Mental Health and Substance Abuse Services

1. Mental Health and Substance Abuse Services Mimi Martinez McKay, M.A., M.L.I.S. Chief of Staff/Information Services Director mimi.mckay@dshs.state.tx.us

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

3. Overview • DSHS/MHSA overview • System Improvement • DSHS Legislative Update • Drug Demand Reduction Advisory Committee • Partnership for a Drug Free Texas

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 2008 Budget $2,750,231,703 Full-Time Positions 12,206 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 2008 Budget (total funding) Community Mental 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. Estimated Economic Costs of Substance Abuse, 2007 by Cost Category (Total: $33.4 Billion) 11% Other 43% 27% Work Lost Crime 19% Premature Death Economic Impact of Substance Abuse in Texas Source: Decision Support Unit, MH & SA, DSHS.

10. 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.

11. 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)

12. PREVENTION OUTCOMESOutcomes Positive among Youth in DSHS-Funded Substance Abuse Prevention Over Time Percent of Youth Completing SA Prevention Number of Schools Participating in SA Prevention Source: DSHS Behavioral Health Integrated Provider System (BHIPS).

13. PREVENTION OUTCOMESPercentage of Texas Youth Who Used Substances in the Past Month Decreasing Over Time Source: Texas School Survey of Substance Use, DSHS.

14. 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

15. TREAMTMENT OUTCOMESClinical Outcomes Positive among Adults Completing DSHS-Funded Substance Abuse Treatment Over Time Source: DSHS Behavioral Health Integrated Provider System (BHIPS).

16. TREATMENT OUTCOMESClinical Outcomes Positive among Youth Completing DSHS-Funded Substance Abuse Treatment Over Time Source: DSHS Behavioral Health Integrated Provider System (BHIPS).

17. Current and Emerging Challenges • Changing trends in drug use patterns • Cost pressures on treatment providers • Workforce development • Availability of specialized services • Ensuring a continuum of care

18. 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

19. 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. • Suboxone (buprenorphine + naloxone) as treatment option for young heroin clients. • Proportion of Black crack users continues to decrease. • Decreased availability and increased price due to late 2008 gang moratorium and Colombians not fronting cocaine on consignment to Mexican traffickers.

20. Trends in Substance Abuse (Con’t) • Methamphetamine availability down and price up. • Mexican limits on importation of pseudoephedrine have dropped from 140 tons in 2005 to 12 tons in 2007 • Small meth labs starting up again

21. TX-Mexico Border concerns • magnitude of the substance abuse and mental health problem on the Border is of serious concern. • Concern that people in need of substance abuse and mental health services will become more “closeted” and afraid to ask for help due to repercussions related to the safety of their families and/or immigration issues. • Increasing numbers of youth involved in drug trafficking and fewer options for them. Choosing whether or not to become involved in drugs and gangs is less a “choice” and instead a decision based on threats and fear.

22. Data Source • Jane Maxwell, Ph.D. • Center for Excellence in Drug Epidemiology • Gulf Coast Addiction Technology Transfer Center • http://www.utexas.edu/research/cswr/gcattc/documents/Texas2009_002.pdf • E-Mail: jcmaxwell@mail.utexas.edu

23. System Improvement • Clinical Management Behavioral Health System (CMBHS) • Access to Recovery (ATR) • Texas Recovery Initiative (TRI) • Licensure

24. Clinical Management Behavioral Health System (CMBHS) • CMBHS will: • Integrate clinical management tool for Substance Abuse and Mental Health service providers • Capture demographic, service and clinical data for Substance Abuse and Mental Health clients • Track service utilization and client progress • Facilitate State and Federal reporting requirements

25. 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.

26. 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. • Training began earlier this month, with rollout to providers by region. • Helpdesk services will be available to all CMBHS users.

27. CMBHS Provider Benefits • Efficient, seamless administrative and clinical processes for gathering, updating, and sharing client information. • Convenient and accessible from any computer that has a browser and Internet connection, allowing access from almost any location. • Free of charge to community Mental Health and Substance Abuse treatment providers who provide services under contract to DSHS.

