Sec. 181. Behavioral health programs

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A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Title VII of the Indian Health Care Improvement Act ( 25 U.S.C. 1665 et seq.) is amended to read as follows: In this subtitle: The term alcohol-related neurodevelopmental disorders or ARND means, with a history of maternal alcohol consumption during pregnancy, central nervous system abnormalities, which may range from minor intellectual deficits and developmental delays to mental retardation. ARND children may have behavioral problems, learning disabilities, problems with executive functioning, and attention disorders.

The neurological defects of ARND may be as severe as FAS, but facial anomalies and other physical characteristics are not present in ARND, thus making diagnosis difficult. The term assessment means the systematic collection, analysis, and dissemination of information on health status, health needs, and health problems. The term behavioral health aftercare includes those activities and resources used to support recovery following inpatient, residential, intensive substance abuse, or mental health outpatient or outpatient treatment.

The purpose is to help prevent or deal with relapse by ensuring that by the time a client or patient is discharged from a level of care, such as outpatient treatment, an aftercare plan has been developed with the client. An aftercare plan may use such resources as a community-based therapeutic group, transitional living facilities, a 12-step sponsor, a local 12-step or other related support group, and other community-based providers. The term dual diagnosis means coexisting substance abuse and mental illness conditions or diagnosis.

Such clients are sometimes referred to as mentally ill chemical abusers (MICAs). The term fetal alcohol spectrum disorders includes a range of effects that can occur in an individual whose mother drank alcohol during pregnancy, including physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term fetal alcohol spectrum disorders may include— fetal alcohol syndrome (FAS); partial fetal alcohol syndrome (partial FAS); alcohol-related birth defects (ARBD); and alcohol-related neurodevelopmental disorders (ARND).

The term FAS or fetal alcohol syndrome means a syndrome in which, with a history of maternal alcohol consumption during pregnancy, the following criteria are met: Central nervous system involvement, such as mental retardation, developmental delay, intellectual deficit, microencephaly, or neurological abnormalities. Craniofacial abnormalities with at least 2 of the following: Microophthalmia. Short palpebral fissures. Poorly developed philtrum. Thin upper lip. Flat nasal bridge.

Short upturned nose. Prenatal or postnatal growth delay. The term rehabilitation means medical and health care services that— are recommended by a physician or licensed practitioner of the healing arts within the scope of their practice under applicable law; are furnished in a facility, home, or other setting in accordance with applicable standards; and have as their purpose any of the following: The maximum attainment of physical, mental, and developmental functioning. Averting deterioration in physical or mental functional status.

The maintenance of physical or mental health functional status. The term substance abuse includes inhalant abuse. The purposes of this section are as follows: To authorize and direct the Secretary, acting through the Service, Indian tribes, and tribal organizations, to develop a comprehensive behavioral health prevention and treatment program which emphasizes collaboration among alcohol and substance abuse, social services, and mental health programs. To provide information, direction, and guidance relating to mental illness and dysfunction and self-destructive behavior, including child abuse and family violence, to those Federal, tribal, State, and local agencies responsible for programs in Indian communities in areas of health care, education, social services, child and family welfare, alcohol and substance abuse, law enforcement, and judicial services.

To assist Indian tribes to identify services and resources available to address mental illness and dysfunctional and self-destructive behavior. To provide authority and opportunities for Indian tribes and tribal organizations to develop, implement, and coordinate with community-based programs which include identification, prevention, education, referral, and treatment services, including through multidisciplinary resource teams. To ensure that Indians, as citizens of the United States and of the States in which they reside, have the same access to behavioral health services to which all citizens have access.

To modify or supplement existing programs and authorities in the areas identified in paragraph (2). The Secretary, acting through the Service, Indian tribes, and tribal organizations, shall encourage Indian tribes and tribal organizations to develop tribal plans, and urban Indian organizations to develop local plans, and for all such groups to participate in developing areawide plans for Indian Behavioral Health Services. The plans shall include, to the extent feasible, the following components:

An assessment of the scope of alcohol or other substance abuse, mental illness, and dysfunctional and self-destructive behavior, including suicide, child abuse, and family violence, among Indians, including— the number of Indians served who are directly or indirectly affected by such illness or behavior; or an estimate of the financial and human cost attributable to such illness or behavior. An assessment of the existing and additional resources necessary for the prevention and treatment of such illness and behavior, including an assessment of the progress toward achieving the availability of the full continuum of care described in subsection (c).

An estimate of the additional funding needed by the Service, Indian tribes, tribal organizations, and urban Indian organizations to meet their responsibilities under the plans. The Secretary, acting through the Service, shall coordinate with existing national clearinghouses and information centers to include at the clearinghouses and centers plans and reports on the outcomes of such plans developed by Indian tribes, tribal organizations, urban Indian organizations, and Service areas relating to behavioral health.

The Secretary shall ensure access to these plans and outcomes by any Indian tribe, tribal organization, urban Indian organization, or the Service. The Secretary shall provide technical assistance to Indian tribes, tribal organizations, and urban Indian organizations in preparation of plans under this section and in developing standards of care that may be used and adopted locally. The Secretary, acting through the Service, shall provide, to the extent feasible and if funding is available, programs including the following:

A comprehensive continuum of behavioral health care which provides— community-based prevention, intervention, outpatient, and behavioral health aftercare; detoxification (social and medical); acute hospitalization; intensive outpatient/day treatment; residential treatment; transitional living for those needing a temporary, stable living environment that is supportive of treatment and recovery goals; emergency shelter; intensive case management; diagnostic services; and promotion of healthy approaches to risk and safety issues, including injury prevention.

Behavioral health services for Indians from birth through age 17, including— preschool and school age fetal alcohol spectrum disorder services, including assessment and behavioral intervention; mental health and substance abuse services (emotional, organic, alcohol, drug, inhalant, and tobacco); identification and treatment of co-occurring disorders and comorbidity; prevention of alcohol, drug, inhalant, and tobacco use; early intervention, treatment, and aftercare; promotion of healthy approaches to risk and safety issues; and identification and treatment of neglect and physical, mental, and sexual abuse.

