The House Select Committee on Mental Health met to hear invited testimony regarding the status of mental healthcare in Texas and the funding received by agencies for behavioral health programs.
 
Opening Comments

  • Chair Four Price comments that access to mental health care is dependent on a wide variety of issues, and Texas’ mental and behavioral health system can oftentimes be difficult to address, thanks Speaker Straus for his effort in addressing these issues and creating the committee
  • Chair Price expects to have 4 more hearings after this initial hearing
  • $ 3.6 billion total allocated for mental health issues, $2.6 billion of which will go to DSHS specifically, this does not include waiver monies
  • Vice Chair Joe Moody comments that mental health issues involve 18 state agencies, committee is very important for sorting through this complicated field, wants to focus on structural issues with mental health and preventative care as well as criminal justice crossover issues
  • Rep. Senfronia Thompson would like to track down very specific areas to focus on, perhaps bed numbers, recidivism, and drug issues
  • Rep. Garnet Coleman wants to be educated on the issues
  • Rep. Chris Turner comments that Texas has a high level of interest in this committee’s work, great need exists for changes to the current mental health system

 
Sonja Gaines, HHSC, Mental Health Services Overview

  • Mental health refers generally to particular diagnoses associated with mental health (schizophrenia, depression, etc.), behavioral health refers to mental health issues combined with other issues like substance abuse
  • HHSC has started to focus on telemedicine to serve the rural areas of Texas
  • Integrated health has also been a huge impact, includes 1115 waiver
  • Veteran and homeless populations are also being focused on, recent legislative efforts have been a huge boon
  • Behavioral health issues have also been identified in IDD individuals, major gains are being made in this area
  • Just over 500,000 adults in Texas live with serious and persistent illness, 250,000 children have severe emotional issues
  • Adults with untreated conditions are eight times more likely to be incarcerated
  • There are 1.7 million veterans in Texas who may seek behavioral health treatment
  • Approximately 26,300 Texas students are receiving special education services with a primary diagnosis of emotional disturbance.
  • There are approximately 32,000 children in DFPS conservatorship, and it is estimated that over 50% of those children have a diagnosed mental illness.
  • Approximately 50% of youth in the juvenile justice system have been identified with need for mental health treatment; approximately 80% of state committed youth have a need for alcohol or drug use treatment.
  • Oftentimes hospitals are not appropriately equipped to deal with IDD patients with dual-diagnoses for mental health issues
  • Texas has partnered with local health clinics and primary care doctors to serve individual communities and address the specific needs of that community
  • Mental health has many different funding streams, 1115 waiver, federal funding, insurance, local leverage funds, etc.
  • Leverage funds and synergy between specialties are crucial to ensuring mental health care in each community
  • DADS is moving forward with crisis services, looking to solicit funding from DSHS
  • DFPS has started to adopt new assessment tools for identifying issues
  • Chair Price asks how recently some of the new programs (crisis services, etc.) were implemented
    • Crisis services array has been around for around 10 years and grown significantly in this time, includes 24 hour call centers and mobile crisis response teams
    • Residential treatment centers came from the 83rd sessions, targeted towards kids at risk for or in conservatorship
    • Assessment tools are fairly new, adapted from other services rendered by HHSC
    • YES waiver is new, targeted towards children who are at-risk of being institutionalized and promotes individualized care
  • Rep. Moody asks if the assessment tools are focused on the foster population
    • “CANS tools” have been in use by HHSC, currently trying to adapt for use with foster care
  • Rep. Moody wants updates on progress, believes efforts like this will greatly benefit preventative care
  • Use of peers as an outreach tool has been growing in Texas, has been very beneficial in engaging individuals in services, peers are individuals who have received treatment from mental health services
  • HHSC is working with Hogg Foundation and stakeholders to see services affected by peers
  • HHSC has also reshuffled advisory committees generally, currently have around six and committees have been very helpful with recommendations
  • 9 total state hospitals throughout Texas, DSHS has contracted for 15 new community beds, 47 non-state psychiatric hospitals provide care
  • HHSC works with TDCJ, TCOOMMI program involves interlocal agreements for community based treatment program
  • Rep. Coleman comments that indigent care is within the Texas constitution, this care is “not an option” and has been in Texas law for quite some time
  • HHSC also works with Juvenile Justice Department focusing on psychiatric and mental health services, substance abuse treatment, and general rehabilitation
  • Chair Price asks what is being done to attack juvenile alcohol and drug use “on the front end,” early identification and prevention
    • Some state funded prevention and intervention programs exist through DSHS
    • HHSC works with schools to identify problems early and provide appropriate care
    • State funded dollars also go towards in-patient and out-patient services for children
  • Chair Price wants to know if outcomes are tracked, does not think that much difference has been made
    • Some outcomes are tracked, Rep. Thompson is correct in saying some things need to be focused on and perhaps juvenile substance abuse is one of these areas
  • Chair Price comments that Texas will always have high needs in these areas due to growing population, but measures should be tracked
    • HHSC is currently working with Sunset recommendations to look at outcome and impact tracking
  • Federally Qualified Health Centers provide primary and preventive health care services to people who otherwise may lack access to medical care due to where they live, language barriers, income level, and/or their complex health care needs, serve nearly 1.2 million patients annually
  • Since the start of the 1115 waiver, Texas has partnered extensively with FQHCs to look at holistic healthcare needs of individuals
  • Rep. James White comments that 1115 waiver has existed for 5 years, wants a progress update on the accomplishments
    • Lisa Kirsch, HHSC, responds that waiver is nearing its end, just recently submitted a 5 year extension request for the waiver
    • Until the request is negotiated, HHSC is looking for a shorter extension to study Uncompensated Care in Texas, federal services likely waiting on this
  • Chair Price wants a brief breakdown of the 1115 waiver and its use
    • Kirsch responds that 1115 waiver is an opportunity to do “something different” with managed care programs in Texas
    • Waiver includes STAR, STAR Kids, etc., also includes two pools $17.6 billion UC pool and $11.2 billion for delivery system reforms
    • Governmental and nongovernmental payments to each, nongovernmental includes IGTs from local public funds
    • Waiver is locally and regionally driven, 20 regional healthcare partners and 300 providers are doing projects in Texas
    • Great interest and great need for behavioral healthcare in waiver, includes projects focusing on proper use of hospitals, crisis, telemedicine, and access projects
    • Projects tend to take a few years to get started, Texas has started to realize improvements in outcomes, compliance, and follow-up care
  • Department of Veterans Affairs addresses behavioral health through 7 VA Regional Healthcare Systems and provides services realting to depression, anxiety, substance abuse, PTSD, and other mental issues

