Senate Health and Human Services Committee October 13, 2008

1. Senate Health and Human Services CommitteeOctober 13, 2008 David L. Lakey, M.D. Commissioner On behalf of Mental Health and Substance Abuse Program Services at the Texas Department of State Health Services, or DSHS, welcome legislators and public stakeholders. I’m Karen Ruggiero, and I am going to provide you with an overview of DSHS-Funded Community Mental Health and Substance Abuse. As you will see, we are moving toward quality behavioral healthcare for Texans. On behalf of Mental Health and Substance Abuse Program Services at the Texas Department of State Health Services, or DSHS, welcome legislators and public stakeholders. I’m Karen Ruggiero, and I am going to provide you with an overview of DSHS-Funded Community Mental Health and Substance Abuse. As you will see, we are moving toward quality behavioral healthcare for Texans.

2. 2 Overview of Presentation Impact of Mental Illness Mental Health Transformation DSHS-Funded Mental Health Services Crisis Redesign Resiliency and Disease Management (RDM)

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4. 4 And when community mental health crisis services are lacking, State Mental Health Hospitals and ERs in Texas also feel the brunt. And so, for all of these reasons, the community mental health crisis system in Texas is being redesigned. And when community mental health crisis services are lacking, State Mental Health Hospitals and ERs in Texas also feel the brunt. And so, for all of these reasons, the community mental health crisis system in Texas is being redesigned.

5. 5 Of course, the lack of a responsive system with an appropriate range of community mental health crisis services has also contributed to the increased incarceration of individuals with mental illness in the custody of the Texas Department of Criminal Justice, local jails, and youth in the juvenile justice system. Of course, the lack of a responsive system with an appropriate range of community mental health crisis services has also contributed to the increased incarceration of individuals with mental illness in the custody of the Texas Department of Criminal Justice, local jails, and youth in the juvenile justice system.

6. 6 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 illness.

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10. 10 Transformation Working Group (TWG) Office of the Governor Chairman, Senate Health and Human Services Committee Chairman, House Public Health Committee Department of Aging and Disability Services Department of Assistive and Rehabilitative Services Department of Family and Protective Services Department of State Health Services Health and Human Services Commission Texas Education Agency Texas Juvenile Probation Commission Texas Department of Criminal Justice Texas Workforce Commission Texas Veterans Commission Texas Department of Housing and Community Affairs Texas Youth Commission Office of Rural Community Affairs Veterans Integrated Services Network Consumers and Family Members

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12. 12 Community Collaboratives

13. 13 Community Collaboratives San Antonio – Crisis Intervention Team Training for School Officers Williamson County – Project Emerson – Hardware and Software for Electronic Emergency MH Record Llano Estacado Alliance for Families (LEAF) – Systems Of Care grant and promoting employment of MH consumers with area employers Nacogdoches – Development of community response to crisis through a regional crisis center Dallas – Workforce Development – 750 officers trained Coastal Bend – integration of care with telemedicine and navigator system Tarrant County – Building community consensus for implementing evidence-based treatment for children and youth

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15. 15 Focus on Veterans Workgroup established August 5, 2008 Workgroup members: Governor’s Office, TWG representation, family member representation, HHSC, DSHS, Texas Military Forces, Texas Veterans Commission, Texas Workforce Commission, Texas Council of Community MHMR Centers, Texas Association of Community Health Centers Two meetings: September 18 and October 2, 2008 Workgroup reviewed needs, services and gaps Invisible wounds of war – Post Traumatic Stress Disorder and Traumatic Brain Injury Impacted family members have very limited access to benefits

16. 16 Focus on Veterans Gaps in Services for Veterans Gaps between Need and Use Quality of Care Gaps Access Gaps Gaps in Coordination and Communication

17. 17 Focus on Veterans Recommendations Support Texas Military Forces and Texas Veterans Commission requests for dedicated eligibility workers and case management staff Facilitate access to eligibility information by laypersons Provide training to peers and other connectors Provide evidence-based treatment training to practitioners Next Steps Outline of components and funding by November 3, 2008. Need for ongoing analysis and study of the issues.

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20. 20 Texas Community MHMR Center Service Areas

21. 21 DSHS-Funded Community Mental Health In terms of access to community mental health services, the number of children with severe emotional disturbance and adults with serious mental illness served at DSHS-Funded Community Mental Health Centers increased slightly from Fiscal Year 2005 to 2006. Children’s service packages range from brief to intensive outpatient and after-care. Adult service packages range from pharmacological management, patient and family education and routine case-management to Assertive Community Treatment. Whereas over 131,000 children and adults in total were served in Fiscal Year 2005, more than 136,000 were served in Fiscal Year 2006. In terms of access to community mental health services, the number of children with severe emotional disturbance and adults with serious mental illness served at DSHS-Funded Community Mental Health Centers increased slightly from Fiscal Year 2005 to 2006. Children’s service packages range from brief to intensive outpatient and after-care. Adult service packages range from pharmacological management, patient and family education and routine case-management to Assertive Community Treatment. Whereas over 131,000 children and adults in total were served in Fiscal Year 2005, more than 136,000 were served in Fiscal Year 2006.

