1 Substance Abuse Prevention and Treatment Block Grant Overview U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services.

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Substance Abuse Prevention and Treatment Block Grant Overview

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

WELCOME

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History and Intent of the Substance Abuse Prevention and Treatment Block Grant

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Public Law 97-35 (PL 97-35) created the Alcohol, Drug Abuse and Mental Health Services (ADMS) Block Grant.

PL 97-35 became effective on October 1, 1981.

In addition to funding alcohol and drug services, the ADMS Block Grant included funds for mental health services.

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The ADAMHA Reorganization Act (Public Law 102-321, 102d Congress) of 1992 created several significant changes in the Block Grant, including the following:

It created a distinct block grant for mental health services and a distinct block grant for substance abuse services.

It changed the name of the portion of the Block Grant for alcohol and drug services to the Substance Abuse Prevention and Treatment (SAPT) Block Grant.


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The current Block Grant regulations were released in the Federal Register in March 1993.

The official citation of the current regulations is Title 45 of the Code of Federal Regulations Part 96 (45 CFR Part 96), Substance Abuse Prevention and Treatment Block Grants; Interim Final Rule.

The regulations authorize the Secretary of the Department of Health and Human Services (DHHS) to provide Block Grants to States for the purpose of planning, carrying out, and evaluating activities to prevent and treat substance abuse.


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The SAPT Block Grant also incorporates provisions from each of the following:

The Tobacco Regulation for Substance Abuse Prevention and Treatment Block Grants, otherwise known as the “Synar” regulations, published in the Federal Register in January 1996.

The Office of Management and Budget (OMB) Circular A-133.

The Charitable Choice final rules published in the Federal Register on September 30, 2003.

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The Children’s Health Act of 2000 altered the following SAPT Block Grant requirements:

States are no longer required to spend a minimum of 35 percent of their Block Grant funds specifically on drug-related activities and a minimum of 35 percent on alcohol-related activities.

States do not have to maintain a $100,000 revolving loan fund to support homes for persons recovering from substance abuse—this is now optional.


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States may allocate Block Grant funds to faith-based treatment programs that maintain their religious character and hire people of their same faith.

The Secretary may exempt from maintenance of effort requirements any one-time infusion of funds that are used for a single purpose.

The Children’s Health Act also required that by 2002 the Secretary submit to Congress a plan that outlines how the Block Grant program will become a performance-based system.


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Block Grant recipients must adhere to SAMHSA’s National Outcome Measures (NOMs).


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§ 96.122 Application Content and Procedures and § 96.123 Assurances

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Block Grant recipients include each of the 50 States, each U.S. territory, the District of Columbia, and the Red Lake Band of Chippewa Indians of Minnesota.

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The Block Grant application requires States to complete standard forms, tables, and narrative sections, including:An annual report that describes the amounts of

Block Grant expenditures and the activities funded by the grant

A State Plan outlining the intended use of SAPT Block Grant funds, including how the State will comply with the Block Grant requirements

Assurances that the State will comply with the Block Grant requirements as well as other applicable Federal requirements

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§ 96.133 Submission to Secretary of Statewide Assessment of Needs

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States are required to submit an assessment of statewide and locality-specific need for authorized [Block Grant] activities.

The needs assessment must include the incidence and prevalence of drug abuse, alcohol abuse, and alcoholism.

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Incidence and prevalence data must be obtained using generally accepted research methods.

“Incidence” refers to the number of new cases that emerge with a given period of time.

“Prevalence” refers to the total number of cases at a given moment in time.

Social indicator studies and household surveys are examples of generally accepted research methods.

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State and sub-State data have to be collected and reported by:

Age

Sex

Race/ethnicity

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Data must include five substance abuse problems:

Marijuana (including hashish)

Cocaine (including crack)

Hallucinogens (including PCP)

Heroin

Alcohol

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States should also use common diagnostic criteria (e.g., DSM criteria) to measure dependence.

States must provide detailed descriptions of:Current prevention and treatment activities

Intended use of prevention and treatment funds

Treatment capacity

Primary prevention activities must be broken down by strategies used and other characteristics outlined in the Block Grant regulations.

