SA Prevention

Program Guidance for Contract Deliverables
Program Guidance for Prevention Services Authority: 42 U.S.C. s. 300x‐2 45 C.F.R., pt. 96, sub. L. Frequency: Ongoing Due Date: Not Applicable Description: SUMMARY The managing entity shall: 
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Purchase substance abuse prevention services, in compliance with 45 C.F.R. pt.96, sub. L. Purchase services for children with serious emotional disturbances, and children at risk for emotional disturbances, in compliance with 42 U.S.C. s. 300x‐2. Ensure prevention providers comply with state reporting requirements. Verify delivery of services. Procure, contract, and provide oversight of Prevention Partnership Grant (PPG) grantees. Facilitate the controlled purchases of tobacco, in compliance with federal law. DISCUSSION Defining Prevention Programs designed to prevent the development of mental, emotional, and behavioral disorders 1 are commonly categorized in the following manner: Universal Prevention Preventive interventions that are targeted to the general public or a whole population group that has not been identified on the basis of individual risk. The intervention is desirable for everyone in that group. Universal interventions can directly serve an identifiable group of participants who have not been identified on the basis of individual risk (e.g., school curriculum, after school program, parenting class). This also could include interventions involving interpersonal and ongoing/repeated contact (e.g., coalitions). Indirect universal interventions, on the other hand, are population‐based programs and environmental strategies (e.g., establishing policies, modifying advertising practices). This also could include interventions involving programs and policies implemented by coalitions. Selective Prevention Preventive interventions that are targeted to individuals or to a subgroup of the population whose risk of developing mental, emotional, or behavioral disorders is significantly higher than average. The risk may be 1
This is a broad term that encompasses both disorders diagnosable using DSM‐IV‐TR criteria and problem behaviors associated with them – such as violence, aggression, and antisocial behavior – and mental illness and substance abuse. National Research Council and Institute of Medicine. (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: The National Academies Press. 1 Program Guidance for Contract Deliverables
imminent or it may be a lifetime risk. Risk groups may be identified on the basis of biological, psychological, or social risk factors that are known to be associated with the onset of a disorder. Examples include programs offered to children exposed to risk factors, such as parental divorce, parental mental illness, death of a close relative, or abuse, to reduce risk for adverse mental, emotional, and behavioral outcomes. Indicated Prevention: Preventive interventions that are targeted to high‐risk individuals who are identified as having minimal but detectable signs or symptoms that foreshadow mental, emotional, or behavioral disorder, as well as biological markers that indicate a predisposition in a person for such a disorder but who does not meet diagnostic criteria at the time of the intervention.2 Substance abuse prevention strategies are activities that “are aimed at the individual, family, community, or substance and that preclude, forestall, or impede the development of substance use problems and promote responsible lifestyles.”3 The Department of Children and Families (department) also interprets prevention as including “activities and strategies that are used to preclude the development of substance abuse problems.”4 The departments’ Office of Substance Abuse and Mental Health (OSAMH) operationally defines prevention more broadly to include mental health outcomes using two reimbursable codes: Prevention Prevention services are those involving strategies that preclude, forestall, or impede the development of substance abuse and mental health problems, and include increasing public awareness through information, education, and alternative‐focused activities. These services may be directed either toward a Level II prevention target where the client has been identified, or at a Level I prevention target where the client is not identifiable (these levels are explained in more detail below). Prevention/Intervention ‐ Day This cost center includes school‐based day services for children and adolescents. For children with mental health problems, these services include school‐based mental health services for children who have been identified by the school as having, or are at risk of developing, mental health problems. For children and adolescents with substance abuse problems it includes targeted prevention programs serving students who are identified as at risk for alcohol or other drug abuse. These programs are designed to promote skills building and reduce the risk of establishing patterns of use. Counselors provide individual, group and family counseling and school personnel implement an intensive education program.5 Integration In addition to the focus on substance abuse and mental health, the department requires that the managing entity develop prevention strategies, through the sub‐contracted network, in connection with child welfare providers. 2