Behavioral health services for Indians from age 18 through 55, including— early intervention, treatment, and aftercare; mental health and substance abuse services (emotional, alcohol, drug, inhalant, and tobacco), including sex specific services; identification and treatment of co-occurring disorders (dual diagnosis) and comorbidity; promotion of healthy approaches for risk-related behavior; treatment services for women at risk of giving birth to a child with a fetal alcohol spectrum disorder; and sex specific treatment for sexual assault and domestic violence.

Behavioral health services for families, including— early intervention, treatment, and aftercare for affected families; treatment for sexual assault and domestic violence; and promotion of healthy approaches relating to parenting, domestic violence, and other abuse issues. Behavioral health services for Indians 56 years of age and older, including— early intervention, treatment, and aftercare; mental health and substance abuse services (emotional, alcohol, drug, inhalant, and tobacco), including sex specific services; identification and treatment of co-occurring disorders (dual diagnosis) and comorbidity; promotion of healthy approaches to managing conditions related to aging; sex specific treatment for sexual assault, domestic violence, neglect, physical and mental abuse and exploitation; and identification and treatment of dementias regardless of cause.

The governing body of any Indian tribe, tribal organization, or urban Indian organization may adopt a resolution for the establishment of a community behavioral health plan providing for the identification and coordination of available resources and programs to identify, prevent, or treat substance abuse, mental illness, or dysfunctional and self-destructive behavior, including child abuse and family violence, among its members or its service population. This plan should include behavioral health services, social services, intensive outpatient services, and continuing aftercare.

At the request of an Indian tribe, tribal organization, or urban Indian organization, the Bureau of Indian Affairs and the Service shall cooperate with and provide technical assistance to the Indian tribe, tribal organization, or urban Indian organization in the development and implementation of such plan. The Secretary, acting through the Service, Indian tribes, and tribal organizations, may make funding available to Indian tribes and tribal organizations which adopt a resolution pursuant to paragraph

(1)to obtain technical assistance for the development of a community behavioral health plan and to provide administrative support in the implementation of such plan. The Secretary, acting through the Service, shall coordinate behavioral health planning, to the extent feasible, with other Federal agencies and with State agencies, to encourage comprehensive behavioral health services for Indians regardless of their place of residence. Not later than 1 year after the date of enactment of the Indian Healthcare Improvement Act of 2017 , the Secretary, acting through the Service, shall make an assessment of the need for inpatient mental health care among Indians and the availability and cost of inpatient mental health facilities which can meet such need. In making such assessment, the Secretary shall consider the possible conversion of existing, underused Service hospital beds into psychiatric units to meet such need. Not later than 1 year after the date of enactment of the Indian Healthcare Improvement Act of 2017 , the Secretary, acting through the Service, and the Secretary of the Interior shall develop and enter into a memoranda of agreement, or review and update any existing memoranda of agreement, as required by section 4205 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 ( 25 U.S.C. 2411 ) under which the Secretaries address the following: The scope and nature of mental illness and dysfunctional and self-destructive behavior, including child abuse and family violence, among Indians. The existing Federal, tribal, State, local, and private services, resources, and programs available to provide behavioral health services for Indians. The unmet need for additional services, resources, and programs necessary to meet the needs identified pursuant to paragraph (1). The right of Indians, as citizens of the United States and of the States in which they reside, to have access to behavioral health services to which all citizens have access. The right of Indians to participate in, and receive the benefit of, such services. The actions necessary to protect the exercise of such right. The responsibilities of the Bureau of Indian Affairs and the Service, including mental illness identification, prevention, education, referral, and treatment services (including services through multidisciplinary resource teams), at the central, area, and agency and Service unit, Service area, and headquarters levels to address the problems identified in paragraph (1). A strategy for the comprehensive coordination of the behavioral health services provided by the Bureau of Indian Affairs and the Service to meet the problems identified pursuant to paragraph (1), including— the coordination of alcohol and substance abuse programs of the Service, the Bureau of Indian Affairs, and Indian tribes and tribal organizations (developed under the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 ( 25 U.S.C. 2401 et seq.)) with behavioral health initiatives pursuant to this Act, particularly with respect to the referral and treatment of dually diagnosed individuals requiring behavioral health and substance abuse treatment; and ensuring that the Bureau of Indian Affairs and Service programs and services (including multidisciplinary resource teams) addressing child abuse and family violence are coordinated with such non-Federal programs and services. Directing appropriate officials of the Bureau of Indian Affairs and the Service, particularly at the agency and Service unit levels, to cooperate fully with tribal requests made pursuant to community behavioral health plans adopted under section 702(c) and section 4206 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 ( 25 U.S.C. 2412 ). Providing for an annual review of such agreement by the Secretaries which shall be provided to Congress and Indian tribes and tribal organizations. The memoranda of agreement updated or entered into pursuant to subsection

(a)shall include specific provisions pursuant to which the Service shall assume responsibility for— the determination of the scope of the problem of alcohol and substance abuse among Indians, including the number of Indians within the jurisdiction of the Service who are directly or indirectly affected by alcohol and substance abuse and the financial and human cost; an assessment of the existing and needed resources necessary for the prevention of alcohol and substance abuse and the treatment of Indians affected by alcohol and substance abuse; and an estimate of the funding necessary to adequately support a program of prevention of alcohol and substance abuse and treatment of Indians affected by alcohol and substance abuse. Each memorandum of agreement entered into or renewed (and amendments or modifications thereto) under subsection

