The House Select Committee on Mental Health has released their interim report to the 85th Legislature which includes background, lists of challenges and recommendations. Below is a spotlight on the summary recommendations directly from the report; however, for complete details please refer to the report.
Interim Charge: Mental Health Overview
Recommendations
- Seek consideration of various forms of financing to improve operations, purchase private beds to increase needed capacity and to update, remodel and construct new state hospitals in accordance with a strategic plan.
- Improve opportunities for integrated health care. x Develop a comprehensive plan for workforce development.
- Address instability of over-reliance on and sustainability of the 1115 Waiver.
- Provide for a definition of peer support services in the Insurance Code and require insurers to pay for peer support services. Also review considerations for the expansion of support services provided by certified substance use recovery coaches.
- Utilize and expand use of technology through the use of telemedicine & mobile applications.
- Review reciprocity of psychiatrists and other mental health professional licenses to ensure maximum utilization of providers and services.
- Review MCOs and the alignment of financial incentives as well as the loop hole regarding coverage by MCOs for persons in jail.
- Numerous programs are in place and much funding is provided for mental health and behavioral health but comments are being heard about the system not working. Create a team from the Behavioral Health Coordinating Council to ascertain the hindrances in the system and enhance the Council's plan to address the specific issues found.
- New and innovative programs are many times needed as population grows and technology changes; however, proven and best practices are being utilized throughout the state and can potentially be wholly or partially implemented by others if the knowledge is made available. The lead administrator of the state programs needs to be intricately familiar with the actual programs and practices in-place by the various entities and able to guide other areas in adoption of proven best practices across areas of the state.
- Review funding by HHSC/DSHS to LMHAs based on innovativeness of programs. The assessments and funding award are made based on "value" as determined by DSHS personnel. Some LMHAs may be more "sophisticated" and thus more innovative, others may just need additional help in retaining psychiatrists or other mental health professionals or help in realizing efficiencies in providing services. Also, there is not consistency in services that LMHAs provide, such as some do not offer any children's services. True coordination of community services should incorporate the LMHA.
- Further support LMHAs to permit additional leadership for community services — increase funding and support for LMHAs and restructure how funding is awarded by DSHS utilizing strengthened measures and outcomes of programs; unlock local innovation and waive the current 10 percent financial withhold penalty from LMHAs who have proven records and where all local governments agree to work together, but continue with penalty of areas that continue to have silos or refuse to collaborate with other entities; streamline performance contract on flexibility and accountability; leverage 27 existing flexibility statute and allow LMHAs to move resources around; reduce regulatory barriers, such as with substance use disorder and mental health integration; streamline crisis stabilization units (CSU) requirements (the Texas Administrative Code currently mirrors psychiatric hospital requirements but CSUs do not provide the same level of care as a hospital); and strengthen outcome measurement.
- Define Continuum of Care and provide funding for step-down beds. x Have targeted funding for mental health programs in rural areas.
- Increase funding for Texas Veterans + Family Alliance in underserved communities. x Eliminate the overly burdensome prior authorization rules by insurers.
- Increase access to substance abuse treatment and housing supports and continued investment in mental health outpatient services.
- Review and address access to inpatient care in rural and high need areas, possibly through purchased beds around the state.
- Continue review of university affiliations, including provision of medical and psychiatric services and enhanced training for psychiatric residents.
Interim Charge: Mental and Behavioral Health Services and Treatments for Children
Recommendations
- Require at least annual mental health screenings during Texas Healthy Steps visits.
- Review creating a psychiatric and adolescent psychiatric innovation grant that will allow medical schools to create psychiatric and adolescent psychiatric programs to increase the number of physicians in these areas of practice.
- Develop referral networks that link non-mental health providers and parents to child mental health treatment specialists (depending on the progress of integrated care, as the design of blending primary care and mental health in single sites, would eliminate most referral networks). The all-too-common practice of giving a parent of a mentally ill child a phone number would be unacceptable for any other serious condition, such as hearing deficit or diabetes.
- School-age children see varied school employees on a near daily basis. Improve the access to MHFA so that mental health illness signs can be recognized as early as possible to allow for early intervention.
- Promote integrated care practices as integrated care supports mental health affect physical health. The two are intertwined in childhood in ways that require us to treat the whole child.
- Review MCOs and their non-flexibility of payment models being not timely/available for innovative programs and for too much time being spent by providers for prior authorizations on medications. Consider allowing ISDs to contract with MCOs to receive reimbursements from Medicaid for treatments.
