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The withdrawal was required to carry out a significant purpose; and

The need for additional funds to purchase supplies or equipment, negotiate contracts or perform similar functions could not reasonably have been anticipated in the most recent President's Budget. Numerous procedural safeguards have been incorporated to meet the needs and the opinions of the Congress. In addition to the provisions just mentioned, these include:

Congressional authorization of both the amount of deposits into and withdrawals permitted from the contingency account as part of the Department's annual appropriation act;

À prohibition against using funds from this account to conduct an activity for which funds were denied by the Congress in considering the appropriation bill for that year;

A requirement that the program to be financed must be otherwise authorized by law;

At least 10 days' prior notification to the Committees on Appropriations of any intended use of the contingency account; and

Submission of an annual report to the Congress on the operations of the account. Thus within carefully prescribed limits, the Secretary of Health, Education, and Welfare would be able to react swiftly to important new findings gained from the Department's programs to extend the frontiers of man's knowledge. Support for large-scale clinical trials of a vaccine to protect pregnant women and their offspring from the ravages of German measles, and exploration of promising new leads in the quest for a fully implanted artificial heart are but two illustrations of how funds from the contingency account might conceivably be used.

Research does not represent the only area which may benefit from this proposal, however. Of equal importance is the opportunity to move quickly to cope with threats to the Nation's health or safety, broaden the dissemination of newly acquired knowledge, or deal with the impact of natural disasters.

This, then, Mr. Chairman, is the administration flexibility and operational efficiency which we seek to achieve through the establishment of a contingency account under the direction of the Secretary of Health, Education, and Welfare.

Thank you very much for giving me the opportunity to come before you to testify on these provisions of H.R. 6431. I know of your deep interest in mental health, and I urge that you report this bill favorably. If you have any questions, Dr. Stewart, Dr. Yolles, Mr. Kelly, and I will be happy to answer them. (The report referred to by Mr. Cohen follows:)

COMMUNITY MENTAL HEALTH CENTERS PROGRAM STATUS REPORT
(By Director, National Institute of Mental Health, March 31, 1967)

PART 1–GENERAL OVERVIEW Twenty-one years ago, when the National Mental Health Act was passed, only very few workers in the field were concerned with the development of community mntal health services. Even to them, the goal of effective services near home seemed distant and remote, barely visible on the horizon. The limited community

mental health facilities of the day served primarily as transfer agents-between the shattered lives and homes of citizens and the back wards of custodial institutions. Across the country, the American's attitude toward mental illness was still heavy with centuries-old traditions of shame and fear.

The challenge was great and it could not be denied--a challenge embodied in those hundreds of thousands of mentally ill Americans, whose doom was being inexorably sealed in isolated hospitals across the country. Today, only three years after the passage of the historic Community Mental Health Centers Act, we can gauge the degree of our progress : Our Government has now supported the development of 173 community mental health centers, with funds totaling 73 million dollars to be devoted to the dual tasks of construction and staffing. By the end of Fiscal Year 1967 we will have supported 286 centers serving 47.2 million persons.

As of March 27, 1967 : Grants made: Construction only -

100 Staffing only--

47 Construction and staffing

26 Total number of centers funded..

173 Funds Obligated : Construction :

FY 1965: 33.6 million or 94% of 35 million.

FY 1966: 21 million or 42% of 50 million. Applications pending : approximately 28 million or 56% of 50 million.

FY 1967 : 300,000 obligated or 0.6% of 50 million.
Staffing:

FY 1966: 15.2 million or 80% of 19 million (new grants) (4 month availability).

FY 1967: 2.6 million or 14% of 19 million (new grants). Applica

tions pending: 19.5 million or 102.6% of 19 million. Funds obligated at all levels (Federal, State, Local) $209 million. Averaging as follows: Construction cost per center 1.2 million ; 1st year operating cost $776 thousand; Rate of Federal participation 50%.

Currently, 28 million persons have community mental health centers available to them, or have centers slated for construction and/or staffing in their communities. Each center serves an average population group of 165,000.

These centers--the symbols of a new era in mental health care-serve 45 States and Territories. They have sprung from the creative collaboration of mental health professionals, and political and civic leaders at the Federal, State and local level. And, they have evolved from a solid base: a broad range of public and private agencies-hospitals, clinics, medical schools—many of them combining their efforts to develop a single comprehensive center.

Procedures for implementation are functioning well-as NIMH staff members join with professionals and volunteers in States and communities across the Nation, taking those necessary technical steps that lead, ultimately, to the construction of individual centers. State plans are being reviewed as they are developed and submitted—a prerequisite for the formal submission of proposals for specific centers within the State. In this way, inventories of existing community resources and surveys of current needs are made to mesh with projected goals.

There are those who, sharing our own zeal, would have wanted us to speed ahead at a faster pace-- who would like to see new community mental health centers offering services in every American community now. Today. In the face of our country's need, they share our own impatience.

