OMB Ss-a-n-ssats 3.6.19_final

^National Survey of Substance Abuse Treatment Services (N-SSATS)

SUPPORTING STATEMENT

A. JUSTIFICATION

1. Circumstances of Information Collection

The Substance Abuse and Mental Health Services Administration (SAMHSA) requests a revision of the National Survey of Substance Abuse Treatment Services (N-SSATS) data collection (OMB No. 0930-0106), which expires on December 31, 2018. N-SSATS provides both national and state-level data on the numbers and types of patients treated and the characteristics of facilities providing substance use treatment services. It is conducted under the authority of Section 505 of the Public Health Service Act (42 U.S.C. 290aa-4) to meet the specific mandates for annual information about public and private substance use treatment providers and the clients they serve.

This request includes:

• N-SSATS, an annual census of substance use treatment facilities which collects descriptive data on the location, scope, services provided, and operational characteristics of all known substance use treatment facilities in the United States and its jurisdictions, and on utilization of services by means of a single-day count of clients in treatment; and

• data collection activities associated with updating the treatment facility universe, named the Inventory of Behavioral Health Services (I-BHS). The inventory includes both mental health treatment facilities and substance use treatment facilities, making it a “behavioral health” inventory.

Both I-BHS and N-SSATS are components of the Behavioral Health Services Information

System (BHSIS).

Not included in this request, although considered part of the overall BHSIS system, is the National Mental Health Services Survey (N-MHSS). N-MHSS, which provides data on the number and characteristics of mental health treatment facilities in the United States, maintains a separate OMB approval (OMB No. 0930-0119). Also not included in this request is the Treatment Episode Data Set (TEDS), which collects client-level data submitted by states on admissions to and discharges from state-funded substance use and mental health treatment facilities and maintains a separate OMB approval (OMB No. 0900-0335).

The two data collection activities included in this request are described as follows:

I-BHS: The I-BHS is a master listing of all organized substance abuse treatment facilities and mental health treatment facilities known to SAMHSA and will serve as the universe for both the N-SSATS and the N-MHSS facility surveys.

Substance use treatment facilities: All substance use treatment facilities or programs, public and private, are eligible to be in the universe frame. SAMHSA does not include jails or prisons.  SAMHSA does not include solo practitioners unless the Single State Agency (SSA) specifically requests that they be included. That is the universe frame. I-BHS includes two substance use treatment facility components: 1) a listing of facilities providing substance use treatment that are licensed, certified, or otherwise approved by a state substance use agency; and 2) a supplemental listing of other treatment facilities, referred to as non-state-approved facilities that SAMHSA has identified through augmentation activities or through requests from individual facilities. Information on the state-approved facilities is provided by state substance abuse agency representatives, who update the information throughout the year using the web-based I-BHS Online system. The online system allows the addition of new facilities and revision of information on existing facilities in a password protected environment (https://dasis3.samhsa.gov/brc).The state updates are continuous. Identification of non-state-approved facilities through an augmentation involves a periodic search of professional listings, business directories, and other sources for substance use treatment facilities not included in the I-BHS. Also, facilities not previously listed can request to be included in the inventory through a link on SAMHSA’s online Behavioral Treatment Services Locator (available at https://findtreatment.samhsa.gov).

In order to be listed on the locator, a substance use treatment facility MUST be “approved” by the SSA. This typically includes those facilities that the state licenses, certifies, or otherwise monitors.  There are other facilities that the State does not monitor, but recognizes are legitimate substance use treatment facilities. The SSA may then indicate that they are “directory eligible” so that they may be listed on the locator. With the exception of federal facilities (Department of Veterans Affairs, Department of Defense, Indian Health Service) and SAMHSA-certified Opioid Treatment Programs, it is the SSA that determines if a facility can be included in the locator.  If the state SSA does not indicate that the facility may be listed, it will not be listed. Additionally, if a facility chooses to not be listed, it will not be listed.

The state SSA has access to the I-BHS online and will go into this system to update contact information for their state’s facilities. This includes indicating that a facility is no longer active (gone out of business, no longer treating substance use disorder, etc.). If these facilities are removed before the file is “frozen” before each (N-SSATS) survey year, they are not in that year’s survey. SAMHSA also sends out an “advance letter” notifying facilities of the upcoming survey. Another purpose of this letter is to determine those facilities that have closed, moved, or are no longer at that address. When the post office returns these letters, a “locating” team researches them and determines their status. If they are closed, they are reported as such. Other facilities notify us that they are no longer in service and they are then “closed.”  Updates with the I-BHS occur monthly and any “closed” or “not active” facilities are indicated as such (and removed from the locator if they were on the locator). As for response rates for the N-SSATS, every facility on the frozen file receives a status by the end of the survey. For the “universe response rate,” closed facilities are considered as having “responded.” SAMHSA typically has approximately a 10% “closed” response. When SAMHSA looks at “actual completes,” SAMHSA considers only those that are active facilities.

Mental health treatment facilities: Likewise, the I-BHS includes two components for mental health treatment facilities: 1) treatment facilities identified by state mental health agencies and 2) facilities identified through listings of various mental health organizations and through requests from individual facilities. Facility requests come through SAMHSA’s online Behavioral Health Treatment Services Locator (available at https://findtreatment.samhsa.gov). The mental health treatment facility universe is updated through state agency input into I-BHS Online, through augmentation searches of various mental health organizations and other listings, and through applications from individual facilities.

It is anticipated that more than one agency within a state may be involved for mental health treatment facility registration, since multiple agencies are often involved in providing mental health treatment.

