Partnering with DSHS: It’s more fun than you think! TAAP Conference 2010

1. Partnering with DSHS:It’s more fun than you think!TAAP Conference 2010 Mimi Martinez McKay, M.A., M.L.I.S. MHSA Chief of Staff Information Services Director/Legislative Liaison

2. Scope of Duties • Legislative Liaison • Stakeholder Communications • Web Services Administrator • Information Services Director • DDRAC Coordinator • PDFT Contract Administrator • NASADAD Liaison • Etc!

3. Focus on . . . • DSHS/MHSA brief overview • DSHS Budget/Legislative Update • Drug Demand Reduction Advisory Committee • Workforce • Border • Texas Recovery Initiative/SAMHSA Recovery Partners • Health Care Reform

4. DSHS Overview Texas Department of State Health Services (DSHS) became operational on September 1, 2004 in accordance with HB2292. Health Department Mental Health Agency Substance Abuse Agency

5. DSHS Overview Mission To improve health and well-being in Texas Fiscal Year 2009 Budget $2,750,231,703 Full-Time Positions 12,206 (more than half are MHSA) Page 5

6. DSHS Organizational Structure Page 6

7. MHSA Overview Mission Provide statewide leadership, direction and oversight for services to help Texans prevent mental health or substance abuse problems, build resiliency and facilitate recovery in their home or community. Fiscal Year 2009 Health Services: $482,316,409 Mental Health Hospital Services: $373,730,280 Substance Abuse Services: $164,575,118 Division includes 11 state hospitals, and has service contracts with 39 mental health centers, and 270 substance abuse providers. Full-Time Positions 7,734 Page 7

8. Division Summary • Substance Abuse Prevention, Intervention, and Treatment Services • Inpatient Psychiatric Services (State Hospitals) • Community-Based Mental Health Services • Projects for Assistance in Transition from Homelessness (PATH) • NorthSTAR – Community-Based Mental Health, Substance Abuse and Co-Occurring Services • South Texas Health Care System • Texas Center for Infectious Disease (TCID)

9. Substance Abuse Prevention and Early Intervention Services • Primary Prevention • HIV Early Intervention and Outreach • Outreach, Screening, Assessment and Referral Services (OSAR) • Tobacco Prevention and Control • Pregnant and Post-partum Intervention for Women (PPI)

10. Substance Abuse Treatment Services • Detoxification • Intensive and Supportive Residential (adult and youth) • Outpatient (adult and youth) • Opioid Replacement Therapy • Co-Occurring Psychiatric and Substance Abuse Disorders (COPSD) Services • Specialized Female Services

11. Clinical Management Behavioral Health System (CMBHS) • Clinical management tool for Substance Abuse and Mental Health service providers • Captures demographic, service and clinical data for Substance Abuse and Mental Health clients • Tracks service utilization and client progress • Facilitate State and Federal reporting requirements

12. Who Can Use CMBHS? • All Mental Health & Substance Abuse Treatment providers contracted with DSHS’ Mental Health and Substance Abuse division. • CMBHS will serve as a connection point to other publicly-funded behavioral health service systems and related programs. • Clients will not currently have direct access to information in CMBHS. A future expansion may provide this service.

13. Substance Abuse Treatment Providers and CMBHS • CMBHS will replace BHIPS, DSHS’ legacy system for managing substance abuse treatment. • CMBHS is web-based. Providers need only a computer with Internet access to use the system. • Rollout began to substance abuse providers December 2009. • Full deployment by Sept 1, 2010.

