Mental Health Plans: Many States May Not Meet Deadlines for Plan Implementation

Published by the Government Accountability Office on 1990-09-18.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

 I    4
                   United   States   General   Accounting   Office

GAO                Report to Congressional Committees I7

!kptember   1990
                   MENTAL HEALTH
                   Many States May Not
                   Meet Deadlines for
                   Plan Implementation
                  United States
GAO               General Accounting Office
                  Washington, D.C. 20648

                  Human Resources    Division


                  September 18, 1990

                  The Honorable Edward M. Kennedy
                  Chairman, Committee on Labor and
                    Human Resources
                  United States Senate

                  The Honorable John D. Dingell
                  Chairman, Committee on Energy
                    and Commerce
                  House of Representatives

                  This report responds to a provision of Public Law loo-690 requiring the
                  Comptroller General to evaluate states’ implementation of the State
                  Comprehensive Mental Health Services Plan Act of 1986 (P.L. 99-660)
                  and report on it by September 30, 1990. This law requires states to plan
                  and implement community-based care for their seriously mentally ill;’ it
                  also directs the Department of Health and Human Services (HHS)to pro-
                  vide planning assistance. We have concluded that it is too early to fairly
                  and adequately assess implementation because states are not required to
                  fully implement their plans until September 1991. During discussions
                  with the Senate Committee staff, we agreed to examine state planning
                  activities and assess the National Institute of Mental Health’s (NIMH) role
                  in helping states develop plans.

                  Toward this end, the objectives of this review were to assess the

                  usefulness and timeliness of the assistance NIMII provided to help states
                  develop plans,
                  processes NIMHused to review plans and the outcomes of the reviews,
                  benefits states derived from the act, and
                  problems states may have in meeting the act’s implementation time

                  To achieve our objectives, we carried out several activities:
Methodology   .   At NIMH,we interviewed officials for descriptions of the kinds of plan-
                  ning assistance they gave to states. We also observed NIMH’Spanel ses-
                  sions, at which the plans were reviewed, and gathered information
                  about the final outcomes of these reviews. (We did not attempt to make

                                        usestheterm“chronically”mentallyill, subsequent
                  we thepreferredterm“seriously”mentallyill.

                  Page1                                        GAO/HRLHKI-142

             services. (3) States complied with it by defining and identifying the seri-
             ously mentally ill. (4) It was also responsible, national mental health
             advocacy organizations said, for greater involvement of the mentally ill
             and their advocates in mental health planning at the state level.

             Most of the 51 states we contacted said they would have difficulty
             meeting the act’s deadlines. Forty-one states anticipated problems
             meeting the September 1990 deadline requiring substantial implementa-
             tion, and 45 states, the September 1991 deadline requiring full imple-
             mentation. Several problems will hamper timely implementation, such
             as the major changes states said they need to make in their mental
             health delivery systems, which will take longer than the 2 years pro-
             vided in the act.

             Title V of the 1986 act requires each state to develop and submit to HHS
Background   a comprehensive mental health services plan that would be used to
             develop community-based care for the seriously mentally ill.” To develop
             the plans, the Congress appropriated $4.8 million for fiscal year 1988
             and $4.7 million for fiscal year 1989. The first plans were originally due
             September 1988, but NIMHextended the deadline to January 1989
             because planning funds were not provided until June 1988. The deadline
             for the second set of plans was September 30, 1989.

             In their plans, states were to include evidence that they had responded
             to eight requirements set forth in the act. It directed the Secretary of HHS
             to assist the states, including giving them a model plan, which HHSdid in
             October 1987. The Secretary was to evaluate state plans against the
             act’s requirements and impose penalties on states if plans did not
             comply. Penalties could be as much as 10 percent or as little as 0.2 per-
             cent of a state’s Alcohol, Drug Abuse, and Mental Health block grant
             allotment. The Secretary could not, however, require states to spend
             more money on mental health services than they would have spent
             without the act’s planning requirement.

