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Policy Information Center Highlights: Vol. 2, No. 4

In This Issue:



On any given night, up to 600,000 Americans are homeless, and of this group, about one-third of the single adults are severely mentally ill. In addition to their mental problems, these people may lack adequate income and social supports, may suffer from alcohol and/or other drug abuse, and may experience community resistance and discrimination. In response to this problem, the Interagency Council on the Homeless charged the interdepartmental Task Force on Homelessness and Severe Mental Illness to develop strategies that the federal and state governments as well as the private sector could use in enhancing housing, treatment, and support services for homeless people with severe mental illness.

The report resulting from that request, Outcasts on Main Street: Report of the Federal Task Force on Homelessness and Severe Mental Illness, presents more than 50 action steps that federal agencies can take to end homelessness among the severely mentally ill. The study outlines essential elements of a coordinated, integrated service system for homeless people with severe mental illness and proposes measures that states and communities can adopt in improving the organization, financing, and delivery of a wide range of services for this population.

Among task force participants there was widespread agreement on the critical components of such a service system. The homeless mentally ill need aggressive outreach; integrated care management; and "safe havens," or stable residences where they can recover from the street environment and develop linkages to benefits, treatment, and supports. They require housing, services that can help them remain housed, mental health care, treatment for alcohol and other drug abuse, and health care for the wide range of physical ailments they may suffer. They also need vocational training, employment assistance, income support, and legal services.

The report also describes how the federal government can promote service integration, expand housing options, enhance access to existing programs, and disseminate information. Two major recommendations already being implemented are (1) that HHS, in conjunction with a number of other federal departments, make available to the states Access to Community Care and Effective Services and Supports (ACCESS) grants, designed to encourage partnerships that will lead to the integration of federal, state, local, and voluntary services for severely mentally ill homeless people; and (2) that the Department of Housing and Urban Development (HUD) propose to Congress a new demonstration program that would assess the feasibility of providing a form of safe, low-cost, stable housing for those unwilling to enter the existing shelter system. Finally, the report proposes that HHS' National Institute of Mental Health (NIMH) identify exemplary programs that have combined housing assistance with supportive services and that it disseminate information on how such programs can be developed and replicated elsewhere.

The study was compiled by the interdepartmental Task Force on Homelessness and Severe Mental Illness, which is now active in implementing the report's recommendations. Dr. Walter Leginski, Acting Director, Homeless Programs Section, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, is the agency contact. Copies of the final report, #4657, are available from PIC.



Past research has shown that drug promotions involving items of value affect physicians' prescribing practices. Previous reports compiled by the Office of Inspector General (OIG) indicate that drug firms offer doctors gifts and items of value related to studies, speaking engagements, and program attendance in promoting their products. The pharmaceutical industry and the medical community consider certain promotional practices involving items of value to be inappropriate; however, it is unclear how their recently developed ethical guidelines will affect drug firms and physicians.

The report, Prescription Drug Promotion Involving Payments and Gifts: Physicians' Perspectives, describes drug promotions that result in physicians receiving money and other gifts, examines the extent to which doctors receive gifts and payments from drug manufacturers, and explains the ways in which the government and the pharmaceutical industry regulate drug promotions.

A nationwide survey of 617 physicians and reviews of ethical guidelines developed by the American Medical Association (AMA) and the Pharmaceutical Manufacturers Association (PMA) show that, in the year prior to fall 1991, pharmaceutical companies offered gifts or other payments on at least one occasion to 82 percent of physicians; these gifts and payments included pens, pharmaceutical samples, and travel expenses. During the period, drug firms also offered 27 percent of physicians gifts or payments that current AMA/PMA guidelines define as inappropriate, such as honoraria for attending educational programs or meetings. Finally, because pharmaceutical firms offered many doctors gifts or payments that fell into gray areas in the AMA/PMA guidelines in the year prior to 1991, the report concludes that the guidelines' definitions of inappropriate promotions may not be precise in some cases.

A number of federal and private-sector initiatives have focused on regulating drug promotions. In December 1990, the Senate Labor and Human Resources Committee conducted hearings highlighting questionable drug practices. At that time, the AMA announced the release of its ethical guidelines regarding drug firms' gifts to physicians. The PMA immediately adopted these guidelines in full. In addition, the Commissioner of the Food and Drug Administration (FDA) has implemented a hotline that physicians and pharmacists can call to report inappropriate promotional activities.

To enhance these efforts, the study recommends that the PMA work with the AMA to more specifically define lines of propriety in the remaining gray areas of its guidelines. The report also advises that the Public Health Service (PHS), through the FDA, finalize guidelines specifying what it considers promotional activity and what it considers scientific interchange.

In commenting on the report, the PHS agreed that FDA should provide guidance to pharmaceutical companies regarding the distinction between independent scientific exchange and promotional activities. PHS further noted that FDA's Deputy Commissioner for Policy is developing a policy guidance document in consultation with the Office of the Assistant Secretary for Health. FDA expects that the document will be finalized and published in fiscal year 1993.

The study was conducted by the Office of Evaluation and Inspections, Office of Inspector General. Copies of the final report, #4652.1, are available from PIC.



