Tab C - Comments

Page 10 – State Comments and SAMHSA Response

State Comments on Proposed Changes to the FY 2011-2013 Uniform Application for the SAPT Block Grant In Response to November 17, 2009 Federal Register Notice, November 17, 2009 and SAMHSA’s Response

In all, ten Single State Agencies (SSA) for substance abuse prevention and treatment responded to the opportunity to comment on the November 17, 2009 Federal Register Notice (FRN). The FRN proposes to renew the information collection requirements for the SAPT Block Grant, alter the annual State Plan requirement to a 3-year cycle, consolidate attachments into their relevant Federal goal narrative requirement, add a form to collect information on States’ priorities and remove an underutilized data form. The remaining States and the National Association of State Alcohol and Drug abuse Directors (NASADAD) did not submit written comments on the proposal nor did any other stakeholder.

In general:

Several States stated that the redesigned, multi-year State plan and single year annual report and application should result in a useful improvement to the structure of the application. The change to a 3-year plan results in a “…more cohesive and meaningful strategic plan,” “… some workload reduction in time by moving to a three year planning cycle,” and “…it can be advantageous to develop goals/plans for farther into the future than one year.”

Timing of New Application

State Comments:

CA, HI, IL, NY, and PA – During the month following release of the FRN and draft uniform application, several States submitted a letter under separate covers requesting delay of the implementation of the proposed changes due to adverse economic climate and staffing difficulties. The States of Wisconsin and Florida mentioned similar concerns. Several States submitted separate letters after the comment period had closed.

SAMHSA Response:

SAMHSA responded to several States (California, Hawaii, Illinois, New York, and Pennsylvania) on January 11 that the proposed changes to the SAPT Block Grant Uniform Application would need to move forward in concordance to agreements reached with the Single State Agencies for substance abuse prevention and treatment and other key stakeholders. In addition, the information collection process requires SAMHSA to seek approval of a new uniform application.

State Comments:

IL – The State suggests delaying new application for one year and redirect staff efforts towards providing “administrative relief.”

NY – The State argues that with economic burdens on States, the timing of this change is difficult and unfortunate.

HI – The State indicates that recessionary economic impacts and staff limitations make implementing change difficult. Fiscal year references in the application should be reviewed to determine if the references are appropriate.

WI – The State feels it could only implement system with Strategic Prevention Framework (SPF) by 2012.

FL – The State relates that it is in agreement with the letter submitted by the five States (CA, HI, IL, PA and NY) suggesting that the addition of a three year plan along with the expectation that the plan be updated annually, if necessary, creates an unequal exchange of workload. FL is also concerned about the timelines for release of the new uniform application and how this affects States’ preparation and submission.

SAMHSA Response:

Implementation of this change results in a reporting burden reduction in years 2 and 3 of a 3-year plan, consolidates all attachments with the relevant Federal required narratives, improves the clarity of instructions throughout the uniform application and prepares States for the altered requirements under the proposed reauthorization.

OMB clearance must be obtained for FY 2011-2013. The application, along with the State plan and annual report, is required by the authorizing legislation and implementing regulation.

The current revision proposal contains changes that are minimal. Specifically, the proposed change to the planning narrative adds an additional two pages to the former three page limit during the first year. Burden becomes reduced during years 2 and 3 of the multi-year application and report process. Preparation of the plan in years 2 and 3 only requires updates to the needs assessment and planning sections if changes have occurred potentially saving substantial preparation time.

In addition, SAMHSA has worked with the National Association of State Alcohol and Drug Abuse Directors (NASADAD) to identify sections of the application that were redundant or unclear. As already described, SAMHSA has used State and NASADAD input through their Application Re-Design Workgroup to consolidate reporting requirements and related attachments into one section on Federal requirements. Furthermore, form and narrative instructions have been altered throughout the application in an effort to enhance clarity. Finally, with the assistance of quality assurance consultants employed by NASADAD, references in the application have been thoroughly examined and revised to improve clarity and ensure that appropriate years are referenced when multiple or single years are to be addressed.