             To avoid penalties, states must (1) develop acceptable plans by Sep-
             tember 30, 1989, (2) substantially implement them by September 30,

             “Theactallowseachstateto defineitsownseriously  mentallyill population. NIMHprovidedguid-
             ancein theformof modeldeftitionsfor adultsandchildren.According    to themodel,diagnostic
             factorsshouldincludethe(1)typeof illness,(2)levelof disability,and(3)durationof illness.

             Page3                                           GAO/HRD90-142

    March 1990, most states had revised their plans and HHShad approved
    them. Two plans were not approved and NIMHrecommended that HHS
    impose the penalties called for by the act.

    To evaluate submitted state plans, NIMHconvened panels of mental
    health experts in November and December 1989. These panels consisted
    of medical practitioners, service providers, academicians, hospital per-
    sonnel, representatives of state mental health organizations and private
    nonprofit organizations, and the mentally ill or their family members or
    both. The use of knowledgeable reviewers outside the agency to eval-
    uate plans gave ~TMFIan independent perspective on the plans’ efficacy.

    Panel members reviewed and commented on (1) the responsiveness of
    each state’s plan to the eight requirements outlined in the law and (2)
    other issues relating to mental health planning and community-based
    services. Some problems include these:

l Panelists raised questions about plan input from the seriously mentally
  ill in many states.
. Panelists expressed concern that many state plans did not provide ade-
  quate financial support. For example, panel members noted that state
  mental health planners in Alaska and New Jersey acknowledged that
  inadequate state financing could make service goals unattainable. Panel
  members thought Iowa’s plan should have addressed the availability of
  county funds in addition to state mental health funds.
. Panel members found a lack of commitment by some states to move
  toward a community-based system of care. In one state’s plan, for
  example, they found that the ratio of allocated resources between hospi-
  tals and community services was expected to remain constant at 80 per-
   cent for hospitals and 20 percent for community services.

    NIMH’Sreview was confined to the act’s requirements. Its primary con-
    cern involved the information on numbers to be served-19 state plans
    did not have this information. Other concerns dealt with (1) inadequate
    descriptions of activities that would reduce the rate of hospitalization
    and (2) insufficient evidence of consultation with state institutions’ and
    nursing homes’ employee representatives.

     In January 1996, I\~IMIIapproved 26 state plans as submitted and
     required the remaining states to revise their plans to bring them into
     compliance with act requirements. By March 1990, all plans but those of
     Guam and Puerto Rico had been revised and approved. Guam had not
     included information on numbers to be served, and Puerto Rico had not

     Page5                                  GAO/IUD90.142

                      seriously mentally ill in 1990 and 9, the same number as in 1989. State
                      officials told us they would serve, collectively, about 5 percent more
                      seriously mentally ill people in 1990 than in 1989. State officials also
                      estimated they would serve, on average, almost 44 percent of their seri-
                      ously mentally ill population, with estimates ranging widely from 15 to
                      89 percent. (See app. II.)

                      Many states said, and NIMHofficials agree, that states will have diffi-
Many States May Not   culty meeting the act’s deadlines for full implementation. Of the 51
Meet Implementation   states we spoke with, 41 said the September 30, 1990, deadline allowed
Time Frames           too little time to substantially implement the plans; 45 said the Sep-
                      tember 30, 1991, deadline allowed too little time to fully implement
                      them. Problems delaying implementation include (1) differences
                      between the federal and state cycles for planning, budget, plan
                      approval, and program operation; (2) the uncertainty of funds for imple-
                      menting the plans; and (3) the major changes many states have to make
                      to their mental health systems to comply with the act.

                      The federal and state cycles for mental health planning, budgeting, and
                      program operations differ. The plans submitted by the states were for
                      the federal fiscal year, October 1, 1989, to September 30, 1990. Most
                      state fiscal years, however, are July 1 to June 30. Twenty states sought
                      mental health funding from their state legislatures to meet the objec-
                      tives of their plans on or after January 1, 1990. The funding their legis-
                      latures approve will be for the states’ fiscal years, starting July 1, 1990,
                      leaving only 3 months for states to meet the act’s September 30, 1990,
                      deadline. Six states told us they are under biennial planning and
                      budgeting cycles, making it difficult to quickly change their mental
                      health plans.

