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The House Committee on Public Health and the House Committee on Human Services met jointly on August 9 to consider an interim charge on the effect of substance abuse and mental health disorders on children and families involved with Child Protective Services and foster care. The committees also heard an update on contracts with the Office of Refugee Resettlement.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. It is not a verbatim transcript of the hearing, but is based upon what was audible or understandable to the observer and the desire to get details out as quickly as possible with few errors or omissions.

 

Update on Contracts with the Office of Refugee Resettlement

Hank Whitman, Department of Family and Protective Services

  • Have had 512 or so investigation into facilities, 9 still pending; no investigations have found incidents yet
  • Raymond – Typically who brings these to you?
    • Anyone, Professionals, doctors, teachers, etc.
  • Facility personnel are aware they need to contact statewide intake if there is any neglect or abuse
  • Raymond – And you haven’t found instances of abuse or neglect?
    • No, we have not
  • Raymond – I accept this, there are many out there who feel these facilities are not exactly day care centers; to some extent they are detention centers & there is concern about the environment
  • Raymond – Even if they are federal facilities, any reports of abuse or neglect are investigated by the state DFPS
  • Raymond – Shares story of infant who died shortly after release, discusses with Whitman the lack of named individuals to contact and investigate the incident

 

Victoria Ford, Health and Human Services Commission

  • Updating on 4 pending applications to become a General Residential operation in Texas; in addition to Houston, there are 3 more in San Benito County and Los Fresnos
  • All 4 are in the late stages, but still some work to be done
  • Raymond – When someone applies, if they are in a municipality you will not grant the license until they’ve gotten everything they need locally?
    • Correct, will not grant until all codes are complied with, etc.
  • Raymond – To what extent do you have the right to deny a permit?
    • If they turn in all the paperwork and meet requirements, HHSC is directed to grant the permit; statute directs this
  • Raymond – Would like to see the statute; have been asked if state has discretion & assumed that we did not
    • Very proscriptive statute

 