 
Lisa Kirsch, HHSC, Medicaid and 1115 Waiver Overview

  • Texas Medicaid provides care for medication counseling, psychotherapy, substance abuse treatment, intervention
  • More and more Texas is in a managed care environment, moving away from fee for service
  • Chair Price asks if there is a difference in services between MCOs for treatment
    • All MCOs are required to cover the benefits Texas covers for children or adults, children receive generally more service
    • MCOs are required to meet Texas standards, but management areas, like prior authorizations, are subject to organization discretion
  • S.B. 58, 83rd Legislature, Regular Session, 2013, directed HHSC to:
    • Include covered mental health rehabilitation and mental health targeted case management, into managed care
    • Establish an advisory committee tasked with providing formal recommendations on the inclusion of services in managed and integration of physical and behavioral health by September 2014
    • Develop two health home pilots for the integration of physical and behavioral health.
  • HHSC has focused recently on extending services to typically underserved populations
    • Rep. Coleman comments that he is very proud of how HHSC has started to focus on targeted case management and veteran’s issues
  • Rep. Thompson comments that TPPF study is going to receive state funding, will not have to cut into HHSC budget
  • Kirsch highlights some projects under DSRIP and 1115 waiver, programs have the ability to earn $2.6 billion over all funds
    • Rep. Coleman comments that the great gains are due to the ability to match local funding
  • Waiver’s ability to pull federal funds and promote local activity has directly led to increased mental health care in Texas
  • Chair Price agrees wholeheartedly

