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Senate Health and Human Services Committee October 13, 2008. David L. Lakey, M.D. Commissioner. 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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Senate Health and Human Services CommitteeOctober 13, 2008

David L. Lakey, M.D.

Commissioner


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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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Impact of Mental Illness

  • Individuals with severe mental illness have a life expectancy that is 25 years shorter than the overall population.

  • Significant mental illness is often linked to obesity, smoking and substance abuse

  • Underserved populations with MH or SA issues often go to ERs for treatment


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Impact of Mental Illness

  • 53% of admissions to Texas State Mental Health Hospitals are for crisis care (emergency reasons for 24 hours; DSHS Hospital Management Data Services, 2007).

  • 46% of all ER visits in Texas (Medicaid clients) have behavioral health issues as a basic or contributing factor (HHSC Strategic Decision Support, 2007).


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Impact of Mental Illness

  • 20% of persons in the custody of Texas Department of Criminal Justice (prison, probation, parole) have received a service in the Texas public mental health system (San Jose, Mason, & Ruggiero, 2008).

  • 18% of persons booked at local jails have a history in the Texas public mental health system(DSHS Mental Health & Substance Abuse Decision Support Unit, 2008).

  • 67% to 70% of youth in the juvenile justice system have a diagnosable mental health disorder (Skowyra & Cocozza, 2006).


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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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Texas Mental Health Transformation (MHT)

  • The Six New Freedom Commission Goals:

    • Texans understand that mental health is essential to overall health.

    • Mental Health Care Is Consumer and Family Driven.

    • Disparities in mental health services are eliminated.

    • Mental health screening, assessment & referral to services are common.

    • Excellent mental health care is delivered and research is accelerated.

    • Technology is used to access mental health care and information.


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Texas Mental Health Transformation

  • Overarching goal is to improve the mental health of all Texans and support the development of state infrastructure for implementing the President’s New Freedom Commission goals

  • October 2005 - Texas was awarded a 5 year grant at $2.73 million a year

    • 8 other states received grants


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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

Transformation Working Group (TWG)


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Implementation

  • FY2006 was a required planning year to assess needs and create a Comprehensive Mental Health Plan (CMHP)

  • FY 2007-2010 are CMHP implementation years

  • Priority projects are planned and implemented by TWG agencies, TWG work groups and action teams, or consumer and family network organizations.

  • Six areas of focus for fiscal year 2009 are:

    • Consumer, Youth and Family Infrastructure

    • Prevention and Early Intervention

    • Evidence-Based Services

    • Workforce Development and Expansion

    • Technology for Behavioral Health Transformation

    • Behavioral Health Community Collaboratives



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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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TWG Workgroups

  • Children and Adolescents

  • Adults

  • Data/IT

  • Workforce

  • Housing

  • Consumer Voice

  • Returning Veterans and their families


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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


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Focus on Veterans

  • Gaps in Services for Veterans

    • Gaps between Need and Use

    • Quality of Care Gaps

    • Access Gaps

    • Gaps in Coordination and Communication


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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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Community Mental Health Services

  • Community mental health centers provide services at the local level.

  • 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.


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Texas Community MHMR Center Service Areas

Source: Texas Council of Community MHMR Centers, Inc.


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DSHS-Funded Community Mental Health

Sources:

2008 Adult (18+)/Child (≤17) Population from Demographic Analysis Unit, Research Division, HHSC, based on population projections for 18+ by the Texas State Data Center at the University of Texas (San Antonio).

2008 Estimate of Adults with Serious & Persistent Mental Illness (2.6%)/Children with Severe Emotional Disturbance (2.5%) based on methodology from Federal Register, Volume 64, Number 121, Thursday, June 24, 1999, Notices, pages 33890-33897 and DSHS Community Mental Health Block Grant.

FY2008 Number of Adults/Children Served with Resiliency & Disease Management (Service Package 1-4) from LBB Served, DSHS Mental Retardation and Behavioral Health Outpatient Warehouse, 09/17/08.

Note: Adults with serious and persistent mental illness and children (families) with severe emotional disturbance may not necessarily seek treatment, and those who do might do so outside the DSHS-Funded Community Mental Health system.