Jean Shaw, Health and Human Services Commission

  • Raymond – Have you ever denied a facility application/ORR?
    • No, we have not
  • Alvarado – When you look at an application like Southwest Keys, do you look at their history in other states? This particular company had very strong allegations of sexual misconduct on part of an employee in Arizona
    • We look at who the governing body is & look at any revocations of licenses in other states, not necessarily compliance history
    • We do look at how they meet TX rules and laws with other licenses in TX
  • Alvarado – It seems like the Arizona case was very high profile, in light of this and the death of the child; would like to see if HHSC would hold or pend licenses until these items are investigated?
    • We don’t have the authority to do this, must grant the licenses if they meet requirements
  • Alvarado – Will you be looking at Southwest Keys? My understanding is they have an improper restraints policy in Arizona
    • Wouldn’t look at Arizona, but would look at TX restraint policies
  • Alvarado – Asks after background checks for employees
    • Pretty extensive, fingerprint checks, DFPS system checks, etc.
  • Alvarado – Have you been able to sit down with Southwest Keys and see if they have extra layers of scrutiny?
    • Unsure if they were compliant with Arizona law, but will hold them accountable for Texas law
  • Alvarado – has knowledge of the Arizona incidents given you pause or cause to ask additional info? I understand a previous application was denied
    •  Was not denied, but was returned for more info
  • Alvarado – Does an application expire if local permits, etc. are not granted?
    • No expiry policy
  • Raymond – Has several questions written down that were delivered to DFPS for responses at a later date
  • Raymond – Would not put up with abuse or neglect of children regardless of origin, concerns should be brought to Whitman at DFPS; if there is any impropriety, the facilities should be shut down
  • Miller – Let’s say they clear the background check in Jan, but commit a crime in Feb, the facility where they work would have no knowledge?
    • No, we have a “rap back” system that automatically alerts with new arrests & will determine ability to continue working
  • Miller – And this notification comes how quickly?
    • I believe it’s within 24 hours
  • Wu – Could you elaborate on the professional reporter?
    • Whitman, DFPS – Licensed individual with the duty to report abuse & neglect
  • Wu – And this applies to any person who is a professional?
    • Yes, anyone licensed by the state of Texas
  • Wu – Would it be fair to say anyone in a childcare facility is considered a professional?
  • Raymond – Wouldn’t think so, I think they need to be licensed
  • Wu – I’m trying to think through, if you have a licensed RTC, would the individuals within the RTC fall into this?
    • There are clinicians, therapists in the RTC who are licensed
  • Wu – Trying to figure out who is under obligation to report
    • Shaw, HHSC – Facilities are given info and workers are given training during the inspection process
  • Wu – Asks after requirements at federal detention centers
    • We don’t have these, only Residential Centers subject to state requirements
  • Wu – Who has responsibility to investigate whether a professional reporter failed to report?
    • Ford, HHSC – I don’t know how we would know if a reporter failed to report, if there is not report
  • Wu – You could find out through the family, the media, etc., if they don’t report there are criminal penalties
    • Whitman, DFPS – This is a crime, would report to law enforcement
  • Wu – Do you investigate if there was a failure to report?
    • Would assist law enforcement
  • Wu – DFPS has a responsibility to refer this to law enforcement, who would you report to?
    • Whichever law enforcement office has jurisdiction, DA’s Office, etc.
  • Wu – I’m unsure whether the statute calls for prosecution by the state or the local DA?
    • Local DA represents the state
  • Klick – Say you have a child who needs medical care in the facilities, how are consent regulations handled?
    • Shaw, HHSC – Must get a medical consent form at the time the child is admitted, rules exist for medical needs
    • Psychotropic medications require additional consent by legalized authorized person
  • Klick – If they fail to do this, what would happen rom a regulatory perspective?
    • Cite for first violations, if it is systemic or ongoing there is an enforcement framework
  • Minjarez – If an investigation is conducted and abuse is believed to have occurred, do you have authority to remove that child?
    • Whitman, DFPS – We can in emergency circumstances, would still go before the court
  • Alvarado – are the fire inspections statutory or agency rule?
    • Shaw, HHSC – Statutory that they have to have fire approval, but also in Administrative Code
  • Alvarado – Has the agency gone into the facility where the child died after release?
    • We reached out to the facility to see if they are aware of any child who has passed away after release & they are not; we have not gone in to do an investigation
  • Alvarado – Houston lawyer made this allegation, stated that the child was exposed to a disease, based on this would you go in to investigate?
    • Whitman, DFPS – We are being asked to investigate with no name, would like to, but need info
  • Alvarado – Can you clarify your jurisdiction for investigating facilities over abuse & neglect?
    • Can go in if it is licensed by HHSC, instructed by judge to treat the Dilley, TX facility as if it was licensed
  •  Alvarado – Language states you have authority to investigate state facilities licensed by HHSC
    • If they put the facility on federal reservation, then we do not; army base, etc.
  • Alvarado – How would this be handled?
    • Would need to be handled by federal officials
  • Zedler – What is the reputation of Southwest Key?
  • Raymond – Depends who you ask
    • Ford, HHSC – We list out the number of citations in the written material, Southwest Key is listed
    • There are close to 2,000 requirements that facilities need to meet, so citations fit into this number; Southwest Key has 4 citations
  • Alvarado – Regarding Southwest Key, there was a situation in Arizona, record of at least two sexual molestation and abuse incidents, one pending from June
  • Whitman clarifies that DFPS has no jurisdiction to remove children from federal locations

 

Analyze the prevalence of children involved with Child Protective Services (CPS) who have a mental illness and/or a substance use disorder. In addition, analyze the prevalence of children involved with CPS due to their guardian’s substance abuse or because of an untreated mental illness. Identify methods to strengthen CPS processes and services, including efforts for family preservation; increasing the number of appropriate placements designed for children with high needs; and ensuring Texas Medicaid is providing access to appropriate and effective behavioral health services.

