Research and Service Programs in the PHS Challenges in Organization (1991) / Chapter Skim
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Co-Administration of Research and Services
Co-Administration of Research and Services
Pages 69-108
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From page 69... ...
Increase funding and authorization of new demonstration programs, as well as large increases in block grant funding for drug abuse treatment programs, brought with them increasing interest by Congress to ensure that funds were reaching their target populations. New offices and programs were created within the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA)
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From page 70... ...
It then discusses organizational effectiveness as seen in research, demonstration, and services development programs and concludes with a discussion of organizational capacity and program placement. RESEARCH AND SERVICES MISSIONS OF THE PHS Congressional authorizations and statements of mission strongly influence the "culture" and activities of government organizations.
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From page 71... ...
A review of the history of the PHS and its agencies suggests that clarity about the research mission of the PHS has been a critical factor in the growth and development of research programs and structures within NIH institutes and, increasingly, within ADAMHA institutes. Interviews conducted with current agency and institute directors suggest that the ability to achieve a coherent federal mission at the agency, institute, or bureau level is important for a number of reasons.
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From page 72... ...
There remains significant confusion about the PHS mission with regard to services development, especially regarding expectations for services funded through block grants that are administered by the states. Although it is well known among the states that federal oversight of block grant programs (particularly with regard to drug abuse)
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From page 73... ...
One outcome of the discrepant views of the administration and Congress about the importance of block grant programs to the missions of ADAMHA and HRSA seems to be unstable organizational placement of services demonstrations and block grant administration. In a number of instances, the agencies and organizational units that administer services development and block grant programs are not congressionally authorized (e.g., the Centers for Disease Control [CDCl, HRSA, and OTI)
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From page 74... ...
Abbreviations: NIH, National Institutes of Health; AI) AMHA, Alcohol, Drug Abuse, and Mental Health AdIrinistration; CDC, Centers for Disease Control; HRSA, Health Resources and Services Administration.
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From page 75... ...
When responsibility for research and services development and demonstration programs for a single problem (such as substance abuse among pregnant women) is divided among several agencies, the difficulties of communicating and collaborating across agency boundaries can also inhibit success in addressing the problem.
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From page 76... ...
THE RESEARCH-SERVICES CONTINUUM The ultimate goal of biomedical research is improved health of the population. One presumption that seems to lie behind questions about the effectiveness of co-administration is that biomedical research and services development and demonstration programs exist along a continuum, the end result of which is nationwide diffusion of clinical practices, technologies, and system innovations (Figure 4-31.
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From page 77... ...
. One of the expectations in the creation of ADAMHA in 1973 was that the administration of research and services development or demonstration programs in a single agency would result in easier information transfer to the health delivery system.
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From page 78... ...
As a previous study of research and development programs in NIH noted: Trying to capture important technical and social complexities in a one-dimensional continuum oversimplifies and obscures some critical organizational processes such as transferring knowledge produced in one part of the organization to other parts, or the organization's response to the concerns of groups in the environments Exclusive reliance on the classic, linear model has also been responsible, at least in part, for the lack of explicit attention to coordinating the various objectives of federal research and services programs. Most of the scientific community believes that, to protect the creativity of investigators and the vigor of research, planning of research should be done by scientists using scientific criteria.
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From page 79... ...
The relationships among applied research, applications, and implementation are less clear than the relationship between basic and applied research. As Beryl Radin notes in her background paper on linkage mechanisms, "The specific formulation depends on the nature of the policy area, the difference in federal policy roles related to the area of concern, the nature of the population with the problem, and the type of research required.n9 In the last decade, as pressure has mounted for tangible results of biomedical research, Congress has expressed its clear intent that demonstrations, information dissemination, and technology transfer be an important part of the activities of all federal agencies engaged in research.
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From page 81... ...
CO-ADMINISTRATION OF RESEARCH AND SERVICES | The ~field" generates ideas for research 1 ADAMHA-funded research generates findings worthy of demonstration Office of Substance Abuse Prevention/ Office of Treatment Improvement launch demonstrations 1 Demonstrations produce ideas worthy of transfer to field .1 1 Field service sector incorporates new ideas 81 FIGURE 4-5 Alcohol, Drug Abuse, and Mental Health Administration researchservices "paradigm.'" SOURCE: R Schmidt, "Research Planning and Priority Setting in the Alcohol, Drug Abuse, and Mental Health Administration," paper prepared for the IOM Committee on Co-Administration of Service and Research Programs of the NIH, ADAMHA, and Related Agencies, 1991.
