Sam Shore, LMSW Director, Mental Health Transformation Mental Health and Substance Abuse Division

1. Meeting the Mental Health Needs of Texans:The State of Mental Health Challenges and Innovations in Texas Sam Shore, LMSW Director, Mental Health Transformation Mental Health and Substance Abuse Division

2. Overview • Identify key data points that indicate the mental health needs and challenges of Texans • Describe Innovations In Policy, Programs and Practices that are being tested, or widely deployed, to address the needs of Texans

3. Needs and Challenges

4. Mental Illness Strikes More Americans Each Year Than Other Serious Illnesses Serious Mental Illness CVD Mental Illness Diabetes Cancer Asthma CDC BRFSS, SEER Cancer Statistics Review, 1975-2002, “Prevalence, Severity, and Co-morbidity of 12-Month DSM-IV Disorders”Arch Gen Psychiatry.  Vol. 62, June 2005

5. Need Met for Community Mental Health Services in TexasADULT 2010 Adult Population (18+ years) 18,789,238 2010 Estimated Number with Serious and Persistent Mental Illness 488,520 FY2010 Number Served in DSHS-Funded Community Mental Health Services (including NorthSTAR) 156,880 (33.6%) Sources: 2010 Adult (18+)/Child (9-17) 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). 2010 Estimate of Adults with Serious & Persistent Mental Illness based on methodology from Federal Register, Volume 64, Number 121, Thursday, June 24, 1999, Notices, pages 33890-33897. 2010 Estimate of Children with Severe Emotional Disturbance based on methodology from Federal Register, Volume 63, Number 137, Friday, July 17, 1998, Notices, pages 33661-38665. FY2010 Number of Adults/Children Served with Resiliency & Disease Management (Service Package 1-4) including NorthSTAR. Prepared by: Decision Support Unit, Mental Health & Substance Abuse Division, DSHS.

6. Need Met for Community Mental Health Services in TexasCHILDREN 2010 Child Population (9-17 years) 3,094,475 2010 Estimated Number with Severe Emotional Disturbance 154,724 FY2010 Number Served in DSHS-Funded Community Mental Health Services (including NorthSTAR) 44,787 (28.9%) Sources: 2010 Adult (18+)/Child (9-17) 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). 2010 Estimate of Adults with Serious & Persistent Mental Illness based on methodology from Federal Register, Volume 64, Number 121, Thursday, June 24, 1999, Notices, pages 33890-33897. 2010 Estimate of Children with Severe Emotional Disturbance based on methodology from Federal Register, Volume 63, Number 137, Friday, July 17, 1998, Notices, pages 33661-38665. FY2010 Number of Adults/Children Served with Resiliency & Disease Management (Service Package 1-4) including NorthSTAR. Prepared by: Decision Support Unit, Mental Health & Substance Abuse Division, DSHS.

7. Adults and Children Waiting for DSHS-Funded Community Mental Health Services Increasing Source: DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), 10/07/10. Prepared by: Decision Support Unit, Mental Health & Substance Abuse Division, DSHS.

8. Smoking among BH Population • Persons with behavioral health conditions, defined as mental illness and/or substance abuse disorders, accounted for 44% of all cigarettes smoked in the United States (Lasser, et.al., JAMA,2000) • Adults with BH disorders account for 25% of population and consume almost 2X the cigarettes as general pop. (SAMHSA/NSDUH, March 20, 2013) • Adults with BH disorders are twice as likely to be smokers

9. Adverse Childhood Experiences:The impact of trauma on health outcomesMany chronic diseasesin adults are determineddecades earlier, in childhood.

11. Their risk factors are alsoreliable markers for antecedent problems.“In my end is my beginning.”T.S. Eliot - Quartets

12. Dismissing them as “bad habits” or“self-destructive behavior” totallymisses their function.

13. What is conventionallyviewed as a problem is actually a solution to an unrecognized prior adversity.

14. The risk factors underlyingthese adult diseases areeffective coping devices.

15. Premature mortality and excess morbidity are typically the result of a small number of common diseases. ACE = Parental Loss

16. Evidence from ACE Study Suggests:These chronic diseases in adults are determined decades earlier, by the experiences of childhood. Affective Response

17. Evidence from ACE Study Suggests:Risk factors for these diseases are initiated during childhood or adolescence . . . Seeking to Cope

18. Evidence from ACE Study Suggests: ..... and continue into adult life. Outcome: social and biomedical damage

19. Another possible outcome.

20. Evidence from ACE Study Suggests:Adverse childhood experiences are the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs.