(a)shall be published in the Federal Register. At the same time as publication in the Federal Register, the Secretary shall provide a copy of such memoranda, amendment, or modification to each Indian tribe, tribal organization, and urban Indian organization. The Secretary, acting through the Service, shall provide a program of comprehensive behavioral health, prevention, treatment, and aftercare, which may include, if feasible and appropriate, systems of care, and shall include— prevention, through educational intervention, in Indian communities; acute detoxification, psychiatric hospitalization, residential, and intensive outpatient treatment; community-based rehabilitation and aftercare; community education and involvement, including extensive training of health care, educational, and community-based personnel; specialized residential treatment programs for high-risk populations, including pregnant and postpartum women and their children; and diagnostic services. The target population of such programs shall be members of Indian tribes. Efforts to train and educate key members of the Indian community shall also target employees of health, education, judicial, law enforcement, legal, and social service programs. The Secretary, acting through the Service, may enter into contracts with public or private providers of behavioral health treatment services for the purpose of carrying out the program required under subsection (a). In carrying out this subsection, the Secretary shall provide assistance to Indian tribes and tribal organizations to develop criteria for the certification of behavioral health service providers and accreditation of service facilities which meet minimum standards for such services and facilities. Pursuant to the Act of November 2, 1921 ( 25 U.S.C. 13 ) (commonly known as the Snyder Act ), the Secretary shall establish and maintain a mental health technician program within the Service which— provides for the training of Indians as mental health technicians; and employs such technicians in the provision of community-based mental health care that includes identification, prevention, education, referral, and treatment services. In carrying out subsection (a), the Secretary, acting through the Service, shall provide high-standard paraprofessional training in mental health care necessary to provide quality care to the Indian communities to be served. Such training shall be based upon a curriculum developed or approved by the Secretary which combines education in the theory of mental health care with supervised practical experience in the provision of such care. The Secretary, acting through the Service, shall supervise and evaluate the mental health technicians in the training program. The Secretary, acting through the Service, shall ensure that the program established pursuant to this section involves the use and promotion of the traditional health care practices of the Indian tribes to be served. Subject to section 221, and except as provided in subsection (b), any individual employed as a psychologist, social worker, or marriage and family therapist for the purpose of providing mental health care services to Indians in a clinical setting under this Act is required to be licensed as a psychologist, social worker, or marriage and family therapist, respectively. An individual may be employed as a trainee in psychology, social work, or marriage and family therapy to provide mental health care services described in subsection

(a)if such individual— works under the direct supervision of a licensed psychologist, social worker, or marriage and family therapist, respectively; is enrolled in or has completed at least 2 years of course work at a post-secondary, accredited education program for psychology, social work, marriage and family therapy, or counseling; and meets such other training, supervision, and quality review requirements as the Secretary may establish. The Secretary, consistent with section 702, may make grants to Indian tribes, tribal organizations, and urban Indian organizations to develop and implement a comprehensive behavioral health program of prevention, intervention, treatment, and relapse prevention services that specifically addresses the cultural, historical, social, and child care needs of Indian women, regardless of age. A grant made pursuant to this section may be used— to develop and provide community training, education, and prevention programs for Indian women relating to behavioral health issues, including fetal alcohol spectrum disorders; to identify and provide psychological services, counseling, advocacy, support, and relapse prevention to Indian women and their families; and to develop prevention and intervention models for Indian women which incorporate traditional health care practices, cultural values, and community and family involvement. The Secretary, in consultation with Indian tribes and tribal organizations, shall establish criteria for the review and approval of applications and proposals for funding under this section. 20 percent of the funds appropriated pursuant to this section shall be used to make grants to urban Indian organizations. The Secretary, acting through the Service, consistent with section 702, shall develop and implement a program for acute detoxification and treatment for Indian youths, including behavioral health services. The program shall include regional treatment centers designed to include detoxification and rehabilitation for both sexes on a referral basis and programs developed and implemented by Indian tribes or tribal organizations at the local level under the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 450 et seq.). Regional centers shall be integrated with the intake and rehabilitation programs based in the referring Indian community. The Secretary, acting through the Service, shall construct, renovate, or, as necessary, purchase, and appropriately staff and operate, at least 1 youth regional treatment center or treatment network in each area under the jurisdiction of an area office. For the purposes of this subsection, the area office in California shall be considered to be 2 area offices, 1 office whose jurisdiction shall be considered to encompass the northern area of the State of California, and 1 office whose jurisdiction shall be considered to encompass the remainder of the State of California for the purpose of implementing California treatment networks. For the purpose of staffing and operating such centers or facilities, funding shall be pursuant to the Act of November 2, 1921 ( 25 U.S.C. 13 ). A youth treatment center constructed or purchased under this subsection shall be constructed or purchased at a location within the area described in paragraph

(1)agreed upon (by appropriate tribal resolution) by a majority of the Indian tribes to be served by such center. Notwithstanding any other provision of this title, the Secretary may, from amounts authorized to be appropriated for the purposes of carrying out this section, make funds available to— the Tanana Chiefs Conference, Incorporated, for the purpose of leasing, constructing, renovating, operating, and maintaining a residential youth treatment facility in Fairbanks, Alaska; and the Southeast Alaska Regional Health Corporation to staff and operate a residential youth treatment facility without regard to the proviso set forth in section 4( l ) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b( l )). Until additional residential youth treatment facilities are established in Alaska pursuant to this section, the facilities specified in subparagraph

(A)shall make every effort to provide services to all eligible Indian youths residing in Alaska. The Secretary, acting through the Service, may provide intermediate behavioral health services, which may , if feasible and appropriate, incorporate systems of care, to Indian children and adolescents, including— pretreatment assistance; inpatient, outpatient, and aftercare services; emergency care; suicide prevention and crisis intervention; and prevention and treatment of mental illness and dysfunctional and self-destructive behavior, including child abuse and family violence. Funds provided under this subsection may be used— to construct or renovate an existing health facility to provide intermediate behavioral health services; to hire behavioral health professionals; to staff, operate, and maintain an intermediate mental health facility, group home, sober housing, transitional housing or similar facilities, or youth shelter where intermediate behavioral health services are being provided; to make renovations and hire appropriate staff to convert existing hospital beds into adolescent psychiatric units; and for intensive home- and community-based services. The Secretary, acting through the Service, shall, in consultation with Indian tribes and tribal organizations, establish criteria for the review and approval of applications or proposals for funding made available pursuant to this subsection. The Secretary, in consultation with Indian tribes and tribal organizations, shall— identify and use, where appropriate, federally owned structures suitable for local residential or regional behavioral health treatment for Indian youths; and establish guidelines for determining the suitability of any such federally owned structure to be used for local residential or regional behavioral health treatment for Indian youths. Any structure described in paragraph