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From page 82... ...
Interviews conducted for the case study of substance-abusing pregnant women and for analyses of planning and priority-setting processes indicated that this functional reorganization (which removed responsibility for administration of many demonstrations and much of the block grant program from ADAMHA institutes) has allowed programs housed in NIMH, NIAAA, and NIDA to focus almost exclusively on research and thereby to grow and develop.
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From page 83... ...
The effectiveness of biomedical research programs within NIH has often been attributed to the ability of the research institutes to defend their boundaries and limit their mission to research. Not surprisingly, therefore, interviews conducted with current institute division directors in ADAMHA for the case studies of schizophrenia and substanceabusing pregnant women, as well as for analyses of demonstrations and block grant programs, indicated that programs administered by research institutes, if they are not directly related to their basic and clinical research missions, are viewed as stepchildren and may not be appropriately incorporated into planning and priority setting.
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From page 84... ...
SOURCE: R W~lkington, "Allocations in the Public Health Service," paper prepared for the IOM Co~n~nittee on Co-Administration of Service and Research Programs of the NIH, ADAMHA, and Related Agencies, 1991; adapted from information provided by the National Institutes of Health and the Alcohol, Drug Abuse, and Mental Health Ad~nir~i~tration budget offices.
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From page 85... ...
Questions were raised in the case studies of schizophrenia and substance-abusing pregnant women about whether the increasing service component of ADAMHA might make it difficult in future to ensure stable scientific leadership at the agency level. It was pointed out in the analyses of planning, priority setting, and budgeting that within ADAMHA, block grant and demonstration programs have become increasingly significant responsibilities of the administrator.
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From page 86... ...
Given the complexity of administering federal research and service programs, functional organization (i.e., the administration of research, services development, and prevention programs by three separate agencies, namely, NIH, MESA, and CDC) can be helpful in allowing for the development of specialized skills that lead to improved performance.
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From page 87... ...
Nor did it suggest that research findings were translated more effectively or benefited patients more quickly under the organizational structure of either ADAMHA or NIH. At the agency level, no evidence could be found that organizational structure bears any necessary relation to allocations for research or services development and demonstration programs.
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From page 88... ...
PLANNING, PRIORITY SETTING, AND BUDGETING The effectiveness of ADAMHA, NIH, and other PHS agencies is dependent on their ability to carry out such management functions as planning, priority setting and budgeting; responding to new information and policies; disseminating research findings; coordinating programmatic objectives; and recruiting and retaining leadership. To balance the needs of research, applications, and services development and demonstration programs, an organization must possess criteria for setting priorities, evaluating work in progress, assessing relationships with other organizations, and guiding action.
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From page 89... ...
Budget decisions are largely incremental, and the most important single factor in determining a current budget is the last year's budget. Exceptions are relatively rare and reflect either major policy issues (such as drug abuse or AIDS)
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From page 90... ...
SOURCE: R Wnlkington, "Allocations in the Public Health Service," paper prepared for the IOM Committee on Co-Administration of Service and Rewash Programs of the NIH, ADAMHA, and Related Agencies, 1991; adapted from information provided by the NIH and ADAMHA budget offices.
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From page 91... ...
Because its mission is research oriented, congressional decisions to increase or decrease health care financing or servicesrelated budgets are largely irrelevant to NIH concerns. Strategic planning for science has been important in many NIH institutes.
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From page 92... ...
This appears to reflect a realistic response to a rapidly changing and developing field of research. ADAMHA's budgeting and planning process recognizes that the agency is unique in its mix of research and services development and demonstration programs.
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From page 93... ...
Its more recent growth is driven by perceptions of problems arising from substance abuse and AIDS. In both cases, budget growth was triggered by presidential and congressional needs for visible action.
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From page 94... ...
The committee wanted to know whether, within a single agency such as ADAMHA, there were fewer obstacles to the translation of research findings into service programs. As described earlier, within the ADAMHA model of the so-called research-services continuum, more than in other models, demonstrations provide a theoretical link between the findings of clinical research and the introduction of innovations into the structure and delivery of services.~9 However, few of the models include replication
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From page 95... ...
Demonstration programs are also administered in other parts of DHHS (for example, the Office of Human Development Services tOHDS] , the Family Support Administration [FSAl, and the Health Care Financing Administration tHCFAl)
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From page 96... ...