                      Over half of the states mentioned funding and staffing problems as fac-
                      tors that may impede plan implementation. The act requires certain ser-
                      vices, such as case management services, but does not provide
                      additional federal funding. Some states said staffing problems, including
                      the need to hire and train community mental health workers, would
                      slow the pace of implementation.

                      In addition to resource problems, 15 states said the act requires major
                      changes to their current systems, which will take longer than 2 years to
                      completely implement, for example:

                      Page7                                    GAO/HRD-90142

Please call me on (202) 275-1655 if you or your staffs have any ques-
tions about this report. Other major contributors to this report are listed
in appendix III.

Linda G. Morra
Director, Intergovernmental
   and Management Issues

Page9                                    GAO/HRD!W142

                           The plans were to address the following eight requirements:
Plan Content
                       . Establish and implement an organized community-based system of care
                         for the seriously mentally ill.
                       . Specify quantitative   targets to be achieved in implementing such a
                         system, including number of seriously mentally ill people residing in the
                         areas to be served under such a system.
                       . Describe services to be provided for the seriously mentally ill that would
                         enable them to gain access to mental health services, including access to
                         treatment, prevention, and rehabilitation services.
                       . Describe rehabilitation services, employment services, housing services,
                         medical and dental care, and other support services to be provided for
                         the seriously mentally ill in order to enable them to function outside of
                         inpatient institutions to the maximum extent of their capabilities.
                         Provide “activities” (programs) that would reduce the rate of hospitali-
                         zation for the seriously mentally ill.
                         Provide case management services for the seriously mentally ill who
                         receive substantial amounts of public funds or services.
                         Provide for the establishment and implementation of a program of out-
                         reach to, and services for, the seriously mentally ill who are homeless.
                         Consult with representatives of employees of state institutions and
                         public and private nursing homes who care for the seriously mentally ill.

                           The act provides that if the Secretary of HHSdetermines that a state has
Penalties for Failure to   not developed the required plan by September 30, 1989, he must reduce
Comply                     the state’s ADMSblock grant allotment for fiscal year 1990. Furthermore,
                           if the Secretary determines that a state has not (1) developed and sub-
                           stantially implemented its plan by September 30, 1990, and (2) devel-
                           oped and completely implemented its plan by September 30, 1991, he
                           must reduce the state’s ADMSblock grant allotment for the affected fiscal
                           years and succeeding years. This reduction is to continue until the state
                           has developed and completely implemented the required plan.

                           Legislation (P.L. 100-690, section 2041) in November 1988 specified the
                           amount and range of grant reductions. Grants to states may be reduced
                           by the maximum amount the state is permitted to spend for administra-
                           tive expenses (10 percent of the state’s allotment) for fiscal year 1986.
                           This legislation authorizes the Secretary, after determining that the
                           state is making a good faith effort to comply, to reduce the penalty to as
                           little as 2 percent of the amount the state was permitted to spend on
                           administrative expenses (0.2 percent of the state’s allotment).

