the behavioral health system- dshs presentation to the
TRANSCRIPT
The Behavioral Health System
Presentation to the House Select Committee on Mental Health
John Hellerstedt, M.D.Commissioner
Lauren Lacefield LewisAssistant Commissioner
Division for Mental Health and Substance Abuse
February 18, 2016
Social and Economic Costs of Untreated Behavioral Health Conditions
Joblessness• 17.5% of people served by LMHAs reported having gainful
employment.
Homelessness• 96.6% of people served by LMHAs reported living in stable housing.
Criminal Behavior• An estimated 30% of inmates have one or more serious mental
illnesses. This equates to nearly 20,000 people in Texas county and jails with serious mental illnesses.
2
Social and Economic Costs of Untreated Behavioral Health Conditions
Adverse Health effects• Chronic medical conditions present at more advanced stages or at
crisis points. • More risky behavior leads to injury and illness.
Emergency Room Use• Behavioral health-related conditions comprise 8.5 percent of initial
Texas Medicaid inpatient admissions.• 25.8 percent are potentially preventable readmissions.
Suicide • In 2013, there were 3,059 suicides in Texas.• 90% of people who die by suicide experience mental illness. • 1 in 3 people who commit suicide are under the influence of drugs
or alcohol. 3
Outcomes for a Behavioral HealthContinuum of Care
Mental Health • Stable housing• Sustained employment• Reduced incarcerations• Fewer hospital admissions• Reduced emergency room visits
Substance Abuse • Increased abstinence• Reduction in relapse
4
Mental Illness in Texas: Estimated Adult Need
515,875
240,088
173,815
Estimated Need for Mental Health Services, Texas Adults: FY 2014
Total Adult SPMI Population in Texas
Adult SPMI Population below 200% FPL
Adults Served below 200% Federal Poverty Level (FPL)
173,815 (72.4% of Adult SPMI below 200% FPL)
240,088 (46.5% of total Adult SPMI in Texas)
515,875 (2.6% of the Texas Adult Population)
Sources: Texas State Data Center, CMHS, SAMSHA, HHS, Census Bureau, DSHS 5
Adult Mental Health Community Wait Lists, 2011 - 2015
53,6
28
52,7
80
53,6
55
53,5
43
53,5
97
52,6
21
52,6
08
52,1
64
51,4
54
50,6
35
51,2
61
51,2
09
51,6
34
51,2
35
51,8
73
52,3
52
55,5
39
59,1
15
61,4
36
63,3
07
65,2
51
65,4
59
66,6
47
67,4
48
5248
5908
6417
70226631 6717 6827
72356934
6156 6032 5876 5745
5264 5161
4751
2896
777285 360 511
628
1107
1562
0
2,000
4,000
6,000
8,000
10,000
0
20,000
40,000
60,000
80,000
2010 Q1 2010 Q2 2010 Q3 2010 Q4 2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1 2014 Q2 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4
Average Monthly Number of Adults Served Adult Waiting List
September 2013, $23 Million
6
Mental Illness in Texas: Estimated Youth Need
248,525
126,052
47,289
Estimated Need for Mental Health Services, Texas Youth: FY 2014
Total Youth SEDPopulationin Texas
Youth SED Population below 200% FPL
Youths Served below 200% FPL
Sources: Texas State Data Center, CMHS, SAMSHA, HHS, Census Bureau, DSHS
47,289 (37.5% of Youth SED below FPL)
126,052(50.7% of total Youth SED in Texas)
248,525(7.0% of total Texas Youth, aged 9 – 17)
7
Children’s Mental Health Community Wait Lists, 2011 - 2015
12,8
80
13,2
56
14,0
81
13,6
31
13,5
86
13,6
18
13,9
45
13,3
86
13,2
14
13,2
62
13,6
27
13,0
98
13,1
59
13,3
57
13,7
80
13,2
83
14,0
60
14,4
64 15
,900
16,0
18
16,8
21 18
,032
20,0
12
19,1
54
527
330
379
205230
291 303
241
292 286260
169
215191 202
150
42 11 1 6 6 13 308
0
200
400
600
800
1,000
0
4,000
8,000
12,000
16,000
20,000
FY2010Q1
FY2010Q2
FY2010Q3
FY2010Q4
FY2011Q1
FY2011Q2
FY2011Q3
FY2011Q4
FY2012Q1
FY2012Q2
FY2012Q3
FY2012Q4
FY2013Q1
FY2013Q2
FY2013Q3
FY2013Q4
FY2014Q1
FY2014Q2
FY2014Q3
FY2014Q4
FY2015Q1
FY2015Q2
FY2015Q3
FY2015Q4
Average Monthly Number of Children Served Child Waiting List
September 2013, $1 million
8
9
Ten Percent Withhold
Performance Measures for Adults• Employment: The percentage of adults in a Full Level of Care with paid
employment that is independent, competitive, supported, or self-employment.• Adult Community Tenure: The percentage of adults authorized in a Full Level
of Care that avoid hospitalization in a DSHS-operated or contracted psychiatric inpatient hospital bed.