28. CMBHS Client Benefits • A person seeking services will experience more streamlined intake, admission, assessment, diagnosis, treatment plan development, treatment and discharge processes by: • Reducing time for staff to perform administrative tasks and gather basic client information • Using a single process that assesses a person’s need for mental health and/or substance abuse treatment • Creating a single client record that can be shared, eliminating need to create and maintain multiple client records • Allowing access to previous health records that can help identify what types of treatment have been most effective in the past and facilitate current treatment plans.

29. When Will CMBHS Be Ready For Use? • CMBHS will begin an incremental rollout to Substance Abuse and NorthSTAR providers beginning in August. • Region 7 Substance Abuse Providers, 08/10/09 • Region 6 Substance Abuse Providers, 09/08/09 • NorthSTAR Substance Abuse Providers, 10/05/09 • Region 3 Substance Abuse Providers, 11/02/09 • Region 5 Substance Abuse Providers, 12/01/09

30. When Will CMBHS Be Ready For Use? • (CMBHS Release One Deployment Continued) • Region 4 Substance Abuse Treatment Providers, January 2010 • Region 2 Substance Abuse Treatment Providers, February 2010 • Region 11 Substance Abuse Treatment Providers, March 2010 • Region 9 Substance Abuse Treatment Providers, April 2010 • Region 10 Substance Abuse Treatment Providers, May 2010 • Region 8 Substance Abuse Treatment Providers, June 2010 • Region 1 Substance Abuse Treatment Provider, July 2010

31. Connecting CHMBHS to Other Systems

32. Access to Recovery(ATR) • Federal SAMHSA Grant awarded 2004 • $22.8 million for three years • Federal target 8,928 clients; served 15,000 • Voucher issued to client rather than contract with provider • 30 participating drug courts in 13 counties • Second ATR Meth Grant awarded 2007 • $13.5 million for three years • Federal target 6,038 clients • Focus on methamphetamine use • Partnership with Governor’s Office/Criminal Justice Division

33. Substance Abuse Services Performance Improvement • 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

34. Texas Recovery Institute’s Next Steps • Emphasize integration in all efforts. • Make public health messages readily available to individuals seeking recovery. • Expand existing infrastructure through peer case management at the treatment level, community recovery services at the OSAR level and seek additional funding for additional wrap-around ancillary services to support recovery.

35. Proposed Facility Licensure Rules Revision • Chemical Dependency Treatment Facility Licensure Rules, TX Administrative Code, Chapter 448 are under review for revision • A stakeholder meeting for input and feedback on the preliminary revised Chapter 448 draft was held in Austin on July10th • Input from that meeting is being used to revise the rules draft

36. Proposed Facility Licensure Rules Revision • The subsequent revised Ch. 448 rules draft is expected to be available today (7/31): http://www.dshs.state.tx.us/hfp/hottopics.shtm • Current Ch. 448 rules are available here: http://www.dshs.state.tx.us/hfp/rules.shtm#substance

37. Proposed Facility Licensure Rules Revision • Another stakeholder meting on the draft rules will be held on Friday, Aug. 7 from 9:00 a.m. to 4:00 p.m. UT Austin JJ Pickle Research Center Campus PRC Commons Center Building 137, Room 1.102 (Big Tex) 10100 Burnet Rd. Austin, TX 78753

38. Proposed Facility Licensure Rules Revision (con’t) Stakeholder meeting #3 • Date: September 11, 2009 • Time: 9:00 am – 4:00 pm • Location: UT Commons Center – J.J. Pickle Campus

39. Proposed Facility Licensure Rules Revision • Contact for questions on the proposed rules revisions: Jack Montague Manager, Substance Abuse Compliance Group Regulatory Division TX Dept. of State Health Services (512) 834-6700, ext. 2126 jack.montague@dshs.state.tx.us