                           Page13                                 GAO/HRDW142
Append’ix II

Seriously Mentally IlI Population by State

                                                       In 1990
                         Served         To be            Estimated         To be served
                State     (1989)       served           population          (in percentP
                AK                 t              h          5,750                          .
                AL        24,378        29,000              43,000                    674
                AR         8,328         9,000              16,000                    563
                AZ        10037         10.037                         h                    .
                CA       150,000       150,000             300,000                    500
                                   /              r        144,300                          .
                CT        35.000        36,000             245,000                    147
                DC                                1,                   b                    .
                DE         2 780         3.200                5,200                   61 ii
                FL        35502         37,127              50,628                    733
                HI         3000          6,696               II ,000                  60 9
                IA                                /I        25,000                        .
                ID         7 128         7,484                         b                    .
                IL                      51,850               61,589                   842
                IN        17884         19,000               38,000                   50 0
                KS        -6000          8,000               10,360                   772
                KY        16.000        16.000               28,000                   57 1
                LA        23000         25.530               52,026                   491
                MA                      35.000               57.000                   61 4
                MD                                I>        137,000                      .
                ME        37 783        37.950               54,000                   703
                MI        18500         26,000               92,000                   283
                MN                                /a         85,000                             .
                MO        20218         20.218               42,139                   480
                MS        18019         23,779               35,180                   676
                MT                                ,.          5.836                             .
                NC        38667         45,286              103,218                   439
                ND         5550          5912                12.083                   489
                NE         2900          3,050                4,236                   720
                NH         5088           5,700               7,036                   81 0
                NJ        67030         67,680              108,685                   623
                NM         5601           5,925              12,260                   483
                NV          5615          7.351              11957                    61 5
                NY       155000        155,000              228,000                   680
                OH        27973         28,000               60,000                   467
                OK        24 000        29,434               49,056                   60 0
                OR        27 383        28,615               67,086                   427

                Page15                      GAO/HRD-W-142
Appendix III

Major Contributors to This Report

                   Carl R. Fenstermaker. Assistant Director, (202) 275-6169
Human Resources    John M. Ka,nensky, Assistant Director
Division,          Robert F. Derkits, Assignment Manager
Washington, D.C.   Benjamin C. Ross, Evaluator
                   Joanne R. Frankel, Senior Social Scientist
                   Mark S. Vinkenes, Social Science Analyst

                   Wayne L. Marsh, Evaluator-in-Charge
San Francisco      Susan S. Mak, Evaluator
Regional Office    Lisa Lensing, Evaluator

(118846)           Page17                                 GAO/HRE-SO-142
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!kiously MentallyIll Populationby State

                                                                         In 1990
                           Served                     To be                Estimated         To be SeNed
State                       (1969)                   served               population          (in percent)
PA                                    h                         b             588,000                          .
RI                            5,305                     5,305                    9,000                   58.9
SC                           11700                    12,800                    24,000                   53.3
SD                                    II                        I>               5,069                          .
TN                          46199                     48,509                    61,439                   79.0
TX                         136,000                   136,000                  628,000 -                  21 7
UT                           10500                    11,500                    42,500                   27 1
VA                           18500                    22.000                    60.000                   367
VT                            2.656                     2,880                    3,500                   823
WA                           27650                    28,341                    32.000                   886
WI                           33000                    35,000                             b                      .
WV                           18,132                   18,132                    24,605                   73.7
WY                            4974                      5,855                    8,821                   66.4
TotaP                   1,145,304                 1,203,264                 2,709,966
“Average percent to be served during 1990 IS 44 4

“State could not prowde total population estimates for the seriously mentally III that included Institution-
allzed and nonlnstltut~onallzed adults. adolescents and children, and homeless
%cludes   only the 37 states provldlng complete InformatIon for all three categories

Page16                                                     GAO/~W-142 StateMentalHealthPlans

                       For each of fiscal years 1988 and 1989, the 1986 act authorized
Federal Funds for      $10 million to aid states in developing their plans. The Congress appro-
Planning               priated about $4.8 million for fiscal year 1988 and about $4.7 million for
                       fiscal year 1989. HHSretained $101,600 of the fiscal year 1988 appropri-
                       ation and $113,000 of the fiscal year 1989 appropriation to provide
                       technical assistance to the states.

                       Each state received $82,200 in fiscal year 1988 and $81,000 in fiscal
                       year 1989. The Congress did not authorize any funds for mental health
                       planning for fiscal year 1990.