 

Hank Whitman, Department of Family and Protective Services

  • Gives overview of common effects of substance abuse and behavioral health issues, 70% of removals involve substance abuse & issues can be mirrored in parents and children
  • Important to identify mental health and substance abuse issues early to provide care to the child and caregiver
  • Opioids are not the only substance affecting families, marijuana was identified in over half of child fatality, abuse, & neglect cases; methamphetamine was also present in high numbers
  • Substance abuse alone is not the reason for removal, but use can lead to abuse & neglect
  • Substance abuse can lead to parents passing out and rolling over onto their children, leads to suffocation or death; impairments to ability to care for children should push us to address these issues
  • Frank – Do you have any more detail on the 53% of children with substance use/mental health issues
    • Stephanie Muth, HHSC – Do not have this data breakout, based on usage data
  • Frank – This seems almost staggeringly high, there are many people who benefit from this diagnosis financially; are there those who could?
    • Kristene Blackstone, DFPS – Only if the level of care is assessed to be above a basic level
  • Frank – My understanding is this works for medication as well, like for ADHD, etc.; is there any check and balance on over diagnosis? E.g. diagnosis of depression seems easy to grant, many things push diagnoses
    • There are utilization reviews, Youth for Tomorrow also does reviews, file reviews, diagnosed by licensed professionals, Superior has a review process
  • Frank – It is stunning that we say 53% are at the point of mental illness or substance abuse
    • It is weighted heavily towards mental illness, very small substance abuse
  • Frank – Would you agree there is a huge incentive to diagnose
    • Whitman, DFPS – I think this would be a huge conspiracy, wouldn’t see how it is possible
  • Raymond – I would hope doctors would want to act as doctors
  • Frank – It starts with foster families, etc., based on what is put on the paperwork
  • Raymond – Would hope that doctors would review and diagnose
    • Whitman, DFPS – Absolutely, caseworkers do not diagnose
  • Frank – Are there numbers on what conditions these are?
    • Muth, HHSC – I do have the most common diagnoses; adjustment disorder, adjustment disorder with mixed disturbance of emotions and conduct, ADHD, mood disorder, etc.
  • Raymond – I’d be surprised that it’s not higher than 53%
  • Frank – Maybe I have an issue with “mental illness,” labeling with “mental illness” for depressions and these disorders seems challenging
  • Frank – Labeling seems to stick
  • Wu – I think there is a confusion on what is a mental health issue & what is a mental health disorder; in most of these cases it is an issue leading from abuse & neglect, family separation, etc., things that can go away over time with therapy and perhaps medication is needed to help
  • Wu – If everything is working correctly, person recommending medication is the doctor; decision is reviewed at multiple levels and can be challenged
  • Frank – I would say one of the challenges is that levels go with medications, there is definitely a financial disincentive to bring kids off of medications, regardless of the system of review for the medication initially; foster care payments drop
  • Wu – This is something we spoke about in 2017 with CPS reform, there are some foster families doing this for the paycheck; with mental health, we do not put a kid on medication unless a doctor prescribes and a length is specified
  • Wu – I think this can occur when a family keeps bringing a child to the doctors thought he doctor says the child is fine, though I think this is relatively rare
    • Blackstone, DFPS – I think HHSC has done some work on this and has data
    • Muth, HHSC – Refers to HHSC presentation (link)
    • The high point for use of psychotropic medication was in 2004 when ~41% of children were receiving it for some period of time
    • DFPS, HHSC, and DSHS came together and formed psychotropic medication use and dose parameters
    • Health plan is required to conduct psychotropic use reviews regularly, use has been significantly reduced
  • Frank – So less than 25% of children are on medications, but 53% have mental disorders
    • There are other treatments aside from medication

 