For both mental health and substance use treatment facilities, approval is requested for the state updates through I-BHS Online, for individual facility applications, and for screening calls to potential treatment facilities discovered through augmentation activities. The purpose of the screening calls is to determine eligibility for inclusion in the I-BHS. The specific I-BHS forms for which approval is requested are listed below:

• I-BHS Online Facility Add/Update Forms (state registration and update of facilities) (see Attachment A1);

• I-BHS Facility Application Form (individual facility online request which is scalable for any electronic device (i.e., computer, tablet, smart phone)) (see Attachment A2 for computer screen); and

• Facility Augmentation Screener (for screening facilities identified through augmentation sources) (see Attachment A3).

Included in this request are two versions of the N-SSATS survey, an N-SSATS (Version A) which includes one-day client counts to be conducted in 2019 and 2021, and an N-SSATS (Version B) which is a version without client counts, fielded every other year in efforts to minimize burden on respondents while still obtaining timely, crucial, current data on clients. The shortened version also allows the addition of timely new modules of questions every other year without greatly increasing response burden above approximately 40 minutes per response on any year. During this 2019-2021 cycle, however, it is not expected that any new modules of questions will be included in Version A or B; if they are, either a modification or a new package will be submitted. The 2019 N-SSATS (Version A) questionnaire and 2020 N-SSATS (Version B) questionnaire are provided at Attachment B1 and B2, respectively. Also included in this request is the Between-cycle N-SSATS (N-SSATS BC), to be conducted between the annual surveys to collect information on new facilities for inclusion in the Treatment Locator. The N-SSATS BC, which contains questions used primarily to populate the Locator, is described later is this section and is provided at Attachment B3.

The alternating schedule of a Version A and Version B annual N-SSATS (rather than all N-SSATS survey questions every year) was implemented to reduce burden on facilities. A similar schedule was implemented for the N-MHSS. The current N-MHSS OMB clearance includes this alternating schedule in which data on facility operational characteristics and utilization are collected every other year.

In any one year, one survey with client counts (either N-SSATS or N-MHSS) and the other survey without client counts (either N-SSATS or N-MHSS) will be fielded. Conducting two full-length/all question surveys every year would not be practical and could be burdensome for the approximately 11 percent of behavioral health facilities that provide both substance use and mental health treatment services. However, it is important to collect these client count data to be able to provide current and accurate numbers of clients in treatment at the local level for community projections needs and funding. For example, recently one state was planning safety procedures in the event of a major catastrophe (earthquake) in a neighboring highly populated area; they needed to know numbers of opioid clients from that area that they might expect to see coming into their area so that they could put procedures into place to be able to accommodate the influx. During recent hurricanes, SAMHSA was asked for numbers of substance use clients in affected counties so states could provide appropriate and sufficient care in evacuation areas.

This submission requests approval to conduct an N-SSATS (Version A) in 2019 and 2021 and an N-SSATS (Version B) in 2020. Conversely, the current approval for N-MHSS includes an N-MHSS with client counts to be conducted in 2018. The next request for approval for the N-MHSS will include N-MHSS (no client counts) in 2021 and an N-MHSS (with client counts) to be conducted in 2020 and 2022.

The 2020 N-SSATS (Version B) instrument will collect information needed to update the Behavioral Health Treatment Services Locator, such as facility name and address, services offered, special groups served, and other information that describes the facility. Detailed client counts, will be collected and reported biennially, sufficient for most research and reporting uses of the data. It was originally expected that questions about electronic health records would be included in Version B. However, testing of the questions has not yet been completed; therefore, those questions will not be included in this 2019-2021 cycle.

The 2019 and 2021 N-SSATS (Version A) will be conducted through an online web survey, with a mail questionnaire option and telephone follow-up of non-respondents. The online version is the primary response mode, with about 92 percent of facilities responding online in 2017. Attachment B4 provides a copy of the web screens for the 2019 N-SSATS online response option. The online survey utilizes the same survey questions as the N-SSATS paper questionnaire and imposes no additional burden for respondents. In actuality, burden for respondents is lessened because the skip patterns are programmed in so respondents see only the questions that apply to them based on their responses and many questions are pre-filled if the facility replied the previous year because services responses often remain consistent from year to year. The 2020 N-SSATS (Version B) will also be conducted through an online web survey with a mail questionnaire option and telephone follow-up of non-respondents. Both web versions are scalable and display well on smart phones and tablets.

In addition to the alternating Version A/Version B annual N-SSATS, a Between-cycle N-SSATS will be conducted periodically as new facilities are identified. The N-SSATS BC is a procedure for collecting the services data from newly identified facilities between main cycles of the N-SSATS in an effort to keep the listing of treatment facilities in the online Behavioral Health Treatment Services Locator up-to-date. The between-cycle survey data collection from newly identified facilities allows facilities to be added to the Locator in a timelier manner, without waiting a full year for the next regular N-SSATS survey. The N-SSATS BC will be conducted with an online instrument and by telephone.

Approval is requested to conduct the N-SSATS (Version A), the N-SSATS (Version B), and the N-SSATS BC, as follows:

1. N-SSATS (Version A) (the 2019 N-SSATS questionnaire which includes detailed one-day client counts is provided at Attachment B1) (Changes in the questionnaire from the 2017 N-SSATS are summarized in Section A.2);

2. N-SSATS (Version B) (the 2020 N-SSATS questionnaire is provided at Attachment B2) (Changes in the questionnaire from the 2019 N-SSATS are summarized in Section A.2); and

3. Between-survey N-SSATS BC for new facilities (uses an abbreviated questionnaire and is provided at Attachment B3.) (Changes in the questionnaire from the 2020 N-SSATS are summarized in Section A.2)

2. Purpose and Use of Information

The N-SSATS is an annual census of drug and alcohol treatment facilities in the United States. The list frame for the N-SSATS is comprised of all active substance use treatment facilities on the I-BHS. The N-SSATS serves three main purposes:

1. to describe the location, scope, organizational characteristics, services provided, and utilization of facilities for analytic reporting.

