House Human Services Committee

1
House Human Services Committee

• Mental Health and Substance Abuse Services
• May 24, 2006

2
Public Mental Health System in Texas

• DSHS mental health services are only part of the
  public mental health system in Texas.
• Law enforcement, education, Medicaid, CHIP, the
  criminal justice system, hospitals and other
  entities all play major roles in treating Texans
  with mental illnesses.

3
Behavioral Health Issues Impact Other Systems

• 75 of children placed in foster care have
  parents with behavioral health problems DFPS,
  DSHS, DARS
• 75 of kids in the juvenile justice system have
  behavioral health problems TJPC, TYC, TDCJ,
  DSHS
• 30 of kids in the juvenile justice system will
  end up in the adult justice system TJPC, TYC,
  TDCJ, DSHS
• 46 of all ER visits have behavioral health
  issues as a basic or contributing factor DADS,
  TWC, DSHS
• 30 of all truancy is related to behavioral
  health problems TEA, TWC, TJPC, TYC, DSHS

4
Mental Health as a Public Health Crisis
Comparative mortality statistics, 2001
Source Centers for Disease Control and
Prevention
5
Mental Illness Strikes More Americans Each Year
Than Other Serious Illnesses
Mental Illness
Serious Mental Illness
CVD
Diabetes
Cancer
Asthma
CDC BRFSS, SEER Cancer Statistics Review,
1975-2002, Prevalence, Severity, and Comorbidity
of 12-Month DSM-IV Disorders  Arch Gen
Psychiatry.  Vol. 62, June 2005
6
DSHS Mental Health and Substance Abuse Services

• Community-based services
• 39 Local Mental Health Authorities
• Dallas Area NorthSTAR Authority
• 180 Substance Abuse contracts
• 10 State Hospitals

7
Funding Mechanisms

• Community Mental Health and Substance Abuse
  payment mechanisms
• Substance Abuse Treatment Fee-for-service
• Substance Abuse Prevention Cost reimbursement
• Community Mental Health Centers Prepayment for
  services

8
Funding Equity for MH Services

• The 2006-07 General Appropriations Act (Article
  II, Special Provisions, Sec. 29) requires the
  Department of State Health Services to implement
  a long term plan to achieve equity in state
  funding allocations among local mental health
  authorities.
• The plan will be implemented from fiscal years
  2006-2013. The goal of the plan is to achieve
  equity to the greatest extent possible by fiscal
  year 2013.
• Any funding reductions to a local authority for
  the purpose of achieving equity may not exceed 5
  percent of allocated general revenue in a fiscal
  year.
• The plan also ensures that improving funding
  equity is a priority in distributing any new
  state or federal funds that may become available
  for allocation to community centers.
• Progress to date 5 percent estimated to be
  achieved by end of FY06.

9
Community Mental Health Services

• Community mental health centers are locally-
  governed components of the Department of State
  Health Services (DSHS) service delivery system.
• DSHS delegates to a community mental health
  center the responsibilities of a local mental
  health authority which ensures the provision and
  continuity of services for individuals with
  mental illness, efficient use of resources,
  consumer satisfaction, and accountability.

10
Contract Management

• Performance contracts between DSHS and the Local
  Mental Health Authorities include important
  general provisions denoting the terms of the
  contract.
• Attachments to the contracts stipulate the
  services targets, performance measures, outcomes,
  and remedies, sanctions, and penalties that may
  result from failing to fulfill contract
  expectations.
• Provisions include expectations of low
  administrative overhead, utilization management
  completion rates, and measures related to
  appropriateness of services delivered and
  percentage of clients receiving the minimum
  number of Resiliency and Disease Management
  service package hours.
• Penalties/recoupment for the Second Quarter of
  Fiscal Year 2006 totaled 163,858.

11
HB 2292 Mental Health Service Requirements

• Integration of Physical Health and Behavioral
  Health
• Priority Population Redefined
• Resiliency and Disease Management
• Jail Diversion

12
Resiliency and Disease Management (RDM)

• Evidence-based
• Intended to better match services to Mental
  Health consumers needs, and to use limited
  resources most effectively by providing the right
  service to the right person in the right amount
  to have the best outcomes.
• Includes medication management, case management,
  skills training, family training, supports and
  partners, psychosocial rehabilitation, individual
  and group counseling, supported employment,
  supported housing, and Assertive Community
  Treatment (ACT)

13
RDM Key Components

• Uniform Assessment
• Standard Service Packages
• Utilization Management
• Data Analysis and Performance Evaluation

14
Numbers Served in Community Mental Health
Services in FY2005
15
Percent of Clients Receiving Minimum Number of
Service Hours Shows 50 Percent Improvement from
When RDM Implemented Statewide in Quarter 1 FY2005
16
Community MH Service Outcomes

• Average monthly number of adults receiving
  community mental health services

17
Individuals with Criminal Justice Involvement
Experienced Positive Clinical Outcomes at DSHS
Community Mental Health Centers, All of which
Implemented Jail Diversion during FY2005
18
FY2005 Texas Monthly Hospital Emergency Room (ER)
Costs 31 Percent Lower for Medicaid Clients with
Mental Illness or Substance Abuse Receiving DSHS
Behavioral Health Treatment
ER COST OFFSET - 36 Average per Client per
Month 31 REDUCTION
Source Prepared by Research Team, Strategic
Decision Support, HHSC, 3/23/2006. Average of ER
costs per month for Medicaid clients not
receiving needed DSHS Mental Health and Substance
Abuse services (Untreated) vs. average of ER
costs per month for Medicaid clients receiving
needed DSHS Mental Health and Substance Abuse
services (Treated).
19
Innovative Local Treatment Models