- Link crisis mental health networks to first responders, emergency departments, and hospitals; immediate continuity of care to prevent declines after discharge.
- Link family support services to providers working with higher risk child populations.
- Establish specialized service networks for children with serious or co-morbid conditions – – there are varying degrees of severity.
- Expand on best practice programs such as ones located at Elgin ISD, Hutto ISD, and Austin ISD for early intervention. Children who are affected by mental health issues are less likely to perform well in school, and early intervention will help for the long-term.
- Restructure mental health first aid (MHFA) to address concerns about DSHS not knowing statistics regarding the breakdown of which regions, which schools, and the specific personnel benefiting from the courses offered through the LMHAs.
- Require OSARs to interact with public schools and increase services for youth with mental health and/or substance abuse needs.
- Statutorily include TEA as a member of the Texas Behavioral Health Coordinating Council and identify the programs and amounts of indirect funding for mental health to TEA and other state agencies.
- Currently, classroom teachers must complete 150 clock hours every five years. School counselors, learning resource specialists/librarians, educational diagnosticians, reading specialists, master teachers, superintendents, principals, and assistant principals must complete 200 clock hours every five years. However, except for a single hour required on suicide prevention, there is no hour required on how to spot a potential mental health condition. Dyslexia CAPE training is required for educators who teach students with dyslexia. Increase the one-hour suicide prevention requirement to 3 hours of training on mental health discussion. Fund the LMHAs to provide such training at a local ESC where educators attend many times throughout the year. In other words, teach in the environment they are naturally comfortable thereby further breaking down barriers.
- Establish and fund a Texas Center on Mental Health in Schools, similar to the Texas School Safety Center at Texas State University in San Marcos.
- Expand the role and funding of the Texas Behavior Support Network within Region 4 Education Service Center (ESC) to include training and support to all school districts statewide on the effects of trauma, school-based trauma-informed practices, and integrating mental health training and services into a positive behavior interventions and supports (PBIS) framework.
- Statutorily authorize ISDs to contract with LMHAs for providing mental health services on their campuses and to contract with the MCOs to receive reimbursements from Medicaid for treatment. x Provide funding to sustain the TWITR project and to expand the program to additional rural counties and other Health Science Centers.
- In school environments, accept psychologists as in-network providers with all private and government insurance companies and organizations in the area, as allowing campus based mental health providers to be designated as in-network will increase access to much needed services.
- Consider requiring all foster care children to receive a mental assessment within 72 hours of being placed in foster care and then require that the children receive the necessary treatment as indicated by the mental health assessment. Provide a mental health medical home during permanency planning for foster care children that have mental health issues. Ensure that there is an integrated care for physical and mental health care. The model is the Rees-Jones Center for Foster Care Excellence at Dallas Children’s Hospital. Require that CPS coordinate with the child’s mental health care givers regarding all aspects of placement, transition planning, and permanency. Consider revising policy to include participation by a child’s actively treating medical team and mental/behavioral health treatment team in Primary Medical Needs staffing calls. Provide for a continuum of mental care when the child ages out of the foster system via mental health care at LMHAs or Health Science Centers.
- Judge Hathaway spoke of bringing in families and not just the juvenile offender for the meetings and treatment plan discussions. Children who go back into the same environment will likely continue the same actions. Review funding allocated to juvenile programs and consider making more flexible to utilize for enhanced family involvement and not be exclusively for the juvenile offender.
- Require recognition and utilization of resources available; Judge Hathaway mentioned that every county has access to a CRCG – so such resources could potentially be relied upon more for wraparound services as an example.
Interim Charge: Mental and Behavioral Health Services and Treatment Access, Continuity of Care, Coordination, and Workforce
Recommendations
- Review creating a psychiatric and adolescent psychiatric innovation grant that will allow medical schools to create psychiatric and adolescent psychiatric programs to increase the number of physicians in these areas of practice.
- Provide grant funding to nursing and medical schools to address the workforce shortage. x Increase number of psychiatry residency slots.
- Realize potential of each of the varied mental health professionals, and increase utilization accordingly. Review allowing such professionals to practice to the full scope of their authority and knowledge.
- Provide loan forgiveness for varied mental health professionals who practice for 4 years in rural and frontier areas.
- Amend Medicaid rules to allow Masters of Social Work to be reimbursable service providers. x Increase service provider rates in rural regions.