National Research Council and Institute of Medicine. (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: The National Academies Press. 3
S. 397.311(18)(c), F. S. 4
Ch. 65D‐30.002, F.A.C. 5
DCF Pamphlet 155‐2. Client‐Specific Service Event Data Set. Retrieved from www.dcf.state.fl.us/programs/samh/publications/c7v10.pdf. 2 Program Guidance for Contract Deliverables
In the context of federal health care reform, the managing entity is also encouraged to develop strategies that address primary care and behavioral health promotion. How is Treatment Distinguished from Prevention? Prevention interventions occur prior to the onset of a disorder and are intended to prevent or reduce risk for the disorder. In other words, prevention activities are not applied to individuals with diagnosable disorders. Prevention activities target multiple populations whose levels of risk vary, but they are not identified on the basis of having a disorder. Unlike prevention, treatment targets an individual identified as currently suffering from a diagnosable disorder, and is intended to cure the disorder, reduce the symptoms or effects of the disorder, or prevent relapse.6 However, substance use, including underage drinking, is a problem behavior of significant public health concern even when the symptoms are not severe enough to be considered a substance use disorder. Such problem behaviors as early substance use, violence, and aggression are often signs or symptoms of mental health disorders, although they may not be frequent or severe enough to meet diagnostic criteria. Nonetheless, intervention when these signs or symptoms are apparent, or actions to prevent them from occurring in the first place, can alter the course toward disorder and are an important component of prevention.7 Mental health promotion refers to interventions that aim to enhance the ability to achieve developmentally appropriate tasks and a positive sense of self‐esteem, mastery, well‐being, and social inclusion and to strengthen the ability to cope with adversity. Prevention emphasizes the avoidance of risk factors; promotion strives to promote supportive family, school, and community environments and to identify and imbue in young people protective factors, which are traits that enhance well‐being and provide tools to avoid adverse emotions and behaviors. Prevention and health promotion both focus on changing common influences on the development of young people in order to aid them in functioning well in meeting life’s tasks and challenges and remaining free of cognitive, emotional, and behavioral problems that would impair their functioning.8 Substance Abuse Prevention and Treatment Block Grant Federal regulations that apply to the Substance Abuse Prevention and Treatment Block Grant require the state to spend at least 20% of the award on services for individuals who do not require treatment for substance abuse. This entails the implementation of a comprehensive primary prevention system which includes a broad array of prevention strategies directed at individuals not identified to be in need of treatment. This means that Block Grant prevention funding is not approved for consumer recovery services or relapse prevention. Primary prevention programs include activities and services provided in a variety of settings for both the general population, and targeted sub‐groups who are at high risk for substance abuse.9 At‐risk populations that must be prioritized include: 
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Children of substance abusers Pregnant women/teens Drop‐outs Violent and delinquent behavior 6
Supra note 1. Id. 8
Id. 9
45 C.F.R. pt. 96, sub. L. 7
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Mental health problems Economically disadvantaged Physically disabled Abuse victims Already using substances Homeless and/or runaway youth.10 Shared Risk Factors and Overlapping Missions ‐ An Integrated Approach Many people have co‐occurring disorders, diagnosed as having both a substance use disorder (dependence or abuse) and one or more other mental health disorder. Compared to the general population, individuals diagnosed with mood or anxiety disorders are about twice as likely to also suffer from substance use disorders. Likewise, individuals diagnosed with substance use disorders are roughly twice as likely to also be diagnosed with mood or anxiety disorders.11 According to the National Institute on Drug Abuse (NIDA), the high prevalence of co‐occurring disorders does not mean that one condition caused the other, even if one appeared first. At least three interpretations, all of which, in varying degrees, probably contribute to how and whether co‐occurring disorders develop, should be considered: 