2. to update facility information on SAMHSA’s Behavioral Health Treatment Services Locator, available at: https://findtreatment.samhsa.gov, and an electronic (PDF) equivalent known as the National Directory of Drug and Alcohol Abuse Treatment Programs, and

(3) to provide the most up-to-date and accurate data to assist SAMHSA, state, and local governments in assessing the nature and extent of services provided in substance use treatment facilities and in forecasting substance use treatment resource requirements, as well as to analyze substance use treatment services trends and conduct comparative analyses for the nation, regions, states, counties, and communities. N-SSATS, which typically receives a greater than 90% response rate, is an annual census of all treatment facilities. The high response rate indicates that most of the facilities want to respond to the survey and let others know information about their facilities. The ability to monitor trends and access, in both services and utilization in large and small geographical areas (national, regional, state, county, community) so policy makers and national and state personnel can forecast and address potential deficits in treatment is critical. To see what types of information is disseminated from SAMHSA, please see the 2017 N-SSATS annual report at: https://wwwdasis.samhsa.gov/dasis2/nssats/2017_nssats_rpt.pdf

The I-BHS provides a national listing of all known substance use and mental health treatment facilities in the United States and territories. I-BHS serves as the universe for N-SSATS and N-MHSS, as well as for other surveys of substance use and mental health treatment facilities.

For more than two decades, the N-SSATS has provided national data on the nature and distribution of the drug and alcohol treatment resources in the United States and territories, the number of the clients treated, services provided, and operational characteristics of treatment facilities. The products produced from N-SSATS are primarily used by all stakeholders in the Behavioral Health system in the following ways:

• The Behavioral Health Treatment Services Locator (https://findtreatment.samhsa.gov) and the annual National Directory of Drug and Alcohol Abuse Treatment Programs are facilitated by the I-BHS and in close coordination of the N-SSATS and N-MHSS. The Locator permits searches for substance use and mental health treatment facilities (or facilities offering both types of treatment) through a single website.

• An annual report that describes the substance use treatment system in the United States, including information on facility location, services provided, operational characteristics, and number of persons in treatment on the survey reference date; and

• Public-use analytic data files that can be used by researchers or other members of the public to perform research on treatment services provided in the United States. These data have been used to illustrate treatment “deserts” so that states and communities can better justify placement of resources, not only with services but numbers treated within those deserts. With the current “opioid crisis,” policy makers need numbers of clients within small areas to better allocate their limited resources.

This information is also used to describe and assess the nature and extent of these resources, to identify gaps in services, to provide a public listing for treatment referrals, and to provide data for researchers. Not only is the N-SSATS the only means for updating the Locator and the Directory, it is also the only source of national, state, and local data on the characteristics and utilization of the specialty substance use treatment system. Users of N-SSATS data include the Congress, Federal agencies and offices such as the Office of National Drug Control Policy (ONDCP), state legislatures and agencies, local communities, organizations (e.g., the National Association of State Alcohol and Drug Abuse Directors), researchers, treatment facilities (e.g., for referral of clients), and individuals seeking treatment.

Changes to N-SSATS

Changes are required periodically to stay responsive to current trends and needs of the population. For example, the “opioid crisis” has prompted the Federal government to make prevention and treatment of opioid use disorder a priority area of focus. In SAMHSA’s Strategic Plan (FY2019 – FY2023), the first of five priorities is “Combating the Opioid Crisis through the Expansion of Prevention, Treatment, and Recovery Support Services.” For this effort, it is critical to know the numbers of facilities offering medication assisted treatment (MAT) and the numbers of clients receiving those treatments, as well as where they obtain that medication. Additionally, because alcohol is still the most used substance, officials are asking for numbers of facilities that treat alcohol and how many clients are receiving MAT for alcohol use disorder. Local communities have their individual challenges and they request specifics about their localities. New medications for treatment of specific substances have recently been approved by the FDA and through research, new therapeutic approaches are being established. N-SSATS must remain current with the field to provide the best possible information to the public, policy makers, and researchers. Finally, because SAMHSA collaborates with other agencies (CDC, ONC, etc.), SAMHSA is able to include questions that are mutually important for all collaborating agencies and therefore reduce the burden of paperwork for the treatment facilities.

OMB approval is requested for the following changes:

N-SSATS: The N-SSATS (Version A) will be conducted in odd years. Approval is requested for the following changes from the 2017 N-SSATS to the 2019 N-SSATS (Version A) questionnaire:

2017 Q8. The religious affiliation question has been deleted. (The data did not provide the desired information, and was misunderstood and used incorrectly.)

2017 Q15. The question asking about the facility’s standard operating procedures has been deleted. (There was little variability with most responses in this question among facilities.)

2017 Q31d. The question about outpatient capacity has been deleted. (This question was not reliable or understood; because of the many various ways of understanding “capacity” there was no way to determine what the responses actually meant.)

2017 Q27. The question asking how (paper/electronic/both) a facility performs selected activities has been deleted. (It was expected that the new electronic health record questions would provide the needed information; this removal was approved by both CSAT within SAMHSA and ONC who were working with SAMHSA on the new questions.)

2017 Q26. Item 8, which asks about Access to Recovery (ATR) client payments, has been deleted. (The program has ended.)

2019 Q13a. Add a question about where clients obtain their medications for opioid use disorder if Q13.4 is selected. (This question was added in response to the opioid crisis and requests of SAMHSA leadership to better understand how MAT is utilized.)