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24. 24 State Mental Health Hospitals

25. 25 State Hospital Capacity

26. Crisis Redesign But no public behavioral heathcare system is without its challenges, and DSHS is no exception. But no public behavioral heathcare system is without its challenges, and DSHS is no exception.

27. 27 Crisis Redesign Goals With this special appropriation, DSHS aims to ensure that: Stakeholders will be satisfied with improvements made to the community mental health crisis system. Texans who are experiencing a mental health crisis will be served in appropriate settings in a timely manner. Communities have more local alternatives that are less restrictive for resolving mental health crises. Community mental health crisis services will be cost-effective. With this special appropriation, DSHS aims to ensure that: Stakeholders will be satisfied with improvements made to the community mental health crisis system. Texans who are experiencing a mental health crisis will be served in appropriate settings in a timely manner. Communities have more local alternatives that are less restrictive for resolving mental health crises. Community mental health crisis services will be cost-effective.

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31. 31 Outpatient Competency Restoration Pilots In April 2008, DSHS awarded $3.5 million to 5 sites: Tarrant County MHMR Center for Healthcare Services (San Antonio) MHMR Authority of Harris County Austin-Travis County MHMR North Texas Behavioral Health Authority (NorthSTAR) SB 867 made changes to the Code of Criminal Procedure that clarified procedures for outpatient alternatives to inpatient competency restoration for certain defendants. These changes have and will help gain efficiency of resources and free up bed space in state mental hospitals.

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34. 34 Indicators of Progress FY2007 FY2008 AAS Accredited Hotlines 1 38 Mobile Crisis Outreach Teams 4 38 Crisis Stabilization Units 3 3 Extended Observation Units 3 6 Crisis Residential Facilities 10 13 Crisis Respite Facilities 4 14 Outpatient Competency Restoration 1 4

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37. 37 Community Mental Health Exceptional ItemsFY2010-11 Maintain crisis redesign at FY09 levels: FY2010 FY2011 Biennium $13.7 million $13.7 million $27.4 million Enhance community mental health services: FY2010 FY2011 Biennium $39.3 million $49 million $88.3 million But no public behavioral heathcare system is without its challenges, and DSHS is no exception. But no public behavioral heathcare system is without its challenges, and DSHS is no exception.

39. 39 Crisis Expansion ¦ $28,762,070 GOAL: Expand options to underserved communities with crisis funds, assuring targeted services to children and adolescents. HOW: Provide more Psychiatric Emergency Services Centers (PESCs) and Children’s Crisis Projects (e.g., respite). NUMBERS SERVED PER YEAR: PESCs = 8,736 individuals. Children’s Respite = 226 children.

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41. 41 Transitional Services ¦ $28,762,070 GOAL: Break the cycle of crisis-stabilize-crisis. HOW: Intensive supports for difficult to engage, high-need individuals. NUMBERS SERVED PER YEAR: Adults = 4,163. Children = 630.

42. 42 Need for Intensive Ongoing Services

43. 43 Intensive Ongoing Services ¦ $28,762,070 GOAL: Increase access to ongoing services for difficult to engage individuals transitioning from crisis. HOW: Increase capacity in intensive ongoing services. NUMBERS SERVED PER YEAR: FY2010: 1,735 Adults and 249 Children/Adolescents=1,984 total. FY2011: 3,470 Adults and 497 Children/Adolescents=3,967 total.

44. Resiliency and Disease Management (RDM) On behalf of Mental Health and Substance Abuse Program Services at the Texas Department of State Health Services, or DSHS, welcome legislators and public stakeholders. I’m Karen Ruggiero, and I am going to provide you with an overview of DSHS-Funded Community Mental Health and Substance Abuse. As you will see, we are moving toward quality behavioral healthcare for Texans. On behalf of Mental Health and Substance Abuse Program Services at the Texas Department of State Health Services, or DSHS, welcome legislators and public stakeholders. I’m Karen Ruggiero, and I am going to provide you with an overview of DSHS-Funded Community Mental Health and Substance Abuse. As you will see, we are moving toward quality behavioral healthcare for Texans.