• Adult Improvement: The percentage of adults authorized into a Full Level of Care who show reliable improvement in at least one of the following Adult Needs and Strengths Assessment (ANSA) domains: Risk Behaviors, Behavioral Health Needs, Life Domain Functioning, Strengths, Substance Use, Adjustment to Trauma.
• Adult Monthly Service Provision/Engagement: The percentage of adults authorized in a Full Level of Care who receive at least one face to face, telehealth, or telemedicine encounter of any service per month.
• Residential Stability: The percentage of adults authorized in a Full Level of Care with acceptable or improved residential stability.
10
Ten Percent Withhold
Performance Measures: Mental Health Services for Children• Juvenile Justice Avoidance: The percentage of children/youth enrolled in a Full
Level of Care with no arrests or a reduction in number of arrests between the first and last (most recent) assessments.
• Child and Youth Community Tenure: The percentage of children and youth in a Full Level of Care who avoid psychiatric hospitalization in a DSHS Purchased Inpatient Bed after authorization into a Full Level of Care.
• Child and Youth Improvement: The percentage of children/adolescents authorized in a Full Level of Care who demonstrate reliable improvement in at least one of the following Child and Adolescent Strengths Assessment (CANS) domains/modules: Child Strengths, Behavioral and Emotional Needs, Life Domain Functioning, Child Risk Behaviors, Adjustment to Trauma, School Performance, Substance Use.
• Child and Youth Monthly Service Provision/Engagement: The percentage of children and youth authorized in a Full Level of Care or the Yes Waiver program who receive at least one face to face, telehealth or telemedicine encounter of any service per month.
11
Ten Percent Withhold
Performance Measures: Community Mental Health Crisis Services• Hospitalization: The (equity-adjusted) percentage of adults and children with
DSHS operated or funded psychiatric inpatient hospital stays in relation to population of the local service area.
• Effective Crisis Response: The percentage of individuals who receive crisis services and avoid admission to a DSHS operated or contracted psychiatric inpatient hospital bed for 30 days after the start of the crisis episode.
• Frequent Admissions: The percentage of adults and children authorized in a Full Level of Care who are admitted 3 or more times within 180 days to a DSHS operated or contracted inpatient psychiatric bed.
• Access to Crisis Response Services: The percentage of true crisis hotline calls that result in face to face encounters within one day.
• Adult Jail Diversion: The (equity-adjusted) percentage of adult bookings entered into the Texas Law Enforcement Telecommunications System with a history of DSHS-funded mental health services.
12
Accessing the Behavioral Health System
Local Mental Health Authorities (LMHAs): the ‘Front Door’ to the behavioral health system. Persons obtain access through the intake process at Local Mental Health Authorities, where they obtain a diagnosis and a standardized assessment (CANS/ANSA).
Texans can access the behavioral health system through the following mechanisms:
• Crisis hotlines• Screening and assessment through the LMHA
Challenges related to accessing the behavioral health system include:• Demand (population growth)• Complex populations• Periodic waiting lists for services
13
Accessing the Behavioral Health System: Enhancements
• The 84th Texas Legislature moved Substance Abuse Outreach, Screening, Assessment and Referral (OSAR) services to Local Mental Health Authorities.
• OSAR services help people navigate the continuum of care for substance abuse and link to community-based support services after treatment.
• Previously, OSAR services were additionally provided by either LMHAs or other third party contractors.
• DSHS now contracts with twelve Local Mental Health Authorities for substance abuse OSAR services.