(1)may be used under such terms and conditions as may be agreed upon by the Secretary and the agency having responsibility for the structure and any Indian tribe or tribal organization operating the program. The Secretary, Indian tribes, or tribal organizations, in cooperation with the Secretary of the Interior, shall develop and implement within each Service unit, community-based rehabilitation and follow-up services for Indian youths who are having significant behavioral health problems, and require long-term treatment, community reintegration, and monitoring to support the Indian youths after their return to their home community. Services under paragraph

(1)shall be provided by trained staff within the community who can assist the Indian youths in their continuing development of self-image, positive problem-solving skills, and nonalcohol or substance abusing behaviors. Such staff may include alcohol and substance abuse counselors, mental health professionals, and other health professionals and paraprofessionals, including community health representatives. In providing the treatment and other services to Indian youths authorized by this section, the Secretary, acting through the Service, shall provide for the inclusion of family members of such youths in the treatment programs or other services as may be appropriate. Not less than 10 percent of the funds appropriated for the purposes of carrying out subsection

(e)shall be used for outpatient care of adult family members related to the treatment of an Indian youth under that subsection. The Secretary, acting through the Service, shall provide, consistent with section 702, programs and services to prevent and treat the abuse of multiple forms of substances, including alcohol, drugs, inhalants, and tobacco, among Indian youths residing in Indian communities, on or near reservations, and in urban areas and provide appropriate mental health services to address the incidence of mental illness among such youths. The Secretary, acting through the Service, shall collect data for the report under section 801 with respect to— the number of Indian youth who are being provided mental health services through the Service and tribal health programs; a description of, and costs associated with, the mental health services provided for Indian youth through the Service and tribal health programs; the number of youth referred to the Service or tribal health programs for mental health services; the number of Indian youth provided residential treatment for mental health and behavioral problems through the Service and tribal health programs, reported separately for on- and off-reservation facilities; and the costs of the services described in paragraph (4). Not later than 1 year after the date of enactment of the Indian Healthcare Improvement Act of 2017 , the Secretary, acting through the Service, may provide, in each area of the Service, not less than 1 inpatient mental health care facility, or the equivalent, for Indians with behavioral health problems. For the purposes of this subsection, California shall be considered to be 2 area offices, 1 office whose location shall be considered to encompass the northern area of the State of California and 1 office whose jurisdiction shall be considered to encompass the remainder of the State of California. The Secretary shall consider the possible conversion of existing, underused Service hospital beds into psychiatric units to meet such need. The Secretary, in cooperation with the Secretary of the Interior, shall develop and implement or assist Indian tribes and tribal organizations to develop and implement, within each Service unit or tribal program, a program of community education and involvement which shall be designed to provide concise and timely information to the community leadership of each tribal community. Such program shall include education about behavioral health issues to political leaders, tribal judges, law enforcement personnel, members of tribal health and education boards, health care providers including traditional practitioners, and other critical members of each tribal community. Such program may also include community-based training to develop local capacity and tribal community provider training for prevention, intervention, treatment, and aftercare. The Secretary, acting through the Service, shall provide instruction in the area of behavioral health issues, including instruction in crisis intervention and family relations in the context of alcohol and substance abuse, child sexual abuse, youth alcohol and substance abuse, and the causes and effects of fetal alcohol spectrum disorders to appropriate employees of the Bureau of Indian Affairs and the Service, and to personnel in schools or programs operated under any contract with the Bureau of Indian Affairs or the Service, including supervisors of emergency shelters and halfway houses described in section 4213 of the Indian Alcohol and Substance Abuse Prevention and Treatment Act of 1986 ( 25 U.S.C. 2433 ). In carrying out the education and training programs required by this section, the Secretary, in consultation with Indian tribes, tribal organizations, Indian behavioral health experts, and Indian alcohol and substance abuse prevention experts, shall develop and provide community-based training models. Such models shall address— the elevated risk of alcohol abuse and other behavioral health problems faced by children of alcoholics; the cultural, spiritual, and multigenerational aspects of behavioral health problem prevention and recovery; and community-based and multidisciplinary strategies for preventing and treating behavioral health problems. The Secretary, acting through the Service, consistent with section 702, may plan, develop, implement, and carry out programs to deliver innovative community-based behavioral health services to Indians. The Secretary may award a grant for a project under subsection