 
Sonja Gaines, HHSC, Behavioral Health Resources Overview

  • Resources developed by HHSC include websites, mobile apps, and healthcare resource guides
  • Chair Price comments that the Texas Veterans Mobile App is a very good tool
  • HB 1191 promoted enhancements to 211 website to promote mental health housing services
  • Mental Health First Aid programs have recently been spread across school systems, extended now to students as well as teachers
  • Rep. Thompson asks after the rising incidence of transgender issues in schools
    • Many resource centers are becoming aware of these issues and services are being looked at
  • Chair Price asks if mental health first aid is a local initiative, asks how these programs are being advanced and training is being promoted
    • HHSC has partnered with TEA to promote training programs and promoting identification of mental health issues
    • Training is being pushed to people who have incidental contact with children or students (CPS workers, etc.), 2,000 state employees have been trained
  • Rep. Coleman asks what is being done to connect kids with services
    • Training has been promoted aggressively, HHSC is early in the process
  • Rep. Galindo asks if school counselors are included in statistics for mental health professionals
    • If they are a licensed LPC then they are, generally counselors do not provide mental health services and do not provide mental health counseling
  • Rep. Coleman comments that training is mandatory, goal is to get schools to inform parent’s of issues and guide kids to treatment
  • Rep. Chris Turner asks if HHSC has information on specific issues faced by students, such as depression, etc.
    • That data is available, trauma and substance abuse are prevalent and HHSC can provide additional information
  • The 84th Legislature created the Statewide Behavioral Health Coordinating Council (House Bill 1, Art. IX, Section 10.04) for the purpose of creating a five-year statewide behavioral health strategic plan to:
    • Eliminate redundancy
    • Utilize best practices in contracting standards
    • Perpetuate identified, successful models for mental health and substance abuse treatment
    • Ensure optimal service delivery
    • Identify and collect comparable data on results and effectiveness
  • Coordinated expanses portion is due June 1st
  • HHSC is focused on unifying Texas’ approach to mental health, combining service delivery, statewide data, prevention, funding, and agency coordination
  • Several chief weaknesses have been identified by stakeholders, including inadequate substance abuse providers, behavioral health workforce problems, and lack of safe integrated housing
  • Chair Price asks if there are challenges for individuals with mental health issues living independently
    • Yes, sometimes individuals may live independently, but different housing options are needed to accommodate issues (supervised housing, transitional housing, etc.)
  • HHSC is vetting all behavioral health exceptional items and is coordinating expenditures for submittal to the LBB
  • HHSC is looking at useful data to capture as a representation of mental health across the state, long term goal
  • Gaines highlights different programs that have helped HHSC’s unified approach:
    • DADS Crisis Service Enhancements Implementation
    • TDCJ TCOOMI Program
    • Texas System of Care programs
    • United School Age Children (USAC)
    • Crisis Service Array
    • NorthSTAR Transition
    • Behavioral Health-focused DSRIP Projects through 1115 Waiver
    • Healthy Community Collaboratives
    • YES Waiver
    • Texas Veterans + Family Alliance Grant Program
    • Certified Community Behavioral Health Clinics (CCBHC) SAMHSA Grant
    • Mental Health First Aid
  • Financial alignment is helped by coordinating expenditures, carve-ins for case management and rehabilitation, and state and local investments in specialty projects
  • First step includes cross-agency information exchange, maximizing infrastructure, expansion of training assets, and increased partnerships tackling statewide initiatives
  • Rep. Chris Turner asks what positions will need to be filled
    • APNs, physician assistants, rural positions, and licensed counselors and practitioners are key positions
  • Rep. Toni Rose asks what issues surround substance abuse, wants updates on progress
    • Availability of substance abuse services is a big issue, urban areas have more robust services
  • In summary, mental health is a varied field with many different facets, local partners have been a great boon in addressing issues, room exists for growth and system improvements
  • Rep. Rose comments that many mental health problems are really access to care problems, but oftentimes mental health is co-morbid with other issues like substance abuse
  • Rep. Thompson asks for the things Gaines would like the state to focus on
    • Gaines would like support for the programs to be vetted by HHSC
    • Also support for people with the highest need and problems that were comingled with mental health issues
    • “Stay the course” in addressing individuals with the highest need
    • At-risk children
  • Rep. Thompson asks if HHSC has found that families of veterans need help, if there are ways to help families support their veterans
    • Huge need exists for family support, PTSD has an impact on the family
  • Rep. Sarah Davis comments that legislature has invested a significant amount of funding in mental health issues, urges HHSC to focus on best practices and outcomes, also highlights foster care issues
    • HHSC is actively working on improving outcomes data collection
  • Rep. Davis would also like a focus on children who “age out” of foster care
  • Chair Price agrees, “everyone” will want to how effective mental health services will utilize funding