                       In 1989,’ we reported that of 14 states surveyed, 13 (1) used their fiscal
Use of Federal Funds   year 1988 funds to hire new staff within their mental health planning
                       offices to do planning, coordination, and clerical activities or (2) con-
                       tracted with mental health consultants to write their plans. The other
                       state used its funds to support administrative expenses, such as printing
                       and data processing costs. Ten states also used the funds for travel
                       expenses incurred by their planning councils. Several states supple-
                       mented the federal funds with their own funds-for       example, New
                       Mexico and Puerto Rico each provided an additional $50,000 for devel-
                       oping their plans.

                                               for FuturePlanning

                       Page14                                    GAO/HRD-90.142
Appendix I


             Millions of people in this country suffer from some serious-that is, per-
             sistent and severe-form of mental illness. Many reside in institutional
             settings, such as state mental hospitals and nursing homes. Others live
             in residential treatment centers, group homes, and sheltered apartments,
             as well as independently or with their families. Still others move
             between hospitals, homelessness, and jails due to inadequacies in state
             and local service systems.

             The Congress and the federal government, for over 20 years, have been
             working to develop programs to assist in the treatment and rehabilita-
             tion of the seriously mentally ill; the goal of the programs has been to
             move these mentally ill from institutions to community-based systems.
             Primary among these programs was the Community Mental Health Cen-
             ters Act of 1963 (P.L. 88-164), which provided federal funds to states
             for the construction of community-based mental health centers. This act
             was amended and extended several times between 1963 and 1981. In
              1981, the Congress created the Alcohol, Drug Abuse and Mental Health
             Services (ADMS)block grant (P.L. 97-35), which consolidated several cat-
             egorical programs, including the Community Mental Health Centers pro-
             gram, into a single block grant to the states.

             Despite the federal support provided during the past 20 years, the Con-
             gress has continued to express concern about the frequency with which
             people with long-term mental illness fall through the cracks of mental
             health and social service systems. These people frequently have been
             unnecessarily rehospitalized, placed in the criminal justice system for
             minor infractions, or become homeless.

             To help establish or further develop comprehensive systems of ser-
             vice-including    Medicaid, vocational rehabilitation, psychosocial reha-
             bilitation, housing, income support, education, and health and mental
             health services-the Congress, in November 1986, passed the State
             Comprehensive Mental EIealth Services Plan Act of 1986 (P.L. 99-660).
             Title V required each state to develop and submit to the Department of
             IIealth and Human St>rvices (HHS)comprehensive mental health services
             plans that would establish and implement community-based systems of
             care for the seriously mentally ill. In developing their plans, states were
             to consult with employee representatives of (1) state mental institutions
             and (2) public and private nursing homes who care for the seriously
             mentally ill.

             Page12                                  GAO/HRD-W-142

Letter                                                                                        1
Appendix I                                                                                   12
Background               Plan Content
                         Penalties for Failure to Comply
                         Federal Funds for Planning                                          14
                         Use of Federal Funds                                                14

Appendix II                                                                                  15
Seriously Mentally Ill
Population by State
Appendix III
Major Contributors to
This Report


                         ADMS   Alcohol, Drug Abuse, and Mental Health Services
                         HHS    Department of Health and Human Services
                         NASMHPDNational Association State Mental Health Program Directors
                         NIMH   National Institute of Mental Health

                         Page10                              GAO/HRD9@142

                      Four states said that they needed additional time to coordinate and inte-
                      grate the efforts of various service providers.
                      One state said it would have to significantly expand community-based
                      services to reduce its hospitalization rate, explaining that it would take
                      more than 2 years to set up local management systems and to redirect
                      resources to meet local needs.

                      Because states realized that these changes would take a long time to
                      implement, 18 plans covered periods ranging from 4 to 10 years. Full
                      implementation, in these cases, within the 2 years provided by the act
                      would not occur.

