This relationship suggests that providers need to address trauma related issues in concert with mental health and substance abuse treatment issues to best help the homeless

consumer.

SUBSTANCE ABUSE AND THE HIV EPIDEMIC

Ms. Pelosi: Substance abuse is increasingly involved in the HIV epidemic, and is an important part of the reason the spread of HIV remains stable at 40,000 new infections per year in this country. Given the growing role of substance abuse in the epidemic, I was disappointed to see that in the President's request, SAMHSA's HIV/AIDS budget would grow only 3%, or $2.7 million to $95.5 million in FY 2000. Could you tell us about the success of HIV/AIDS-related programing, and what could be done with additional funds in the HIV-related accounts?

Dr. Chavez: We believe that all our substance abuse prevention and treatment activities, as well as many of our mental health programs, have a direct impact on HIV prevention. Among our most recent successes are a wide variety of programs in the areas of substance abuse prevention and treatment and mental health services. These programs, carried out as knowledge development and application activities and targeted capacity expansion activities are aimed at identifying best practices so that they can be replicated. We have also developed a wide array of materials in the areas of substance abuse prevention and treatment and mental health which are very useful to practitioners and service providers.

An example of a specific program area with excellent results is our outreach program. The Center for Substance Abuse Treatment has supported HIV/AIDS outreach projects since 1992. Over the course of this funding, 32 programs have provided outreach services to a diverse client range, including injecting drug users (IDUs), their needle sharing partners, and other non-IDU drug abusers from high risk, chronic, and hard to reach ethnic, cultural, gender, geographic, and age-specific populations. These programs have been instrumental in modifying behavioral patterns with respect to needle and syringe sharing, reducing risk taking sexual behaviors, and providing real avenues to treatment services.

With additional funding, HIV/AIDS outreach grants will be provided to high incidence cities to develop community-based outreach projects targeting African American and Hispanic/Latino chronic, hardcore drug users and their sex and/or needle sharing partners including women, IDUs, men who have sex with men, and adolescents.

PATH PROGRAM FOR THE HOMELESS

Ms. Pelosi: The Administration is requesting a $5 million increase for the PATH program that provides services to individuals with severe mental illness who are homeless or at risk of becoming homeless. Could you tell us about the impact this increase would have on decreasing both the number of homeless with mental illness, and the burden on Local communities in attempting to serve this population?

Dr. Chavez: In FY 1999, the PATH program will fund contacts with approximately 102,000 of an estimated 600,000 persons during the year who are homeless and have serious mental illnesses. The increase of $5 million will enable providers to contact an estimated 13,000 more persons in FY 2000. An estimated 4,000 persons contacted are expected to become clients and will be provided assistance in obtaining housing and mental health services. CMHS is also attempting to provide information to State PATH contacts about the most effective services, e.g., descriptions of effective services in persons with co-occurring mental health and substance abuse services were provided in the last fiscal year.

Based on this experience, we can reasonably expect that the budget increase will assist persons exhibiting psychiatric symptoms to move off the streets and into treatment. We are currently developing measures to assess more quantitatively, outcomes of PATH provided services and to encourage studies of impact on Local services.

TREATMENT ON DEMAND

Ms. Pelosi: In Subcommittee Reports for both FY 1998 and FY 1999, SAMHSA is urged to work with the City of San Francisco in support of the City's innovative treatment on demand program. Could you give us an update on this collaboration?

Dr. Chavez: The Center for Substance Abuse Treatment (CSAT) has provided $500,000 through two funding mechanisms in support of San Francisco's Treatment on Demand efforts. The following is a synopsis of efforts to-date, accomplishments, and future plans:

1. $250,000 was awarded through a supplement to the San Francisco Target Cities (TC) Cooperative Agreement to assist with data collection and evaluation, covering:

a. Staff training in San Francisco to assist in generating reports on baseline and services delivery data on all individuals receiving services for substance abuse treatment;

b. A consultant to assist San Francisco in planning for maximum use of the current

1

c. Additional staff positions to extract the data necessary to generate reports and data on baseline and ongoing services to support evaluation of Treatment on Demand initiative.

2. A Task Order was awarded at the end of Fiscal Year 1998 to the University of California at San Francisco (UCSF) to work with the city/county of San Francisco to develop and implement an evaluation of the Treatment on Demand efforts.

a. A process evaluation is underway with Lisa Moore, Ph.D., of San Francisco State University (as a subcontractor to UCSF), to document the development of the intervention and "tell the story" of how Treatment on Demand develops visa-vis the planned intervention. This is a process of documenting what was intended, versus what was implemented, and the steps necessary to put the system in place.

b. A utilization/cost-effectiveness study, under the leadership of James Kahn, M.D., of UCSF, is investigating the budgeted health services funding for the treatment system to document where the dollars come from, what they buy, and the status of slot utilization in San Francisco.

c. James Sorenson, Ph.D., and Joseph Guydish, Ph.D., both of UCSF, are leading a study of two sites to provide a picture of the change in access due to Treatment on Demand efforts. Two sources of data are being used: the current wait-list data reported by all providers; and the a pilot study of two of the larger programs in San Francisco (one a residential program, and the other a methadone treatment program) to interview clients when they present for treatment, and 3 months later to ascertain how quickly they are able to access treatment once Treatment on Demand dollars are available to bolster treatment capacity (versus baseline assessment of access relying on retrospective data from the city/county system once reports can be generated - see paragraph 1).