• Crisis Stabilization
• Tri-County MHMR (Montgomery, Liberty and Walker
  Counties)
• Jail Diversion
• Center for Health Care Services (Bexar County)
• MHMRA of Harris County

20
Community Substance Abuse Services

• Prevention Primarily school-based
• Intervention OSAR HIV PPI
• Treatment
• Adults
• Specialized Female Programs
• Women with children
• Youth
• Pharmacotherapy
• COPSD

21
Numbers Served in Substance Abuse Prevention and
Intervention Services in FY2005
22
53,420 People Accessed Substance Abuse Treatment
in FY2005
23
Access to Recovery (ATR)

• Access to Recovery supports clients by providing
  needed treatment or recovery support services to
  successfully complete their drug court program
• Drug courts offer a cost-effective alternative to
  incarceration by providing community-based
  treatment as a condition of probation
• Cost effectiveness of the ATR drug court program
  in Texas is reflected by preliminary data, which
  indicates that participating ATR clients are
  experiencing the following successful outcomes
• 92 Abstinent
• 59 Employed or in School
• 91 No Further Arrests
• 99 Not Homeless
• 87 Socially Connected

24
State Mental Health Hospitals

• 10 Mental Health facilities provide inpatient
  hospitalization for persons with severe mental
  illness who need intensive treatment
• North Texas State HospitalVernon campus, serves
  as the statewide maximum-security unit
• The Waco Center for Youth is the only
  state-operated residential treatment facility in
  Texas for youths
• All facilities are JCAHO Accredited

25
State Mental Health Hospital Capacity
26
Cost of In-patient Mental Health Services
27
Population Growth Compared to Funded State
Hospital Beds
Funding for State Mental Hospital Beds has
declined while the Texas population has grown
28
Growth in Forensic Patients
Total Forensic Patients as a percent in Texas
Mental Health Facilities
29
State Mental Health Hospital Daily Census for
FY2005
30
State Mental Health Hospital Capacity

• In February 2006, the LBB approved 13.4 million
  in additional expenditures for state mental
  health hospital capacity.
• As a result, statewide hospital system capacity
  was increased by 96 forensic commitment beds and
  144 civil commitment beds.
• This increase in state hospital capacity has
  greatly enhanced our ability to meet the needs of
  local communities.
• We continue to plan for long-term,
  community-based solutions to address the hospital
  capacity issue.

31
Crisis Services Redesign

• One goal of DSHS mental health services is to
  help consumers avoid mental health crises.
  However, the reality is that crises do occur.
• February 2006, DSHS established the Crisis
  Services Redesign Committee to develop
  recommendations for a comprehensive array of
  crisis services.
• Members of the committee include medical experts,
  citizen stakeholder groups, law enforcement
  representatives, county probate court judge
  representation, and county representatives, as
  well as individuals from professional
  organizations and provider groups.
• A redesign of crisis services will build on the
  service improvements made by the evidence-based
  Resiliency and Disease Management program.
• A thorough review of the current crisis system
  was conducted, including holding public hearings
  around the state.

32
Crisis Services Redesign (cont.)

• The committee plans to finalize its
  recommendations in June for an evidenced-based
  crisis services model that will increase access
  to appropriate and cost-effective services.
• Initial conclusions for recommended services
  include
• 24-hour crisis hotline
• Mobile crisis outreach
• 23-hour hold capacity
• On-call psychiatric services
• Crisis residential services
• Respite
• In-home crisis services
• The committee will also put forth recommendations
  regarding DSHS staff support, coordination and
  training to local professionals (e.g., law
  enforcement crisis intervention training).

33
Mental Health Service Delivery Models in Other
States

• Ohio California County-based service system
  with county taxing authority
• Arizona Regional behavioral health authorities
  managed care system
• New Mexico Single purchasing model
• Pennsylvania County-based, capitated managed
  care model
• Illinois New York Direct state contracts with
  provider network

34
Mental Health Transformation

• Overarching goal is to improve the mental health
  of all Texans and meet the Presidents New
  Freedom Commission goals
• New Freedom Commission Goals are shared by those
  participating on the Transformation Working
  Group
• The Governors Office Department of State Health
  Services Texas Health and Human Services
  Commission Department of Family and Protective
  Services Criminal Justice Department Juvenile
  Probation Commission Texas Youth Commission
  Consumers Family Members Texas Education
  Agency Aging and Disability Services Workforce
  Commission Veterans Administration etc.

35
Mental Health Transformation

• The grant funding is seen as a catalyst to jump
  start some of the efforts of framing the public
  health approach. The 2 primary areas of focus
• Developing and supporting local behavioral health
  collaboratives
• Using cutting edge technology to change work
  processes across agencies
• Improvement of the system will be targeted to the
  following principles
• Apply evidence to health care delivery
• Use information technology
• Align payment policies with quality improvement
• Prepare the workforce