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NorthSTAR

  • 1915c Medicaid waiver program

  • Integrated behavioral health project delivering both mental health and substance abuse services

  • Blended funding: Medicaid, mental health and substance abuse block grant funds, and state GR

  • Seven counties served – Collin, Dallas, Ellis, Hunt, Kaufman, Navarro and Rockwall

  • Value Options and North Texas Behavioral Health Authority


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State Mental Health Hospitals

  • 10 Mental Health facilities provide inpatient hospitalization for persons with severe mental illness who need intensive treatment

  • North Texas State Hospital—Vernon 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


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+

+

North Texas State Hospital

(Vernon/Wichita Falls)

+ Terrell State Hospital

El Paso Psychiatric Center

+

+

Big Spring State Hospital

+ Rusk State Hospital

+

Waco Center for Youth

+ Austin State Hospital

+

Kerrville State Hospital

+

San Antonio State Hospital

+

Rio Grande State Center

State Mental Health Hospitals




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Crisis Redesign Goals

  • Establish better local systems to serve persons in crisis

  • Reduce utilization of emergency rooms, state hospital and other inpatient beds

  • Reduce overtaxing of law enforcement resources

  • Improve consumers’ access to appropriate services


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Crisis Services Funding

DSHS requested and received $82 million from the 80th Legislature for the FY08-09 biennium to redesign the public mental health crisis system

FY 2008FY 2009

$27,317,890 $54,682,110


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Crisis Services Funding

  • $56 million for basic and enhanced crisis services

  • $3.5 million for outpatient competency restoration projects

  • $21.4 million for psychiatric emergency centers, jail diversion and alternatives to hospitalization

  • $350,000 for external evaluation

  • $800,000 for contract management, accreditation fees and training


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Crisis Redesign Services

  • BASIC SERVICES

  • Mobile outreach services

  • 24/7 accredited hotline

  • ENHANCED SERVICES

  • Crisis Residential/Respite

  • Crisis Stabilization Units (CSUs)

  • Extended Observation Services (up to 48 hours)

  • Assistance with transportation costs

  • Mental Health Deputies/Crisis Intervention Teams


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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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Psychiatric Emergency Centers or Alternatives to State Hospitals or Jails(15 sites selected)

Austin Travis County MHMR

Betty Hardwick Center

Bluebonnet Trails MHMR

Burke Center

Central Plains

El Paso MHMR

Heart of Texas MHMR

Helen Farabee MHMR

Hill Country MHMR

MHMR of Nueces County

MHMR of Tarrant County

Spindletop MHMR

Tri-County MHMR

Tropical Texas MHMR

West Texas MHMR


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External Evaluation Hospitals or Jails

  • Rider 69 requires an External Evaluation

  • Texas A&M selected and has begun work

  • Focus on the extent to which:

    • Stakeholders are satisfied with improvements made to the community mental health crisis system

    • Texans who are experiencing a mental health crisis are served in appropriate settings in a timely manner

    • Communities have local alternatives that are less restrictive than state hospitals, emergency rooms and jail for resolving mental health crises

    • Community mental health crisis services are cost-effective


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Indicators of Progress Hospitals or Jails

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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Indicators of Progress Hospitals or Jails

Number of Persons Receiving Crisis Services Per Year

SFY2008

Annual Target = 30,717

Sources: DSHS Client Assignment and Registration (CARE) system and DSHS NorthSTAR Data Warehouse.

Note: SFY2008 YTD includes persons served with old + new GR.


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Indicators of Progress Hospitals or Jails

Percent of Persons Receiving Crisis Services Followed by a

Psychiatric Hospitalization within 30 Days

SFY2008

Annual Target = 17%

Sources: DSHS Client Assignment and Registration (CARE) system and DSHS NorthSTAR Data Warehouse.


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Community Mental Health Hospitals or JailsExceptional ItemsFY2010-11

  • Maintain crisis redesign at FY09 levels:

    FY2010FY2011Biennium

    $13.7 million $13.7 million $27.4 million

  • Enhance community mental health services:

    FY2010FY2011Biennium

    $39.3 million $49 million $88.3 million


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Need for Crisis Expansion Hospitals or Jails

Betty Hardwick

Tarrant County MHMR

Helen Farabee

Central Plains

Heart of Texas

West Texas

Burke Center

Bluebonnet

Tri-County

El Paso

Spindletop

Austin-Travis County MHMR

Hill Country

Nueces County MHMR

Tropical

Areas Currently Funded for Expanded Crisis Services


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Crisis Expansion Hospitals or Jails■ $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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Need for Transitional Services Hospitals or Jails

Sources: DSHS Client Assignment and Registration (CARE) system, DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), and DSHS Behavioral Health Integrated Provider System (BHIPS).