The Treatment on Demand initiative in San Francisco affords the opportunity to analyze the effect of pumping extra resources (approximately $12 million) into a major metropolitan area's treatment system. Additionally, it will yield lessons on what works well and what elements have a more diluted effect on the overall access, utilization and treatment of community drug and alcohol problems. Additional funding would allow for a longitudinal study, which will be necessary to fully document and analyze the systems' change. This should include, but not be limited to, the ability to assess programs other than the two (residential and methadone) programs that have volunteered to have their programs evaluated.

A comprehensive report on this effort will be provided to Congress by March 31,

CHILDREN'S MENTAL HEALTH SERVICES PROGRAM

Ms. Delauro: I am very interested in the Children's Mental Health Services program and the "real world" results it brings to the children it serves. Do you have any information on improvements in the children's ability to function, reductions in their involvement with juvenile justice authorities, and their performance in school? How does the program work with families and involve them in their children's treatment?

Dr. Chavez: The Comprehensive Community Mental Health Services for Children and Their Families Program has generated important information about how children in the program are improving in their ability to function in "real world" settings. The following findings describe functional improvements that children now being served by the program are able to make after one year of services:

Law Enforcement Contacts Reduced. “No law enforcement contacts” were reported for 55 percent of the children who had experienced one or more contacts in the 12 months before entering services. In fact, reports from one program reported a 61 percent reduction in the number of crimes committed by youth in probation during their first year in the program when compared to the 12 months before entry.

School Grades Improve. The percent of children with average or above average school grades increased by more than 20 percent.

Mental Health Functioning Improves. Levels of functional impairment as assessed through the Child and Adolescent Functional Assessment Scales (CAFAS) decreased by almost 20 percent.

Fewer School Absences. The percent of children attending school very infrequently was reduced by 46 percent.

One of the most significant changes that has occurred through this initiative has been the emphasis on in-home services. By working in families' homes, professionals see what the family sees and share the experience. Also, family members in the sites report a significant change in the respect they receive from professionals in the system of care. Many families acknowledge that their strengths are addressed as well as their problems and as a result are often given choice of appropriate services such as family therapy, respite care and parenting classes. They feel supported and like having a case management system as the central point of contact. The majority of sites routinely include siblings and extended family members in social and recreational activities. Most impressive is that over half of the sites have active family support organizations

TARGETED TREATMENT CAPACITY EXPANSION PROGRAM

Mr. Jackson: Dr. Chavez, I am pleased to see that your budget emphasizes treatment for substance abuse. Your budget alluded to a 1996 study that showed that for every dollar spent on treatment, $5.60 is returned in public savings from reduced use of welfare, food stamps, Medicaid funds, crime and reduced imprisonment. This is an idea that I have supported for years. If someone suffers from substance abuse and addiction, incarceration is not going to solve their problem. First of all, can you get me a copy of the 1996 study? Secondly, can you elaborate on the successes and the value of the Targeted Treatment Capacity Expansion program? How do you think the proposed increase in this program will benefit the millions of substance abusers?

Dr. Chavez: A copy of the study you have requested, "Societal Outcomes & Cost Savings of Drug & Alcohol Treatment in the State of Oregon,” prepared for the Office of Alcohol and Drug Abuse Programs, Oregon Department of Human Resources, and Governor's Council on Alcohol and Drug Abuse Programs, by Michael Finigan, Ph.D., 1996, will be provided to your office. In addition, we will also provide you highlights from SAMHSA's "National Treatment Improvement Evaluation Study (NTIES)," and a copy of the Center for Substance Abuse Treatment publication, “Producing Results: A Report to the Nation, 1998." All of these documents reflect that, indeed, treatment does work.

As you may know, even with the level of funding in our block grant program there is a significant disparity between the availability of treatment services for alcohol and substance abuse and the need for such services. Only approximately 37% of individuals in need of substance abuse treatment services can be served through the existing publicly funded system. By providing the additional services that can be obtained through the Targeted Capacity Expansion Program (TCE), we hope to reduce the health and social costs to the public by improving a community's or a group of communities' ability to identify specific treatment gaps, including, for example, specific ethnic or racial groups or geographic areas that have been historically under-represented in both treatment providers and attention to client populations needing services. The Targeted Capacity Expansion Program allows States, cities, counties, and tribal governments to support rapid and strategic responses to the demand for substance abuse services at the Local level.

Because the program funding went out to the States and Local levels in September 1998, we are not yet able to report "successes” in terms of individual recovery or data, but the mere fact that we have been able to provide funding that is getting treatment services to areas that are desperate for them is a success in itself. To illustrate, SAMHSA is providing funds for services to locales as disparate as three remote Yup'ik/Cup'ik Eskimo villages in the Yukon Kuskokwim region of Southwest Alaska, to the San Diego County Drug Court program, to a program serving a minority population in Chicago, to a clinic for IV drug users in a traditionally "blue collar" working community outside of Pittsburgh. The Chicago project, funded through the Illinois