SAMHSA has taken steps to ensure the application is made available to the States as soon as possible. Once OMB approval for the new guidance is received, the SAPT Web Block Grant Application System (Web-BGAS) distributes the newly approved SAPT Block Grant application guidance almost immediately. As in previous cycles, if OMB requires no further changes to the SAMHSA draft application guidance, States that used the draft version to begin their application process will be able to use a SAMHSA provided utility to effortlessly transform their draft uniform application into the OMB-approved version of the FY 2011-2013 Uniform Application for the SAPT Block Grant program.

Additional Planning Section

State Comment:

WI – The State indicates that the specifications for using the planning framework of needs assessment, epidemiologic analysis and informed decision-making process are laudable but timing is one year premature. The State feels that planning processes may be only informative due to internal formula bases for sub-State distribution of funds. Therefore, the State contends that the changes have limited utility. The State is somewhat concerned that the target date for implementing the redesigned uniform application is unrealistic. The State suggests it could only implement system with Strategic Prevention Framework (SPF) by 2012.

SAMHSA Response:

The requirement to report on State planning activities was contained in earlier SAPT Block Grant applications. The proposed revisions to the application do not mandate the restructuring of the State planning system or internal Block Grant allocation processes. The States have been provided guidance, technical assistance (TA) and Federal support to implement needs assessment, outcomes monitoring, data collection and performance management intermittently for many years. An information based decision-making process is explicitly required under Title XIX, Part B, Subpart II and Subpart III of the Public Health Service (PHS) Act. This SAPT Block Grant application requests that States continue to make progress in implementing information-based planning and evaluation processes.

State Comment:

PA – The State indicates that States with a State Epidemiologic Outcomes Workgroup (SEOW) must describe the contribution of these groups to the planning process. To include treatment planning in this discussion is “over-reaching.”

SAMHSA Response:

If SEOWs cannot contribute to treatment planning due to scope of responsibilities or limitation of information or other reasons, this should be reported. If they do contribute to treatment planning, describe how.

In regards to prevention planning, as early as 2004, States have been informed numerous times (State System Reviews, workshops, conferences, meetings, within the provision of technical assistance and other mechanisms) about the importance of infusing the Strategic Prevention Framework (SPF) steps into the SAPT Block Grant. States are encouraged to ensure that these services are culturally responsive to the needs of their specific populations. States are to improve focus on the sustainability of State outcomes. With the use of SEOWs, States can provide for the improvement of practices and targeted funding for the SAPT Block Grant funds for prevention activities (programs, policies, and practices).

State Comment:

PA – The State suggests that instructions requiring a prevention specific component of the three-year plan specify that a separate plan should be developed and submitted. No directions are given about placement of narrative or page limits.

SAMHSA Response:

SAPT Block Grant guidance indicates that the planning narrative addressing the States three-year plan should be no longer than five pages. A prevention plan must be described within this narrative.

State Comment:

IL – The State relates that the planning section specifies that several types of information are expected to be reported. The State indicates it does not have the data systems established to report on some of the new requested information (i.e., number and nature of multi-sector partnerships at all levels, including broad-based community coalitions, how evaluation results inform decision-making processes, and how such information influences allocation decisions and setting of performance targets).

SAMHSA Response:

All States were funded to have a SEOW. The expectation is that States have used these resources and the results of the epidemiology work to create internal epidemiologic infrastructure. As a result of the SEOW funds, States should be in position to identify the most salient substance abuse problem(s) in the State and should be prepared to make data driven decisions on how to address these problem(s).