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Primary prevention strategies should be appropriate for each target group and include, but not be limited to, approaches such as:

Information dissemination

Education

Alternatives

Problem identification and referral

Community-based processes

Environmental strategies

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States must identify the entities that provide prevention and treatment services, and they must describe those services.

States must submit information on treatment utilization that describes the type of care and utilization by primary diagnoses of:

Alcohol abuse

Drug abuse

A combination of alcohol and drug abuse

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States must describe efforts to improve substance abuse treatment and prevention activities, including:

Strategies used to improve existing programs

New programs created

Actions taken to remove barriers

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§ 96.134 Maintenance of EffortRegarding State Expenditures

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§ 96.134 Maintenance of Effort Regarding State Expenditures

The Principal State Agency for substance abuse prevention and treatment must maintain aggregate State expenditures for authorized activities at a level that is not less than the average level of such expenditures for the preceding 2 State fiscal-year periods.

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' 96.124 Certain Allocations

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States were required to establish a base of expenditures for special treatment services for pregnant women and women with dependent children.

Women with dependent children include women who are attempting to regain custody of those children.

Special Services for Pregnant Women and Women with Dependent Children

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' 96.124 Certain AllocationsSpecial Services for Pregnant Women and Women with Dependent Children

States must ensure that programs that receive funds set aside for pregnant women and women with dependent children provide or arrange for:Primary medical care, including prenatal care

Primary pediatric care for the women=s children, including immunizations

Gender-specific substance abuse treatment

Other therapeutic interventions for women addressing issues such as relationships, sexual and physical abuse, and parenting

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Therapeutic interventions for children in custody of women in treatment to address, among other things, developmental needs, sexual abuse, physical abuse, and neglect

Child care while the women are receiving services

Sufficient case management and transportation to ensure that the women and their children have access to the above services

States must also require programs that receive this set-aside to treat the family as a unit and therefore admit both women and their children into treatment, when appropriate.

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The Secretary also strongly encourages States to require programs that receive these set-aside funds to provide or arrange for the following additional services:

Case management to assist in establishing eligibility for public assistance programs provided by Federal, State, or local governments

Employment and training programs

Education and special education programs

Drug-free housing for women and their children

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Therapeutic day care, Head Start, and other early childhood programs for children

Block Grant-funded programs must use the Block Grant as the “payment of last resort” and only for those who have no other financial means for obtaining services for pregnant women and women with dependent children.

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By Federal fiscal year 1994 (October 1, 1993–September 30, 1994), States were required to establish base expenditure levels for services for pregnant women and women with dependent children.

Calculating the Required Expenditure Level for Services for Pregnant Women and Women with Dependent Children

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§ 96.131 Treatment Services for Pregnant Women

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States must require all Block Grant-funded programs to give pregnant women preference in admissions to treatment.

Programs that serve an injecting drug abuse population must give preference to treatment in the following order:

Pregnant injecting drug users first

Other pregnant substance abusers second

Other injecting drug users third

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States must also publicize the availability of services for pregnant women, including the fact that such women receive admissions preference.

States must require Block Grant-funded programs to refer pregnant women to the State when such women cannot be admitted due to insufficient capacity.

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For women referred to States because of lack of capacity, States must:

Refer the women to programs with the capacity to admit them or

Ensure that interim services, including prenatal care, are made available to the women within 48 hours after the women seek treatment

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Therefore, States must maintain:

A continually updated system for identifying treatment capacity for pregnant women who cannot be admitted

A mechanism for matching such women to treatment programs with sufficient capacity

States must also have effective strategies for monitoring programs= compliance with this section.