2019 Q13d. Add a question about the percent of clients on MAT for opioid use disorder that receive maintenance services, detoxification, and relapse prevention. (This question was added in response to the opioid crisis and requests of SAMHSA leadership to better understand how MAT is utilized.)

2019 Q14. Add a question about how facilities treat alcohol use disorder (This question was added in response to SAMHSA leadership’s request.)

2019 Q14a. Add a question about where clients obtain their medications for alcohol use disorder if Q14.3 is selected. (This question was added in response to SAMHSA leadership’s request.)

2019 Q14b. Add a question about whether the facility only treats alcohol use disorder. (This question was added in response to SAMHSA leadership’s request.)

2019 Q25d. Add a question about how many hospital inpatients received Disulfiram, Naltrexone, and Acamprosate for alcohol use disorder. (This question was added in response to SAMHSA leadership’s request.)

2019 Q26d. Add a question about how many residential clients received Disulfiram, Naltrexone, and Acamprosate for alcohol use disorder. (This question was added in response to SAMHSA leadership’s request.)

2019 Q27d. Add a question about how many outpatient clients received Disulfiram, Naltrexone, and Acamprosate for alcohol use disorder. (This question was added in response to SAMHSA leadership’s request.)

2017 Q6. Removed asterisk from the question about primary focus of the facility, which means the information will no longer be published on the N-SSATS locator. (While it is important for internal use in understanding the facilities, this variable was universally misunderstood by the public and many outside researchers.)

2017 Q11. Changes as follows: (These changes are being made in response to requests by SAMHSA leadership, to stay current with medications and practices, and to streamline the questionnaire.)

1. Under “Testing”

• Change “Screening for Hepatitis B” to “Testing for Hepatitis B (HBV)” (Q11.11)

• Change “Screening for Hepatitis C” to “Testing for Hepatitis C (HCV)” (Q11.12)

• Add “Testing for metabolic syndrome”

• Add “Drug and alcohol oral fluid testing”

2. Under “Assessment and Pre-Treatment Services”

• Add “Professional interventionist/educational consultant”

• Change “Screening for mental health disorders” to “Screening for mental disorders”

3. Break out “Ancillary Services” into “Recovery Support Services,” “Education and Counseling Services,” and “Ancillary Services”

4. Under the new “Recovery Support Services,” include from the old “Ancillary Services”

• Mentoring/peer support (Q11.22)

• Self-help groups (for example AA, NA, SMART Recovery) (Q11.37)

• Assistance in locating housing for clients (Q11.26)

• Employment counseling or training for clients (Q11.25)

• Assistance with obtaining social services (for example, Medicaid, WIC, SSI, SSDI) (Q11.24)

5. Under the new “Recovery Support Services,”

• Add “Recovery coach”

• Add “We do not offer any of these recovery support services.”

6. Under the new “Education and Counseling Services” include from the old “Ancillary Services,” and add vocational training or educational support

• HIV or AIDS education, counseling, or support (Q11.29)

• Hepatitis education, counseling, or support (Q11.30)

• Health education other than HIV/AIDS or hepatitis (Q11.31)

• Substance abuse education (Q11.32)

• Smoking/tobacco cessation counseling (Q11.38)

• Add “Vocational training or educational support (for example, high school coursework, GED preparation, etc.)”

• We do not offer any of these education and counseling services

7. Under the new “Education and Counseling Services” add (from Q13) [The old Q13 would be eliminated and the question changed into a “check all that apply.”]

• Individual counseling (Q13.1)

• Group counseling (Q13.2)

• Family counseling (Q13.3)

• Marital/couples counseling (Q13.4)

8. Keep under “Ancillary Services”

• Case management services (Q11.20)

• Social skills development (Q11.21)

• Child care for clients’ children (Q11.23)

• Domestic violence—family or partner violence services (physical, sexual, and emotional abuse) (Q11.27)

• Early intervention for HIV (Q11.28)

• Transportation assistance to treatment (Q11.33)

• Mental health services (Q11.34)

• Acupuncture (Q11.35)

• Residential beds for clients’ children (Q11.36)

• We do not offer any of these ancillary services (Q11.39)

9. Under “Transitional Services”

• Add “Naloxone and overdose education”

• Add “Outcome follow-up after discharge” (Moved from Q15-2017 NSSATS)

10. Under “Pharmacotherapies”

• Add “Medications for HIV treatment (for example, antiretroviral medications such as tenofovir, efavirenz, emtricitabine, atazanavir, and lamivudine)”

• Add “Medications for Hepatitis C (HCV) treatment (for example, sofosbuvir, ledipasvir, interferon, peginterferon, ribavirin)”

• Add a category “Buprenorphine (extended-release, injectable, for example, Sublocade®)”

• Add “Lofexidine”

• Add “Clonidine”

11. Under a new category “Medical Services” _

• Add “Hepatitis A (HAV) vaccination”

• Add “Hepatitis B (HBV) vaccination”

• Add “We do not offer any of these medical services”

2017 Q12. Changes as follows: (These changes provide further clarification based on respondents comments.)

• Add “For this question, MAT refers to any or all of these medications unless specified.”

• Reword category 5 to say “This facility administers naltrexone to treat opioid use disorder. Naltrexone use is authorized through any medical staff who have prescribing privileges.”

• Added a category, “This facility prescribes buprenorphine to treat opioid use disorder. Buprenorphine use is authorized through a DATA 2000 waivered physician, physician assistant, or nurse practitioner.”

• For the last option, change the wording to “This facility is a federally-certified Opioid Treatment Program (OTP). (Most OTPs administer/dispense methadone; some only use buprenorphine.)”