Since 2004, SAMHSA has expressed the importance of moving the Strategic Prevention Framework (SPF) process into the prevention portion of the SAPT Block Grant. The five steps of the SPF are: needs assessment, capacity building, planning, implementation and evaluation. States have been informed numerous times (State System Reviews, workshops, conferences, meetings, within the provision of technical assistance and other mechanisms) about the importance of infusing these SPF steps into the SAPT Block Grant, ensuring that they are culturally responsive to the needs of their populations, and focusing on sustainability of State outcomes.

As of the latest reports, the SPF process is being implemented within the planning process for the States’ primary prevention set-aside of the SAPT Block Grant:

58 States/Territories use SPF for State prevention need assessments; 56 States/Territories use SPF for building State capacity; 59 States/Territories use SPF for State prevention planning; and over two-thirds of the States use SPF for State prevention program implementation and evaluation efforts.

Reporting Burden

State Comments:

IL – The State argues that the proposed application increases burden for the States without offsetting such increases elsewhere.

NY and NE – The States suggest the SAMHSA estimate of 16 weeks of FTE for completion under-represents necessary time for completion of the uniform application, annual report and plan. NY estimates it takes 48 weeks or 1 FTE. The State also expresses concern that there are no data forms deleted and adjustments to narrative do not provide adequate burden reduction. NE estimates that it is possible that it takes 7,000 hours to complete the application. This represents one-fourth of NE’s staff time.

WI – The State suggests that implementation of a strategic planning process would take additional months versus 10 additional hours to complete a 3-year plan.

SAMHSA Response:

A properly functioning public health system would incorporate needs assessment, planning processes and appropriate data collection as an inherent function. SAMHSA infers that these States are erroneously applying program development and implementation staff time to their estimates of burden. The estimated burden of the data collection and reporting to meet the SAPT Block Grant information collection assumes the data is routinely collected for program administration purposes. The hours calculated would apply to compiling and analyzing internal program data and completing the application package.

State Comment:

NY – The State suggests the SAMHSA estimate of prevention planning under-represents necessary time for responding to the substance abuse prevention components of the uniform application.

SAMHSA Response:

All States, except for one, already have completed or are developing a comprehensive strategic plan in the State. Again, since 2004, States have been advised to infuse the SPF process into the prevention reporting section of the SAPT Block Grant. Step three of the SPF is planning.

Information Contents Required in the Application

State Comment:

WI – The State suggests that the quality and usefulness of the data to be collected is a determination that rests with SAMHSA. Additionally, the State suggests that implementing a national software system and database would provide real-time, comparable data.

SAMHSA Response:

Congress specifies the information collection requirements of the SAPT Block Grant application. These information items are required under 45 CFR §§96.122-124 and 42 U.S.C. §300x-45. In implementing such requirements, SAMHSA provides interpretation for the States a specified under 42 U.S.C. §300x-54. SAMHSA has undertaken continuous review of the information requirements and has annually sought the assistance of NASADAD and other stakeholders to improve the clarity of instructions in the application and to reduce redundancy in reporting requirements. In addition, a number of forms may now be pre-populated with data collected and reported to SAMHSA’s Office of Applied Studies’ (OAS) Drug and Alcohol Services Information System (DASIS) Treatment Episode Date Set (TEDS), the National Survey on Drug Use and Health (NSDUH) and previously submitted data through the Block Grant Application System.

Finally, while SAMHSA supports States adoption of national data standards and use of open-source data system technologies, States and often times their sub-State entities cannot be required to adopt a “national software and database.” DASIS/TEDS utilizes State-based information system data to create a national database; however, the timeliness of State data submissions precludes this database from being a “real-time” database.

Data Definitions

State Comments:

LA, PA, HI – Several States request that SAMHSA clarify and standardize definitions across the application citing specifically the prevention sections.

SAMHSA Response:

SAMHSA and NASADAD’s Performance Data Workgroup have worked over the years to improve collaboration in order to ensure the application contains clear definitions and consistent use of terms throughout the application. Specific terms that are unclear should be identified to SAMHSA. For example, see below. PA provided information about the Form 9b and SAMHSA made changes to clarify this data form’s instructions.