                      States and NIMHhave complied with the act’s planning requirements. In
Conclusions           addition, the act has achieved beneficial results, including a greater role
                      for the mentally ill, their families, and advocates in mental health plan-
                      ning, as well as, in many states, more money for community mental
                      health services. However, it appears that many states will have diffi-
                      culty meeting the act implementation deadlines and, as a result, will be
                      subject to reductions in block grant allotments in fiscal years 1991 and
                      1992. States believe, and NIMHagrees, that it will take more time than
                      provided in the act to implement their plans.

                      HHSand the National Association of State Mental Health Program Direc-
Agency Comments       tors (NASMHPD)provided comments on this report. HHSsaid the report
                      (1) was helpful in understanding the act’s initial effects on state mental
                      health systems and (2) accurately reflected NIMH'Srole and responsibili-
                      ties under the act. HHSalso suggested some technical corrections that we
                      have incorporated into the report as appropriate.

                      NASMHPD   agreed that the act stimulated increased state planning and
                      actions for the seriously mentally ill and that many states may not be in
                      full compliance by the act’s September 1991 deadline. NASMHPD    pointed
                      out that some states clearly chose longer time frames for their plans and
                      frequently presented optimal sets of goals, many of which depend on
                      additional funding.

                      Copies of this report will be sent to the Secretary of HHSand other
                      appropriate congressional committees. Copies will also be made avail-
                      able to others on rcqucxst,.

                      Page8                                   GAO/HHD9O-142

                provided information on consultation with employee representatives of
                nursing homes. In March, NIMHrecommended that the Secretary of HHS
                impose the penalties provided for in the act.

                The act’s planning requirements achieved some beneficial results. States
Act, Has Been   (1) involved state mental health planning councils, including the men-
Beneficial      tally ill and their family members, in the mental health planning pro-
                cess; (2) directed more funds toward community-based services; and (3)
                defined and identified their seriously mentally ill populations. States’
                estimates of the mentally ill to be served vary widely, ranging between
                15 and 89 percent of the identified seriously mentally ill population. At
                least 31 states intend to serve more of this population in 1990 than in

                NIMHencouraged states to develop their plans in consultation with ser-
                vice users and their advocates. Our survey of state mental health offi-
                cials disclosed that this occurred frequently. States told us their
                planning councils, which included the seriously mentally ill and their
                advocates, (1) reviewed and commented on their plans and (2) wrote
                parts of 25 plans and formally approved 18. Officials of three major
                mental health organizations-the      National Alliance for the Mentally Ill,
                the National Mental Health Association, and the National Association of
                State Mental Health Program Directors-also cited increased involve-
                ment by service users and advocates as one of the act’s major

                Many states attributed to the act increased funding for community-
                based mental health services in 1990. Eighteen states said the act was
                “definitely responsible” for funding increases, and another 18 states
                said it was “probably responsible” for the increases.

                Most states also defined and identified their seriously mentally ill popu-
                lation. Although NIMHprovided guidance in the form of a model defini-
                tion, the act allowed each state to define its population. We reviewed 28
                plans and found that 16 definitions were equal to, or broader than, the
                model definition and 8 were narrower. We were unable to characterize
                the definitions in 4 plans.

                Forty-seven states were able to estimate the size of their seriously men-
                tally ill populations; 40 states provided the number served in 1989 and
                42, the number they expect to serve in 1990. Of the 40 states that pro-
                vided both 1989 and 1990 data, 31 estimated they would serve more

                Page6                                    GAO/HRD90142

                       1990, and (3) fully implement them by September 30, 1991.4 As of June
                       1990, NIMHhad not defined “substantially implement,” but was studying
                       different methods to be used to assess states’ implementation of their
                       plans. The legislative requirements, the nature of the penalties, and
                       additional background information are in appendix I.