14. 2010 Budget & Legislative Update

15. Summary of 2012-13 LAR/proposed cuts • 10% Reduction Schedule $245 M • Approach • Evaluate opportunities to reduce administrative and operating costs • Identify services which could/are being performed by other governmental entities potentially eliminating the need for the state to conduct those services • Assess the impact on public health risk • Identify new revenue sources and/or increases to existing revenue sources • Consider Patient Protection and Affordable Care Act (HCR) impact on existing programs • Identify the areas with the highest levels of GR/GRD (MHSA)

16. LAR/Budget • 6 July 2010 DSHS Stakeholder Budget Forum • 75%+ spoke to MHSA issues and funding • No cuts to base budget at 5% • Proposed reductions for next 10%: • $4M/$4M Substance Abuse Intervention • $33M/$47M Community MH Services • $30M/$14M State Hospitals

17. LAR Timeline • Timeline • Stakeholder Meeting – July 6 • Deadline for written comments to LAR@dshs.state.tx.us by July 12 • Begin ABEST Entry – July 16 • LAR Due Date – August 16 • 82nd Legislative Session – January - May 2011

18. MHSA funding as a result of 81st Legislative Session Amount Received: $127,255,486 Community MH: $64,187,486 (transitional and intensive ongoing/no additional crisis $) Hospital Services: $63,078,000 (maintain current levels) Information Technology: $0 Substance Abuse Services: $0 Page 18

19. Relevant Bills - 81st Legislative Session HB 1232 - The Department of State Health Services shall establish a local behavioral health intervention pilot project for children in Bexar County. HB 2196 - The Health and Human Services Commission shall establish a workgroup to recommend best practices in policy, training and service delivery to promote the integration of health and behavioral health services in the state. HB 4451 - Relating to continuity of care services or mental health commitment proceedings for youth with mental illness or mental retardation who are transferred, discharged or paroled from the Texas Youth Commission SB 526 - Relating to grants for Federally Qualified Health Centers

20. Emerging Legislative Issues • Workforce • Border • Jail Diversion • K2, prescription drug monitoring, tax on alcohol, gambling? • Setting the stage for health care reform • Return on investment!

21. Relevant interim studies • Study current re-entry programs and procedures across the juvenile and adult criminal justice continuum. • Ensure access to support programs to allow successful re-entry and integration into the community. • Assess working relationship between state agencies facilitating re-entry and make recommendations on how to achieve greater efficiency and cost savings. • Examine policies and programs designed to identify, divert, and enhance the supervision and treatment of special needs offenders within local jails and state correctional facilities. • Recommend appropriate alternatives to incarceration or institutionalization.

22. Relevant interim studies (con’t) • Evaluate the effectiveness of state operations at controlling drug-related crimes and other violence along the Texas-Mexico border. Joint Interim Charge with House Committee on Public Safety • Study the benefits, costs and effectiveness of the prevention and early intervention programs at the HHS agencies, the criminal justice agencies and other government agencies whose programs address mental illness, substance abuse, child abuse and neglect, domestic violence, single-parent families, absentee fathers, early pregnancy and unemployment. • Study other states' efforts to administer these programs through a merged prevention department. Make recommendations to improve the efficiency and effectiveness of these programs.

23. Relevant interim studies (con’t) • Study the state's role for facilitating the exchange of health care information in the future, including using the Medicaid exchange as a framework for the statewide exchange of health information between health care providers to improve quality of care. • What information the state should provide; how to use this information to improve care management, prevent medical errors, and reduce unnecessary services; and policies and statutory changes needed to ensure that privacy is protected. • Study the state’s current and long-range need for physicians, nurses, dentists and other allied health and long-term care professionals, particularly focusing on the underserved rural and Border populations.

24. Current and Emerging Challenges (and Opportunities!) • Changing patterns of drug use trends • Substance Abuse Medicaid Benefit • Creating a Recovery Oriented System of Care • Health Care Reform/Parity

25. Estimated Economic Costs of Substance Abuse, 2007 by Cost Category (Total: $33.4 Billion/$358B US) 11% Other 43% 27% Work Lost Crime 19% Premature Death Economic Impact of Substance Abuse in Texas Source: Decision Support Unit, MH & SA, DSHS.

26. Need Met for Substance Abuse Treatment in TexasADJUSTING FOR POVERTY 2008 Texas Population (age 12+) 19,844,757 2008 Estimated Number with Chemical Dependency 1,855,364 SFY2008 Number Served in DSHS-Funded Substance Abuse Treatment Programs (including NorthSTAR) 52,129 (5.8%) Who Are Also Poor 892,882 Source:Decision Support Unit, MH & SA, DSHS.