 
Mike Diehl, LBB, Behavioral Health Service Delivery

  • Presents a breakdown of behavioral appropriations, $2.7 billion in GR dedicated, $3.6 billion in all funds
  • DSHS receives $2 billion, TDCJ receives nearly $500,000, and TJJD receives nearly $200,000, roughly 95% of total funding between the 3
  • Chair Price asks after $0 investment into veteran’s funds, if veteran services receive state money
    • Veteran programs are largely funded by Fund for Veteran Assistance, fund derived mostly from lottery proceeds
  • Rep. Chris Turner comments that not all of this fund is dedicated to behavioral health
    • Amounts listed in LBB reports for veteran’s fund is projections pending Fund decisions, none of this money goes directly to veterans, money is granted to nonprofits and other service organizations
    • $2 million goes to agencies giving general assistance
  • Rep. Chris Turner asks for clarification, if this $2 million does not necessarily go to mental health issues
    • $4 million total is exclusively for behavioral health issues
  • Chair Price asks for an explanation of trustee programs in the Office of the Governor
    • Primarily of juvenile justice, delinquency programs, residential programs, and substance abuse programs
  • Chair Price asks if Dental Board etc. collect funding for their members, asks how this funding is used
    • Programs are assistance programs, statutorily barred from being used for direct treatment
  • Chair Price asks if HHSC has provided LBB with data necessary to calculate behavioral health funding from Medicaid
    • Number should be available “soon”
  • Chair Price thought “soon” was a few weeks ago
    • Expected early March
  • HHSC is required to notify LBB of a statewide plan and submit a coordinated expenditure proposal
  • DSHS receives 76.2% of total state mental health funding for a variety of mental health programs, including outpatient services (LMHAs) LMHAs help provide mental health and substance abuse services and are the first point of contact for many adults with mental health issues
  • Chair Price asks after number of health care recipients in 2015 (66,2001), 2016 target is less, but funding has increased
    • Funding increase is to help LBB address target overshoot from 2015
  • DSHS received:
    • Children’s Community Mental Health Services – $170 million
    • Crisis Services – $250.3 million
    • Substance Abuse SAPT block grant – $252.8 million, maintenance cost of 91 million
    • State Mental Health Hospital system – $667 million
    • Community Hospitals – $189.7 million
  • Rep. Coleman asks if there are still hard caps on LMHAs on who they can serve for GR
    • Agency can speak to that

 
Kelsey Vela, LBB, TDCJ Funding Overview

  • 13.8% of behavioral healthcare funding
  • Appropriated $490.7 million in GR related funds
  • Funding split between Probation, Parole, and Correctional Institution based services
  • TDCJ received:
    • Local CSCDs – $142.3 million
    • SAFPF Facilities – $99.4 million
    • Correctional Institution Services – $166.7 million
    • Substance Abuse Programs – $65.4 million
    • Sex Offender Education Program and Sex Offender Treatment Program – $6.4 million
  • Parole provides various treatment services, including programs for sex offenders
  • Rep. Thompson asks for information on how many parolees are eligible to get off parole and perhaps save the state money
    • Will get with agency to share this information
  • Probation and Parole funding:
    • TCOOMMI serves individuals on probation or parole with IDD and helps link these individuals to support services
    • $46.9 million for TCOOMMI
  • Rep. Thompson asks how long a person needs to wait before being admitted into Safe P program
    • Waiting times have gone down over the years due to funding and bed increase, will get exact numbers to Rep. Thompson

 
Rachel Carrera, LBB, TJJD Funding Overview

  • $169 million, ~5% of total funding
  • TJJD received:
    • Community programs – $29.6 million
    • Integrated rehabilitation – $10.9 million
    • All Parole Program and Services – Exact behavioral health amounts unknown, total $2.9 million
  • 99% of youth in state custody needed some type of state treatment
  • Rep. Moody asks if LBB looked at moving 17 year old population into Juvenile category and how it would affect numbers
    • Several bills from 84th suggested this, fiscal note analysis has been done, but LBB is not prepared to speak on this
  • Rep. Moody asks for information on this issue
    • Criminal Justice Data analysis team should have this information and LBB will provide it
  • Rep. White comments that GR funds for TJJD is roughly $155 million, all funds is $169 million, asks where the balance comes from
    • Likely federal or grant funds, will get back to the committee with this
  • Rep. White asks if any Medicaid federal monies are in any of the TJJD programs
    • Incarcerated youths are not eligible for Medicaid services, some program might be available in communities, but these would not flow through TJJD