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Transitional Services Hospitals or Jails■ $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.


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Need for Intensive Ongoing Services Hospitals or Jails

Average Monthly Service Package Distribution for Adults after Receiving Crisis Services

(03/2008-05/2008)

ADULT RDM LEVELS OF CARE

Level 1 Pharmacological Management, Patient and Family Education, and Routine Case Management

Level 2 Pharmacological Management, Patient and Family Education, Routine Case Management, and Counseling

Level 3 Psychosocial Rehabilitation

Level 4 Assertive Community Treatment


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Intensive Ongoing Services Hospitals or Jails■ $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.



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Overall Goal Hospitals or Jails

  • 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.


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Resiliency and Disease Management Hospitals or Jails

(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.


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Clinical Guidelines Hospitals or Jails

Data Management

Resiliency and Disease Management(RDM)

Uniform

Assessment

Evidence-Based

Levels of Care

Fidelity

3

Outcomes


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RDM Key Components Hospitals or Jails

  • Uniform Assessment

  • Standard Service Packages

  • Utilization Management

  • Data Analysis and Performance Evaluation

  • Jail Diversion


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Uniform Assessment for RDM Hospitals or Jails

  • TRAG: Texas Recommended Assessment Guidelines

  • An instrument for Qualified Mental Health Professionals or Bachelor-level clinicians to assess the service needs of adults and children face-to-face, and recommend a level of care for them in the Texas public mental health system.


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Levels of Care Hospitals or Jails

  • 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)


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Pre RDM Hospitals or Jails

Post RDM

Number of Children Servedat DSHS-Funded Community Mental Health Centers

SFY2008

Annual

Target =

22,239

STATEWIDE IMPLEMENTATION OF RDM

Source: FY2003 = CARE Report HC028488, TDMHMR MH Priority Population Counts by Month for 09-01-02 through 08-31-03, prepared on 09/20/03, total is unduplicated; FY2004 = CARE Report HC028488, TDMHMR MH Priority Population Counts by Month for 09-01-03 through 08-31-04, prepared on09/18/04, total is unduplicated; FY2005, FY2006, FY2007, FY2008 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), Business Objects Corporate Report, LBB RDM Served (i.e., number who received a full RDM service package).


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Pre RDM Hospitals or Jails

Post RDM

Number of Adults Servedat DSHS-Funded Community Mental Health Centers

SFY2008

Annual

Target =

96,802

STATEWIDE IMPLEMENTATION OF RDM

Source: FY2003 = CARE Report HC028488, TDMHMR MH Priority Population Counts by Month for 09-01-02 through 08-31-03, prepared on 09/20/03, total is unduplicated; FY2004 = CARE Report HC028488, TDMHMR MH Priority Population Counts by Month for 09-01-03 through 08-31-04, prepared on09/18/04, total is unduplicated; FY2005, FY2006, FY2007, FY2008 = DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), Business Objects Corporate Report, LBB RDM Served (i.e., number who received a full RDM service package).


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Clinical Effectiveness—Children Hospitals or Jails

Outcomes among Children Assigned to a Full RDM Service Package

at DSHS-Funded Community Mental Health Centers

Source: DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), Business Objects Corporate Report, PM Child Outcomes.


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Clinical Effectiveness—Adults Hospitals or Jails

Outcomes among Adults Assigned to a Full RDM Service Package

at DSHS-Funded Community Mental Health Centers

Source: DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), Business Objects Corporate Report, PM Adult Outcomes Report.


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Cost Effectiveness Hospitals or Jails

ER COST OFFSET

- $25

Average per Client per Month

27%

REDUCTION

Fiscal Year 2005 Texas average monthly emergency room costs were 27 percent lower for Medicaid clients with mental illness who received needed DSHS mental health treatment services.

Source: Research Team, Strategic Decision Support Group, HHSC.


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Summary Hospitals or Jails

  • 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


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