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§ 96.126 Capacity of Treatment for Intravenous Substance Abusers

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§ 96.126 Capacity of Treatment for Intravenous Substance Abusers

States must establish capacity management systems that enable and require programs that provide treatment for intravenous drug abuse to:

Readily report to the State when the programs reach 90 percent of their capacities

Make such reports within 7 days

Capacity Management System

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§ 96.126 Capacity of Treatment for Intravenous Substance AbusersCapacity Management System

The capacity management system should also ensure that the State:

Is capable of maintaining a continually updated record of reports of programs reaching 90 percent of their capacities

Makes excess capacity information available to Block Grant-funded programs that treat intravenous substance abuse

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States must have a waiting list management system that systematically reports treatment demand and requires Block Grant-funded programs that treat intravenous drug abuse to:

Establish waiting lists with a unique client identifier for each waiting list client

Consult the State=s capacity management system to ensure that waiting list clients are transferred to programs within a reasonable geographic area at the earliest possible time

Allow waiting list clients to be removed from the lists only when they cannot be located or the clients refuse treatment

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Block Grant-funded programs that treat individuals for intravenous substance abuse must admit each individual who requests and is in need of treatment for intravenous drug abuse not later than 14 days.

When programs cannot admit individuals for intravenous substance abuse within 14 days, the program must:Admit these individuals within 120 days

Have a mechanism for maintaining contact with individuals awaiting admission

Make interim services available within 48 hours

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Interim services must include counseling and education about:

HIV and TB

The risks of needle sharing

The risks of transmission to sexual partners and infants

Steps that can be taken to ensure that HIV transmission does not occur

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Interim services must also include referrals for HIV and TB services, if necessary.

For pregnant women, interim services should also include referrals for prenatal care and counseling on the effects of alcohol and drug use on the fetus.

Interim services may also include federally authorized methadone maintenance.

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Outreach

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Outreach

States must ensure that entities that receive Block Grant funds to treat intravenous substance abuse conduct outreach activities to encourage individuals in need of such services to undergo treatment.

States must use outreach models that are scientifically sound.

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Outreach

The regulations identify three examples of scientifically sound models:

The Standard Intervention model

The Health Education model

The Indigenous Leader model

If no models are applicable to the local situation, the State can use an approach which reasonably can be expected to be effective.

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Outreach

States must ensure that outreach efforts:

Consist of contacting, communicating with, and following up with high-risk substance abusers, their associates, and neighborhood residents

Adhere to Federal and State confidentiality requirements

Promote awareness about the relationship between injecting drug abuse and communicable diseases

Recommend steps that can be taken to prevent HIV transmission

Address the selection, training, and supervision of outreach workers

Encourage entry into treatment 46

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§ 96.127 Requirements Regarding Tuberculosis

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States must require programs receiving funds to treat substance abuse to routinely make TB services available to each individual receiving treatment for substance abuse.

Required TB services include:Counseling individuals with respect to TB

TB testing

Appropriate medical evaluation and treatment for individuals with TB

Tuberculosis Services

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§ 96.127 Requirements Regarding Tuberculosis Tuberculosis Services

Programs can provide the required TB services either directly or through arrangements with other public or nonprofit private entities.

The Principal State Agency must also establish linkages with other health providers to ensure that TB services are routinely made available.

The Principal State Agency in consultation with the primary State infectious disease authority must have written procedures and protocols to prevent the transmission of TB.

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States must also require Block Grant-funded treatment programs to implement infection control procedures that are consistent with those established by the Principal State Agency.

The infection control procedures must address how programs:Screen patients and identify individuals who are at high risk

of becoming infected

Meet all State reporting requirements while adhering to Federal and State confidentiality requirements, including 42 CFR part 2

Provide case management activities to ensure that individuals receive TB services

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When clients cannot be admitted to a program due to lack of capacity, the program must refer such clients to other providers of TB services.

States must develop effective strategies for monitoring compliance with these requirements, particularly to ensure that required services are being provided.

States must also:

Use SAPT Block Grant funds as the Apayor of last resort@ for TB services

Make reasonable efforts to determine eligibility and bill and collect payment for services

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States were required to establish a base expenditure level for State-appropriated funds expended on TB services for individuals receiving substance abuse treatment.

The base expenditure calculation is the average of the 2 State fiscal years preceding SFY93.

TB Maintenance of Effort

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§ 96.127 Requirements Regarding Tuberculosis TB Maintenance of Effort

Once the base is established, the State must maintain this level of expenditures for each year thereafter.