There seems to be concerns regarding the six prevention strategies, which are defined in the application and regulation. Each risk category is provided to address each strategy and a clear description and coding scheme are also provided. Form 8c defines resource development expenditures for the checklist and Forms 6a and 6b clearly define the primary prevention planned expenditures for each of the six prevention strategies and the Institute of Medicine (IOM) classifications.

Data Forms Overall

State Comment:

LA and HI – The States indicate that there is a lack of clarity about which forms are to be filled in annually or every three years.

SAMHSA Response:

Guidance will be provided on each data form to indicate whether this form is to be filled in annually or every three years with updates, if necessary.

Specific Data Forms

Form 3; Certifications

State Comment:

LA – The State indicates that some requirements regarding waivers, prohibited activities and implementation of the charitable choice requirements could be taken from the requirements section and added to the Form 3 Certifications.

SAMHSA Response:

Form 3 contains specific statutory requirements that require the Governor or Governors designee’s certification. The specific requirements suggested to be added to the Certification form require information beyond the Governor’s commitment that adherence to such requirements will be implemented by the State.

State Comment:

Several States complained about the re-ordering of certain forms and the potential for confusion.

SAMHSA Response:

SAMHSA and NASADAD recognize this as a concern and have taken significant efforts to address this issue. Re-structuring the application in order that its format resembles a plan required that the needs assessment and planning sections now precede sections and forms these sections had previously followed. Efforts have been undertaken to ensure all forms are referenced in a manner that provides information about how the form had been numbered prior to reorganization.

Forms 6a and 6b (formerly Forms 4a and 4b) - Primary Prevention Expenditure Checklists

Sate Comment:

CA – The State argues that the purpose of the IOM is to triage prevention audiences/participants into one of three risk levels and specifies “who” will be engaged through the intervention to be delivered. The IOM risk levels do not address “how” the risk level is to be met or “what” services/activities are needed.

NY – The State suggests that the resource development checklists and prevention strategy reports are “not necessary or useful.” Lack of clarity exists between use of IOM model and primary prevention limitations.

PA – The State comments reflected the same concerns with the IOM model.

SAMHSA Response:

The six prevention strategies in the application respond to “primary prevention” and responding to the Institute of Medicine Model information format is “optional.”

Forms 9 and 9a (formerly Forms 6 and 6a)

Sate Comment:

NY – The States argues that expansion of reporting to all entities funded through SSA is inappropriate and that Form 8 (formerly Form 4) is adequate for reporting purposes. Claims this form takes 375 hours to complete.

MI – The State argues that the reporting requirement for this form and the prevention strategy report (Form 9a) [formerly Form 6a] is a significant burden on staff time. The State requests that the forms be pre-populated with prior year’s data.

SAMHSA Response:

Congress specifically calls for all entities receiving Federal funds to be reported. The majority of the States combines resources or “braid” Federal, State and local revenue streams and it is difficult to gain a clear understanding of the States systems’ operations without a clear delineation of all entities operating with the Single State Agency for substance abuse prevention and treatment resources.

The Web Block Grant Application System (Web-BGAS) now provides the Entity Report (Form 9) with information from the prior year’s application. SAMHSA is examining if Form 9a can be pre-populated.

Specific Federal Requirements

State Comment:

HI – The State asks if under Federal Goal 2, would SAMHSA still require an estimate of the numbers served/to be served for compliance, progress, and intended use for each of the primary prevention strategies or for each of the IOM model categories. The State feels such estimates overlap with Prevention Performance Forms 12a-12b which require reporting the number of persons served for individual-based programs and population-based programs respectively, and optional Form P13 which may be used to report the number of persons served by type of intervention.

SAMHSA Response:

SAMHSA requires an estimate of the numbers served/to be served for compliance, progress, and intended use year for each of the primary prevention strategies. However, as stated earlier, the IOM model categories are “optional.”