(a)to an Indian tribe or tribal organization and may consider the following criteria: The project will address significant unmet behavioral health needs among Indians. The project will serve a significant number of Indians. The project has the potential to deliver services in an efficient and effective manner. The Indian tribe or tribal organization has the administrative and financial capability to administer the project. The project may deliver services in a manner consistent with traditional health care practices. The project is coordinated with, and avoids duplication of, existing services. For purposes of this subsection, the Secretary shall, in evaluating project applications or proposals, use the same criteria that the Secretary uses in evaluating any other application or proposal for such funding. The Secretary, consistent with section 702, acting through the Service, Indian Tribes, and Tribal Organizations, is authorized to establish and operate fetal alcohol spectrum disorders programs as provided in this section for the purposes of meeting the health status objectives specified in section 3. Funding provided pursuant to this section shall be used for the following: To develop and provide for Indians community and in-school training, education, and prevention programs relating to fetal alcohol spectrum disorders. To identify and provide behavioral health treatment to high-risk Indian women and high-risk women pregnant with an Indian’s child. To identify and provide appropriate psychological services, educational and vocational support, counseling, advocacy, and information to fetal alcohol spectrum disorders-affected Indians and their families or caretakers. To develop and implement counseling and support programs in schools for fetal alcohol spectrum disorders-affected Indian children. To develop prevention and intervention models which incorporate practitioners of traditional health care practices, cultural values, and community involvement. To develop, print, and disseminate education and prevention materials on fetal alcohol spectrum disorders. To develop and implement, in consultation with Indian Tribes and Tribal Organizations, and in conference with urban Indian Organizations, culturally sensitive assessment and diagnostic tools including dysmorphology clinics and multidisciplinary fetal alcohol spectrum disorders clinics for use in Indian communities and urban Centers. To develop and provide training on fetal alcohol spectrum disorders to professionals providing services to Indians, including medical and allied health practitioners, social service providers, educators, and law enforcement, court officials and corrections personnel in the juvenile and criminal justice systems. In addition to any purpose under subparagraph (A), funding provided pursuant to this section may be used for 1 or more of the following: Early childhood intervention projects from birth on to mitigate the effects of fetal alcohol spectrum disorders among Indians. Community-based support services for Indians and women pregnant with Indian children. Community-based housing for adult Indians with fetal alcohol spectrum disorders. The Secretary shall establish criteria for the review and approval of applications for funding under this section. The Secretary, acting through the Service, Indian Tribes, and Tribal Organizations, shall— develop and provide services for the prevention, intervention, treatment, and aftercare for those affected by fetal alcohol spectrum disorders in Indian communities; and provide supportive services, including services to meet the special educational, vocational, school-to-work transition, and independent living needs of adolescent and adult Indians with fetal alcohol spectrum disorders. The Secretary, acting through the Substance Abuse and Mental Health Services Administration, shall make grants to Indian Tribes, Tribal Organizations, and urban Indian Organizations for applied research projects which propose to elevate the understanding of methods to prevent, intervene, treat, or provide rehabilitation and behavioral health aftercare for Indians and urban Indians affected by fetal alcohol spectrum disorders. Ten percent of the funds appropriated pursuant to this section shall be used to make grants to urban Indian Organizations funded under title V. The Secretary, acting through the Service, shall establish, consistent with section 702, in every Service area, programs involving treatment for— victims of sexual abuse who are Indian children or children in an Indian household; and other members of the household or family of the victims described in paragraph (1). Funding provided pursuant to this section shall be used for the following: To develop and provide community education and prevention programs related to sexual abuse of Indian children or children in an Indian household. To identify and provide behavioral health treatment to victims of sexual abuse who are Indian children or children in an Indian household, and to their family members who are affected by sexual abuse. To develop prevention and intervention models which incorporate traditional health care practices, cultural values, and community involvement. To develop and implement culturally sensitive assessment and diagnostic tools for use in Indian communities and urban centers. The programs established under subsection

(a)shall be carried out in coordination with programs and services authorized under the Indian Child Protection and Family Violence Prevention Act ( 25 U.S.C. 3201 et seq.). The Secretary, in accordance with section 702, is authorized to establish in each Service area programs involving the prevention and treatment of— Indian victims of domestic violence or sexual abuse; and other members of the household or family of the victims described in paragraph (1). Funds made available to carry out this section shall be used— to develop and implement prevention programs and community education programs relating to domestic violence and sexual abuse; to provide behavioral health services, including victim support services, and medical treatment (including examinations performed by sexual assault nurse examiners) to Indian victims of domestic violence or sexual abuse; to purchase rape kits; and to develop prevention and intervention models, which may incorporate traditional health care practices. Not later than 1 year after the date of enactment of the Indian Healthcare Improvement Act of 2017 , the Secretary shall establish appropriate protocols, policies, procedures, standards of practice, and, if not available elsewhere, training curricula and training and certification requirements for services for victims of domestic violence and sexual abuse. Not later than 18 months after the date of enactment of the Indian Healthcare Improvement Act of 2017 , the Secretary shall submit to the Committee on Indian Affairs of the Senate and the Committee on Natural Resources of the House of Representatives a report that describes the means and extent to which the Secretary has carried out paragraph (1). The Secretary, in coordination with the Attorney General, Federal and tribal law enforcement agencies, Indian health programs, and domestic violence or sexual assault victim organizations, shall develop appropriate victim services and victim advocate training programs— to improve domestic violence or sexual abuse responses; to improve forensic examinations and collection; to identify problems or obstacles in the prosecution of domestic violence or sexual abuse; and to meet other needs or carry out other activities required to prevent, treat, and improve prosecutions of domestic violence and sexual abuse. Not later than 2 years after the date of enactment of the Indian Healthcare Improvement Act of 2017 , the Secretary shall submit to the Committee on Indian Affairs of the Senate and the Committee on Natural Resources of the House of Representatives a report that describes, with respect to the matters described in paragraph (1), the improvements made and needed, problems or obstacles identified, and costs necessary to address the problems or obstacles, and any other recommendations that the Secretary determines to be appropriate. The Secretary, in consultation with appropriate Federal agencies, shall make grants to, or enter into contracts with, Indian tribes, tribal organizations, and urban Indian organizations or enter into contracts with, or make grants to appropriate institutions for, the conduct of research on the incidence and prevalence of behavioral health problems among Indians served by the Service, Indian tribes, or tribal organizations and among Indians in urban areas. Research priorities under this section shall include— the multifactorial causes of Indian youth suicide, including— protective and risk factors and scientific data that identifies those factors; and the effects of loss of cultural identity and the development of scientific data on those effects; the interrelationship and interdependence of behavioral health problems with alcoholism and other substance abuse, suicide, homicides, other injuries, and the incidence of family violence; and the development of models of prevention techniques. The effect of the interrelationships and interdependencies referred to in subsection (a)(2) on children, and the development of prevention techniques under subsection (a)(3) applicable to children, shall be emphasized. Congress finds that— the rate of suicide of American Indians and Alaska Natives is 1.9 times higher than the national average rate; and the rate of suicide of Indian and Alaska Native youth aged 15 through 24 is— 3.5 times the national average rate; and the highest rate of any population group in the United States; many risk behaviors and contributing factors for suicide are more prevalent in Indian country than in other areas, including— history of previous suicide attempts; family history of suicide; history of depression or other mental illness; alcohol or drug abuse; health disparities; stressful life events and losses; easy access to lethal methods; exposure to the suicidal behavior of others; isolation; and incarceration; according to national data for 2005, suicide was the second-leading cause of death for Indians and Alaska Natives of both sexes aged 10 through 34; the suicide rates of Indian and Alaska Native males aged 15 through 24 are— as compared to suicide rates of males of any other racial group, up to 4 times greater; and as compared to suicide rates of females of any other racial group, up to 11 times greater; and data demonstrates that, over their lifetimes, females attempt suicide 2 to 3 times more often than males; Indian tribes, especially Indian tribes located in the Great Plains, have experienced epidemic levels of suicide, up to 10 times the national average; and suicide clustering in Indian country affects entire tribal communities; death rates for Indians and Alaska Natives are statistically underestimated because many areas of Indian country lack the proper resources to identify and monitor the presence of disease; the Indian Health Service experiences health professional shortages, with physician vacancy rates of approximately 17 percent, and nursing vacancy rates of approximately 18 percent, in 2007; 90 percent of all teens who die by suicide suffer from a diagnosable mental illness at time of death; more than 1⁄2 of teens who die by suicide have never been seen by a mental health provider; and 1/3 of health needs in Indian country relate to mental health; often, the lack of resources of Indian tribes and the remote nature of Indian reservations make it difficult to meet the requirements necessary to access Federal assistance, including grants; the Substance Abuse and Mental Health Services Administration and the Service have established specific initiatives to combat youth suicide in Indian country and among Indians and Alaska Natives throughout the United States, including the National Suicide Prevention Initiative of the Service, which has worked with Service, tribal, and urban Indian health programs since 2003; the National Strategy for Suicide Prevention was established in 2001 through a Department of Health and Human Services collaboration among— the Substance Abuse and Mental Health Services Administration; the Service; the Centers for Disease Control and Prevention; the National Institutes of Health; and the Health Resources and Services Administration; and the Service and other agencies of the Department of Health and Human Services use information technology and other programs to address the suicide prevention and mental health needs of Indians and Alaska Natives. The purposes of this subtitle are— to authorize the Secretary to carry out a demonstration project to test the use of telemental health services in suicide prevention, intervention, and treatment of Indian youth, including through— the use of psychotherapy, psychiatric assessments, diagnostic interviews, therapies for mental health conditions predisposing to suicide, and alcohol and substance abuse treatment; the provision of clinical expertise to, consultation services with, and medical advice and training for frontline health care providers working with Indian youth; training and related support for community leaders, family members, and health and education workers who work with Indian youth; the development of culturally relevant educational materials on suicide; and data collection and reporting; to encourage Indian tribes, tribal organizations, and other mental health care providers serving residents of Indian country to obtain the services of predoctoral psychology and psychiatry interns; and to enhance the provision of mental health care services to Indian youth through existing grant programs of the Substance Abuse and Mental Health Services Administration. In this subtitle: The term Administration means the Substance Abuse and Mental Health Services Administration. The term demonstration project means the Indian youth telemental health demonstration project authorized under section 723(a). The term telemental health means the use of electronic information and telecommunications technologies to support long-distance mental health care, patient and professional-related education, public health, and health administration. The Secretary, acting through the Service, is authorized to carry out a demonstration project to award grants for the provision of telemental health services to Indian youth who— have expressed suicidal ideas; have attempted suicide; or have behavioral health conditions that increase or could increase the risk of suicide. Grants under paragraph