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Drug abuse can cause symptoms of mental illness. Mental illness can lead to drug abuse. Both substance use disorders and other mental illnesses may be caused by common, overlapping risk factors like underlying neurological problems, genetic vulnerabilities, or early exposure to trauma or stress.12 In light of these findings, it is important to develop an integrated approach to preventing mental, emotional, and behavioral disorders and related problem behaviors. Risk and protective factors provide a framework for developing an integrated approach. According to the National Research Council and Institute of Medicine, a risk factor is a characteristic at the biological, psychological, family, or community level that precedes and is associated with a higher likelihood of problem outcomes. A protective factor is a characteristic at the biological, psychological, family, or community level that is associated with a lower likelihood of problem outcomes or that reduces the negative impact of a risk factor on problem outcomes.13 Causal risk and protective factors are those that are modifiable by an intervention and for which modification is associated with change in outcomes. Strategies predicated on changing risk and protective factors can only work if there is a causal relationship between those factors and substance use or related harms. Some risk and protective factors are associated with a broad spectrum of behavioral disorders and related problem behaviors for young people, either directly or indirectly through their influence on other risk or protective factors. As a result, preventive strategies may be aimed at these key risk and protective factors rather than at specific disorders. For example, negative life events at the family, school, peer, and community levels have been associated with multiple psychopathological conditions. Similarly, social support and problem‐solving coping skills appear to have broad protective effects. Good physical health also contributes to good mental health. Likewise, good mental health often 10
Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment. FY 2012 Annual Report – Substance Abuse Prevention and Treatment Block Grant. 11
National Institute on Drug Abuse. (2008). Comorbidity: Addiction and Other Mental Illnesses. NIH Publication No. 08‐5771. 12
Id. 13
National Research Council and Institute of Medicine. (2009). Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities. Washington, DC: The National Academies Press. 4 Program Guidance for Contract Deliverables
contributes to good physical health. These findings also highlight the importance of viewing mental and physical health more holistically.14 Furthermore, while the long‐term benefits are greatest for prevention efforts that focus on young people, it is important to adopt a developmental perspective and employ evidence‐based strategies that address risk and protective factors at all stages of life. Several shared risk factors are particularly important to address with an integrated approach that crosses different agencies and systems. According to the National Research Council and Institute of Medicine, poverty and child maltreatment are two of the most powerful risk factors for multiple mental, emotional, and behavioral disorders.15 Coalitions and Environmental Strategies Environmentally‐directed prevention is based on the view that all behavior, including the decision to use drugs or abstain, is influenced by one’s physical, social, economic, institutional, and cultural environment. Environmental prevention strategies can reduce drug use by influencing the complex set of factors that comprise the overall community system. These factors include community conditions, policies, standards, and institutions. Environmental prevention strategies are most effectively implemented in the context of a community problem solving process. This makes community coalitions uniquely situated to bring about the kind of environmental changes that are needed to influence the attitudes, perceptions, skills, beliefs, and behaviors of individuals within communities. Community coalitions are local partnerships between multiple sectors of the community that respond to community conditions by developing and implementing comprehensive plans that lead to measurable, population‐level reductions in drug use and related problems. Both providers and coalitions may implement environmental strategies depending on which organization has the greatest capacity to bring about change. Staff time spent participating in coalition work or on multi‐agency collaborative groups focused on the prevention of substance abuse are allowable expenses under the Substance Abuse Prevention and Treatment Block Grant prevention set‐aside. The managing entity is encouraged to utilize existing community resources to develop a similar strategy for mental health promotion. The Strategic Planning Framework and the Substance Abuse Response Guide In order to maximize their impact on the problems they confront, it is important that community and neighborhood organizations, whether they are anti‐drug coalitions or some other group of concerned citizens, engage in a strategic planning process. The strategic planning process is a conceptual framework that can be used in a variety of different contexts, though it is designed for prevention initiatives that address substance abuse and mental health issues. Given the versatility of this framework, it may be referred to by different names. The Center for Substance Abuse Prevention calls this process the Strategic Prevention Framework (SPF). The SPF contains five basic elements,16 and two overarching principles17that overlap and interact throughout the process. 14
Id. Id. 16
Assessment, planning, implementation, evaluation, and capacity. 17
