House Human Services Committee Mental Health and Substance Abuse Services May 24, 2006.

House Human Services Committee

Mental Health and Substance Abuse Services

May 24, 2006

House Human Services Committee House Human Services Committee DSHS Mental Health and Substance Abuse Services Overview DSHS Mental Health and Substance Abuse Services Overview May 24, 2006 May 24, 2006 2

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 illnesses.


Behavioral Health Issues Impact Other Systems

• 75% of children placed in foster care have parents with behavioral health problems: DFPS, DSHS, DARS

• 75% of kids in the juvenile justice system have behavioral health problems: TJPC, TYC, TDCJ, DSHS

• 30% of kids in the juvenile justice system will end up in the adult justice system: TJPC, TYC, TDCJ, DSHS

• 46% of all ER visits have behavioral health issues as a basic or contributing factor: DADS, TWC, DSHS

• 30% of all truancy is related to behavioral health problems: TEA, TWC, TJPC, TYC, DSHS


Mental Health as a Public Health Crisis

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

HIV/AIDS Homicide SuicideComparative mortality statistics, 2001

Source: Centers for Disease Control and Prevention


Mental Illness Strikes More Americans Each Year Than Other Serious Illnesses

0

5

10

15

20

25

30

% A

dult

s

Mental Illness

Serious Mental Illness

CVD Diabetes Cancer Asthma

CDC BRFSS, SEER Cancer Statistics Review, 1975-2002, “Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders” Arch Gen Psychiatry. Vol. 62, June 2005


DSHS Mental Health and Substance Abuse Services

• Community-based services– 39 Local Mental Health Authorities– Dallas Area NorthSTAR Authority– 180 Substance Abuse contracts

• 10 State Hospitals


Funding Mechanisms

• Community Mental Health and Substance Abuse payment mechanisms:– Substance Abuse Treatment: Fee-for-service– Substance Abuse Prevention: Cost

reimbursement– Community Mental Health Centers:

Prepayment for services


Funding Equity for MH Services• The 2006-07 General Appropriations Act (Article II, Special

Provisions, Sec. 29) requires the Department of State Health Services to implement a long term plan to achieve equity in state funding allocations among local mental health authorities.

• The plan will be implemented from fiscal years 2006-2013. The goal of the plan is to achieve equity to the greatest extent possible by fiscal year 2013.

• Any funding reductions to a local authority for the purpose of achieving equity may not exceed 5 percent of allocated general revenue in a fiscal year.

• The plan also ensures that improving funding equity is a priority in distributing any new state or federal funds that may become available for allocation to community centers.

• Progress to date: 5 percent estimated to be achieved by end of FY06.


Community Mental Health Services

• Community mental health centers are locally- governed components of the Department of State Health Services (DSHS) service delivery system.

• 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.


Contract Management• Performance contracts between DSHS and the Local

Mental Health Authorities include important general provisions denoting the terms of the contract.

• Attachments to the contracts stipulate the services targets, performance measures, outcomes, and remedies, sanctions, and penalties that may result from failing to fulfill contract expectations.

• Provisions include expectations of low administrative overhead, utilization management completion rates, and measures related to appropriateness of services delivered and percentage of clients receiving the minimum number of Resiliency and Disease Management service package hours.

• Penalties/recoupment for the Second Quarter of Fiscal Year 2006 totaled $163,858.


HB 2292 Mental Health Service Requirements

• Integration of Physical Health and Behavioral Health

• Priority Population Redefined

• Resiliency and Disease Management

• Jail Diversion


Resiliency and Disease Management (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.

• Includes 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)


RDM Key Components

• Uniform Assessment

• Standard Service Packages

• Utilization Management

• Data Analysis and Performance Evaluation


Numbers Served in Community Mental Health Services in FY2005

19,902

105,131

26,213

0

20,000

40,000

60,000

80,000

100,000

120,000

Front-Door CrisisServices

Adult RDM ServicePackages

Child RDM ServicePackages


Percent of Clients Receiving Minimum Number of Service Hours Shows 50 Percent Improvement from When RDM

Implemented Statewide in Quarter 1 FY2005

34%

42%

55%62%

73%

84%

0%

20%

40%

60%

80%

100%

Quarter 1FY2005

Quarter 2FY2005

Quarter 3FY2005

Quarter 4FY2005

Quarter 1FY2006

Quarter 2FY2006


Community MH Service OutcomesAverage monthly number of adults receiving community

mental health services

64,82868,659

73,357 73,758 73,731 75,004

0

20,000

40,000

60,000

80,000

100,000

120,000

FY2005Quarter 1

FY2005Quarter 2

FY2005Quarter 3

FY2005Quarter 4

FY2006Quarter 1

FY2006Quarter 2


Individuals with Criminal Justice Involvement Experienced Positive Clinical Outcomes at DSHS Community Mental Health Centers, All

of which Implemented Jail Diversion during FY2005

90%

78%

81%

80%

85%

96%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

IMPROVED/STABILIZED CO-OCCURRING SUBSTANCE USE

IMPROVED/STABILIZEDHOUSING

IMPROVED/STABILIZEDEMPLOYMENT

IMPROVED/STABILIZEDFUNCTIONING

IMPROVED/STABILIZED RISK OFHARM

AVOIDED CRISIS

Percent Who Experienced Positive Outcome


FY2005 Texas Monthly Hospital Emergency Room (ER) Costs 31 Percent Lower for Medicaid Clients with Mental

Illness or Substance Abuse Receiving DSHS Behavioral Health Treatment

Untreated$115

Treated$79

$0

$115

ER Costs per Medicaid

Clientper Month

Source: Prepared by Research Team, Strategic Decision Support, HHSC, 3/23/2006. Average of ER costs per month for Medicaid clients not receiving needed DSHS Mental Health and Substance Abuse services (Untreated) vs. average of ER costs per month for Medicaid clients receiving needed DSHS Mental Health and Substance Abuse services (Treated).