 
Mike Diehl, LBB, Other Agencies Funding Overview

  • DADS received IDD funding
  • DFPS received contracted behavioral health services funding
  • HHSC received funding for veteran’s health, youth programs, and coordination
  • UT Health Sciences Centers received funding for mental health workforce programs
  • Texas Military Department received funding for Texas military persons counseling
  • Dental Examiners, Pharmacy, Veterinary, Nursing, Mental Health and Chemical Treatment
  • Behavioral health services are available to people enrolled in full benefit Medicaid
  • DSRIP and Transformation Waiver are expected to draw down $1.2 billion in federal funds with additional IGTs
  • Community Mental Health Centers were directed to help draw down federal funds, totaling $385 million
  • Chair Price asks if Texas can expect a similar draw down moving forward
    • Waiver ends September of 2016, 1.2 billion includes current biennium
  • Chair Price asks if 1.2 bil and 3.6 bil funding and Medicaid spending portion, maybe $1.5 to 3 bil is added together 6.5 to 8 bil on behavioral health in Texas
    • LBB agrees, accurate estimation of behavioral health allocations
  • Rep. Chris Turner asks for data to show what the funding need is for different behavioral health issues, unclear as to if funding is covering a significant proportion
    • Total need is difficult to determine and LBB does not track this, performance measures generally revolve around people served
  • Rep. Chris Turner asks if LBB tracks this kind of data in other areas of the state budget
    • Not really, no
  • Rep. Chris Turner says this is “interesting,” metrics might be an area to focus on
  • Chair Price thinks that data would be useful for money spent and performance, wants to avoid spending money on the same problem twice and focus on efficient use of resources
    • LBB can work with HHSC to see what information is available