Kristene Blackstone, Department of Family and Protective Services

  • SB 11 created the Family-Based Safety Services, required contracting with provider to deliver these services in-home in two areas of the state; started in El Paso and mission is to reduce abuse & neglect, works with OSARs & uses evidence-based practices to reduce entry into foster care
  • Children can experience trauma that doesn’t manifest until later, can cause cascading problems; DFPS has provided some funding to stabilizing children in danger of placement breakdowns
  • Children in foster care often have a higher level of need, children do need higher level of services; Legislature supported massive expansion of community-based care through performance contracts
  • Contract pays on a blended rate, which incentivizes the contractor to step children down to less-restrictive environments; also requires contractors to build capacity for all children
  • Also running 3 contracts supporting foster care with foster parents who have received extensive training
  • Legislature also approved a rate for those providing care to children with intense needs
  • HB 1542 reclassifying cottage homes as a least restrictive setting, expands capacity for children no longer needing intensive care
  • Barriers exist for parents to seek treatment for substance abuse, waitlists, geography, etc., running facilities that allow children to remain with parents while they are receiving services
  • Can be difficult for parents to retain proper employment or childcare services while receiving treatment
  • Bulk of DFPS appropriation for substance abuse goes to drug testing, ~$5.28 million; drug testing is necessary at all steps of the process
  • Also contract for counseling and therapeutic services, paid for in limited circumstances such as when parents are on waitlists
  • Family drug courts have spun up in a number of places around the state, e.g. Bexar county has implemented a family drug treatment court, outcomes are proven nationally
  • Would like to explore ways to provide more supportive services to parents & build capacity
  • Cortez – Regarding Bexar County, is this something that can be replicated statewide?
    • We have drug courts in a number of places in TX< have seen the Judge present on his model
  • Wu – We don’t have great data on children in foster care with drug issues?
    • Whitman, DFPS – No, we do not have regional data of what is more prominent where
  • Wu – One of our local judges had requested this data through my office to present on addiction in children in foster care; what data is available?
    • Blackstone, DFPS – We can get Superior data on children diagnosed
  • Wu – Two part concern, children can pick up drug addiction because of the parents & then later become involved with CPS for their children
    • Whitman, DFPS – Correct, can become a generational problem
  • Wu – I want good data on the children and parents; what type of treatment is available for the children from the state? I know parents need to rely on 3rd parties
    • Muth, HHSC – Since children on foster care qualify for Medicaid, treatment services are available (pg. 6 of HHSC presentation)
    • Can break the data on substance abuse issues for children in foster care, see cannabis dependence and abuse, psychoactive abuse, etc.
  • Raymond – Not a good idea to legalize marijuana for recreational use, has effects on children’s development; legalization sends a signal to young children that it is okay
  • Sheffield – If these CPS children had mentally healthy, emotionally stable, and nurturing parents, they probably wouldn’t be in CPS
    • Whitman, DFPS – Correct
  • Sheffield – We are finding mental illness has a genetic component, if we can’t stabilize the parents, then we can’t expect them to approach children’s issues correctly
  • Rose – There are medical benefits for marijuana, I think the cry for marijuana is not for recreational use, but has medical uses for palliative care, etc.
  • Raymond – These are two different conversations, my comments are specifically about recreational use; would vote for specific legislation about leukemia or terminal illnesses
  • Rose – Advocates in my office have never said anything about recreational use
  • Rose – What other incidents aside from child rollovers are related to marijuana?
    • No, just these incidents
  • Rose – So every incident where the child died had to do with parents suffocating a child?
    • No, also had an incident where a parent using marijuana left children in a hot car

 