Children who enter the child welfare system have faced serious adversities -- including abuse, neglect, and abandonment -- that are likely to have negative effects on their mental health. If left untreated, problems related to these experiences can lead to delinquency, trouble forming relationships, or difficulty keeping a job, and could escalate to levels requiring intensive interventions such as hospitalization or incarceration. Until now, however, the adequacy and availability of services for these children, especially those who are not labeled severely emotionally disturbed (SED), have not been documented.

The report, Community-Based Mental Health Services for Children in the Child Welfare System, examines the efforts of five communities that have demonstrated exemplary approaches in helping children and their families. The study focuses on the kinds of services provided to these children, particularly those who are not labeled SED; reviews the extent to which communities' child-serving agencies are collaborating to improve service delivery; and describes the factors that were influential in developing coordinated systems of care for children.

The study finds that the communities' only clear criteria for defining children's mental health needs were those developed to identify children who are labeled SED. Children who are not clearly SED are recognized as needing services because of behavioral or conduct problems. Few sites have programs specifically for child welfare clients; most serve a broader population, within which children in the child welfare system may or may not be a priority. When a wide array of services is available, these children do not always benefit because of constraints such as eligibility criteria and program capacity. Some of the sites have attempted to involve multiple agencies and families in service planning; however, most efforts are independent initiatives that may or may not be shared with others.

The report concludes that, even in these model communities, there is a need to develop and fund services for child welfare clients and to overcome the fragmented state of the current service system. Providing these services will mean expanding priorities so that children who do not have the most severe emotional or behavioral problems also receive needed care; designating leadership responsibility for coordinating efforts to address children's mental health needs; and exploring consistent, long-term funding sources to enable lasting improvements of the mental health service delivery system.

The study was conducted by Macro International, Inc., under contract to the Office of the Assistant Secretary for Planning and Evaluation. The study's project officer, Elisa Koff, can be reached on 202-690-5880. Copies of the executive summary, #4368, are available from PIC.



During the past 20 years, the federal government has utilized a number of strategies in funding social services for individuals in need. In 1974, Congress created Title XX of the Social Security Act, designed to eliminate recipients' economic dependency, to remedy the neglect or abuse of children and adults who are unable to protect their own interests, and to reduce the incidence of inappropriate institutional care. In 1981, the Omnibus Budget Reconciliation Act amended Title XX to create the Social Service Block Grant (SSBG), which consolidated funding for the original Title XX social services, child day care, and social service staff training. The goals of the SSBG were the same as those of Title XX, but the block grant gave states greater flexibility and authority in managing the program.

The report, Assessment of the Social Service Block Grant Program, presents a retrospective look at states' experiences with SSBG during the decade in which the program has existed and describes innovative practices states have developed in dealing with the changing environment for social services. The study focuses on the flexibility of the block grant and gives special attention to states' administration and implementation of the SSBG.

Literature reviews, discussions with 57 officials of a representative group of nine states, and the use of a panel of experts revealed that the states highly value the changes made in shifting from Title XX to the SSBG. Under the block grant, states can determine which services they will provide, who will be eligible, and how funds will be distributed among the services offered within the state. Services typically supported by SSBG include foster care and adoption, protective services for children and adults, child day care, education and training, information and referral services, family planning, and home-based services.

Respondents believe that SSBG has had a positive impact on the ways in which states deliver, plan, and integrate services; serve target groups; and make funding decisions. Specifically, the flexibility of SSBG has aided states in improving or reorganizing service delivery strategies, making administrative changes, becoming more responsive to community needs, and determining funding priorities that will reflect state or local needs. SSBG also has allowed states to serve a greater number and variety of clients and has improved states' capacities to respond to a variety of societal problems.

As a result of SSBG, some states have implemented innovative practices such as funding emergency child care services for parents and child care providers and establishing telephone services that provide information and social service referrals. Other states have used SSBG funds to establish community-based group home facilities for discharged mental patients or to give salaries to licensed foster parents who care for hard-to-place 15- to 18-year-old males. Finally, respondents clearly prefer the flexibility of the block grant to other approaches that made use of more stringent requirements and mandates. State officials most commonly recommend that the flexibility of the block grant be maintained and that funding levels for SSBG be increased.

The study was conducted by the Cygnus Corporation under contract to the Administration for Children and Families. The study's project officer, Dr. K.A. Jagannathan, can be reached on 202-401-0981. Copies of the executive summary, #4671, are available from PIC.


Recently Acquired Reports

  • Prescription Drug Advertisements in Medical Journals
  • Urban Poor: Tenant Income Misreporting Deprives Other Families of HUD-Subsidized Housing
  • Child Abuse: Prevention Programs Need Greater Emphasis



The Policy Information Center (PIC) is a centralized source of information on in-process, completed, and on-going evaluations; short-term evaluative research and; policy-oriented projects conducted by HHS as well as other Federal departments and agencies. The PIC on-line database provides project descriptions of these studies. It is available on-line at: Inquiries regarding PIC services should be directed to Carolyn Solomon, Technical Information Specialist, at 202-690-5694. Or E-mail PIC at:

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