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§ 96.128 Requirements Regarding Human Immunodeficiency Virus

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§ 96.128 Requirements Regarding Human Immunodeficiency Virus

States with 10 or more HIV cases per 100,000 people are considered HIV Designated States.

Designated States must provide one or more HIV early intervention projects at the sites at which individuals are undergoing treatment for substance abuse.

Your State is not currently an HIV Designated State.

HIV Services

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§ 96.135 Restrictions on Expenditureof the Grant

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§ 96.135 Restrictions on Expenditure of the Grant

States cannot expend the Block Grant to:Provide inpatient hospital services except under

those conditions outlined in the regulations

Make cash payments to intended recipients of health services

Purchase or improve land

Purchase, construct, or permanently improve buildings or other facilities

Purchase major medical equipment

Satisfy any requirement for the expenditure of non-Federal funds as a condition for the receipt of Federal funds

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§ 96.135 Restrictions on Expenditure of the Grant

Provide financial assistance to any entity other than a public or nonprofit private entity

Provide individuals with hypodermic needles or syringes

Expend more than the amount of Block Grant funds expended in FFY91 for treatment services provided in penal or correctional institutions of the State

States cannot expend more than 5 percent of SAPT Block Grant funds to administer the grant.

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§ 96.132 Additional Agreements

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In their funding agreements with Block Grant-funded prevention and treatment programs, States must ensure that such programs make continuing education available to employees who provide those services.

Principal State Agency must coordinate with other appropriate services such as health, social, correctional and criminal justice, educational, vocational, and employment service systems.

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States can use methods such as the following to demonstrate service coordination:Memoranda of agreement

Inclusion of service coordination requirements in grants and contracts

Principal State Agency and subrecipients of Block Grant funds must have a system to protect patient records from inappropriate disclosure.

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The systems that States and programs use to protect clients records must:

Comply with all applicable State and Federal laws and regulations, including 42 CFR part 2

Include provisions for employee education on the confidentiality requirements and the fact that disciplinary action may occur upon inappropriate disclosures

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§ 96.136 Independent Peer Review

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States must have independent peer review systems that assess the quality, appropriateness, and efficacy of Block Grant-funded treatment services.

The regulations define Quality as the provision of treatment services that meet accepted standards and practices that will improve patient/client health and safety in the context of recovery.

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The regulations define Appropriateness as the provision of treatment services consistent with each individual=s identified clinical needs and level of functioning.

To determine quality and appropriateness of treatment, reviews must include an examination of a representative sample of client/patient records.

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In reviewing client/patient records, reviewers will examine:

Admission criteria/intake processes

Assessments

Treatment planning

Documentation of implementation of treatment strategies

Discharge and continuing care planning

Indications of treatment outcomes

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Independent peer reviewers must consist of individuals who are:

Experts in the substance abuse field

Representative of the various disciplines used by the program being reviewed

Knowledgeable about the modality being reviewed and its underlying theoretical approach to addictions treatment

Sensitive to the cultural and environmental issues that may influence the quality of services being provided

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Not providers/practitioners of the program under review

Not individuals who have administrative oversight of or authority to make funding decisions about the program under review

The peer review system must review a minimum of 5 percent of the State’s Block Grant-funded treatment programs each year.

States must ensure that independent peer review is not conducted as a part of the program licensing/certification process.

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§ 96.129 Revolving Funds for Establishment of Homes in Which

Recovering Substance Abusers May Reside

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Before the Children’s Health Services Act of 2000 was passed, States were required to maintain a $100,000 revolving fund to support homes for persons recovering from substance abuse.

The Children’s Health Services Act makes this provision optional.