2017 Q12b. Changes as follows: (This change was requested by SAMHSA leadership.)

• Add a category “Detoxification from opioids of abuse with lofexidine or clonidine”

• Add a response category stating, “We do not offer any of these medication services.”

• Add a category for “Other (Specify:)

2017 Q13. Delete the question about the types of counseling by percent range, and place in 2017 Q11, as indicated above. (Streamlining the questionnaire for easier response.)

2017 Q14. Changes as follows: (Streamlining the questionnaire for easier response and to stay current with the terminology in the field.)

1. Change this question into a “Mark all that apply” list similar to the format of Q11 and change the question stem wording to “Which of the following clinical/therapeutic approaches listed below are used frequently at this facility?”

2. Change the wording of Q14.14 to “Telemedicine/telehealth (including Internet, Web, mobile, and desktop programs)”

3. Add “We do not use any of these clinical/therapeutic approaches”

2017 Q19a. Add “Clients with co-occurring pain and substance use” (Requested by respondents and people searching the locator)

2017 Q31a Changes as follows: (Requested by SAMHSA leadership.)

1. Change the question so it states: As of March 29, 2019, how many active clients were receiving each of the following outpatient substance abuse services at this facility?

2. Change the instructions so they state: An active client is a client who received treatment in March and is still enrolled in treatment on March 29, 2019.

2017 Q35. Change the question so it states: Does this facility operate transitional housing, a halfway house, or a sober home for substance abuse clients at this location, that is, the location listed on the front cover? (Current terminology)

2019 Q6. Add a question about Federally Qualified Health Centers (FQHC). (Requested by SAMHSA leadership.)

The N-SSATS (Version B) without client counts will be conducted in even years. Approval is requested for the following change to the 2020 N-SSATS (Version B) questionnaire:

All changes to the 2019 N-SSATS are requested for the 2020 N-SSATS except:

2018 Q28 and 28a. Add the question asking if a facility is part of an organization with multiple facilities or sites, and if applicable, the question asking the information about the parent site. (Needed for survey administration.)

2019 Q13d. Remove the question about the percent of clients on MAT for opioid use disorder that receive maintenance services, detoxification, and relapse prevention. (Client counts are not collected in “even” years.)

2017 All of Section B (Reporting Client Counts), Q28-34 has been deleted. This includes: how the facility will complete client counts; number of facilities in client counts; names and addresses of additional facilities reported for; number of hospital inpatient client counts by category, by number under age 18, number receiving methadone, buprenorphine, or naltrexone, and number of dedicated beds; number of residential client counts by category, by number under age 18, and number receiving methadone, buprenorphine, or naltrexone, and number of dedicated beds; number of outpatient client counts by category, by number under age 18, and number receiving methadone, buprenorphine, or naltrexone; type of substance abuse problem, percent of co-occurring clients; and 12-month admissions. These client counts are collected every other year to lessen burden on the facilities.

2019 Q25d, Q26d, and Q27d. Remove questions about how many hospital inpatients, residential clients, and outpatient clients received Disulfiram, Naltrexone, and Acamprosate for alcohol use disorder. (Client counts are collected only in “odd” years.)

While it was originally planned to add electronic health record questions in 2020, the required question testing has not yet been completed. Therefore, these questions will not be included in this 2019-2021 package for the 2020 N-SSATS, or for 2019 or 2021. If testing is completed in sufficient time, a new package will be submitted for inclusion of these questions.

I-BHS: While the internal structure and forms have been updated as technology has changed, there is no change in functionality.

N-SSATS BC: The same changes to the 2020 N-SSATS (Version B) are requested for the N-SSATS BC.

3. Use of Information Technology

I-BHS: The I-BHS Online forms used by states to update the information on state-approved or state-funded facilities are posted to a website that can be accessed only by authorized state behavioral health representatives and SAMHSA/BHSIS employees and contractors. State representatives use the I-BHS Online system to enter new facilities or update information on existing facilities. All I-BHS updates (including additions, deletions, and changes) are made electronically via the I-BHS Online. An online facility application form available on the Behavioral Health Treatment Services Locator will allow the submission of registration application requests by facilities not currently on the Locator.

N-SSATS: The primary mode of data collection for the main survey of treatment facilities had traditionally been by a mailed paper questionnaire until the online web survey, introduced in 2002, gradually became the primary response mode (about 92 percent of facilities responded online in 2017.) In 2019, N-SSATS will be an online web survey, with a mail questionnaire option. Non-responding facilities will be followed up by telephone using Computer Assisted Telephone Interview (CATI) technology, which links into the web survey. The web/mail/CATI combination has been successful with around 95 percent of facilities expected to respond by web in 2019. The web and CATI version incorporate range limits and consistency checks, prompting the user to resolve inconsistencies before permitting movement to the next question. This has greatly reduced the number of post-survey edit callbacks required.

The Behavioral Health Treatment Services Locator is available on the Internet with a mapping/locator capability (https://findtreatment.samhsa.gov), and is based on information collected in the N-SSATS. The Treatment Locator has attracted the attention of people in search of treatment for themselves or someone else, and of treatment facilities. Facilities that are listed in the Locator frequently contact the Locator’s Webmaster when their status or services have changed. The Locator is then corrected immediately. An online facility application form is available for facilities seeking to be listed on the Locator. (Two requirements for a substance use treatment facility to be listed are that the facility is licensed or approved by their state substance abuse agency, and that the facility responds to the N-SSATS or N-SSATS BC.)

The use of this web technology is expected to help states maintain their I-BHS facility listings, retain the high N-SSATS response rate, and improve the accuracy of the Treatment Locator.

3. Efforts to Identify Duplication

Consultation with states and other federal agencies involved in the development of N-SSATS and I-BHS confirms that I-BHS is the only comprehensive inventory of all known substance use and mental health treatment facilities and their characteristics in the United States and that N-SSATS is the only regularly conducted census of all known substance use treatment facilities.

