The Behavioral Health System Presentation to the House Select Committee on Mental Health John Hellerstedt, M.D. Commissioner Lauren Lacefield Lewis Assistant 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 Suicide Behavioral health-related conditions comprise 8.5 percent of initial Texas Medicaid inpatient admissions. 25.8 percent are potentially preventable readmissions. 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 Health Continuum 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 Estimated Need for Mental Health Services, Texas Adults: FY 2014 Adults Served below 200% Federal Poverty Level (FPL) 173,815 (72.4% of Adult SPMI below 200% FPL) 173,815 Adult SPMI Population below 200% FPL 240,088 (46.5% of total Adult SPMI in Texas) 240,088 Total Adult SPMI Population in Texas 515,875 515,875 (2.6% of the Texas Adult Population) Sources: Texas State Data Center, CMHS, SAMSHA, HHS, Census Bureau, DSHS 5
53,628 52,780 53,655 53,543 53,597 52,621 52,608 52,164 51,454 50,635 51,261 51,209 51,634 51,235 51,873 52,352 55,539 59,115 61,436 63,307 65,251 65,459 66,647 67,448 Adult Mental Health Community Wait Lists, 2011-2015 Average Monthly Number of Adults Served Adult Waiting List 80,000 10,000 60,000 September 2013, $23 Million 8,000 40,000 5248 5908 6417 7022 6631 6717 6827 7235 6934 6156 6032 5876 5745 5264 5161 4751 6,000 4,000 20,000 2896 2,000 0 1562 511 285 360 1107 777 628 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 0 6
Mental Illness in Texas: Estimated Youth Need Estimated Need for Mental Health Services, Texas Youth: FY 2014 Youths Served below 200% FPL 47,289 (37.5% of Youth SED below FPL) 47,289 Youth SED Population below 200% FPL 126,052 (50.7% of total Youth SED in Texas) 126,052 Total Youth SED Population in Texas 248,525 248,525 (7.0% of total Texas Youth, aged 9 17) Sources: Texas State Data Center, CMHS, SAMSHA, HHS, Census Bureau, DSHS 7
12,880 13,256 14,081 13,631 13,586 13,618 13,945 13,386 13,214 13,262 13,627 13,098 13,159 13,357 13,780 13,283 14,060 14,464 15,900 16,018 16,821 18,032 19,154 20,012 Children s Mental Health Community Wait Lists, 2011-2015 Average Monthly Number of Children Served Child Waiting List 1,000 20,000 September 2013, $1 million 800 16,000 12,000 527 600 8,000 4,000 330 379 205 230 291 303 241 292 286 260 169 215 191 202 150 400 200 0 FY2010 Q1 FY2010 FY2010 FY2010 FY2011 FY2011 FY2011 FY2011 FY2012 FY2012 FY2012 FY2012 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 42 11 1 6 6 13 FY2013 FY2013 FY2013 FY2013 FY2014 FY2014 FY2014 FY2014 FY2015 FY2015 FY2015 FY2015 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 30 8 0 8
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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 84 th 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 Care for Adults and Youth Outpatient Delivery System: a person-centered approach to service provision that moves away from the historical disease-focused model. TRR focuses 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
Peer-Centered Services Ongoing Behavioral Health Care: Enhancements 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 17
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. 18
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 83 rd 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 84 th 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 20
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-theclock 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 22
State Psychiatric Hospitals ~2,000 acres 557 buildings Building construction dates between 1857-1996 Average age >55 years old 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
Number of State-funded Psychiatric Beds State Hospital System 4,000 State-funded Psychiatric Bed Capacity: FY 1994-2015 3,500 3,343 3,291 3,159 3,189 3,074 3,000 2,500 2,000 1,500 1,000 500 0 2,969 2,911 3,123 2,847 3,071 2,939 2,949 2,834 2,491 2,611 2,670 2,670 2,666 2,693 2,670 2,764 2,858 2,928 2,890 2,919 2,478 2,461 2,729 2,671 2,607 2,235 2,355 2,477 2,477 2,484 2,484 2,461 2,461 2,461 2,501 2,463 2,463 2,285 2,268 State Operated Psychiatric Hospitals Totals State Funded Psych Beds Totals Grand Total State Psychiatric Beds 220 220 220 240 240 240 240 240 256 256 El Paso Psychiatric Center 193 193 193 193 182 209 209 Year Legislative Authorization Waco Center for Youth Added Seven 3rd Party Beds Opened Montgomery County Mental Health Treatment Facility 303 Reduced Capacity at Terrell State Hospital by 28 Beds Contract with Private Psych Hospitals Contract with UTHSC 397 427 427 456 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 25
Rate of State-funded Psychiatric Beds per 100,000 Population State Hospital System State-funded Psychiatric Bed Capacity: FY 1994-2015 20 18 16 14 12 18.2 17.0 17.6 16.4 16.5 16.4 15.4 15.2 15.6 14.3 14.8 13.6 14.0 12.8 13.4 12.2 11.4 11.8 11.0 10.8 11.4 11.2 10.9 10.9 10.6 10.8 11.2 11.3 10.7 10.5 10 8 10.3 10.6 10.2 9.9 10.6 10.3 10.2 10.1 9.8 9.6 9.6 9.7 9.1 8.9 6 State Operated Psychiatric Beds Total State Psychiatric Beds 4 2 0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year 26
State Hospital System 2500 Civil vs. Forensic Patient Population of State Hospitals 2000 1500 1000 2,054 500 399 Forensic 1,8471,817 1,6311,667 1,5961,5571,520 1,4871,473 1,397 1,451 1,312 480 550 560 603 671 781 818 832 871 876 975 1,065 Civil 1,244 1,197 1,226 1,127 1,118 1,098 0 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 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