 
John Hellerstedt, DSHS
Lauren Lacefield Lewis, DSHS

  • 96.6% of people served by LMHA reported living in stable housing
  • Chair Price does not understand this statistic
    • LMHAs do a very good job of stabilizing housing for homeless individuals who come to them, not just serving people in stable housing
  • Chair Price comments that the number as presented seemed to say LMHAs were serving housed peoples, asks if legislature should be concerned that LMHAs are not serving the homeless population
    • Large homeless population exists, number partially reflects how effective services have been in addressing homelessness
  • Individuals with behavioral health issues have a large number of co-morbid conditions, practical and ethical reasons exist to work to lower human and financial costs of these conditions
  • Rep. Thompson asks if DSHS has number on increase of suicides
    • Number not immediately available
  • Rep. Thompson asks what age group is mostly affected by suicide
    • Suicide is a high cause of death in young individuals, unsure how it measures to other demographics
  • Presents demand data for Severe Persistent Mental Illness
  • Texas has historically struggled with length of wait for mental health services, though Texas is doing well compared to past levels
  • Chair Price is concerned over impact of 10% withhold of funds due to pending legislation affecting HHSC services
  • Rep. Rose is concerned about the mental health waitlist, wants to know if DSHS has data on demographics
    • Yes, can send this information to Rep. Rose
  • Rep. Coleman comments that risk of relapse is high, highlights the need for indigent individuals to stay stable to maintain waitlist numbers
  • Chair Price comments that the waitlist will always exist in some way
  • Rep. Coleman comments hat waitlist is why he would like data on hard caps for number of serviceable people
    • No cap exists, data is tracked over funding allocated and people served
  • Rep. Thompson and Rep. Coleman discuss the difficulty of determining most effective funding solutions, Coleman cautions that waiver funds will disappear eventually
  • Chair Price asks if different LMHAs are receiving different funding and treating different individuals, do they get to decide how best to allocated that funding, in other words does mental health care look different region to region
    • Yes, structure exists for regularity, but LMHAs do have ability to customize care services
  • Rep. Kenneth Sheets asks for data on how many individuals are underserved
    • DSHS track via CANS and ANSA assessments and assigns appropriate level of care based on this
    • Some care deficiencies are apparent from this data, DSHS expects to be at equilibrium over the next biennium
  • Rep. Davis comments that a lot of the work done to address care equity was done during conference committee
  • Rep. Rose asks if there is a waitlist in Dallas county
    • No, structure precludes a list
  • Rep. Rose asks if there will be a waitlist in Dallas county given recent changes
    • DSHS is as yet unsure
  • Rep. Thompson asks why Dallas county does not have a waitlist
    • Chair Price comments that the Dallas program was maybe “a mile wide and an inch deep” in terms of people served versus services
  • Rep. Greg Bonnen asks if insurance guarantees coverage for mental health issues
    • Rep. Coleman responds that Texas is measuring who gets turned down for treatment under exchange plans, this problem was supposed to have been fixed
  • Rep. Bonnen wants to know more of what is happening in the private sector, his assumption is that psychologists and psychiatrists are primarily in a cash environment and that perhaps they have difficulty operating
  • Chair Price comments insurance and coverage are two “very different” things, cash basis is not uncommon in the mental health world
  • Rep. Chris Turner comments that, in his district, roughly 65% of adults do not have coverage
    • This carries for the rest of the state, roughly 60% of adults do not have mental health coverage
  • LMHAs and mental hospitals are a key player in mental health, thus DSHS is a key component
  • DSHS is very focused on outcomes, 10% of funding is withheld contingent on outcomes in Texas
  • DSHS outcome tracking includes employment, unnecessary hospital visits, service engagement, and residential stability
  • DSHS allocates funding to LMHAs quarterly, 10% withheld contingent on outcomes and released when outcomes are met, unmet outcome funding is distributed to other areas
  • Chair Price asks how often LMHAs do not meet outcomes and do not receive withhold money
    • Very small portion of LMHAs do not earn the dollars back
  • DSHS also closely looks at juvenile justice involvement, juvenile improvements, decreasing children’s stays in hospitals, and youth engagement in services as well as crisis measures such as relative percentage of adults and youth with inpatient hospital stay, avoiding admission after crisis encounter, and crisis responses
  • Mental health population is very complex and difficult to accommodate entirely, waitlists are a result of this
  • DSHS is trying to establish a structure for service delivery, includes targeting services to appropriate people and data outcomes
  • DSHS has been developing systems for those awaiting trial to be returned to competency in an outpatient setting to return beds to other individuals
  • Initiatives have also been focused on tracking and serving the incarcerated populations in Harris county
  • TCOOMMI has been very beneficial, strides have been made in Medicaid billing for some services
  • Mental Health Block Grant will be getting an increase in the very near future, DSHS is looking forward to increased funding
  • Clubhouse projects and grants have supported expansion of peer services
  • Chair Price asks for information on peer services
    • Clubhouses are employment focused and attempt to push individuals towards employment and structuring life around the work day
  • Rep. Rose comments that Gaines quoted 400 peer service personnel in Texas, asks if DSHS has a breakdown of these services
    • DSHS can get this data
  • Rep. Moody asks after Harris County Diversion program and how many people are served
    • Goal was 200 individuals, can get information on exact criteria on tracked individuals
    • Looking to divert incarcerated individuals and exacerbating mental health issues
  • Rep. Galindo asks if DSHS has any initiative to correct any unintended consequences related to open carry and hospitals
    • Not at this time
  • Rep. Chris Turner comments that hospitals receiving state funds are prohibited from preventing open carry
    • This is correct for certain categories of institution, including state psychiatric hospitals
  • Rep. Coleman asks for clarity on this
    • State psychiatric hospitals are not subject to state licensure, vetted by accreditation programs
  • DSHS has projects focusing on peer accreditation that have been approved and will be launching this year
  • DSHS has “very robust” efforts focused on suicide prevention, including a prevention coordinator with many ongoing initiatives including screening and assessments
  • Chair Price asks if DSHS has seen statistical data to support its prevention efforts
    • Difficult to track a change in death data
  • DSHS believes service providers need to do a better job of responding to individuals, asking “what’s happened” instead of “what’s wrong with you”
  • Chair Price asks if this applies to all types of trauma
    • Yes, DSHS tries to be sensitive of all trauma
  • Mental Health First Aid and Public Awareness campaign are some of DSHS popular new initiatives
  • DSHS has been slowly creating more facility based crisis alternatives in Texas, should be moving into West Texas and in the panhandle
  • Not every county has a mobile crisis outreach team, important to have teams that can screen and respond appropriately
  • Rep. Thompson asks DSHS to explain the system in Harris county
    • Harris county was an early leader in investing in the crisis service delivery programs
  • Rep. Thompson comments that Harris county has psychiatrists accompanying crisis response teams and that this initiative helps with early identification and reducing costs
  • Aging infrastructure and workforce issues affect ability to render mental health service
  • Rep. Rose asks who was brought in to assist with state hospital problems
    • Cannon design, their reports include information on status of facilities and demand problems
  • Rep. Rose asks if state has a current contract with Geo
    • State contracts with a local entity who contracts with Geo (Geo has changed names)
  • Texas struggles to maintain nurses and other staff, as well as qualified physicians
  • Rep. Chris Turner asks if the problem is lack of applicants
    • Large contributor is salary, current budget does not generate competitive salaries even with other agency positions
  • Rep. Rose asks what problems contribute to demand issues
    • Capacity to meet demand and qualified medical staff are the chief problems
  • Rep. Galindo asks if workforce issues can be mitigated by increasing scope
    • Has not been identified as a solution
  • Rep. Galindo asks if DSHS has any strategies to mitigate this
    • Primary challenge is to fill and maintain all of the open positions
  • Since 2002, Texas has worked consistently to get bed capacity back into the mental health system, 100 beds expected in biennium
  • While increased capacity efforts have been massive, growing population requires at least 100 beds each year, DSHS is looking to contract for periodic bed space
  • More people in state hospitals currently with a forensic commitment than a civil commitment, but Texas is doing fairly well in serving the civil population
  • $18 million is available to address critical hospital repairs, however $188 million exists in deferred repairs
  • DSHS highlights importance of substance abuse support, outpatient, inpatient, and crisis response services
  • Rep. Bonnen asks how workforce breakdowns between psychiatry and psychology
    • Will provide committee with a report on the broader need for both
  • Rep. Bonnen would like information after specific workforce needs to develop strategies
  • Rep. Coleman comments that existing report developed a new fund to offset psychiatric and psychologist training
  • Chair Price would like all data to be provided to an individual member to provide it to the committee at large