3. Involvement of Small Entities

Many treatment facilities participating in N-SSATS are small businesses. Since the survey collects only necessary information, it has no significant impact on small entities.

3. Consequences if Information Collected Less Frequently

Legislation requires that information provided by N-SSATS be collected each year. Specifically, 42 USC 290aa-4 requires that:

Each year, the Director shall ensure the collection of data on-

“(C) the number and variety of public and private nonprofit treatment programs, including the number and type of patient slots available;

(D) the number of individuals seeking treatment through such Programs”.

The need for up-to-date information is demonstrated by the large number of facilities that open, close, relocate, or change services each year. If collection of data were discontinued or conducted less frequently, valuable information on new facilities and up-to-date information on existing facilities and the clients they serve would not be available on a timely basis for the range of N-SSATS users. Without frequent collection of client count data from all facilities, the ability to use the N-SSATS and I-BHS as a sampling frame for other surveys would be diminished with no ability to determine size of new facilities. State, county, and community numbers would not be available.

The Locator is authorized by the 21st Century Cures Act (Public Law 114-255, Section 9006; 42 U.S.C. 290bb-36d). SAMHSA endeavors to keep the Locator current. All information in the Locator is updated monthly from facility responses to SAMHSAs National Survey of Substance Abuse Treatment Services (N-SSATS) and National Mental Health Services Survey (N-MHSS). New facilities that have completed an abbreviated survey and met all the qualifications are added monthly. Updates to facility names, addresses, telephone numbers, and services are made weekly for facilities informing SAMHSA of changes.

3. Consistency with the Guidelines in 5 CFR 1320.5(d) (2)

These data systems fully comply with the guidelines in 5 CFR 1320.5(d) (2).

3. Consultation Outside the Agency

A Federal Register Notice was published on July 27, 2018 (83 FRN, No. 145, page 35670) to solicit comments on N-SSATS. No comments were received.

3. Payment to Respondents

Respondents to N-SSATS do not receive payment. State substance abuse agencies receive monetary support through on-going BHSIS state agreements.

3. Assurance of Confidentiality

I-BHS and N-SSATS collect only facility-level information. For N-SSATS data reports, facility data are aggregated by state or by facility type and do not identify specific facilities. The public-use data file for the N-SSATS masks the identity of individual facilities.

On the N-SSATS questionnaire SAMHSA includes the following pledge that describes the level of protections provided to the respondents:

The information you provide will be protected to the fullest extent allowable under the Public Health Service Act (42 USC 290aa (p)). This law permits the public release of identifiable information about an establishment only with the consent of that establishment and limits the use of the information to the purposes for which it was supplied. With the explicit consent of treatment facilities, information provided in response to survey questions marked with an asterisk will be published in SAMHSA’s Online Behavioral Health Treatment Services Locator, the National Directory of Drug and alcohol Abuse Treatment Programs, and other publically available listings. Responses to non-asterisked questions will be published with no direct link to individual treatment facilities.

The I-BHS and N-SSATS contain a unique identifier assigned to each facility. This number is used to facilitate tracking, monitor response rates, ensure adequate quality control, assess analytic consistency from survey to survey, and produce SAMHSA’s online Behavioral Health Treatment Services Locator and National Directory of Drug and Alcohol Abuse Treatment Programs, which are available to the public. Information reported in the Locator/National Directory is limited to generally available information such as facility name, address, and telephone number; type of care (hospital inpatient, residential, outpatient); and similar information about the facility and its services and other information indicated by an asterisk on the survey. Facilities are asked in the N-SSATS questionnaire if they want to be listed in the Locator/Directory. Of the 13,857 substance use treatment facilities that completed the N- SSATS in 2017, a total 12,942 (or 93.4%) indicated that they wanted to be listed in the Directory/Locator if eligible. A total of 784 facilities (5.7%) indicated that they did not want to be listed. One hundred thirty one (131) facilities (0.95%) did not respond to the question (or were otherwise missing). Examples of facilities that do not want to appear in the Locator or Directory are those that specialize in serving abused women and do not want to advertise their location and facilities with very specific eligibility requirements that do not want to receive inquiries from the general public.

The I-BHS Online is password protected with two-factor authentication for login. Passwords are provided only to those state agency staff that are approved by the state staff person who serves as the State BHSIS Manager. Each state has access only to the facilities in that state.

The contractor-maintained BHSIS data systems undergo Security and Authorization procedures conducted by SAMHSA’s Office of Management, Technology and Operations/Division of Technology Management (OMTO/DTM) periodically. The most recently completed Security Authorization (Authorization to Operate [ATO]) for the BHSIS program was approved and reauthorized at the moderate level by SAMHSA’s Information Security on July 13, 2018. The SAMHSA IT Clearance Officer stated:

“The information system is reauthorized without any significant restrictions or limitations. This security reauthorization is my formal declaration that adequate security controls have been implemented in the information system and that a satisfactory level of security is present."

3. Questions of a Sensitive Nature

The N-SSATS survey does not include questions of a sensitive nature.

3. Estimates of Annualized Hour Burden

The estimated annual burden for the I-BHS and BHSIS activities is as follows:

Type of Respondent and Activity	Number of Respondents	Responses per Respondent	Total Responses	Hours per Response	Total Burden Hours	Wage Rate	Total Hour Cost
STATES
I-BHS Online1	56	75	4,200	0.08	336	$23	$7,728
State Subtotal	56		4,200		336		$7,728
FACILITIES
I-BHS application2	800	1	800	0.08	64	$17	$1,088
Augmentation screener	1,300	1	1,300	0.08	104	$17	$1,768
N-SSATS questionnaire	17,000	1	17,000	0.66	11,333	$42	$475,986
N-SSATS BC	1,000	1	1,000	0.58	580	$42	$24,360
Facility Subtotal	20,100		20,100		12,081		$503,202
TOTAL	20,156		24,300		12,417		$510,930

1. States use the I-BHS Online system to submit information on newly licensed/approved facilities and on changes in facility name, address, status, etc.