14
Ongoing Behavioral Health Carefor Adults and Youth
Outpatient Delivery System: a person-centered approach to service provision that moves away from the historical disease-focused model. TRRfocuses on resilience and recovery, which are fundamental principles of the mental health system.
Basic elements of the TRR system include: • Evidence-based practices• Consistent levels of care (low to high)• Data and outcomes
Challenges related to TRR include:• Demand (population growth)• Complex/high needs
15
Ongoing Behavioral Health Care:Enhancements
Behavioral Health Services for Veterans• DSHS Partners: Texas Veterans Commission and Texas A&M
University to provide behavioral health services to veterans.• Veterans Jail Diversion Services: Trained peers and coordinators
provide services in coordination with 24 veteran treatment courts.
Criminal Justice System• Outpatient Competency Restoration Program • Harris County Jail Diversion• Partnership with Texas Correctional Office on Offenders with
Medical or Mental Impairments (TCOOMMI)
16
Ongoing Behavioral Health Care:Enhancements
Peer-Centered Services• Clubhouse Program Expansion: recovery-oriented program for adults diagnosed
with a mental illness aimed at improving an individual’s ability to function successfully in the community through involvement in a peer-focused environment
Peer Reintegration• Program in development that will use Certified Peer Specialists to assist in the
transition from a county jail into community-based services. • Certified Peer Specialists will receive training in the provision of Forensic/Re-entry
services, and will be able to provide support and assist individuals in accessing services at a Local Mental Health Authority
Housing Assistance Services• Supportive Housing Program• HUD Section 811 Project Rental Assistance Program• Healthy Community Collaboratives
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Ongoing Behavioral Health Care:Enhancements
Suicide Prevention• Youth Suicide Prevention: aims to reduce deaths and attempts among
youth and families in Texas by developing and implementing the strategies of the Texas State Plan for Suicide Prevention.
• Zero Suicide in Texas (ZEST): with the support of a federal grant, DSHS partners with community mental health centers to develop suicide safe care in communities through adoption of best practices.
Trauma-Informed Care• Providers recognize clients may be impacted by traumatic experiences or are
survivors of traumatic events.• Services are delivered in a way to avoid re-traumatization.• Best practice approach fosters consumer/individual participation.
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Behavioral Health Outreach
Local Mental Health Authorities perform outreach to increase public awareness about available services.
Basic elements of outreach include:• Broad based publicity efforts: educational websites and community
events• Targeted efforts: Projects for Assistance in Transition from
Homelessness (PATH)
Challenges related to outreach include:• Stigma associated with diagnosis• Non-traditional outreach necessary for hard-to-reach populations
19
Behavioral Health Outreach: Enhancements
Mental Health First Aid (MHFA)• MHFA training teaches skills to respond to the signs of mental illness and
substance use in Texas students.• The 83rd Legislature authorized DSHS to provide grants to LMHAs to train
staff and contractors in Mental Health First Aid; the focus was on educator training.
• The 84th Legislature expanded MHFA, allowing more school employees to receive training, and expanding reach to more students who may benefit from MHFA.
Speak Your Mind Public Awareness Campaign• Build broad awareness• Reduce stigma• Equip people to recognize the warning signs of mental illness and
substance abuse disorders• Connect individuals with treatment
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The Crisis System
Local Mental Health Authorities provide crisis screening and assessment, inpatient alternatives, and linkage to inpatient and outpatient care, as needed.
Basic elements of the crisis system include:• Access through Crisis hotline or as a walk in• Crisis screening and assessment• Connection to crisis services • Transition into ongoing community services
Challenges related to the crisis system include:• High demand and need for crisis services• High complexity needs of individuals in crisis services• Limited inpatient capacity
21
The Crisis System: Enhancements
Mobile Crisis Outreach Teams (MCOT)• Local Mental Health Authority service that provides around-the-
clock services that include crisis assessment, crisis intervention, crisis follow-up, and relapse prevention services.
