non-medical Use of Rx Pain Relievers

past year 12+ 9.9 5.8 ↑ 46

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Mental Health

Mental Health—American Indians and Alaska Natives

National Survey on Drug Use and Health 2013 age AI-AN Nat’l Comparison

Mental health

Any Mental Illness/AMI (past year) 18+ 26.0 18.5 ↑

Serious Mental Illness/SMI (past year) 18+ 5.8 4.2 ↑

Major Depressive Episode/MDE (past

year)18+ 8.9 6.7 ↑

Mental health service utilization

(past year)18+ 15.7 14.6 ↑

Suicidal thoughts 18+ 4.8 3.9 ↑

Comorbidity

Co-occurring AMI-SUD 18+ 7.4 3.2 ↑

Co-occurring SMI-SUD 18+ 1.1 1.0 ↑47

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NIDA Principles of Drug Addiction Treatment 3rd Edition

http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-

based-guide-third-edition/frequently-asked-questions/how-effective-drug-addiction-

treatment

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NIDA Principles of Drug Addiction Treatment 3rd Edition

http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-

based-guide-third-edition/frequently-asked-questions/how-effective-drug-addiction-

treatment

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• Mental health problems increase risk for physical health problems.

• Substance use disorders increase risks for chronic diseases, HIV/AIDS, STDs.

• Cost of treating common diseases higher with untreated behavioral health problems– Hypertension – 2X the cost– Coronary heart disease – 3X the cost– Diabetes – 4X the cost

Connecting with Primary Care: Impact of Behavioral Health on Physical Health

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Connecting with Primary Care: Behavioral Health Conditions Increase Costs

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Moving Toward Integration: Continuum of Care

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Opioids

oxycodone hydrocodone

heroin

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Prescription Opioids and Heroin: Public Health Challenge

In 2014, 1.9 million people had a prescription opioid use disorder and nearly 600,000 had a heroin use disorder. The national data on overdose deaths are startling: in 2014, there were 28,647 overdose deaths involving prescription opioid medications and/or heroin.

That is equivalent to an average of one death every 18 minutes.

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The Growing Drug Overdose Epidemic

55 New York Times – NYtimes.com

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Fentanyl Deaths

Numbers of Past Year Initiates of Selected Substancesamong People Aged 12 or Older: 2014

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Perceived Great Risk from Substance Use among People Aged 12 or Older: 2014

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Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older:

2012-2013

Note: The percentages do not add to 100% due to rounding.1The Other category includes the sources “Wrote Fake Prescription,” “Stole from Doctor’s Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”

White House 2011 Prescription Drug Abuse Prevention Plan

Four Pillars:

1.Education

2.Tracking and

Monitoring

3.Proper

Medication

Disposal

4.Enforcement

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Comprehensive Addiction Recovery Act (CARA)

• Passed the House of Representatives on July 8th, 2016 with vote of 407-5;

• Passed the Senate on July 13th, 2016 with vote of 92-2;

• Signed into Law by the President July 22nd, 2016

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HHS Strategy to Address Opioid Epidemic

1. Improve prescriber practices.

2. Increase naloxone use.

3. Expand MAT access.

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SAMHSA’s Rx Drug/Opioid Abuse Prevention Efforts

• Prescriber Education

• PCSS-Opioids and PCSS-MAT

• Screening, Brief Intervention, and Referral to Treatment – SBIRT

• SAMHSA/CDC Prescription Drug Abuse Prevention Campaign

• Not Worth the Risk, Even If It’s Legal (pamphlet series)

• Federal Drug-Free Workplace Program

• Prescription Drug Monitoring Program (grants and pilots)

• Opioid Overdose Prevention Toolkit

• Drug Free Communities

• Substance Abuse Block Grant

• Partnerships for Success grants

• SPF Rx grants (new)

• PDO grants (new)

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Education: Prescriber

SAMHSA Funded Free Courses

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Providers Clinical Support System for Opioid Therapies (PCSS – O)

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Screening, Brief Intervention, and Referral to Treatment (SBIRT)

SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers, and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur.