§ 96.129 Revolving Funds for Establishment of Homes in Which Recovering Substance Abusers May Reside

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Each loan:

Must be for homes of six or more people

Can only be made to private nonprofit entities

Cannot exceed $4,000

Must be repaid within 2 years

Has to be repaid in monthly installments


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Comes with the condition that alcohol or illegal drug use must be prohibited in the home, and residents who violate the conditions must be expelled

Must require that residents pay the costs of housing, including fees for rent and utilities

Must require the majority vote of residents to establish policies governing the house


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States must also:

Identify and define the purposes for which loan funds will be spent

Set reasonable criteria for determining eligibility of prospective borrowers

Establish procedures and a process for applying for a loan

Provide clear written instructions to applicants concerning what is expected of them


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Keep a written record of the number and amounts of loans as well as the identities of borrowers and their repayment history

Establish reasonable criteria for selecting a fund management group, if the State decides to delegate fund management to a separate organization

The State and any entity managing the revolving fund must abide by all Federal, State, and local laws and regulations in managing the revolving fund.


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Other Applicable Requirements

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The Office of Management and Budget (OMB) Circular A-133 prescribes the conditions under which non-Federal entities must have single State and program-specific audits.

According to OMB Circular A-133, a non-Federal entity that has $500,000 or more in Federal expenditures during the entity=s fiscal year must receive a single State audit.

Single State Audit

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A non-Federal entity with $500,000 or more in Federal expenditures may elect to have a program-specific audit if:

The expenditures are under only one Federal program and

The Federal program does not require an A-133 audit

Other Applicable RequirementsSingle State Audit

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A non-Federal entity that expends less than $500,000 in Federal awards during the entity=s fiscal year:

Is exempt from Federal audit requirements for that year

Must retain records to support expenditures and must make those records available for review or audit by appropriate officials of the Federal agency, the pass-through entity, and the General Accounting Office

Other Applicable RequirementsSingle State Audit

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The OMB A-133 Compliance Supplement identifies important compliance requirements that the Federal Government expects to be considered for each major program that is audited under the auspices of OMB A-133.


OMB A-133 Compliance Supplement

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One section of the Supplement specifically addresses the audit requirements associated with the SAPT Block Grant program including:

Objectives and procedures for conducting an A-133 audit of the Block Grant program

Objectives and suggested audit procedures for determining compliance with SAPT Block Grant requirements

Other Applicable RequirementsOMB A-133 Compliance Supplement

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OMB A-133 defines recipients of Federal Awards as “Pass-through Entities” and “Subrecipients.”

A Pass-through Entity is a non-Federal entity that receives a Federal award and passes portions of it on to subrecipients to carry out a Federal program.

A Subrecipient is a non-Federal entity that expends Federal awards received from a pass-through entity to carry out a Federal program.


Subrecipient Monitoring

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For example, when an Principal State Agency subcontracts with programs to provide Block Grant-funded prevention, treatment, and rehabilitation services, the Principal State Agency is the pass-through entity and programs are subrecipients.

Other Applicable RequirementsSubrecipient Monitoring

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OMB A-133 requires pass-through entities to:

Inform each subrecipient of Federal awards, including the Catalogue of Federal Domestic Assistance title and number, the award name and number, and the award year

Convey requirements from Federal laws and regulations, the provisions of contracts or grant agreements, and any supplemental requirements imposed by the pass-through entity


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Monitor subrecipients to ensure that Federal awards are used for authorized purposes in compliance with laws, regulations, and the provisions of contracts or grant agreements and that performance goals are achieved

Ensure that subrecipients meet applicable OMB A-133 audit requirements

Issue management decisions on audit findings within 6 months after receiving subrecipients' audit reports

Ensure that the subrecipients take appropriate and timely corrective action to resolve any audit findings


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Determine if the subrecipient audits call for adjustments in the pass-through entity's own records

Require each subrecipient to permit the pass-through entity and auditors to have access to the records and financial statements


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States are exempt from the provisions of OMB cost principle circulars; therefore, State cost principle requirements apply to the SAPT Block Grant instead.


Fiscal Controls

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States and subrecipients cannot use the Block Grant to pay salaries in excess of Level I of the Federal Senior Executive Service pay scale (e.g., no more than $191,300 in 2008).

Salary Limitation

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SAMHSA’s National Outcome Measures (NOMs)

All recipients of the following grants must now comply with and report on the NOMs:

SAPT Block Grant

Community Mental Health Services Block Grant

CSAT, CSAP, and CMHS discretionary grants

SAMHSA’s National Outcome Measures

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States must have systems in place to avoid duplicated client counts.