21. Challenges

22. Texas Health Regions

23. + + 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 Facilities Approximately 10 beds per 100,000 population (2008)

24. Texas Community Center Service Areas Source: Texas Council of Community MHMR Centers, Inc.

25. Bridging the Quality Chasm Recovery/Resilience Promising and Evidence Based Practice Information Technology The behavioral health care that we know to be effective The behavioral health care that Americans receive

26. Challenges • Increasing Population • In last decade Texas grew by more than entire population of Vermont and Arkansas combined (U. S. Census) • Increase in diversity - culturally and linguistically • Uninsured Individuals • Texas has highest number of uninsured in all of the 50 states • Lack of insurance is disincentive to seek care early - people are further in their disease when they seek help • Workforce Shortages • 60% of licensed professionals in the state are located in Houston, San Antonio and Ft. Worth (DSHS survey of LMHA’s excluding NorthSTAR) • In rural areas one licensed professional may be covering six or more counties-not uncommon (DSHS survey of LMHA’s excluding NorthSTAR) • Provider population is aging

27. Mental Health HPSAs

28. Innovations

29. Innovations in Programs and Practices • Focus on Recovery and Resiliency (wellness and strengths versus illness and deficits – internal activation) • Person Centered Recovery Planning • Wrap Around Planning • Use of evidence based and promising practices • Trauma-informed care and trauma-specific tx

30. Innovations in Programs • Self Directed Care • Peers and Family Support Services • Consumer Operated Service Programs • Veterans Services that target trauma • Jail diversion programming • Employment, Education and Housing • Integrated Care across service type and settings

31. Innovations in Use of Technology Information Technology • Electronic Health Record • Data Sharing and interoperable Systems • Use of Technology to Improve Access to Services • Telemedicine for Psychiatric Services • Training • Distance Learning • Online Resource for Educators to I.D. and respond to signs and symptoms of suicide risk

32. Innovations in Financing • Center for Medicare and Medicaid Services (CMS) • Money Follows the Person (MFP) • Demonstration to Maintain Independence and Employment (DMIE) • 1915 (c) Medicaid Waiver for Children's Services – Youth Empowerment Services (YES) • Medicaid Incentives for Prevention of Chronic Disease (MIPCD) • 1115 Transformation Waiver

33. The 1115 Transformation Waiver • Five year demonstration waiver (2011-2016) • Managed care expansion • Allows statewide Medicaid managed care services • Includes pharmacy carve-in and dental managed care • Under the waiver, historic Upper Payment Limit (UPL) funds and additional new funds are distributed to hospitals and other providers through two pools: • Uncompensated Care (UC) Pool • Costs of care provided to individuals who have no third party coverage for the services provided by hospitals or other providers (beginning in first year). • Medicaid Shortfall - The unreimbursed cost of Medicaid inpatient and outpatient hospital services furnished to Medicaid patients. • Delivery System Reform Incentive Payments (DSRIP) • Support coordinated care and quality improvements through 20 Regional Healthcare Partnerships (RHPs) to transform care delivery systems (beginning in later waiver years).

34. Delivery System Reform Initiatives • Category 1: Infrastructure • Examples: telemedicine, improve service availability (hours, locations, mobile clinics), increase access to crisis stabilization, workforce enhancement • Category 2: Innovations • Examples: Targeted interventions for special populations, integration of primary care and behavioral health, peer support, improve transition from inpatient • Category 3: Outcomes • Related to Cat 1 or 2 projects. Examples: Reduce preventable readmissions, improve management of chronic conditions

35. 1115 Funding Distribution DY = Demonstration Year • FY 2011 UPL hospital payments: $2.8 billion per year.