Further, the NOMs Forms P-12a - P-13 were agreed upon by SAMHSA/CSAP and a cadre of States to be reported in the SAPT Block Grant starting in Federal fiscal year 2007 SAPT Block Grant application.

State Comment:

NY – The State requests that certain goal narratives be deleted as these are covered in the Governor’s certifications (Form 3). Suggest goal narratives 5, 14, 15, 16, and 17 be removed.

SAMHSA Response:

Congress specifically requires detailed information including reports on activities within specific time periods. These items are specified in 45 CFR §§96.121-124 and 42 U.S.C. §300x-45.

State Comment:

NY – The State argues that Goal 6 and Goal 15 attachments include duplicative and “non-essential” reports.

SAMHSA Response:

The attachments have been integrated into narrative responses and include only essential information collection items as specified in Title XIX, Part B, Subpart II of the PHS Act (42 U.S.C. §§300x-21-66) or as promulgated through the Substance Abuse Prevention and Treatment Block Grant; Interim final Rule (45 C.F.R. §96.46; §§96.120-137).

State Comment:

PA – The State feels that notes added to Federal Goal narrative requirements for Goals 4, 5, 9, 14 and 17 add language that does not appear to be appropriate to the goal. For example, PA cites Goal 14 narrative requirements asking States to discuss how Federal funds are precluded from funding needle exchange and the “note” suggesting States may want to discuss activities or initiatives related to the provision of: Prohibitions written into provider contracts; compliance site visits; peer review; training/TA. PA does not seem to understand how peer review and training TA may be related.

SAMHSA Response:

Several States use peer review activities to assist in their monitoring of providers implementation of the restrictions on expenditures for needle exchange programs. Many States provide training and TA on all Federal requirements including this ban on the use of Federal funds for needle exchange.

Forms 10a and 10b - Treatment Utilization Matrices

State Comment:

PA – The State relates concerns about a new data cell on Form 10b which allows for reporting on clients provided treatment services (excluding primary prevention by definition) at service levels that are not captured by the Treatment Episode Data set.

SAMHSA Response:

SAMHSA has no intention of “blurring the lines” between treatment and non-treatment services nor altering how States crosswalk their service definitions to the TEDS. However, a number of States provided direct services outside of the DASIS/TEDS definitions and such services are not currently being included in the enumeration of how many people are served by this program. Services such as early intervention, screening, brief intervention and peer support are not being appropriately credited to the efforts of the States and the achievements of the SAPT Block Grant program. This additional cell on Form 10b (formerly 7b) facilitates States reporting. SAMHSA does not provide an exhaustive definition in order to avoid creating an undue burden or increasing complexity by attempting to define such a varied construct across the States. Some services examples outside of DASIS/TEDS have been added to the instructions to clarify the intent.

T1-T7 and P1-P15 - Treatment and Prevention Performance Forms

State Comment:

NE – The State mentions that allowing the pre-population of performance forms is a “…way to enhance quality, utility and clarity of the information collected.”

State Response:

SAMHSA concurs that pre-population of the forms allows for increased quality and uniformity of the data.

Form T7

State Comment:

PA – The State argues that Form T7 misconstrues the instructions to provide a single value describing the range between the 25^th and 75^th percentile.

SAMHSA Response:

The instructions are clarified to state that the values sought are the 25^th and 75^th percentile values. Both values are placed in this cell with the 25^th percentile value coming first.

P1-P15 - Prevention Performance Report Forms

Sate Comment:

PA – The State expresses a concern that the majority of the Prevention NOMs “…have no direct connection to what State’s fund with the 20% set aside.”

SAMHSA Response:

The P forms data contents were determined in concert with States, NASADAD and other stakeholders in December 2004. The P1-P11 data is pre-populated NSDUH for the States. The self-reported States data, P-12 through P-15 data requirements, were promulgated in FY 2008.