Mental Health:

HHS Leadership Needed to Coordinate Federal Efforts Related to Serious Mental Illness

GAO-15-113: Published: Dec 18, 2014. Publicly Released: Feb 5, 2015.

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What GAO Found

Agencies identified 112 federal programs that generally supported individuals with serious mental illness in fiscal year 2013. The majority of these programs addressed broad issues, such as homelessness, that can include individuals with serious mental illness. The programs were spread across eight federal agencies: Department of Defense (DOD), Department of Education, Department of Health and Human Services (HHS), Department of Housing and Urban Development, Department of Justice (DOJ), Department of Labor, Department of Veterans Affairs (VA), and the Social Security Administration. Thirty of the 112 programs were identified by the agencies as specifically targeting individuals with serious mental illness. Four agencies—DOD, HHS, DOJ, and VA—reported that they obligated about $5.7 billion for programs that specifically targeted individuals with serious mental illness in fiscal year 2013. Agencies had difficulty identifying all programs supporting individuals with serious mental illness because they did not always track whether or not such individuals were among those served by the program. Agencies also varied in which programs they identified because they had different definitions of what such a program might be. Such inconsistency limits the potential comparability across programs.

Interagency coordination for programs supporting individuals with serious mental illness is lacking. HHS is charged with leading the federal government's public health efforts related to mental health, and the Substance Abuse and Mental Health Services Administration is required to promote coordination of programs relating to mental illness throughout the federal government. In the past, HHS led the Federal Executive Steering Committee for Mental Health, with members from across the federal government. However, the steering committee has not met since 2009. HHS officials told us that the Behavioral Health Coordinating Council (BHCC) performs some functions previously carried out by the steering committee. The BHCC, however, is limited to HHS and is not an interagency committee. Other interagency committees were broad in scope and did not target individuals with serious mental illness. Staff for the majority of the programs targeting serious mental illness reported taking steps to coordinate with staff in other agencies. While coordination at the program level is important, it does not take the place of, or achieve the level of, leadership that GAO has previously found to be key to successful coordination and that is essential to identifying whether there are gaps in services and if agencies have the necessary information to assess the reach and effectiveness of their programs.

Agencies completed few evaluations of the programs specifically targeting individuals with serious mental illness. Of the 30 programs specifically targeting individuals with serious mental illness, 9 programs had a completed program evaluation, 4 programs had an evaluation underway, and 17 programs had no evaluation completed and none planned. However, agency officials said they engaged in other efforts—such as drawing on evidence in published literature—to ensure their programs were effective. GAO's prior work has shown the significance of both performance monitoring activities and program evaluations and noted the importance of formal program evaluations to inform program managers about the overall design and operation of the program.

Why GAO Did This Study

In 2013, about 10 million adults in the United States had a serious mental illness. The U.S. mental health care system includes a range of federal programs—across multiple agencies—for those with mental illness. Past efforts to develop a list of federal programs supporting individuals with serious mental illness have highlighted the difficulty of identifying such programs.

GAO was asked to provide information on federal programs that support individuals with serious mental illness. This report identifies (1) the federal programs that support individuals with serious mental illness; (2) the extent to which federal agencies coordinate these programs; and (3) the extent to which federal agencies evaluate such programs. GAO developed and administered a web-based questionnaire to eight federal agencies regarding program goals, target populations, services offered, evaluations, and coordination. GAO also interviewed agency officials.

What GAO Recommends

GAO recommends that HHS establish a mechanism to facilitate interagency coordination across programs that support individuals with serious mental illness. GAO also recommends that DOD, HHS, DOJ, and VA document which programs targeting individuals with serious mental illness should be evaluated and how often such evaluations should be completed. HHS disagreed with both recommendations. DOD, DOJ, and VA agreed with the second recommendation. GAO continues to believe the recommendations are valid as discussed in the report.

