SAMHSA Update: Phoenix Area IHS Behavioral Health Conference August 16 th, Jon Perez SAMHSA Regional Administrator DHHS Region IX

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2 SAMHSA Update: Phoenix Area IHS Behavioral Health Conference August 16 th, 2016 Jon Perez SAMHSA Regional Administrator DHHS Region IX

3 Total Federal Behavioral Health Spending $168.1 Billion

4 Top Federal Funding 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.

5 Overall Federal Spending 5

6 US Department of Health and Human Services Funding

7 Behavioral Health Spending in Millions of Dollars by Agency,* FY * Excludes the Department of Health and Human Services and the Social Security Administration

8 US Department of Health and Human Services 8 11 DHHS Grant making agencies Administers more than 100 programs across its operating divisions Approximately 80,000 employees FY 16 Budget approximately $1 trillion

9 DHHS Organizational Chart 9 9

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

11 SAMHSA Grant Funding: Tribally Related Programs FY Arizona: $2,975,614 California: $9,275,040 Nevada: $500,000 Total $12,750,

12 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 12

13 Indian Health Service Division of Behavioral Health Overview: Convergent Service Approach

14 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

15 Overview

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19 CAVALRY PICTURE

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21 INTEGRATION NOT SEGREGATION If you do not touch the heart, you will never heal the soul...

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23 INTEGRATION NOT SEGREGATION The spirit must be healed as well as the mind.

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

26 Western Understanding, Traditional Understanding 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 Advances in Indian Health Conference DHHS Indian Health Service

27 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

28 FOCUS ON FUNDING AND DATA Knowledge without application is meaningless

29 OF CIRCLES AND P Circle of Traditions p

30 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.

31 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

32 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

33 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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35 Tribal Behavioral Health Agenda 35 Collaboration Cooperation Engagement

36 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

37 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 37

38 What the TBHA is Not 38 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

39 TBHA Components 39 Strategies Priorities Foundational Elements

40 Moving Toward Integration: Strategic Prevention Framework 40

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42 Bending the Cost Curve, Lowering Health Care Growth: Must Address Behavioral Health Better Integrated Care Expanded Coverage to Uninsured Pay for Outcomes, Not Units Prevention & Wellness

43 ACA and Arizona (2016) ,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

44 ESSENTIAL HEALTH BENEFITS (EHB) 10 BENEFIT CATEGORIES 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

45 SAMHSA s Strategic Initiatives 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

46 Substance Abuse 46 Substance Abuse American Indians and Alaska Natives National Survey on Drug Use and Health 2013 Alcohol age AI-AN Nat l Comparison alcohol use (current) binge alcohol use heavy alcohol use Tobacco tobacco use (current) cigarette use (current) cigar use (current) smokeless tobacco (current) Illicits/Substance Abuse/SUD illicit drug use (current) substance abuse or dependence Non-medical Use of Rx Pain Relievers past year

47 Mental Health 47 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) Serious Mental Illness/SMI (past year) Major Depressive Episode/MDE (past year) Mental health service utilization (past year) Suicidal thoughts Comorbidity Co-occurring AMI-SUD Co-occurring SMI-SUD

48 NIDA Principles of Drug Addiction Treatment 3 rd Edition 48

49 NIDA Principles of Drug Addiction Treatment 3 rd Edition 49

50 Connecting with Primary Care: Impact of Behavioral Health on Physical Health 50 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

51 Connecting with Primary Care: Behavioral Health Conditions Increase Costs 51

52 Moving Toward Integration: Continuum of Care 52

53 Opioids 53 oxycodone hydrocodone heroin

54 Prescription Opioids and Heroin: Public Health Challenge 54 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.

55 The Growing Drug Overdose Epidemic New York Times NYtimes.com

56 Fentanyl Deaths 56

57 Numbers of Past Year Initiates of Selected Substances among People Aged 12 or Older:

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

59 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: Note: The percentages do not add to 100% due to rounding. 1 The Other category includes the sources Wrote Fake Prescription, Stole from Doctor s Office/Clinic/Hospital/Pharmacy, and Some Other Way.

60 White House 2011 Prescription Drug Abuse Prevention Plan Four Pillars: 1. Education 2. Tracking and Monitoring 3. Proper Medication Disposal 4. Enforcement

61 Comprehensive Addiction Recovery Act (CARA) 61 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 22 nd, 2016

62 HHS Strategy to Address Opioid Epidemic Improve prescriber practices. 2. Increase naloxone use. 3. Expand MAT access.

63 SAMHSA s Rx Drug/Opioid Abuse Prevention Efforts 63 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)

64 Education: Prescriber 64 SAMHSA Funded Free Courses

65 Providers Clinical Support System for Opioid Therapies (PCSS O) 65

66 Screening, Brief Intervention, and Referral to Treatment (SBIRT) 66 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.

67 Prescription Drug Monitoring Programs (PDMPs) 67 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.

68 Prescription Drug Monitoring Programs 68 Depending on state law: Prescribers Pharmacists Pharmacies Law Enforcement Licensing Boards Patients Others (delegate accounts allow nurses, licensed social workers to access)

69 Federal Drug-Free Workplace Program 69 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)

70 Opioid Overdose Prevention Toolkit 70 70

71 Addressing Rx and Opioid Abuse (2) Strategic Prevention Framework for Prescription Drugs (SPF-Rx): $10 M (New in substance use prevention) 71 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

72 Addressing Rx and Opioid Abuse (1) 72 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.

73 Drug Prevention Approaches School-based Family-based Community-based Workplace Media Medical settings + Difference between this estimate and the 2014 estimate is statistically significant at the.05 level.

74 SAMHSA 74 Grant Opportunities

75 SAMHSA Discretionary Grant Opportunities Page 75

76 SAMHSA Discretionary Grant Forecast 76 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.

77 HHS Grants and Contracts 77

78 Discretionary Grant Announcement Page Example 78

79 Grants.gov 79

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83 Health Resources and Services Administration (HRSA) HRSA Funding Opportunity Announcements (FOAs) & sign-up for alerts: How to Apply for a HRSA Grant: Open HRSA FOA of interest: Community Health Center Program New Access Points HRSA/Region IX POC for Nevada: Lorenzo Taylor, , ltaylor@hrsa.gov

84 Contact Information 84 Jon T. Perez, Ph.D. Regional Administrator, HHS IX Substance Abuse and Mental Health Services Administration 90 Seventh Street, 8th Floor San Francisco, CA