Case Study: Early Assessment of the Mental Health Block Grant Set-Aside Program for Addressing First Episode Psychosis and Other Early Serious Mental Illness. Notes


  1. This term was not operationally defined by Congress or SAMHSA. We use the term ESMI to refer to three exclusive categories: FEP, a category that includes a number of non-organic and non-affective psychotic disorders (schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, and psychosis not otherwise specified); early stages of affective psychotic disorders (bipolar disorder, major depressive disorder with psychosis); and early stages of any non-psychotic SMI with a gradual onset (e.g., obsessive-compulsive disorder).

  2. Although the white paper was written by NIMH, SAMHSA had the opportunity to review it iteratively. The white paper was the result of a congressional mandate instructing SAMHSA and NIMH to work together to develop guidance for states regarding evidence-based treatment approaches.

  3. NIMH contributed funds for technical assistance activities through an interagency agreement with SAMHSA. NIMH also funded a series of webinars and supported in-person training by CSC experts in five states.

  4. The health home program is an optional Affordable Care Act initiative launched in January 2011 that integrates physical and behavioral health and long-term services and supports for Medicaid-eligible individuals with chronic conditions.

  5. We were able to review sections of mental health plans describing the intended use of the set-aside funds for seven counties that had submitted their plans to the SMHA earlier than other counties. We selected the four-county sample from that larger set based on our assessment that they intended to use the funds to support new ESMI programs.

  6. The state contracts with eight Local Management Entities-MCOs located in eight multicounty geographic areas to manage public funds. These MCOs have two contracts with the state, one for Medicaid and one for state (general revenue) and MHBG funds. MCOs contract with providers across the state for mental health and substance abuse services and intellectual developmental disability services.

  7. Publicly funded community-based mental health services in Texas are provided through LMHAs, government entities serving low-income populations throughout the state. The exception to this publicly operated system is the Northeast region of the state, the NTBHA, where mental health services are delivered by a private sector-operated system managed by ValueOptions, a behavioral health carve-out.

  8. Initially, the state also required that clients have a maximum of one year of treatment but that criterion was dropped before our case study.

  9. Publicly funded community-based mental health services in Virginia are provided through 40 CSBs. While many CSBs are local government entities operating under a city or county charter, some cover multiple jurisdictional areas and are quasigovernmental entities. CSBs are considered non-profits, and their boards consist of representatives of all the counties and cities they serve. CSBs provide services either directly or through subcontracts with private providers.

  10. Virginia Request for Proposals document, pg. 1.

  11. Wisconsin's Request for Proposal document, pg. 5.

  12. Any of two psychosocial rehabilitation programs with established funding streams (larger MHBG, Medicaid).

  13. There are 17 CMHCs in the state that operate on a capitated basis through a Medicaid carve-out.

  14. The state's SMHA contracts with 11 Regional Support Networks (RSNs) comprising one or more counties to provide public mental health services. The state's public behavioral health system is undergoing structural reorganization and the SMHA will directly contract with regionally operated carve-outs for public mental health and substance abuse services, instead of RSNs, beginning in 2016.

  15. A small portion of the set-aside funds are being used to incorporate an FEP component into a suicide prevention program, and to purchase access to an online library of recovery-related materials for providers across the state.

  16. The state is a pioneer in this regard: FEP programs were introduced in 2001 and currently cover more than 90 percent of the state's population.

  17. The relatively narrow clinical criteria for the program raise an issue regarding screening of referrals and disposition for referred individuals who do not meet criteria. In Oregon, where the same inclusion criteria are in effect, one-half to two-thirds of referrals are screened out of the program although they may have serious mental health problems. The New Journeys program will be well positioned to refer these individuals to other services that are available locally because of the broad range of evidence-based practices offered by the parent agency. Of note, the legislature approved additional state funds to help with referrals for these individuals.

  18. These include proximal referral sources (clinic/provider the program is nested within; community-based health care partners; local inpatient units and emergency departments) and more-distal ones (schools, colleges, and universities; primary care practices; social services agencies; law enforcement and jails; advocacy groups; and the community at large.

  19. The Mental Health Services Act provides funds for mental health and substance abuse services through a dedicated state income tax.

  20. The TIP model "prepares youth and young adults with emotional behavioral disturbances for their movement into adult roles through an individualized process, engaging them in their own futures planning process, as well as providing developmentally appropriate and appealing supports and services." (

  21. Imperial County webpage:

  22. FSPs, a core component of the Mental Health Services Act, have a low staff to client ratio, full-time crisis availability, and a team approach that is a partnership between mental health staff and clients.

  23. The PIER model comprises three phases: outreach and engagement; treatment recommendation, which may involve low dose medication; and multifamily groups that meet every two weeks. Case management services follow the participant for 18 months to two years.

  24. Based on prior patterns of care at the university health center, the team expects to serve 4-7 individuals a week and about 200 over the course of a year. The university administration also expects encounters in connection to students needing to be physically removed from campus ("transports").

  25. Alexandria has 15 elementary schools, two middle schools, and one high school.

  26. Each county in Virginia has a Family Assessment Planning Team, a partnership between the school system, CSB, and local court services that develops "recommendations for the treatment of children that are experiencing anything related to behavioral health, to academic, to criminal justice involvement, risk factor involvement, or are already an indicated treatment population."

  27. The Offender Aid and Restoration program is a private, non-profit program that seeks to link ex-offenders coming out of jails to services.

  28. See for more information on AVATAR.

  29. SOURCE: Texas ANSA Manual--revised November 23, 2013.

  30. The work group consisted of representatives from the Office of Mental Health, Office of Support Services, and the Office of Child and Family Services. The Office of Support Services has a data and evaluation team as they are responsible for managing performance contracts.

  31. This organization advocates on behalf of county behavioral health departments at the state level on issues related to mental health and substance use treatment systems.

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