At a minimum, such systems shall include the following:

Recording admission and discharge information for a client’s episode of care as a single record

Using a unique client identifier for each client

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Reduced Morbidity (Abstinence)

Outcome Substance Abuse Treatment Measures

Substance Abuse Prevention Measures

Abstinence from alcohol and drug use

Reduction in/no change in frequency of use at date of last service compared to date of first service

1. 30-day substance use (non-use/reduction)

2. Perceived risk/harm of use

3. Age at first use

4. Perception of disapproval


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Employment/Education



Increased/retained employment or return to/stay in school

Increased/no change in number of employed or in school at date of last service compared to first service

1. Perception of workplace policy

2. Alcohol, tobacco, and drug-related suspensions and expulsions

3. Attendance and enrollment


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Crime and Criminal Justice



Decreased criminal justice involvement

Reduction in/no change in number of arrests in past 30 days from date of first service to date of last service

1. Alcohol-related car crashes and injuries

2. Drug-related crime


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Stability in Housing



Increased stability in housing

Increase in/no change in number of clients in stable housing situation from date of first service to date of last service

Not applicable


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Access/Capacity



Increased access to services (Service capacity)

Unduplicated count of persons served; penetration rate—numbers served compared to those in need

Number of persons served by age, gender, race, and ethnicity


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Retention



Increased retention in substance abuse treatment

Length of stay from date of first service to date of last service and unduplicated count of persons served

1. Total number of evidence-based programs and strategies

2. Percentage of youth seeing, reading, watching, or listening to a prevention message


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Social Connectedness



Increased social supports/connectedness

Under development Family communication around drug use


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Perception of Care



Client perception of care

Under development Not applicable


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Cost Effectiveness



Cost effectiveness (average cost)

Number of States providing substance abuse treatment within approved cost-per-person bands by the type of treatment

Services provided within cost bands


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Use of Evidence-Based Practices



Use of evidence-based practices

Under development Total number of evidence-based programs and strategies


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Charitable Choice (45 CFR Part 54a)

According to Charitable Choice regulations, Federal, State, and local governments that receive funds under these programs cannot discriminate against an organization that is, or applies to be, a program participant on the basis of the organization’s religious character or affiliation.

Applicants for Block Grant funding must certify that they will comply with all the SAMHSA Charitable Choice requirements.

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Under Charitable Choice, Block Grant-funded faith-based organizations:Retain the authority over their internal governance

May retain religious terms in their organizations’ names

May select board members on a religious basis

May include religious references in the organizations’ mission statements and other governing documents

May use space in their facilities to offer Block Grant-funded activities without removing religious art, icons, scriptures, or other symbols

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Block Grant-funded faith-based organizations cannot use these funds for inherently religious activities such as the following:Worship

Religious instruction

Proselytization

Organizations can engage in such religious activities only if:The activities are offered separately, in time or

location, from Block Grant-funded activities

Participation in the activities is voluntary

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In delivering services, including outreach activities, SAMHSA-funded religious organizations cannot discriminate against current or prospective program participants based on:Religion

Religious belief

Refusal to hold a religious belief

Refusal to actively participate in a religious practice

If an otherwise eligible client objects to the religious character of a Block Grant-funded program, the program shall refer the client to an alternative provider within a reasonable period of time of the objection.

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Similar to all other nongovernmental organizations that receive Block Grant funds, religious organizations must use generally accepted auditing and accounting principles to account for Block Grant funds.

Religious organizations shall segregate Federal funds from non-Federal funds. Only the Federal funds shall be subject to audit by the government.

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State or local governments that contribute funds to supplement Block Grant-funded activities have the option of keeping the State/local funds separate from the Block Grant funds or commingling State/local funds with Block Grant funds.

When a State or local government commingles State/local funds with Block Grant funds, the Charitable Choice requirements will apply to all the commingled funds.

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Thank you for your participation!

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

1 Substance Abuse Prevention and Treatment Block Grant Overview U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services.

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