 
Lee Johnson, Texas Council for Community Centers

  • Community Centers are created by law and are responsible to a board of trustees and sponsors
  • Johnson presents a chart of population served by demographic
  • Chair Price asks if some portions take more effort and resources to serve
    • Information presented is based solely on numbers of people served
  • Pharmaceutical partners provide assistance for certain medications through Patient Assistance Programs
  • 1115 Waiver and DSRIP projects have been very beneficial, can go beyond projects paid for solely by state funding
  • Law enforcement is very concerned with travel times to open mental health beds, areas with beds are typically very far from rural communities, beds are not guaranteed open even when law enforcement arrives
  • Chair Price comments that this is a common problem, asks if there is anything being done through DSHS that can help alleviate this issue
    • Some have voiced interest in looking at problems contributing to bed availability, reports and studies are forthcoming that will look at this
  • Chair Price asks there is anything that law enforcement can do to confirm bed availability
    • Unsure and not confident to answer this
  • Failure to invest in mental health infrastructure directly contributes to higher costs, statistics corroborate this
  • 83rd session funding was made partially available to clear waitlists in some areas, allocation was very successful and shows that funding being available leads to concrete results
  • Presents variety of projects shown to alleviate pressure on inpatient system
  • Rep. Coleman comments that 1115 Waiver is not primarily to fund services, but rather to find innovative funding methods and programs that work better
  • Continuum of care for mental health is very important, behavioral wellness and recovery services are very effective and useful for preventing more intensive care, importance should be placed on outpatient services, outreach, and access to care
  • Existing flexibility should be leveraged to support value-based services and efficient use of mental health funding, as well as streamlining cumbersome requirements like licensure via address instead of by entity
  • Intervention in schools could go very far to reducing influx into the juvenile justice system, could be targeted via LMHAs and their partners
  • Bluebonnet Trails Community Services serves 8 counties around Travis counties, identified and diverted 27 behavioral health youth and adults in a 1115 waiver program, 1,500 combined since program started, estimated savings are $5 million
  • Chair Price appreciates the information, especially the appendices supplied with the presentation