For more information, contact Linda Kohn at (202) 512-7114 or kohnl@gao.gov.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HHS did not concur with this recommendation. However, in April 2015, HHS provided GAO information on its efforts to coordinate more effectively within HHS through its Behavioral Health Coordinating Committee. In addition, the Helping Families in Mental Health Crisis Reform Act of 2016 enacted in December 2016 required HHS to establish the Interdepartmental Serious Mental Illness Coordinating Committee, whose members are to include HHS and other federal agencies, among others. The Interdepartmental Serious Mental Illness Coordinating Committee?s responsibilities include, among other things, reporting on specific recommendations for actions that agencies can take to better coordinate the administration of mental health services for adults with a serious mental illness or children with a serious emotional disturbance. This committee sunsets 6 years after the date it is established. In August 2017, the Committee held its inaugural meeting. With the establishment of these mechanisms to facilitate both intra- and interagency coordination, the federal government is better able to develop an overarching perspective of its programs supporting and targeting individuals with serious mental illness.

    Recommendation: To understand the full breadth of federal programs and the scope of federal resources expended on programs supporting those with serious mental illness, the Secretary of HHS should establish a mechanism to facilitate intra- and interagency coordination, including actions that would assist with identifying the programs, resources, and potential gaps in federal efforts to support individuals with serious mental illness.

    Agency Affected: Department of Health and Human Services

  2. Status: Open

    Comments: The Department of Defense's position is that it already engages in periodic program evaluation of its psychological health programs as required. It noted that on November 24, 2014, the Under Secretary of Defense for Personnel and Readiness directed the Military Departments and other Department of Defense components to assist in an initiative to evaluate Psychological Health and Traumatic Brain Injury programs across the Department of Defense. As of September 2017, we have not received a further update on the Department of Defense's actions. We will continue to monitor these efforts and seek to determine whether they result in documentation of which programs should be evaluated and how such evaluations should be completed.

    Recommendation: To help determine if programs are effective at supporting those individuals with serious mental illness, the Secretaries of Defense, Health and Human Services, Veterans Affairs, and the Attorney General--which oversee programs targeting individuals with serious mental illness--should document which of their programs targeted for individuals with serious mental illness should be evaluated and how often such evaluations should be completed.

    Agency Affected: Department of Defense

  3. Status: Open

    Comments: HHS did not concur with this recommendation. The Helping Families in Mental Health Crisis Reform Act of 2016 enacted in December 2016 included a requirement for HHS to develop a strategy for conducting ongoing evaluations of programs related to mental illness--including serious mental illness--and substance use disorders. As of August 2017, HHS is in the process of preparing a report that identifies key programs and activities across the department, as well as summarizes data on those programs and develops criteria for use in prioritizing programs for evaluation. However, this report is not yet complete. We will continue to monitor HHS's efforts in this regard and look for documentation of HHS plans for future evaluations of programs for individuals with serious mental illness.

    Recommendation: To help determine if programs are effective at supporting those individuals with serious mental illness, the Secretaries of Defense, Health and Human Services, Veterans Affairs, and the Attorney General--which oversee programs targeting individuals with serious mental illness--should document which of their programs targeted for individuals with serious mental illness should be evaluated and how often such evaluations should be completed.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: The Department of Justice's Bureau of Prisons developed a program evaluation plan to carry out future evaluations. The updated version of this plan from July 2017 included each of the programs GAO identified as targeting individuals with serious mental illness. The Bureau of Prisons plans to implement this plan over the next several years, which GAO expects should provide the agency with insight into program design and execution and provide an opportunity to identify improvements in efficiency and effectiveness.

    Recommendation: To help determine if programs are effective at supporting those individuals with serious mental illness, the Secretaries of Defense, Health and Human Services, Veterans Affairs, and the Attorney General--which oversee programs targeting individuals with serious mental illness--should document which of their programs targeted for individuals with serious mental illness should be evaluated and how often such evaluations should be completed.

    Agency Affected: Department of Justice

  5. Status: Closed - Implemented

    Comments: In August 2016, the Department of Veterans Affairs identified which programs serving individuals with serious mental illness would be evaluated, and documented how often these program evaluations would be completed. The Department also determined when the initial evaluation would occur for each of the identified programs.

    Recommendation: To help determine if programs are effective at supporting those individuals with serious mental illness, the Secretaries of Defense, Health and Human Services, Veterans Affairs, and the Attorney General--which oversee programs targeting individuals with serious mental illness--should document which of their programs targeted for individuals with serious mental illness should be evaluated and how often such evaluations should be completed.

    Agency Affected: Department of Veterans Affairs

 

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