- Increase the use of telemedicine-psychiatry especially in rural and frontier areas, including use the school and criminal justice settings. Example is Telemedicine Wellness, Intervention, Triage and Referral Project (TWITR) of The F. Marie Hall Institute for Rural and Community Health at TTUHSC.
- Provide additional funding to address post-partum care. Increase the length of treatment to one year after the date a woman gives birth to her child. Consider allowing pediatric providers to conduct and bill for post-partum screenings.
- Provide funding for continuum of care programs to further enable programs to have a long-term effect.
- Review and address capacity needs for growing forensic commitments.
Interim Charge: Insurance Coverage and Parity and Law Enforcement Challenges
Recommendations
- Increase TDI’s investigative budget regarding behavioral health plans.
- Address the billing disparity by modifying or eliminating the HHSC rule affecting rates for social workers, licensed professional counselors and licensed marriage and family therapists.
- Require mental health parity & protect against arbitrary claims denials – require HHSC and have TDI require transparency and parity in reimbursement rates of MCOs and insurers.
- Provide TDI with the specific authority and resources to enforce compliance with the Mental Health Parity and Addiction Equity Act commonly referred to as the ‘Parity’ law.
- Require insurers to make good faith efforts to include more mental health providers in their networks and demonstrate such efforts to TDI.
- Enact a mental health "Parity" state law: either full parity for all mental health conditions or a scaled version requiring parity coverage of specific mental health conditions or all serious mental illnesses.
- Enhance funding of the Texas Correctional Office on Offenders with Medical or Mental Impairments (TCOOMMI) due to the program's success rate.
- Expand crisis intervention services and jail diversion programs. Specifically enhance support for regional crisis intervention teams.
- Review suspension rather than “termination” of Medicaid benefits for those in jail.
- Provide judges more options for restoring competency in addition to commitment to a state hospital.
- Expand judicial education on how to address mental health issues. Require all judges to receive mental health education.
- Review requirements for competency restoration and the potential for diversion of nonviolent offenders and restoration in jail and outside of jail settings.
- Review the possibility for the expansion of the Houston pilot program across the state.
- Require specialty courts to provide for consistent data collection to evaluate specialty court outcomes, recidivism, etc.
- Expand best practices such as mental health court in jail or having a mental health docket.
- Improve transfer procedures both following competency restoration and by clarifying exactly who has authority to transport a person during and outside of a mental health emergency.
Interim Charge: Substance Abuse, Homelessness, and Veterans
Recommendations
- Increase access to peer support services by defining "peer services" so that more service locations may be able to employ and bill for services potentially increasing the ability to provide continuity of care and reduce recidivism. Allow substance abuse recovery coaches, certified mental health peer specialists for "peer services" and "certified family partner services" to be reimbursed for services provided in a manner appropriate to the scope of their practice; define in rule the scope of peer services; expand the Loan Repayment Program (SB239, 84th) to include college debt for certified peer specialists and certified recovery coaches; billing codes reimburse care but also shape and limit the extent of a specialist's practice, currently operating under mental health rehabilitation services is not only insufficient to cover the range of services provided by peer specialists, it is also provided only through LMHAs ޤ these restrictions severely limit the settings in which peer specialists may practice.
- Ensure the Statewide Behavioral Health Coordinating Council remains intact and the plan produced continues to coordinate and financially align the programs among the various state agencies and various entities to address the various needs of the mentally ill. All mental health related funds are not considered "direct," and the Council should learn what other mental health spending is included within the various strategies for the varied agencies and encompass those programs in the coordination of services program.
Interim Charge: State Hospitals, Options for Addressing Needs, and Mental Health Care on Campuses of Higher Education
Recommendations
- House Bill 197 should be amended to tighten compliance and ensure crisis resources are readily available to anyone on the school's website.
- Require the crisis hotline number to be displayed on the back side of every student ID card.
- Require a PHQ9 depression screening for every student who presents to the general campus student health center to increase collaboration between health and counseling centers, as well as emphasize early intervention. If a student falls within a specified guideline on the scale, the student must then be referred to the campus counseling center for a consultation.
- Model after Texas A&M College Station program.
- Promote community resources to help ease the burden of higher education counseling centers. Though community resources vary across the state and each school has access to different kinds of resources, they are valuable and necessary partnerships to help students stay in school and receive services at the same time.
- Promote the psychological health of the counseling center staff with routine staff wellness checks.
- Provide statutory guidance regarding the minimum services state institutions of higher education should provide along with state funding and requiring these institutions to interact with their LMHA.