40. Counselor Licensure Rules • A joint meeting between TAAP, ASAP, TDCJ, DSHS/MHSA and DSHS/Regulatory will convene this fall • Contact: Cynthia Humphrey, ASAP Executive Director, chumphrey@asaptexas.org

41. Contact Information for LCDC Programs • Licensed Chemical Dependency Counselor Program 800/832-9623, option 5 • 512/834-6677 FAX • lcdc@dshs.state.tx.us • http://www.dshs.state.tx.us/lcdc • Mailing address: • Stewart Myrick, Team Lead, LCDC Program Texas Department of State Health Services P.O. Box 149347 (MC-1982) Austin, TX 78714-9347 • 512-834-4565 • stewart.myrick@dshs.state.tx.us

42. 2009 Legislative Update

43. Exceptional Items Community Mental Health ServicesTotal Request Includes funding for: Crisis Expansion - $0 Transitional Services - $25,698,282 Intensive Ongoing Services - $29,301,718 Veterans Mental Health Training and Coordination – $1,200,000 Cognitive Processing Training for LPHAs -$500,000 Web-based eligibility – $500,000 Regional Conferences with Partners Across Texas – $200,000 Amount Received: $56,200,000 Page 43

44. Exceptional Items Community MH Services – Maintenance of Critical ServicesTotal Request Includes funding for: Cost increases for medications, salaries, fuel, vehicles, lab, increase in healthcare costs, utilities, etc Amount Received: $7,977,486 Page 44

45. Exceptional Items Mental Health Hospital Services:Total Request Includes funding for: Maintain Current Service Level - $35,000,000 Stipends for Psychiatry - $850,000 Building & Equipment Repair & Replacement $27,228,000 Amount Received: $63,078,000 Page 45

46. Exceptional Items MHSAInformation Technology Total Request Includes funding for: Clinical Management System for Behavioral Health Care Services (CMBHS) Increase Information Technology Support at Hospitals Increase electronic client record system capacity and bandwidth Automated medicated dispensing system Amount Received: $0

47. Exceptional Items Substance Abuse ServicesTotal Request Includes funding for: Treatment Rate Increase Increase Prevention Services Expand Detoxification Services Enhance Medicaid Benefits Recovery Support and Service Coordination Services OSAR Expansion Services for Persons with Co-occurring Mental Illness Medication Assisted Treatment Amount Received: $0 Page 47

48. Substance Abuse Adult Medicaid Benefit Article IX, Sec. 17.15 of SB 1 Sec. 17.15. Medicaid Substance Abuse Treatment. Out of funds appropriated above in Goal B, Medicaid, the Health and Human Services Commission shall, beginning January 1, 2010, provide coverage for comprehensive substance abuse treatment services under Medicaid to persons who are at least 21 years of age, have a substance abuse disorder, and otherwise qualify for Medicaid. The commission may delay implementation pending federal approval.The commission shall analyze data relating to the provision of those treatment services and provide the data to the Legislative Budget Board in a format and at times requested by the Legislative Budget Board. The commission may not provide those treatment services if the Legislative Budget Board determines that the treatment services have resulted in an increase in overall Medicaid spending. Page 48

49. Who is Eligible for SA Medicaid Benefit and its Potential Array of Benefits • All Medicaid recipients in Texas • Traditional fee for service delivery system and managed care • Clinical assessment, residential levels of care, ambulatory detox, case mgt, outpatient, medication assisted treatment are being reviewed by HHSC and DSHS • Benefits must be approved by CMS prior to implementation

50. Details about SA Medicaid Benefit and Implementation Plan • The rider may allow some greater flexibility in terms of benefit array, timeliness for cost effectiveness study.  • HHSC (lead agency) and DSHS are co-managing roll out.  There are standing workgroups to address the implementation issues, which include: • decisions of IT systems, service delivery system (fee for service vs. managed care),  benefit design/medical policy and CMS approval of benefits, utilization management, provider education, recruitment and enrollment in Medicaid, recipient education, staffing/oversight, how it will relate with and the effect on the SAPT block grant and DSHS provider contracts, and cost effectiveness evaluation component.