Cultural competence and sustainability. 15
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The department has developed the Substance Abuse Response Guide (SARG) – an instruction manual designed to help coalitions learn and apply the SPF by providing guidance and tools, which is described in more detail below. By following the process outlined in the SPF and SARG, Florida’s communities will be able to use scarce resources to achieve sustainable, population‐level changes in risk and protective factors, contributing conditions, substance abuse, and associated problems. Two concepts that need to be addressed at every stage of a coalition’s work and that deserve special attention are cultural competence and sustainability. Cultural Competence Florida’s communities are characterized by an increasing diversity of cultures. Florida’s diversity challenges planners to ensure that its programs and practices are relevant to all Floridians. This means that it is particularly important for community‐based prevention to be culturally competent. Culture refers to “the shared values, traditions, norms, customs, arts, history, folklore, and institutions of a people unified by race, ethnicity, language, nationality, religion or other factors.”18 Cultural diversity goes beyond racial and ethnic identification to include gender, sexuality, socioeconomic status, age, locale, and disability, among other variables. Culture pervades all aspects of our individual and group identities and it constantly influences how we interact with each other and our surroundings. Cultural competence refers to the “ability to bring together different behaviors, attitudes, and policies and work effectively in cross‐cultural settings to produce better results.”19 Attention to cultural differences regarding health and wellness can help reduce disparities in access to, and quality of, health care services. Truly effective coalitions will ensure that cultural competency is integrated into all aspects of their work, from problem assessment, planning and capacity building to implementation and evaluation. The primary aim is to ensure that all Floridians are represented in prevention planning and have access to culturally appropriate services and strategies. Sustainability Sustainability refers to a coalition’s ability to maintain the human, social, and material resources necessary to accomplish the coalition’s long‐term goals for community change. The sustainability of initiatives and outcomes should be a goal established at the outset and addressed throughout all aspects of the process. Prevention planners at all levels need to build systems and institutionalize the practices and strategies that will sustain prevention accomplishments over time. This means that coalitions will have to adopt a comprehensive and long‐term perspective from the outset. Sustaining outcomes in the face of the complex and ever‐changing environments in which coalitions operate will require a sustainability plan. This way, regardless of what happens to internal and external resources, the long‐term viability of coalitions will remain secure. 18
National Community Anti‐Drug Coalition Institute. (2007). Cultural Competence Primer: Incorporating Cultural Competence into Your Comprehensive Plan. 19
Id. 6 Program Guidance for Contract Deliverables
Contracted prevention providers that are contracted for environmental strategies must engage in a process driven by DCF’s Substance Abuse Response Guide (SARG). They must produce locally‐developed and DCF‐approved Needs Assessment Logic Model, Comprehensive Community Action Plan, and Evaluation Plan. More explanation and details on the SARG process can be found here: http://www.myflfamilies.com/service‐programs/substance‐abuse/substance‐
abuse‐response‐guide‐sarg. In addition, SAMHSA indicates that primary prevention programming should be focused on the following main areas: 
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Ensuring data on substance use consumption and consequences are collected and analyzed to identify the substances of abuse and populations that should be targeted with prevention set‐aside funds; Ensuring prevention activities and services purchased with Substance Abuse Block Grant funds are both consistent with this needs assessment data and are not being funded through other public or private sources, including private commercial health insurance or Medicaid; Developing capacity throughout the state to implement a comprehensive approach to substance abuse issues identified by the statewide epidemiological work group; Collaborating with natural partners within the communities and state to focus on health and wellness to assist in implementation; Collecting and analyzing outcome data to ensure the most cost‐efficient use of substance abuse primary prevention funds.20 Prevention Data Reporting Both Provider and Coalition data are stored in the Performance Based Prevention System (PBPS). This system is separate from all other data collected and used by the department. The system can be accessed by contacting technical support at 1‐888‐600‐4777 or https://kitprevention.kithost.net/. The department requires the managing entity to ensure: 