(1)shall be awarded to Indian tribes and tribal organizations that operate 1 or more facilities— located in an area with documented disproportionately high rates of suicide; reporting active clinical telehealth capabilities; or offering school-based telemental health services to Indian youth. The Secretary shall award grants under this section for a period of up to 4 years. Not more than 5 grants shall be provided under paragraph (1), with priority consideration given to Indian tribes and tribal organizations that— serve a particular community or geographic area in which there is a demonstrated need to address Indian youth suicide; enter into collaborative partnerships with Service or other tribal health programs or facilities to provide services under this demonstration project; serve an isolated community or geographic area that has limited or no access to behavioral health services; or operate a detention facility at which Indian youth are detained. In developing and carrying out the demonstration project under this subsection, the Secretary shall consult with the Administration as the Federal agency focused on mental health issues, including suicide. An Indian tribe or tribal organization shall use a grant received under subsection

(a)for the following purposes: To provide telemental health services to Indian youth, including the provision of— psychotherapy; psychiatric assessments and diagnostic interviews, therapies for mental health conditions predisposing to suicide, and treatment; and alcohol and substance abuse treatment. To provide clinician-interactive medical advice, guidance and training, assistance in diagnosis and interpretation, crisis counseling and intervention, and related assistance to Service or tribal clinicians and health services providers working with youth being served under the demonstration project. To assist, educate, and train community leaders, health education professionals and paraprofessionals, tribal outreach workers, and family members who work with the youth receiving telemental health services under the demonstration project, including with identification of suicidal tendencies, crisis intervention and suicide prevention, emergency skill development, and building and expanding networks among those individuals and with State and local health services providers. To develop and distribute culturally appropriate community educational materials regarding— suicide prevention; suicide education; suicide screening; suicide intervention; and ways to mobilize communities with respect to the identification of risk factors for suicide. To conduct data collection and reporting relating to Indian youth suicide prevention efforts. In carrying out the purposes described in paragraph (1), an Indian tribe or tribal organization may use and promote the traditional health care practices of the Indian tribes of the youth to be served. Subject to paragraph (2), to be eligible to receive a grant under subsection (a), an Indian tribe or tribal organization shall prepare and submit to the Secretary an application, at such time, in such manner, and containing such information as the Secretary may require, including— a description of the project that the Indian tribe or tribal organization will carry out using the funds provided under the grant; a description of the manner in which the project funded under the grant would— meet the telemental health care needs of the Indian youth population to be served by the project; or improve the access of the Indian youth population to be served to suicide prevention and treatment services; evidence of support for the project from the local community to be served by the project; a description of how the families and leadership of the communities or populations to be served by the project would be involved in the development and ongoing operations of the project; a plan to involve the tribal community of the youth who are provided services by the project in planning and evaluating the behavioral health care and suicide prevention efforts provided, in order to ensure the integration of community, clinical, environmental, and cultural components of the treatment; and a plan for sustaining the project after Federal assistance for the demonstration project has terminated. The Secretary shall carry out such measures as the Secretary determines to be necessary to maximize the time and workload efficiency of the process by which Indian tribes and tribal organizations apply for grants under paragraph (1). The Secretary, acting through the Service, shall encourage Indian tribes and tribal organizations receiving grants under this section to collaborate to enable comparisons regarding best practices across projects. Each grant recipient shall submit to the Secretary an annual report that— describes the number of telemental health services provided; and includes any other information that the Secretary may require. Not later than 2 years after the date on which the first grant is awarded under this section, the Secretary shall submit to the Committee on Indian Affairs of the Senate and the Committee on Natural Resources and the Committee on Energy and Commerce of the House of Representatives a report that— describes each project funded by a grant under this section during the preceding 2-year period, including a description of the level of success achieved by the project; and evaluates whether the demonstration project should be continued during the period beginning on the date of termination of funding for the demonstration project under subsection