This ideal cannot be faulted, and we will not be satisfied until the entire American community is served. But our enthusiasm must be tempered with realism. Attempts at speed without the careful development and utilization of sound professional and administrative procedures are unrealistic; and, quantity without quality is self-defeating.

Ours is an innovative program-involving new concepts in architecture, in manpower, in services-and such programs require time to build: time between the appropriation of funds and the psychological readiness of communities and States to act : between the readiness to act and the development and submission of tangible plans and proposals; and between the approval of a program and

its actual operation. History teaches us that all new programs—if they are to be successful—must follow a similar course of careful planning and development. Even more important is our insistence on quality—our conviction that there is no substitute for excellence where the health and welfare of our citizens are concerned. Implied here is no lack of concern for human needs, but rather the sure knowledge that we serve these needs best if, as scientists, we adhere to high standards. We mean to build a program in which numbers and novelty will not replace soundness of purpose and design. A community mental health center can only rise from firm foundations: from systematic priorities in the allocation of resources; from convincing evidence that services will in fact reach the people for whom they are intended; from a certainty that care will be comprehensive—that the continuum of human needs will be met by a continuum of responsive services. I want to share with you our conviction that our progress cannot be gauged solely by bricks and mortar. Those of us close to the centers construction task are aware that this new program is far more than one of construction alone— that its impact cannot be measured solely in physical terms. The fact is that we have inspired here a revolution in mental health activities across the country. Old and unrewarding attitudes toward mental health needs are changing, and they are being restructured in communities and States across the Nation. No longer is mental health seen as the privilege of the few who can afford private care—with the sickest and neediest of our fellow men shunted away in distant hospitals, removed from the conscience and concern of the community. All Americans—the indigent along with the wealthy, the laborer and blue collar worker along with the professionals—are beginning to be seen as the community of effort that forms the centers program. A community mental health center can succeed only if it is accepted by the citizens of the community in which it is located. Long entrenched patterns of passivity are changing. Communities have become involved in planning for the mental health of their own residents—with new services appearing at the local level; and, the States—29 of which have now passed Community Mental Health Services Acts—have begun to advance the organization and distribution of their own mental health resources. Patterns in the financing of mental health services have been revolutionized. In some States Federal money is being matched with State money exclusively: in others with State and local money; in still others with private funds. As recommended by the National Governors' Conference, the NIMH–working with the Council of State Governments—is encouraging the development of the broadest possible base for the financing of community mental health programs.

MEASURES OF Progress

It is important at this point to assess the shape as well as the degree of our efforts. We must evaluate the extent to which we are meeting the criteria of quality we set for ourselves and for the millions of citizens who are the potential beneficiaries of this contemparary approach. The program requires, for example, that each community mental health center make its services not only available, but readily accessible to all. How have the results of our efforts matched this objective? It was clear from the outset that communities seeking support for mental health programs would ultimately represent a sweeping cross section of the total American community. Initiative has come from depressed areas and from regions of great wealth; from one-industry towns to cities built on a broad industrial base: from areas containing some of the strongest medical centers in the country to those which have until now attracted few or no professionals in the mental health field. The image of the mental health center as serving populations concentrated only in the metropolis is hardly valid. The developing centers are marked by a broad regional diversity: a third are in cities of a half-million persons or more: another third in cities of fifty to five hundred thousand ; and a final third in communities of fifty thousand residents or fewer. Mental health services will thus reach big city dwellers, suburbanities, and rural residents alike. In fact. nearly 150 predominantly rural counties are included in the population areas served by centers now being formed : residents of many areas will now have mental health professionals in their midst for the first time.

What about the range of services provided? On this score, too, the program requirements were clear. Each center, they prescribed, must assure continuity of care—encompassing five basic treatment services: inpatient services for those who may require short-term hospitalization; partial hospitalization—during the day or over-night; out-patient treatment for patients who might make appointments as they would routinely with their family physicians; emergency services, available around the clock; and consultation and education programs. How have we fared? The center programs, I am pleased to report, are evolving as they were intended to-with a spectrum of services by mental health workers who seek to equal the range of needs brought by citizens in search of help. A number of the centers now under way sprang from agencies already, providing nearly the entire span of essential services. But the program has also given sharp rise to many new and improved services in communities across the country: .New inpatient services will be available in 40 percent of the centers funded, and in an additional 32 percent, they will be enlarged—either through new physical facilities, increased staff, or both. .Over half of the centers currently under way will provide partial hospitalization facilities in areas where no such capacity existed before. .New inpatient services will be available in 40 percent of the centers funded, ters, and an additional 40 percent will improve and expand existing therapeutic approaches used on an outpatient basis—including individual and group psychotherapy, family therapy, and drug treatment. .Half of the centers will offer new emergency services, and a third more will increase them beyond their present levels; many plan to publicize emergency facilities widely within the community in order to assure their increased use. Forty percent of today's centers will offer new consultative services, and another 40 percent will broaden existing ones—reaching out to schools, churches, court and juvenile authorities, and welfare agencies. The community mental health centers program was a bold confrontation of the almost universal problem of fragmentation of services—in which the interests of professional agencies reigned supreme over the needs of the patient and his family. The program placed the patient at its hub, and citizens and professionals alike responded. Already, the community mental health center has served as a model for other programs—from neighborhood centers to community delinquency programs—in which comprehensive and continuous services must replace fragmented and overlapping ones.