ER COST OFFSET

- $36Average per Client per Month

31%REDUCTION


Innovative Local Treatment Models

• Crisis Stabilization– Tri-County MHMR (Montgomery, Liberty and

Walker Counties)

• Jail Diversion– Center for Health Care Services (Bexar County) – MHMRA of Harris County


Community Substance Abuse Services

• Prevention – Primarily school-based

• Intervention – OSAR; HIV; PPI

• Treatment:

– Adults

– Specialized Female Programs

– Women with children

– Youth

– Pharmacotherapy

– COPSD


Numbers Served in Substance Abuse Prevention and Intervention Services in

FY2005

989,569

331,016

46,186

119,920

Youth Prevention Adult PreventionYouth Intervention Adult Intervention


53,420 People Accessed Substance Abuse Treatment in FY2005

7,360

32,800

23,144

8,887

Youth Male Female Priority Female


Access to Recovery (ATR)• Access to Recovery supports clients by providing needed

treatment or recovery support services to successfully complete their drug court program

• Drug courts offer a cost-effective alternative to incarceration by providing community-based treatment as a condition of probation

• Cost effectiveness of the ATR drug court program in Texas is reflected by preliminary data, which indicates that participating ATR clients are experiencing the following successful outcomes: – 92% Abstinent– 59% Employed or in School– 91% No Further Arrests– 99% Not Homeless– 87% Socially Connected


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


State Mental Health Hospital Capacity

Beds - By Psychiatric Facility Type

1,526

408

2,260

State Hospitals

Non Profit

For ProfitFoForr Profit


Cost of In-patient Mental Health Services

* Category represents patients hospitalized in an acute hospital without a psychiatric unit.

Medicare Costs Per Patient Day

By Psychiatric Hospital Type

$0 $500 $1,000 $1,500 $2,000

Acute *

PsychiatricUnits

For-Profit

Non-Profit

State-MH


Population Growth Compared to Funded State Hospital Beds

0

5

10

15

20

25

30

35

40

.

0.0

5.0

10.0

15.0

20.0

25.0

State Hospital Beds 3,560 2,774 2,268

Est. Pop. In Millions 17.7 19.8 22.5

FY '92 FY ' 98 FY '05

Funding for State Mental Hospital Beds has declined while the Texas population has grown


Growth in Forensic Patients

0%

5%

10%

15%

20%

25%

30%

% ForensicPatients

16% 21% 23% 26% 27%

2001 2002 2003 2004 2005

Total Forensic Patients as a percent in Texas Mental Health Facilities


State Mental Health Hospital Daily Census for FY2005

2,100

2,200

2,300

2,400

2,500

Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug

Actual Funded Average


State Mental Health Hospital Capacity

• In February 2006, the LBB approved $13.4 million in additional expenditures for state mental health hospital capacity.

• As a result, statewide hospital system capacity was increased by 96 forensic commitment beds and 144 civil commitment beds.

• This increase in state hospital capacity has greatly enhanced our ability to meet the needs of local communities.

• We continue to plan for long-term, community-based solutions to address the hospital capacity issue.


Crisis Services Redesign

• One goal of DSHS mental health services is to help consumers avoid mental health crises. However, the reality is that crises do occur.

• February 2006, DSHS established the Crisis Services Redesign Committee to develop recommendations for a comprehensive array of crisis services.

• Members of the committee include medical experts, citizen stakeholder groups, law enforcement representatives, county probate court judge representation, and county representatives, as well as individuals from professional organizations and provider groups.

• A redesign of crisis services will build on the service improvements made by the evidence-based Resiliency and Disease Management program.

• A thorough review of the current crisis system was conducted, including holding public hearings around the state.


Crisis Services Redesign (cont.)• The committee plans to finalize its recommendations in June for an

evidenced-based crisis services model that will increase access to appropriate and cost-effective services.

• Initial conclusions for recommended services include:– 24-hour crisis hotline– Mobile crisis outreach– 23-hour hold capacity– On-call psychiatric services– Crisis residential services– Respite– In-home crisis services

• The committee will also put forth recommendations regarding DSHS staff support, coordination and training to local professionals (e.g., law enforcement crisis intervention training).


Mental Health Service Delivery Models in Other States

• Ohio & California: County-based service system with county taxing authority

• Arizona: Regional behavioral health authorities; managed care system

• New Mexico: Single purchasing model• Pennsylvania: County-based, capitated managed

care model• Illinois & New York: Direct state contracts with

provider network


Mental Health Transformation• Overarching goal is to improve the mental health of all

Texans and meet the President’s New Freedom Commission goals

• New Freedom Commission Goals are shared by those participating on the Transformation Working Group:– The Governor’s Office; Department of State Health

Services; Texas Health and Human Services Commission; Department of Family and Protective Services; Criminal Justice Department; Juvenile Probation Commission; Texas Youth Commission; Consumers; Family Members; Texas Education Agency; Aging and Disability Services; Workforce Commission; Veteran’s Administration; etc.


Mental Health Transformation• The grant funding is seen as a catalyst to jump start some of

the efforts of framing the public health approach. The 2 primary areas of focus:– Developing and supporting local behavioral health collaboratives– Using cutting edge technology to change work processes across

agencies

• Improvement of the system will be targeted to the following principles:– Apply evidence to health care delivery– Use information technology– Align payment policies with quality improvement– Prepare the workforce

House Human Services Committee Mental Health and Substance Abuse Services May 24, 2006.

Documents

public mental health

local mental health

services targets

continuity of services

appropriateness of services

mh services

mental illnesses

dshs slide