(g)and ending on the date on which the final report is submitted under paragraph (2). On a determination by the Secretary under clause

(ii)of subparagraph

(A)that the demonstration project should be continued, the Secretary may carry out the demonstration project during the period described in that clause using such sums otherwise made available to the Secretary as the Secretary determines to be appropriate. Not later than 270 days after the date of termination of funding for the demonstration project under subsection (g), the Secretary shall submit to the Committee on Indian Affairs of the Senate and the Committee on Natural Resources and the Committee on Energy and Commerce of the House of Representatives a final report that— describes the results of the projects funded by grants awarded under this section, including any data available that indicate the number of attempted suicides; evaluates the impact of the telemental health services funded by the grants in reducing the number of completed suicides among Indian youth; evaluates whether the demonstration project should be— expanded to provide more than 5 grants; and designated as a permanent program; and evaluates the benefits of expanding the demonstration project to include urban Indian organizations. There is authorized to be appropriated to carry out this section $1,500,000 for each of fiscal years 2017 through 2019. The Secretary, acting through the Administration, shall carry out such measures as the Secretary determines to be necessary to maximize the time and workload efficiency of the process by which Indian tribes and tribal organizations apply for grants under any program administered by the Administration, including by providing methods other than electronic methods of submitting applications for those grants, if necessary. To fulfill the trust responsibility of the United States to Indian tribes, in awarding relevant grants pursuant to a program described in subparagraph (B), the Secretary shall take into consideration the needs of Indian tribes or tribal organizations, as applicable, that serve populations with documented high suicide rates, regardless of whether those Indian tribes or tribal organizations possess adequate personnel or infrastructure to fulfill all applicable requirements of the relevant program. A grant program referred to in subparagraph

(A)is a grant program— administered by the Administration to fund activities relating to mental health, suicide prevention, or suicide-related risk factors; and under which an Indian tribe or tribal organization is an eligible recipient. Notwithstanding any other provision of law, in applying for a grant under any program administered by the Administration, no Indian tribe or tribal organization shall be required to apply through a State or State agency. In this paragraph: The term affected State means a State— the boundaries of which include 1 or more Indian tribes; and the application for a grant under any program administered by the Administration of which includes statewide data. The term Indian population means the total number of residents of an affected State who are Indian. As a condition of receipt of a grant under any program administered by the Administration, each affected State shall— describe in the grant application— the Indian population of the affected State; and the contribution of that Indian population to the statewide data used by the affected State in the application; and demonstrate to the satisfaction of the Secretary that— of the total amount of the grant, the affected State will allocate for use for the Indian population of the affected State an amount equal to the proportion that— the Indian population of the affected State; bears to the total population of the affected State; and the affected State will take reasonable efforts to collaborate with each Indian tribe located within the affected State to carry out youth suicide prevention and treatment measures for members of the Indian tribe. Not later than 1 year after the date of receipt of a grant described in subparagraph (B), an affected State shall submit to the Secretary a report describing the measures carried out by the affected State to ensure compliance with the requirements of subparagraph (B)(ii). Notwithstanding any other provision of law, no Indian tribe or tribal organization shall be required to provide a non-Federal share of the cost of any project or activity carried out using a grant provided under any program administered by the Administration. Due to the rural, isolated nature of most Indian reservations and communities (especially those reservations and communities in the Great Plains region), the Secretary shall conduct outreach activities, with a particular emphasis on the provision of telemental health services, to achieve the purposes of this subtitle with respect to Indian tribes located in rural, isolated areas. The Secretary, acting through the Administration, shall carry out such measures (including monitoring and the provision of required assistance) as the Secretary determines to be necessary to ensure the provision of adequate suicide prevention and mental health services to Indian tribes described in paragraph (2), regardless of whether those Indian tribes possess adequate personnel or infrastructure— to submit an application for a grant under any program administered by the Administration, including due to problems relating to access to the Internet or other electronic means that may have resulted in previous obstacles to submission of a grant application; or to fulfill all applicable requirements of the relevant program. An Indian tribe referred to in paragraph