45. 45 Overall Goal To promote the uniform provision of services based on clinical evidence and recognized best practices to advance the recovery of adults with serious mental illness and the resilience of children with severe emotional disturbance, as defined by Texas House Bill 2292. The overall goal of Resiliency and Disease Management or RDM is to: to promote the uniform provision of services based on clinical evidence and recognized best practices to advance the recovery of adults with serious mental illness and the resiliency of children children with severe emotional disturbance, as defined by Texas House Bill 2292 and in accordance with the President’s New Freedom Commission on Mental Health. The overall goal of Resiliency and Disease Management or RDM is to: to promote the uniform provision of services based on clinical evidence and recognized best practices to advance the recovery of adults with serious mental illness and the resiliency of children children with severe emotional disturbance, as defined by Texas House Bill 2292 and in accordance with the President’s New Freedom Commission on Mental Health.

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47. 47 Resiliency and Disease Management(RDM) The Resiliency and Disease Management model or RDM and each of its components was completely new to us in Texas public mental health. RDM includes a new, stream-lined uniform assessment process that is used to recommend one of five new evidence-based, best-practice levels of care, the fidelity of which is now monitored, followed by a new evaluation of critical outcomes--all under the auspices of a new utilization management system that includes clinical guidelines for the average monthly number of hours per adult consumer among many other parameters, as well as a new data management system that is comprised of a Data Warehouse that houses assignment data, encounter data, financial data, and even Medicaid eligibility data. Implementation of this model began first at four public mental health centers in Texas on September 1st, 2003, with the rest of the public mental health centers in Texas having begun to implement RDM on September 1st, 2004, as mandated by Texas House Bill 2292. The Resiliency and Disease Management model or RDM and each of its components was completely new to us in Texas public mental health. RDM includes a new, stream-lined uniform assessment process that is used to recommend one of five new evidence-based, best-practice levels of care, the fidelity of which is now monitored, followed by a new evaluation of critical outcomes--all under the auspices of a new utilization management system that includes clinical guidelines for the average monthly number of hours per adult consumer among many other parameters, as well as a new data management system that is comprised of a Data Warehouse that houses assignment data, encounter data, financial data, and even Medicaid eligibility data. Implementation of this model began first at four public mental health centers in Texas on September 1st, 2003, with the rest of the public mental health centers in Texas having begun to implement RDM on September 1st, 2004, as mandated by Texas House Bill 2292.

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50. 50 Levels of Care Range from lower to higher intensity services Services include 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)

51. 51 Number of Children Servedat DSHS-Funded Community Mental Health Centers As you can seen, the number of children served at DSHS-Funded Community Mental Health Centers has remained relatively constant from FY2003 to FY2006 — pre-implementation through post-implementation of Resiliency and Disease Management — with 25,622 children being served in FY2003 and 27,665 being served in FY2006. As you can seen, the number of children served at DSHS-Funded Community Mental Health Centers has remained relatively constant from FY2003 to FY2006 — pre-implementation through post-implementation of Resiliency and Disease Management — with 25,622 children being served in FY2003 and 27,665 being served in FY2006.

52. 52 Number of Adults Servedat DSHS-Funded Community Mental Health Centers As you can seen, the number of adult served at DSHS-Funded Community Mental Health Centers has remained relatively constant from FY2003 to FY2006 — pre-implementation through post-implementation of Resiliency and Disease Management — with 110,491 adults being served in FY2003 and 109,227 being served in FY2006. As you can seen, the number of adult served at DSHS-Funded Community Mental Health Centers has remained relatively constant from FY2003 to FY2006 — pre-implementation through post-implementation of Resiliency and Disease Management — with 110,491 adults being served in FY2003 and 109,227 being served in FY2006.

53. 53 Clinical Effectiveness—Children

54. 54 Clinical Effectiveness—Adults

55. 55 Cost Effectiveness In fact, DSHS-Funded Community Mental Health Treatment plays an important role in offsetting ER costs. As we see here, the average monthly ER costs among Medicaid clients receiving needed DSHS-funded community mental health treatment was $68 vs. $93 among Medicaid clients not receiving needed DSHS-funded community mental health treatment — an average savings of $25 per Medicaid client per month. In other words, Texas average monthly ER costs were 27 percent lower for Medicaid clients receiving needed DSHS-Funded Community Mental Health Treatment. In fact, DSHS-Funded Community Mental Health Treatment plays an important role in offsetting ER costs. As we see here, the average monthly ER costs among Medicaid clients receiving needed DSHS-funded community mental health treatment was $68 vs. $93 among Medicaid clients not receiving needed DSHS-funded community mental health treatment — an average savings of $25 per Medicaid client per month. In other words, Texas average monthly ER costs were 27 percent lower for Medicaid clients receiving needed DSHS-Funded Community Mental Health Treatment.

56. 56 Summary Mental illness has a broad impact on Texas Mental Health Transformation holds promise for improving mental health services for Texans Changes from previous legislative sessions have had significant positive results DSHS continues to work on improving our service delivery system More work to be done toward system improvements