Crisis Facilities and Alternatives to Hospitalization and Jails• Crisis Respite Services • Crisis Residential Services• Extended Observation Units• Crisis Stabilization Units• Rapid Crisis Stabilization Beds
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• ~2,000 acres
• 557 buildings
• Building constructiondates between 1857-1996
• Average age >55 years old
State Psychiatric Hospitals
23
State Hospital System
State Hospital Roles:• Provide inpatient psychiatric hospitalization • Work in coordination with LMHAs, substance abuse treatment providers,
and the criminal justice system to ensure continuity of care
Typical Admissions Pathways:• Civil commitment: Presence of an imminent risk of serious harm to
themselves or others, or a substantial risk of mental or physical deterioration • Forensic commitment: through court order, due to incompetence to stand
trial or a verdict of Not Guilty by Reason of Insanity
Challenges include:• Increasing forensic commitments, particularly for maximum security• Growing population and overall capacity• Aging infrastructure• Workforce
24
State-funded Psychiatric Bed Capacity: FY 1994 - 2015
Num
ber
of S
tate
-fun
ded
Psyc
hiat
ric
Bed
s
Year
State Hospital System
3,123 3,0712,939 2,949
2,8342,729 2,671 2,607
2,2352,355 2,285 2,268
2,477 2,477 2,484 2,484 2,461 2,461 2,461 2,501 2,463 2,463
220 220 220 240 240 240 240 240 256 256 193 193 193 193 182 209 209303 397 427 427 456
3,343 3,2913,159 3,189
3,0742,969 2,911 2,847
2,4912,611
2,478 2,4612,670 2,670 2,666 2,693 2,670
2,7642,858 2,928 2,890 2,919
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
State Operated Psychiatric Hospitals Totals
State Funded Psych Beds Totals
Grand Total State Psychiatric Beds El Paso Psychiatric
Center
LegislativeAuthorization
Waco Center for Youth Added Seven 3rd Party Beds
Opened Montgomery
County Mental Health Treatment
Facility
Contract with Private Psych
HospitalsContract with
UTHSC
Reduced Capacity at
Terrell State Hospital by 28
Beds
25
Year
Rat
e of
Sta
te-f
unde
d Ps
ychi
atri
c B
eds p
er 1
00,0
00
Popu
latio
n
State-funded Psychiatric Bed Capacity: FY 1994 - 2015
17.016.4
15.4 15.214.3
13.612.8
12.2
10.3 10.610.2 9.9
10.6 10.3 10.2 10.1 9.8 9.6 9.6 9.79.1 8.9
18.217.6
16.5 16.415.6
14.814.0
13.4
11.4 11.811.0 10.8
11.4 11.2 10.9 10.9 10.6 10.8 11.2 11.310.7 10.5
0
2
4
6
8
10
12
14
16
18
20
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
State Operated Psychiatric Beds
Total State Psychiatric Beds
State Hospital System
26
399 480 550 560 603 671781 818 832 871 876
975 1,065
1,1971,244
1,226
2,0541,8471,817
1,6311,6671,5961,5571,5201,4871,4731,3971,4511,312
1,1271,098
1,118
0
500
1000
1500
2000
2500
Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 Jan-09 Jan-10 Jan-11 Jan-12 Jan-13 Jan-14 Jan-15 Jan-16
Civil vs. Forensic Patient Population of State Hospitals
Forensic Civil
State Hospital System
27
State Hospital System: Enhancements
Psychiatric Residency Program• Participation by three universities in the 2016-2017 academic
school year • Psychiatric residency programs throughout the state:
• San Antonio State Hospital • Kerrville State Hospital • Terrell State Hospital • Dallas Metrocare Services • El Paso Psychiatric Center • MHMRA of Harris County • University of Texas Southwestern Medical Center • Tarrant County Hospital District• Austin Travis County Integral Care
28
State Hospital System: Enhancements
Critical State Hospital Repairs• $18.3 million in appropriations for the FY 2016 - 2017 biennium
Purchase of Private Psychiatric Beds• $50 million in new appropriations for the FY 2016 - 2017 biennium
University Partnerships • Rider 86, FY 2016 - 2017 General Appropriations Act • Collaborating with universities on new State Hospital designs and on
developing solutions to workforce issues
ASH Study – 84th Legislature, SB 200• DSHS, in coordination with other state entities, will study potential
options for relocation of Austin State Hospital• A report detailing the results of the study is due September 1, 2016.
29
Long-term Strategies
• Replacement planning for aging state hospitals.
• Increased capacity for growing forensic commitments.
• Increased access to inpatient care in rural and high need areas, through purchased beds around the state.
• University affiliations, including provision of medical and psychiatric services and enhanced training for psychiatric residents.
• Increased access to substance abuse treatment and housing supports and continued investment in mental health outpatient services.
30