36. 1115 Transformation Progress • 20 Regional Healthcare Partnerships (RHPs), anchored by a public hospital or related entity have submitted DSRIP projects • 1,335 DSRIP projects were proposed ($9.9 billion = 91% of available DSRIP funds) • Projects received from 224 hospitals, 38 community mental health centers, 20 local health departments, and 18 physician practices (included 12 affiliated with academic health science centers) • Projects include infrastructure (e.g., expand specialty care capacity) and innovation (e.g., patient navigation, chronic care management) • All 20 regions submitted behavioral health category projects (320). • Behavioral health projects are estimated to represented over 16 percent of the total value of Category 1 and 2 projects (preliminary data)

37. What is MIPCD? Medicaid Incentives for Prevention of Chronic Disease (Sec 4108 ACA) Competitive five year federal grant opportunity from Centers for Medicare and Medicaid Services (CMS). No state match required. Funds demonstration projects that use evidence-based incentives to help Medicaid clients adopt healthy behaviors, improve outcomes Projects must address at least one of the following goals: tobacco cessation, controlling or reducing weight, lowering cholesterol, lowering blood pressure, or avoiding onset of diabetes or improving management of diabetes.

38. MIPCD State Projects

39. What is WIN? Wellness Incentives and Navigation (WIN) – Texas’ MIPCD Project $9.9 million grant Medicaid & State Health Services partnership Project imbedded in HHSC delivery system Randomized Controlled Trial in Harris Service Delivery Area for Medicaid Managed Care 1,250 participants

40. Target Population • Medicaid Managed Care (STAR+PLUS) members, ages 21 – 55 who: • Live in the Harris service delivery area (Harris, Austin, Waller, Fort Bend, Montgomery, Wharton, Brazoria, Galveston and Matagorda Counties) • Are not receiving Medicare • Have either – • serious mental illness, OR • behavioral + chronic health conditions 40 40 40 40

41. Why WIN? • Risk - People with behavioral health conditions are significantly more likely to suffer chronic physical disease, and to die at a younger age. (29 years earlier than other Texans.) • Cost – Behavioral health conditions contribute significantly to higher medical costs (readmissions, ER visits, etc.) • Opportunity - STAR+PLUS is Texas Medicaid’s dominant health care delivery system for adults with disabilities. Significant potential for large scale change, if successful.

42. Research Structure • Randomized trial • Intervention, Control and Comparison Groups • Intervention and Control Groups in the Harris SDA • Comparison Groups reside outside of Harris • Why a comparison group? • Even in randomized trials, there can be bias in terms of who agrees to enroll • Allows comparison of study participants to the larger STAR+PLUS population

43. Indicators • Development and achievement of personal health goals • Improved health as measured by • Changes in blood pressure • Changes in weight and BMI • HbA1c control • Improved health care use (e.g., reduced potentially preventable inpatient admissions, readmissions, and emergency dept. visits) • Better adherence to treatment such as: • Initiation and maintenance of treatment for alcohol dependence • Initiation and maintenance of treatment for depression • Appropriate use of asthma medications • Comprehensive diabetes care

44. WIN Interventions • Person-centered wellness planning with professional health navigators, who are trained in Motivational Interviewing (MI) techniques. • Wellness Recovery Action Planning training (WRAP) to enable participants with more severe mental illnesses to take full advantage of wellness planning. • Flexible wellness account to support specific health goals defined by the participant in the individual wellness plan. ($1150 / yr., administered through the navigator)

45. Flexible Purchases: Examples • Devices that promote wellness goals (e.g., digital scale, BP monitor, mobile device and / or app for physical activity, etc.) • Transportation to wellness activities (e.g., support groups, gym, etc.) • Subscriptions or memberships to promote wellness (e.g., YMCA, fitness magazine) • Behavioral Interventions not currently covered by STAR+PLUS (e.g., relaxation, visualization, etc.) • Individual wellness education • Family-based Wellness Training and Interventions • Nutritional or Medical Food • Other items approved by the Harris Project Manager

46. Thank You! Sam Shore, LMSW 512-206-5237 Sam.shore@dshs.state.tx.us