                       NIMHprovided several types of planning assistance that were timely and
NIMH’s Technical       useful. One type consisted of technical papers and a manual, including
Assistance WASTimely   (I) a model plan provided early to states as a guide in developing their
and Useful             plans, (2) two technical papers addressing ways to finance a mental
                       health system and methods of gathering data to support mental health
                       planning, and (3) a handbook on how to evaluate a mental health

                       Another type consisted of NIMH’Sreviewing and commenting on state
                       plans. NIMHasked states to submit initial plans by danuary 10, 1989, to
                       strengthen state-planning capacity and establish baselines for future
                       compliance reviews. KIMHprovided timely written feedback to the states
                       on how they could improve their plans for the submissions due Sep-
                       tember 30, 1989. A third type consisted of workshops and on-site visits
                       conducted by the COSMOS  Corporation, a research organization, under
                       contract with NIMH.COSMOS  also (1) disseminated a newsletter, Mental
                       Health Planning News, and (2) developed planning case studies as well
                       as key documents to assist in planning activities.

                       Most states found NIMH’Stechnical assistance helpful. For example, 46 of
                       the 5 1 states we contacted reported that the publications were
                       “helpful”; only 5 said they were “of little or no help.” Of the 43 states
                       that asked for additional assistance, 28 rated the assistance as “very
                       helpful”; 12 said “moderately helpful”; and only 3 said “little or no

                       NIMHassembled panels of mental health experts to evaluate and com-
Most Plans Approved    ment on state plans and also used its own staff to review the plans. NIMH
                       approved 26 plans in January 1990 as meeting the act’s requirements
                       and questioned the completeness of the rest, particularly the adequacy
                       of the information on the number of people to be served. NIMHadvised
                       the states of its concerns and required them to revise their plans. By

                       ‘%.tesarepermittedanadditionalyear,untilSeptember 30,1992,to phasein casemanagement
                              for all theseriously
                                                 mentallyill whoreceive
                                                                               amounts of publicfundsor serwces.

                       Page4                                         GAO/HHLHO-142

                     any independent judgments on plan adequacy, but, rather, relied on
                     NIMH’Sand panel reviewers’ judgments.)
                   l By telephone, we surveyed state mental health officials in all 50 states
                     and the District of Columbia to obtain their views of the usefulness and
                     timeliness of the assistance NIMHgave them in developing their plans.
                     We also asked these officials to comment on the (1) benefits, if any, they
                     derived from the act and (2) problems they might face in meeting the
                     implementation deadlines. (We did not independently verify all the
                     information provided by the states.)
                   . Finally, we interviewed officials of public interest groups for their opin-
                     ions on the effects the legislation might have on state mental health

                       We did our review from January to March 1990 in accordance with gen-
                       erally accepted government auditing standards.

                       Fifty states, the District of Columbia, and seven territories submitted
Results in Brief       plans by the required date, September 30, 1989 (hereafter, the term
                       “states” will include the District and the territories).l NIMHprovided
                       timely and useful technical assistance to help states prepare the plans,
                       including a model plan, technical papers, and contract support. Many
                       states told us this assistance was helpful in developing their plans.

                       In November and December 1989, NIMHconvened panels of experts to
                       review the state plans and reviewed the plans itself. In January 1990,
                       NIMII approved the 26 plans that met the act’s requirements. Reviewers
                       noted that the remaining state plans did not meet one or more of the
                       requirements. NIMHgave these states added time to revise their plans in
                       response to reviewers’ comments. By March 1990, most states had
                       revised their plans so they would conform to the act’s requirements and
                       NIMHhad approved all but two plans, for which it recommended penal-
                       ties for noncompliance.

                       The act has achieved some beneficial results: (1) States and organiza-
                       tions told us it enhanced the participation of the mentally ill and their
                       advocates in state mental health planning. (2) Many states also said it
                       increased the funds directed toward community-based mental health

                       ‘TheterritoriesareAmerica~rSamoa,Federated Statesof Micronesia.Guam,theMashallIslands, the
                       NorthernMarianaIslands.PuertoRico,andtheRepublic   of I’alau.TheVirginIslandswereexempt
                       fromthesubmissmn   deadhnrbecausetheirplanning-related materialsweredestroyed by hurncanr
                       Hugo.TheVu-gm   Islands‘planwassubmittedin April 19RO

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