27. Trends In Substance Abuse • Alcohol is the primary drug of abuse in Texas • Of particular concern is heavy consumption of alcohol, or binge drinking, which is defined as drinking five or more drinks at one time. In 2008, 12 percent of all secondary students said that when they drank, they usually drank five or more beers at one time, and 13 percent reported binge drinking of liquor • In 2008, 27 percent of all clients admitted to publicly funded treatment programs had a primary problem with alcohol

28. Trends In Substance Abuse • Increase in inhaling heroin—not just “Cheese” (heroin+Tylenol PM) but use of other diphenhydramine products such as Benedryl to produce powder from the Tar. • Problems with inhaled heroin continue to increase, especially among youths and young adults. • Meth use is creeping back up • K2/Spice • Prescription Drug Abuse – way up Dr. Jane Maxwell, UT ATTC, 2010 Substance Abuse Trends in Texas

29. Prescription Drug Abuse • Seven of the top 10 abused substances are pharmaceuticals. • Between 1997 and 2007, treatment admissions for prescription painkillers increased more than 400 percent. • Between 2004 and 2008, the number of visits to hospital emergency departments involving the non-medical use of narcotic painkillers increased 111 percent.

30. Substance Abuse Medicaid Benefit The 2009 Texas Legislature authorized a substance abuse benefit for adults in Medicaid through the Appropriations bill. • Outpatient benefits (assessment, ambulatory detoxification, counseling and medication assisted therapy) will be available on September 1, 2010. • Residential benefits (detoxification and treatment) will be implemented in January 2011, pending approval from the Centers for Medicare & Medicaid Services (CMS). 

31. SUD Medicaid Benefit: Eligibility • A person seeking Medicaid-funded SUD treatment must meet current Medicaid eligibility criteria. • A Medicaid client can self-refer or be referred to receive an assessment. No referral from a primary care physician is needed. • An assessment must be made before services can begin. No prior authorization is needed for an assessment.

32. SUD Medicaid Benefit: Reimbursement • The adult SUD treatment benefits will be provided through fee-for-service Medicaid, PCCM (202 mostly rural Texas counties) , and the STAR and STAR+PLUS Medicaid managed care HMOs.  

33. Who Can Provide the SUD Treatment Benefits? • Chemical dependency treatment facilities licensed by DSHS and physicians providing mental health and/or medication assisted therapy if they are enrolled as a Texas Medicaid provider. • LCDCs can provide services when associated with chemical treatment facilities. LCDCs cannot bill Medicaid directly because they are not currently a recognized provider type and cannot enroll as Medicaid providers.

34. SA Medicaid Benefit Implementation Plan (cont.) • HHSC plans to offer training to providers via an interactive desk-top webinar. All licensed SUD providers will be notified in advance. • For more information about the SUD treatment benefits for adults in Medicaid: • http://www.hhsc.state.tx.us/SubstanceAbuseBenefit.shtml • SUDTreatmentBenefit@hhsc.state.tx.us 512/491-1162. 

35. Partnerships and Stakeholder Engagement • Drug Demand Reduction Advisory Committee (DDRAC) • Texas Recovery Initiative • Health Care Reform!

36. Drug Demand Reduction Advisory Committee (DDRAC)

37. Texas Drug Demand Reduction Advisory Committee • The DDRAC is legislatively mandated to develop a comprehensive statewide strategy with recommendations to reduce drug demand in Texas. • 16 state agencies must participate in effort, as well as 5 at-large members from different geographical areas within the state. • 3 Subcommittees: Workforce, Media/Communication/Data and Border issues

38. Recommendations of the DDRAC/2009 • Remove exclusion clause for medical expenses from Uniform Individual Accident and Sickness Policy Provision Law • Statewide public smoking ban • Prescription Drug Monitoring • Mandate comprehensive alcohol and other drug reduction strategies targeting college students • Support the recruitment and retention of quality service providers in the field of substance abuse prevention and treatment

39. Proposed DDRAC Recommendations/2011 • Support the recruitment and retention of quality service professionals in the field of substance abuse prevention and treatment by increasing funds to support wage adjustments, reducing barriers to entering the workforce and maintaining high standards of professional development. • Provide additional treatment and prevention services, as well as increased security and support services for providers, in the border region.