(1)is an Indian tribe— the members of which experience— a high rate of youth suicide; low socioeconomic status; and extreme health disparity; that is located in a remote and isolated area; and that lacks technology and communication infrastructure. There are authorized to be appropriated to the Secretary such sums as the Secretary determines to be necessary to carry out this subsection. In this subsection, the term affected entity means any entity— that receives a grant for suicide intervention, prevention, or treatment under a program administered by the Administration; and the population to be served by which includes Indian youth. The Secretary, acting through the Administration, shall ensure that each affected entity carrying out a youth suicide early intervention and prevention strategy described in section 520E(c)(1) of the Public Health Service Act ( 42 U.S.C. 290bb–36(c)(1) ), or any other youth suicide-related early intervention and assessment activity, provides training or education to individuals who interact frequently with the Indian youth to be served by the affected entity (including parents, teachers, coaches, and mentors) on identifying warning signs of Indian youth who are at risk of committing suicide. The Secretary shall carry out such activities as the Secretary determines to be necessary to encourage Indian tribes, tribal organizations, and other mental health care providers to obtain the services of predoctoral psychology and psychiatry interns— to increase the quantity of patients served by the Indian tribes, tribal organizations, and other mental health care providers; and for purposes of recruitment and retention. The purpose of this section is to authorize the Secretary, acting through the Administration, to carry out a demonstration program to test the effectiveness of a culturally compatible, school-based, life skills curriculum for the prevention of Indian and Alaska Native adolescent suicide, including through— the establishment of tribal partnerships to develop and implement such a curriculum, in cooperation with— behavioral health professionals, with a priority for tribal partnerships cooperating with mental health professionals employed by the Service; tribal or local school agencies; and parent and community groups; the provision by the Administration or the Service of— technical expertise; and clinicians, analysts, and educators, as appropriate; training for teachers, school administrators, and community members to implement the curriculum; the establishment of advisory councils composed of parents, educators, community members, trained peers, and others to provide advice regarding the curriculum and other components of the demonstration program; the development of culturally appropriate support measures to supplement the effectiveness of the curriculum; and projects modeled after evidence-based projects, such as programs evaluated and published in relevant literature. In this subsection: The term curriculum means the culturally compatible, school-based, life skills curriculum for the prevention of Indian and Alaska Native adolescent suicide identified by the Secretary under paragraph (2)(A). The term eligible entity means— an Indian tribe; a tribal organization; any other tribally authorized entity; and any partnership composed of 2 or more entities described in clause (i), (ii), or (iii). The Secretary, acting through the Administration, may establish and carry out a demonstration program under which the Secretary shall— identify a culturally compatible, school-based, life skills curriculum for the prevention of Indian and Alaska Native adolescent suicide; identify the Indian tribes that are at greatest risk for adolescent suicide; invite those Indian tribes to participate in the demonstration program by— responding to a comprehensive program requirement request of the Secretary; or submitting, through an eligible entity, an application in accordance with paragraph (4); and provide grants to the Indian tribes identified under subparagraph

(B)and eligible entities to implement the curriculum with respect to Indian and Alaska Native youths who— are between the ages of 10 and 19; and attend school in a region that is at risk of high youth suicide rates, as determined by the Administration. The term of a grant provided under the demonstration program under this section shall be not less than 4 years. The Secretary may provide not more than 5 grants under the demonstration program under this section. The grants provided under this section shall be of equal amounts. In selecting eligible entities to receive grants under this section, the Secretary shall ensure that not less than 1 demonstration program shall be carried out at each of— a school operated by the Bureau of Indian Education; a Tribal school; and a school receiving payments under section 8002 or 8003 of the Elementary and Secondary Education Act of 1965 ( 20 U.S.C. 7702 , 7703). To be eligible to receive a grant under the demonstration program, an eligible entity shall submit to the Secretary an application, at such time, in such manner, and containing such information as the Secretary may require, including— an assurance that, in implementing the curriculum, the eligible entity will collaborate with 1 or more local educational agencies, including elementary schools, middle schools, and high schools; an assurance that the eligible entity will collaborate, for the purpose of curriculum development, implementation, and training and technical assistance, with 1 or more— nonprofit entities with demonstrated expertise regarding the development of culturally sensitive, school-based, youth suicide prevention and intervention programs; or institutions of higher education with demonstrated interest and knowledge regarding culturally sensitive, school-based, life skills youth suicide prevention and intervention programs; an assurance that the curriculum will be carried out in an academic setting in conjunction with at least 1 classroom teacher not less frequently than twice each school week for the duration of the academic year; a description of the methods by which curriculum participants will be— screened for mental health at-risk indicators; and if needed and on a case-by-case basis, referred to a mental health clinician for further assessment and treatment and with crisis response capability; and an assurance that supportive services will be provided to curriculum participants identified as high-risk participants, including referral, counseling, and follow-up services for— drug or alcohol abuse; sexual or domestic abuse; and depression and other relevant mental health concerns. An Indian tribe identified under paragraph (2)(B) or an eligible entity may use a grant provided under this subsection— to develop and implement the curriculum in a school-based setting; to establish an advisory council— to advise the Indian tribe or eligible entity regarding curriculum development; and to provide support services identified as necessary by the community being served by the Indian tribe or eligible entity; to appoint and train a school- and community-based cultural resource liaison, who will act as an intermediary among the Indian tribe or eligible entity, the applicable school administrators, and the advisory council established by the Indian tribe or eligible entity; to establish an on-site, school-based, MA- or Ph.D.-level mental health practitioner (employed by the Service, if practicable) to work with tribal educators and other personnel; to provide for the training of peer counselors to assist in carrying out the curriculum; to procure technical and training support from nonprofit or State entities or institutions of higher education identified by the community being served by the Indian tribe or eligible entity as the best suited to develop and implement the curriculum; to train teachers and school administrators to effectively carry out the curriculum; to establish an effective referral procedure and network; to identify and develop culturally compatible curriculum support measures; to obtain educational materials and other resources from the Administration or other appropriate entities to ensure the success of the demonstration program; and to evaluate the effectiveness of the curriculum in preventing Indian and Alaska Native adolescent suicide. Using such amounts made available pursuant to subsection

(e)as the Secretary determines to be appropriate, the Secretary shall conduct, directly or through a grant, contract, or cooperative agreement with an entity that has experience regarding the development and operation of successful culturally compatible, school-based, life skills suicide prevention and intervention programs or evaluations, an annual evaluation of the demonstration program under this section, including an evaluation of— the effectiveness of the curriculum in preventing Indian and Alaska Native adolescent suicide; areas for program improvement; and additional development of the goals and objectives of the demonstration program. Subject to paragraph (2), not later than 180 days after the date of termination of the demonstration program, the Secretary shall submit to the Committee on Indian Affairs and the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Natural Resources and the Committee on Education and Labor of the House of Representatives a final report that— describes the results of the program of each Indian tribe or eligible entity under this section; evaluates the effectiveness of the curriculum in preventing Indian and Alaska Native adolescent suicide; makes recommendations regarding— the expansion of the demonstration program under this section to additional eligible entities; designating the demonstration program as a permanent program; and identifying and distributing the curriculum through the Suicide Prevention Resource Center of the Administration; and incorporates any public comments received under paragraph (2). The Secretary shall provide a notice of the report under paragraph

(1)and an opportunity for public comment on the report for a period of not less than 90 days before submitting the report to Congress. There is authorized to be appropriated to carry out this section $1,000,000 for each of fiscal years 2017 through 2020. .

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