This view has led some to suggest that health services research and research demonstrations should be coadministered and that treatment diffusion and services demonstrations that include a health services research component should be co-administered with programs related to the structure and delivery of health care services.20 The committee's analyses also pointed out that both within and outside government, health services research needs strong links to research settings and to the services community. Conflicting expectations on the part of Congress and federal agencies have created a number of difficulties in administration of demonstration programs.
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From page 97... ...
Analyses of many demonstration programs conducted for this study found evidence that the management of demonstration programs has been hampered by differences in agency and congressional objectives. For example, a second cycle of research demonstration grants for an ADAMHA institute was funded by Congress before the first was complete, thus preventing the results of the first cycle from being used to inform the second.
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From page 98... ...
Discontent with this lack of federal direction and oversight began to surface in Congress by the mid-1980s. Under continued pressure from advocacy groups, Congress has increasingly limited state discretion under block grant programs by mandating setaside requirements for expenditures of funds to target specific populations and health problems (e.g., intravenous drug users, substance-abusing pregnant women, health services for mothers and children, and children with special health care needs)
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From page 99... ...
None of the case study analyses found specific mechanisms in place for identifying the emerging results of clinical research or demonstrations that might serve as a basis for initiating intervention trials. The case studies of substance-abusing pregnant women and schizophrenia found no evidence of established mechanisms for identifying demonstration or other research results appropriate for dissemination and introduction into state programs through the block grant program.
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From page 100... ...
As Betel Radin points out in her background paper on linkages between research and service programs in federal agencies, "even when an agency is convinced that it has developed an understanding of an issue through demonstration programs and/or evaluations, there is significant evidence that the diversity of decision settings and populations within the United States makes it difficult to think of simple dissemination of findings.n23 The organizational structure that exists in ADAMHA does not seem, by itself, to foster more rapid or improved dissemination. In 1988, ADAMHA was authorized to set aside between 5 and 15 percent of the total ADMS block grant allocation to be used for data collection, health services research, and technical assistance to states and localities.
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From page 101... ...
Yet none of the case studies or interviews conducted for this study could establish the existence of specific mechanisms or leadership strategies for moving successful services demonstrations from one unit into research demonstrations carried out in the institutes and, subsequently, into a unit responsible for applications and implementation. The case study of substance-abusing pregnant women, for example, noted that in the absence of such mechanisms the Potential for duplication of efforts among the many different services demonstrations is present.n24 Although ADAMHA is also responsible for block grant services and for prevention programs for substance-abusing pregnant women, the Office of the Administrator did not appear to have provided policy direction to such efforts.
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From page 102... ...
In addition, the case study of substance-abusing pregnant women, as well as analyses of information dissemination activities, suggests that current dissemination activities may be insufficient to promote the use of many new clinical practices or systems innovations. Articles in scientific journals targeted to researchers may not meet the needs of all those who use research findings.
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From page 103... ...
gave ADAMHA a new organizational capacity to administer treatment improvement and preventive services and services demonstrations. As noted in the case study of substance-abusing pregnant women and in the analyses of planning, priority setting, and budgeting, the creation of OTI has usefully increased functional specialization within ADAMHA.
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From page 104... ...
When a question is raised, such as the potential movement of the management of the ADMS block grant to HRSA or the appropriate location for management of the National Research Service Awards for primary care, the decision process is informal and ad hoc, with the final decision being made by the Assistant Secretary for Health. An example of this process is the creation of research and services programs for pregnant women with substance abuse problems.
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From page 105... ...
However, substance abuse looms large among the problem of pregnant women who use public health clinics and primary care facilities funded by HRSA. The committee recommends that when Congress initiates or authorizes new research or services programs, it consult with the Secretary of Health and Human Services to determine, within a brief period of time, the appropriate locus of progrmn administration within the department.
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From page 106... ...
R Schmidt, "Research Planning and Priority Setting in the Alcohol, Drug Abuse, and Mental Health Administration," paper prepared for the IOM Committee on Co-Administration of Service and Research Programs of the NIH, ADAMHA, and Related Agencies, 1991; available from the National Technical Information Service, Springfield, Va.*
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From page 107... ...
A Walkington, "Planning, Priority Setting, and Budgeting in the Public Health Service," paper prepared for the IOM Committee on Co-Administration of Service and Research Programs of the NIH, ADAMHA, and Related Agencies, 1991; available from the National Technical Information Service, Springfield, Va.
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From page 108... ...
25. Klerman and Johnson, "A Case Study of Substance-Abusing Pregnant Women, Their Infants and Children." ADDITIONAL BIBLIOGRAPHY H
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