40. Represented on the Workforce Subcommittee • TAAP • ASAP: Association of Substance Abuse Programs • Texas Workforce Commission • Texas Department of Criminal Justice • Academic Partners • DSHS

41. Workforce Subcommittee Recommendations • Mandate all licensed mental health providers and certified educators and those seeking licensure or certification receive pre-service training in substance abuse recognition and referral. • Allow persons with a bachelor’s or more advanced degree in a “non-related” field to enter the field as a Counselor Intern (CI) upon completing 270 classroom hours of accredited chemical dependency education and a 300 hour practicum.

42. Workforce Subcommittee Recommendations • Clarify current interpretation and/or change the statute to eliminate the prohibition that individuals with criminal records cannot begin their CI status until they have met required sanctions. • Establish clear reciprocity guides for each state and all branches of the military.

43. Workforce Subcommittee Recommendations • Request the Texas Workforce Commission to recognize the LCDC profession as a high-demand occupation throughout the state. • To support counselors and aid in career retention, requirement enrollment in a peer assistance program rather than the current stipulation to show “documented access to” these programs. • Encourage state leadership to assist in working with the Texas State Board of Social Worker Examiners to allow LMSWs to continue as a Qualified Credentialed Counselor (QCC) in chemical dependency treatment facility without the supervision of an LCSW.

44. Border Subcommittee Recommendations • Provide additional funds to support the development of and access to a continuum of substance abuse-related services • Target border counties for WIA (Workforce Investment Act) funds to incentivize chemical dependency field • Continuation and expansion of drug courts in the border counties. • Coordinate with the federal government and request that National Guardsmen, ICE and Border Patrol agents be stationed in the region to protect unarmed workers and Texan civilians and provide security cameras for all border programs and providers

45. The Texas Recovery Initiative (TRI) Partnership between DSHS and the substance abuse treatment and recovery communities Identify opportunities and methods for improving the quality and effectiveness of services provided to adult population Process to date has included a series of community meetings, creation of a task force and the presentation of a set of summary findings for service improvement and recommendations

46. TRI Evidence Based Practices • Motivational Interviewing • Motivational Enhancement Therapy • Recovery Support • Screening, Brief Intervention and Referral to Treatment (SBIRT) • Matrix Model • Trauma Informed Treatment • Relapse Prevention Therapy • Medication Assisted Therapy • Cognitive Behavioral Therapy

47. Texas Recovery Initiative Workgroups • Developing/Enhancing Peer Support Services • Recovery Oriented Systems of Care (ROSC) review • Where the Rubber Meets the Road - Housing, Employment, Education, Legal • Having It All: Funding, Advocacy and Political Clout • Getting Specific: Medication Assisted Therapy • Distinctions, Descriptions and Definitions • Health Care Reform

48. Texas Recovery Initiative’s Next Steps Certification/Accreditation of Peer Support Specialists Development of ROSC for adolescents and rural populations Enhance continuity of care through collaborations with supportive employment and housing services Improve access to MAT and blend with intensive outpatient treatment Assess how health care reform will affect ROSC

49. Recovery Month • 2010 marks the 21th Anniversary of Recovery Month, which aims to: • highlight societal benefits of substance abuse treatment • laud the contributions of treatment providers • promote the message that recovery is possible • encourage citizens to help expand and improve availability of effective treatment • educate public on substance abuse, addiction is a treatable disease and recovery possible • reduce and eventually eliminate public stigma associated with substance abuse and recovery

50. Recovery Month Events • Events will be hosted in: • San Antonio • Dallas • Houston • El Paso • Austin • More much more information on Recovery Month can be found at: • http://www.recoverymonth.gov