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Subcontracted Providers and coalitions submit the Prevention Program Description (or Prevention Program Tool, as named in the PBPS). The managing entity must approve or reject the completed PPT in the PBPS before any data submission can be done by the provider. The Data Tools module of PBPS can provide the opportunity to review submissions when not using the application. Subcontracted Providers and coalitions submit prevention data of all program participants, programs and strategies which occurred. This will include the total number of dollars for the contract as well as the dollars noted for prevention programs or environmental strategies. This data can be found within reports contained in the Data Tools module of PBPS. Data submitted to PBPS is consistent with the data maintained in the provider’s program documentation, invoicing and sign‐in sheets. This data can also be found within reports contained in the Data Tools module of PBPS. Subcontracted Providers and coalitions use Minimum Data Set (MDS) coding for services, which is found in PBPS (and in KIT Solutions’ Minimum Data Set) and is used to create the Invoice Support Report which is used for reimbursement. Providers have a set of invoice codes and coalitions have a set of invoice codes 20
Substance Abuse and Mental Health Services Administration. FY 2014‐2015 Block Grant Application. Retrieved from http://www.samhsa.gov/grants/blockgrant/docs/BGapplication‐100312.pdf. 7 Program Guidance for Contract Deliverables
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Reviews the File Upload History screen in PBPS to determine the number of records accepted, updated and rejected. Based on this review, the provider shall download any associated error files to determine which provider records were rejected and to make sure the rejected records are corrected and resubmitted in PBPS. This is only applicable to providers that are uploading data via FTP. Provider Performance Measures Managing entities are required to ensure providers accurately report following the performance measures: 
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A minimum of eighty percent (80%) of tasks and activities shall be completed as outlined in the Work Plan. A minimum of ninety percent 90% of data submitted monthly shall be submitted by the due date. A minimum of ninety percent 90% of Department identified errors in data submitted shall be corrected within thirty (30) days of notification. The Prevention Partnership Grants Prevention Partnership Grants (PPG)21 are awarded once every three years. The PPG is funded via the Substance Abuse Prevention and Treatment Block Grant. PPG encourages the development of effective substance abuse prevention and early intervention strategies for school‐age populations, and is a multi‐agency collaborative effort between the department, the Department of Juvenile Justice, and the Department of Education. In Funding Cycle 2012‐2015, PPG criteria focused on the development of effective evidence‐based substance abuse prevention and early intervention strategies for school or college‐age populations. The Managing Entity shall be responsible for the procurement, contracting, and oversight of PPG grantees. The Managing Entity shall ensure compliance with the language and provisions of the awarded grants. As part of their yearly performance, each PPG‐funded provider must complete the Evidence‐Based Fidelity Self‐
Assessment Survey. The survey for programs funded in 2013 can be viewed here www.surveymonkey.com/s/NBTPT5H. Training related to the survey is available here www.myflfamilies.com/service‐programs/substance‐abuse/prevention‐
partnership‐grants‐ppg. Compliance with the Synar Amendment The Alcohol, Drug Abuse, and Mental Health Administration Reorganization Act of 1992,22 included provision aimed at decreasing youth access to tobacco.23 This provision, so named for its sponsor, Congressman Mike Synar of Oklahoma, requires states to enact and enforce laws prohibiting the sale or distribution of tobacco products to individuals under the age of 18. For the state to receive Block Grant funding, it must: 
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Have in effect a law prohibiting any manufacturer, retailer, or distributor of tobacco products from selling or distributing such products to any individual younger than age 18 Enforce this law; Conduct annual, unannounced inspections in a way that provide a valid probability sample of tobacco sales outlets accessible to minors; 21
s. 397.99, F.S. Pub. L. No. 102‐321. 23
Id. s. 1926. 22
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Negotiate interim targets and a date to achieve a noncompliance rate of no more than 10 percent; and Submit an annual report detailing state activities to enforce its law. The Managing Entity will facilitate coordination between coalitions and the Department of Business and Professional Regulation/Division of Alcoholic Beverages and Tobacco (DBPR/ABT), in order to achieve an equal gender distribution (50/50) between male and female youth inspectors for controlled buys of tobacco. Because uneven gender distribution of youth inspectors can significantly impact the reported retailer violation rate, it is important for Florida to achieve balance regarding the gender distribution of the youth inspectors for future Synar inspections. 9