Meeting special needs

These data do not imply a rigid uniformity among the centers. Far from it. There is no single model, for no two American communities are alike. Each center has its individual characteristics—reflecting the needs and the resources of the area it serves. The range portrays the face of America, and the ingenuity and adaptive ability of its citizens. Some centers, for example, will reach out to crowded metropolitan areas, while others will spread their services across thinly populated mountains and plains. In Texas, Dallas will have a full span of mental health services used in the city's large general hospital. In Louisiana, in contrast, two agencies have devised a plan to serve the people of the bayou country through individual clinical units ranging over four counties; and in Kansas, two agencies have combined to provide comprehensive services to residents of a rural area spanning over 20 counties.

PATTERNS OF FINANCING

The diversity of the center programs is further reflected in funding patterns used across the country. In some States, Federal money is being matched with State money exclusively; in others with State and local money; in still others with private funds. We are encouraging the broadest possible base for the financing of community mental health centers, and some communities have pioneered new funding programs among several counties or regions, and across State lines.

As a result of the Community Mental Health Centers Program, many States have sought to involve their communities directly in the provision of mental health services. The most common mechanism has been a State-implemented Community Mental Health Services Act. Since the passage of the first such act in New York thirteen years ago, twenty-eight States have followed suit. These laws have provided for decentralization in the administration of community services, cost sharing by the State and localities, and the maintenance of local choice and initiative; State funds have typically been provided on a matching basis. Within the last year, several States have considered and passed community mental health services legislation. Perhaps the boldest approach to date has been the recently developed act in Pennsylvania. The Pennsylvania act ensures that the localities of the Commonwealth provide a wide range of mental health services, and pledges State support of 90 percent of eligible costs. It is a source of satisfaction for us to note that community mental health center financing efforts have often grown from the deepest roots of the communities—from the citizenry itself. The Lane County Community Menatl Health Center in Eugene, Oregon, for example, is largely the result of community sponsorship; seventeen county agencies are affiliated with the center, which will serve residents in an area reaching from the Pacific Ocean to the summit of the Cascade Mountains, as well as the 12,000 students at the University of Oregon in Eugene. In Pittsburgh, a grant from the Appalachian Regional Commission will help in the realization of a center to serve an area of 160,000 residents—primarily from low-income, urban areas. At Daytona Beach, Florida, the Volusia County Mental Health Center is the result of a unique community drive to guarantee adequate mental mealth services. The local Mental Health Association initiated a campaign to raise money toward construction of the center, and the largest corporation in the country contributed the services of its public relations department to promote the drive. Civic groups and hundreds of individuals participated—physicians, bankers, lawyers, housewives: one resident contributed the income from an orange grove to the project: the clergy sponsored a Mental Health Sabbath. Most important, the total effort brought all the interests within the county together for the first time in its history.

PART II—SELECTED ExAMPLES OF CENTERS

1. Eartension of high quality care to new population groups.--Temple University, Philadelphia, Pennsylvania:

Staffing grant Fiscal year 1966: Federal share ----------------------------------------------- $420, 240 Total operating cost for 1st 12 months.-------------------------- 921, 240

The Temple University Community Mental Health Center is an example of how a University Department of Psychiatry can develop a Community Mental Health Center which will expand services to its surrounding population area and provide high quality care to a population that has a high incidence of social problems and socioeconomic deprivation. This facility will serve an area in Northeast Philadelphia. This is predominantly a slum area with a high percentage of negroes (63.5% in 1960). It is also an area of social decay and multiple problems, e.g., 60 percent unemployment for youth of 15 to 21 who are not students. One-fourth of the families are at the poverty level, i.e., less than $3,000 per annum income. The Temple University Medical Center is in the center of this area and is readily accessible to its population. It has previously offered diagnostic services to people in the area at an estimated level of 350 patients per year, but very few of these patients received subsequent interviews or treatment. Furthermore, the inpatient service was limited to private and teaching cases. Stimulated in part by the Community Mental Health Centers Program, the Psychiatry Department has just entered a new phase of rapid expansion. A unique feature of the Temple Community Mental Health Center's program which will ultimately serve to improve the delivery of mental health services to the poor is a built-in evaluation system that is designed to provide constant feedback to the administration and assure continuity of patient care. The service program will provide the utilization data ; the evaluation unit will do the follow-up studies, and the Center will draw upon the full resources of the Medical School for survey research and sociocultural data. A variety of resources will thus be brought together into a sophisticated operations research

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