– Screening quickly assesses the severity of substance use and identifies the appropriate level of treatment.

– Brief intervention focuses on increasing insight and awareness regarding substance use and motivation toward behavioral change.

– Referral to treatment provides those identified as needing more extensive treatment with access to specialty care.

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• Many states established PDMPs to reduce prescription drug abuse and diversion.

– Statewide electronic databases:

• Collect prescription records for all outpatient controlled substance prescriptions dispensed in the state

• Distribute patient health information from the database to individuals authorized under state law.

Prescription Drug Monitoring Programs (PDMPs)

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Prescription Drug Monitoring Programs

Depending on state law:

• Prescribers

• Pharmacists

• Pharmacies

• Law Enforcement

• Licensing Boards

• Patients

• Others (delegate accounts allow nurses, licensed social workers to access)

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Federal Drug-Free Workplace Program

• The biggest prevention program in the nation.

• Certifies drug testing labs for federal programs.

• Sets drug testing standards for the workplace.

• Prevention of Prescription Drugs in the Workplace (PAW)

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Opioid Overdose Prevention Toolkit

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Addressing Rx and Opioid Abuse (2)

Strategic Prevention Framework for Prescription Drugs (SPF-Rx): $10 M (New in substance use prevention)

• Raise public awareness about dangers of sharing medications

• Work with pharmaceutical and medical communities to raise awareness on risks of overprescribing

• Develop capacity and expertise in use of data from state prescription drug monitoring programs (PDMPs) to identify communities by geography and high-risk populations

• Eligibility is limited to states and tribal entities that have completed a Strategic Prevention Framework State Incentive Grant (SPF SIG), and have a state-run PDMP

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Addressing Rx and Opioid Abuse (1)

Preventing Opioid Overdose-Related Deaths: $11M (New in substance abuse prevention)

• Grants to 11 states to reduce # of opioid overdose-related deaths

• Help states purchase naloxone not otherwise covered

• Equip first responders in high-risk communities

• Support education on use of naloxone and other overdose death prevention strategies

• Cover expenses incurred from dissemination efforts

• Recipients of the Substance Abuse Prevention and Treatment Block Grant (SABG) are eligible to apply.

+ Difference between this estimate and the 2014 estimate is statistically significant at the .05 level.

Drug Prevention Approaches

• School-based

• Family-based

• Community-based

• Workplace

• Media

• Medical settings

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SAMHSA

Grant Opportunities

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SAMHSA Discretionary Grant Opportunities Page

http://samhsa.gov/grants/grant-announcements

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SAMHSA Discretionary Grant Forecast

The SAMHSA forecast (PDF | 290 KB) provides information on SAMHSA’s upcoming Requests for Applications (RFAs). Prospective Applicants can learn more about SAMHSA’s plans for release of RFAs including brief program descriptions, eligibility information, award size, award number and proposed release date.

http://www.samhsa.gov/grants/grant-announcements-2016

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HHS Grants and Contracts

http://www.hhs.gov/grants/index.html

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Discretionary Grant Announcement Page Example

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Grants.gov

https://www.cms.gov/About-CMS/Contracting-With-CMS/ContractingGeneralInformation/Grant-Information/CMSGrantsHomePage.html

http://www.grants.gov/search-grants.html?agencyCode%3DHHS

Health Resources and Services Administration (HRSA)

• HRSA Funding Opportunity Announcements (FOAs) & sign-up for

email alerts:• www.hrsa.gov/grants

• How to Apply for a HRSA Grant:• www.hrsa.gov/grants/apply

• Open HRSA FOA of interest:

Community Health Center Program New Access Points

http://bphc.hrsa.gov/programopportunities/fundingopportunities/NAP/index.html

• HRSA/Region IX POC for Nevada:

Lorenzo Taylor, 415-437-8125, ltaylor@hrsa.gov

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Contact Information

Jon T. Perez, Ph.D.

Regional Administrator, HHS IX

Substance Abuse and Mental Health Services Administration

90 Seventh Street, 8th Floor

San Francisco, CA 94103

415 437 7600

jon.perez@samhsa.hhs.gov