2. New facilities complete and submit the online I-BHS application form in order to get listed on the Inventory.

Basis for Burden Hour Estimates:

STATES:

• I-BHS Online: States can update the I-BHS on a continuous basis using the I-BHS Online system. The system can be used to enter information for a new facility or to make changes to the information recorded for a previously-entered facility. Based on the most recent year (2017), states submitted an approximately 4,200 new substance use or mental health treatment facilities or updates to existing substance use or mental health treatment facilities. Also based on this experience, it is expected to take about 5 minutes (.08 hours) to enter a new facility or update information on an old facility. This level of activity is expected to remain fairly constant, resulting in a total annual burden of about 336 hours for I-BHS updates for substance use facilities by states. The I-BHS Online forms are included at Attachment A1.

FACILITIES:

I-BHS Application: Individual facilities can request to be included in I-BHS through an online facility application form. Based on prior registration of new facilities, it is expected to take about 5 minutes (.08 hours) to complete the online facility application form. About 600 substance use treatment facilities and 200 mental health treatment facilities inquired about being included in the I-BHS this past year. This level of activity is expected to remain fairly constant, resulting in a total annual burden of about 64 burden hours for I-BHS application by substance use and mental health treatment facilities. The I-BHS facility application form is included at Attachment A2.

• I-BHS Augmentation: An augmentation to identify new substance use treatment facilities and mental health treatment facilities will be conducted in preparation for the 2019, 2020, and 2021 N-SSATS. This will involve searching business and organization directories for potential new substance use treatment and mental health treatment facilities, matching the new facilities against the current I-BHS, and calling all facilities that do not match with the I-BHS to confirm that they provide substance use treatment or mental health treatment services. Based on prior experience with the CATI screening instrument, the calls are expected to take an average of about 5 minutes (0.08 hours). Based on the most recent augmentation process, SAMHSA expects to screen an average of 700 substance use treatment facilities annually and an average of 600 mental health treatment facilities annually, for a total annual burden of 104 burden hours for augmentation screening annually. The augmentation screener to be used for all facilities is included in Attachment A3.

• N-SSATS: Approval is requested for the 2019, 2020, and 2021 N-SSATS. While there are changes (dropping questions and adding questions) in the N-SSATS (Version A) survey for 2019 and 2021, the burden for administering the N-SSATS (Version A) questionnaire is estimated to only slightly increase from 40 to 45 minutes, or to .75 hours per respondent because of extensive pre-filling of many questions answered in the previous year and a balancing between dropping and addition of questions. However, the N-SSATS (Version B) to collect Locator updates will be conducted in 2020, with a burden estimated to decrease from 35 minutes to 30 minutes, or to .50 hours per respondent because of extensive prefilling of questions that typically don’t change from year to year. This is based on recent experience in the annual N-SSATS (Version A) survey and current Version B survey. The overall annual average burden per response for the three years is 40 minutes, or .66 hours per respondent. There will be about 17,000 facilities included in the N-SSATS each year (for the Version A and Version B surveys), for a total annual average burden of 11,333 hours. The 2019 and 2021 N-SSATS (Version A) questionnaire is included at Attachment B1 and the 2020 N- SSATS (Version B) questionnaire is included at Attachment B2. If it is determined that the originally proposed electronic health record questions are adequately tested in sufficient time for inclusion in the 2020 survey, a new package will be submitted.

• Between Cycle N-SSATS: Approval is also requested for the 2019, 2020, and 2021 Between Cycle N-SSATS component of N-SSATS, a procedure for collecting services data from newly identified facilities between main cycles of the survey that will be used to update the listing of treatment facilities in the online treatment facility Locator. About 1,000 newly identified facilities per year will be invited to complete the N-SSATS BC instrument which is expected to take an average of about 35 minutes (.58 hours) to complete, for a total annual burden of 580 hours. The instrument will be the same as Version B of the N-SSATS, and is included at Attachment B3.

Basis for Hour Costs Estimates:

State Agencies: Based on information gained in discussions with the states and data from the Bureau of Labor Statistics, it is estimated that salaries for state staff responsible for the I-BHS updates will average $23 per hour.

Facilities: The facility staff that completes the N-SSATS questionnaires (regular N-SSATS and N-SSATS BC) is generally mid- to senior-level staff, often the director him/herself. Based on data from the Bureau of Labor Statistics, it is estimated that an average salary for this level is $42 per hour, taking into consideration the wide variety of facility types and sizes. The augmentation screening interview is often conducted with a receptionist or other junior staff, because only very basic questions are asked. I-BHS applications are also generally made by junior staff. It is estimated that an average salary for this level is $17 per hour.

3. Estimates of Annualized Cost Burden to Respondents

There are no capital or start-up costs associated with BHSIS and maintenance and operational costs imposed by BHSIS are minimal.

3. Estimates of Annualized Cost Burden to the Government are as follows.

1. BHSIS Contract: The annualized cost to the Government for the I-BHS and N-SSATS components of the BHSIS contract is estimated to be $6.53 million including:

• management of all aspects of N-SSATS, from preparation of forms and mailing lists to carrying out field work, data cleaning and entry, and data analysis;

• management of the I-BHS, including accepting and verifying changes to the I-BHS, producing a master list for N-SSATS, and conducting the frame augmentation activities;

• management of the integrated computer systems that maintain the BHSIS components, including: the I-BHS inventory, the I-BHS Online update site, and the online Treatment Locator; and other data administrative functions, such as data security; and

• preparation of reports, analytic files, and public-use files.