 
Allison Boleware, Hogg Foundation for Mental Health

  • Peer support services, self-directed care both very important to mental health
  • Advance mental health of Texans through research and policy
  • Developed a guide to help inform decision making with regards to mental health
  • Appreciate commitment of committee to continue on progress made to date
  • Must maintain focus on recovery, goal is to allow sufferers of mental illness to lead a meaningful life
  • Hogg Foundation believes that every Texan deserves good mental health and that recovery is possible, coordination of services is vitally important
  • Chair Price asks after what Hogg Foundation envisions as a strategy for coordination
    • An office would exist to coordinate all agencies with mental health planning and focus on outcomes
    • Texas needs a system of oversight and administration for mental health
  • SB 58 Behavioral Health Advisory Committee has generated recommendations that clearly show integrated care is the proper approach to mental healthcare
  • Peer services should supplement visits with mental health providers
  • Self-directed services allow individuals to help lead their own recovery, examples include funding used for college classes to promote job skills or stability
  • Rep. Chris Turner asks if the Hogg Foundation has investigated who is responsible for mental health parity in Texas
    • TDI has been asked, but TDI does not have complete authority to regulate
  • Rep. Bonnen asks for an exact definition of mental health parity
    • Based upon federal act, act says that mental or substance abuse services must be provided at the same level as medical care
  • Rep. Chris Turner is concerned that maybe TDI needs further direction from the legislature to improve access to care
  • Rep. Bonnen comments that many providers have difficulty determining service availability, prefer cash up front and provides another barrier to care
  • Chair Price would like further additional information from the Hogg Foundation on parity issues
  • Hogg Foundation asks for continued support for mental health needs of every Texan, including students and incarcerated individuals
  • Housing opportunities must be supported as well
  • Hogg Foundation intends to release a report in time for the upcoming session

 
Andy Keller, Meadows Mental Health Policy Institute

  • Meadows Mental Health focuses on how to get the best mental healthcare possible in Texas
  • Very appreciative of how open the discussions have gotten with mental health
  • One of the biggest problem areas are the individuals with serious or persistent mental illness, includes 1,000,000 adults and 5,000 children
  • 22,000 “Superutilizers,” adults who continually cycle through jails and mental health services, difficult to treat and a burden on the mental healthcare system
  • Texas needs to shift focus to providing care for certain diagnoses before they become significant issues, very possible if resources are leveraged
  • Early detection and prevention is the key to lowering overall mental healthcare costs
  • Law enforcement tends to be very stressed by mental health issues, law enforcement is often the point of first contact for severe mental health issues and has to expend significant effort to get individuals into beds or care
  • Schizophrenia, depression, and bi-polar disorder tend to be the biggest mental health issues amongst Medicaid recipients
  • Chair Price asks if costs are higher than necessary for Medicaid recipients and other serious issues
    • Certainly for the taxpayer
  • Rep. Coleman comments that some hospitals are not allowed to submit to Medicaid, causes a huge barrier for care involving Medicaid claims
    • There are other limitations to the Medicaid benefit as well that make it difficult to leverage
  • Now is the time to expand focus on everyone with serious mental illness, not just Medicaid; need to consider private payers, insurance, etc.
  • Rep. Coleman noted psychosis is only covered by crisis treatment; limiting things is not always better
    • Limits are understandable but some limits need to be reconsidered to maximize benefits to the taxpayer
  • For a child with psychosis, a parent can take their child to an outpatient facility where the psychiatrist will only speak to the child or to an inpatient facility; there is nothing in between and insurance will not pay for auxiliary services like family education and job skills training
  • For young people in a school setting, normal behavior from depression and mental health issues can cause significant problems like suspension, criminalization of normal behavior and introduction to the justice system; need to be using alternative discipline and early detection/intervention
  • It would be good to have accountability for the funding being used in managed care for mental health
  • There is a loophole in managed care that when a person goes to jail MCOs do not have to pay for them anymore because they lose their Medicaid; this may not be enough motivation for an MCO to provide the best care possible to keep these people out of jail