2. Monitoring: The cost for monitoring the contract and carrying out related work includes salaries for four FTEs, for a total of approximately $600,000.

Total annualized cost to the government is $7.13 million.

3. Changes in Burden

Currently there are 11,754 burden hours in the OMB inventory. SAMHSA is now requesting 12,417 hours. The net increase of 663 hours is due to a 40 hour decrease for BHSIS adjustments and a 703 hour increase due to program changes, as follows:

Adjustments (Total decrease of 40 hours)

• I-BHS Application: Individual facilities can request to be included in the I-BHS through an on-line application form. Based on the most recent year (2017), approximately 600 substance use treatment facilities and 200 mental health treatment facilities submitted the form. Also based on this experience, it is expected to take about 5 minutes (0.08 hours) to complete the form. This level of activity is expected to remain fairly constant, resulting in a total annual burden of about 64 hours for I-BHS applications by substance use and mental health treatment facilities. This represents an increase of 16 hours from the previous approval.

• I-BHS Augmentation: Following augmentation efforts to identify new treatment facilities from various business and organization directories, screening calls are undertaken to determine the suitability of these newly found facilities to be in the I-BHS. Based on the most recent year (2017), approximately 700 substance use treatment facilities and 600 mental health treatment facilities were screened. Also based on this experience, it is expected to take about 5 minutes (0.08 hours) to complete the screening call. This level of activity is expected to remain fairly constant, resulting in a total annual burden of about 104 hours for screening newly found treatment facilities. This represents a decrease of 56 hours from the previous approval.

Program Changes (Total increase of 703 hours)

• N-SSATS questionnaire: In 2019, SAMHSA will continue to implement alternating (every other year) N-SSATS questionnaires. In even years, SAMHSA will field a Version B annual N-SSATS and in odd years a Version A (with client counts), thus maintaining an alternating full and abbreviated N-SSATS as in the previous approval. This submission requests approval to conduct an N-SSATS (Version B) in 2020 and an N-SSATS (Version A) in 2019 and 2021. Therefore the average burden has increased from.61 hours to .66 hours per response over the three years for the 17,000 facilities included in N-SSATS each year. With one response per facility, and an average response time of .66 hours per response, the total burden for this activity will increase from 10,370 hours to 11,333 hours, for an increase of 963 hours. However, this increase is 57 hours less than the approved 11,390 hours when the full N-SSATS with client counts was conducted each year (the OMB approval that expired on December 31, 2012).

• Between Cycle N-SSATS: To allow newly-found facilities to be listed on the locator in a timely manner between main cycles of the survey, a locator-specific will be offered to these facilities. Based on the most recent year (2017), approximately 1,000 substance use treatment facilities completed this N-SSATS BC instrument. Also, based on this experience, it is expected to take about 35 minutes (.58 hours) to complete the survey. This level of activity is expected to remain fairly constant, resulting in a total annual burden of about 580 hours per response to complete the N-SSATS BC. This represents a decrease of 260 hours from the previous approval.

3. Time Schedule, Publication, and Analysis Plans

1. Time Schedule

The annual cycle of activities is as follows:

TASK COMPLETION DATE

2019 N-SSATS*:

• Development of questionnaire October 2018

• Annual N-SSATS survey (reference data March 31) November 2019

• Augmentation activities October – December 2019

• Publication of online National Directory May 2020

• Annual data report and analytic files/reports May 2020

• Public-use data file May 2020

*N-SSATS activities for subsequent years will be on a similar schedule.

I-BHS

• Processing of changes to the I-BHS Ongoing

2. Analyses and Publications

The N-SSATS data will be disseminated in the following manner:

• Behavioral Health Treatment Services Locator – SAMHSA’s public Behavioral Health Treatment Services Locator is a searchable online system of substance use and mental health treatment facilities that include information on services offered and an on-line mapping function (https://findtreatment.samhsa.gov). Data collected through the N-SSATS are used to create and update listings for the substance use treatment facilities in the Locator. Updates to add eligible new facilities are made on a monthly basis; other updates and corrections are made as needed.

• National Directory of Drug and Alcohol Abuse Treatment – This electronic (PDF) publication includes information on thousands of public and private substance use treatment facilities in the states, territories, and District of Columbia that have responded to the most recent N-SSATS and are approved for inclusion by the state alcohol and drug abuse agencies. Listings are alphabetic by state, city, and facility name within city. Information about each facility includes facility name, address, telephone number, types of services, and type of payment. Specific characteristics are indicated by a code. The Directories are online in PDF format.

• N-SSATS Report - This annual publication presents the main findings from the survey using tabulations and descriptive analyses of facility counts and characteristics, including information on methadone treatment. The report is available on the SAMHSA website (http://www.samhsa.gov).

• N-SSATS State Profiles – State profiles for each state, including one for each year since 2002 through the most recent complete year, are available on the SAMHSA website (https://wwwdasis.samhsa.gov/webt/newmapv1.htm).

• State N-SSATS Feedback Reports – Upon request, a state can receive a report or file containing N-SSATS data for that state. These reports or files contain data for local analysis.

• Public Release Data Files - Public release data files of N-SSATS data are available for downloading at https://wwwdasis.samhsa.gov.

3. Display of Expiration Date

All I-BHS and N-SSATS forms will display the OMB expiration date.

3. Exceptions to Certification Statement

There are no exceptions to the certification statement. The certifications are included in this submission.