Stephanie Muth, Health and Human Services Commission

  • Link to HHSC presentation
  • Gives overview of STAR program
  • Statewide model has specific featured tailored to meet the needs of foster children
  • Star Health program helped curtail lag in getting children enrolled in Medicaid
  • Implemented electronic health passport in 2008 to help show all the billings, including pharmacy, for doctors to better manage care for foster care children
    • Helped lower amounts of psychotropic drugs being over prescribed
    • Helped provide better continuity of services
  • Reviewed Medicaid benefit services
    • Noted requirement in first 30 days for the health plan to reach out and attempt to have the child get a full EPSDT screening
  • Discussed Star Health expenditures
  • Price – what substance use specifically are the kids using?
    • Will provide more detail related to that
    • Majority is Cannabis abuse and psychoactive substance abuse and other stimulant abuse
  • Have worked toward appropriate use of psychoactive medication
  • Spoke to Turning Point – a substance abuse diversion program operating in 4 areas of the state
  • MCO is required to build clinical capacity in trauma informed care, evidence-based practices and expertise
  • Briefly described oversight of Star Health program
    • Have external quality review program
    • Engaged them in survey on Star Health Psychiatrists
    • Conducting survey of access to Star Health services and care giver surveys
  • Price – have received a lot of feedback regarding cases that need attention and some of the problems in getting services, your written testimony shows an upcoming audit, can you elaborate?
    • There are two activities related to MDCP, both initiatives will look at Star Kids and Star Health
    • Legislature passed bill for utilization review nurses specifically focused on Star+Plus program
    • Found instances of lack or receipt of services which have been corrected
    • Expanded efforts into Star Kids and Star Health which is underway
  • Miller – how much flexibility in services are there for kids in Medicaid?
    • There is access to medically necessary treatment, the MCO is able to make a denial if it is a service that requires prior authorization
    • There is a review process of that
  • Will be adding new time and distance standards which will go into effect in September of this year
  • $2 million in grants to increase access for targeted case management and rehabilitation services for higher needs foster care children
    • RFP is out and being reviewed
  • Collier discussed time and distance standards in terms of access to care and capacity across the state
  • Discussed telemedicine in calculation of network adequacy
  • Collier – if an MCO does not open the opportunity to use a provider, what happens? Who has the final say, the MCO?
    • They have to look for a solution, even a single use case agreement
  • Collier – is there anybody going back and verifying that the providers are taking new patients?
    • They do not all come together to give us a good picture
    • We asked them to do appointment availability studies, but if a provider says they are not taking Medicaid patients they are removed from the study – an example of issues in getting a more comprehensive view into network adequacy
  • Collier – network adequacy is an area that has received a lot of complaints
    • Discussed a task force charged with improving network adequacy

 

Katie Olse, Texas Alliance of Child & Family Services

  • Described the alliance
  • Wants a focus on preventative service
    • Should better fund those services at the state level
  • Noted many outpatient services are available
    • Highlighted the Hope Clinic in San Antonio and Spirit Reigns north of Austin
  • Since FY 2015 more kids are entering the foster system than leaving
    • FY 18 as of June, more than 900 more kids have entered than have left
  • Spoke to the systemic issues with type and capacity needs
  • Discussed difficulty of identifying trauma and the associated healing process
    • Need abundant supply of trauma informed treatments
  • Hosted focus groups last year with STAR Health Leadership for stakeholders – noted result was determination of addition support for those in the home
  • Correct placement is critical
  • SB 11 provided many opportunities but need to build service capacity

 

Pamela McPeters, TexProtects

  • Provided members with data regarding substance use in their counties
  • Up to 80% of adults associated in child welfare case involve substance abuse
  • In last 10 years Texas has experienced 28% increase in removals due to parental substance abuse
  • Described permanency plans for children in foster care as well as timely manner of adult drug and alcohol rehabilitation programs
  • Reviewed map of locations where the 7 contracted programs with DSHS that offer residential programs for women with their children
    • Hopes the legislature will expand these types of quality programs
  • Discussed possible saving from results of START program in Kentucky
    • Written testimony shows multiple other programs with their cost benefit analysis
  • Recommendations:
    • Establish specialized case workers in locations that have the greatest need, giving them additional training for substance abuse related best practices
    • Invest in substance abuse disorder statewide to ensure adequate geographic distribution
    • Implement performance-based contracting for purchase client services

 

Kate Murphy, Texans Care for Children

  • Untreated substance use has significant health impact on children and adults
  • Drug overdose is significant factor in maternal mortality
  • Seeing trend in younger children being removed related to substance use, 37% are under age of 3 in Texas
  • Raymond – Is Texas matching the national trend?
    • Do not have specific information on that
  • 13% of all referrals to treatment centers are from DFPS
    • About 50% of cases are methamphetamine related
    • Will provide the other percentages to the committee
  • There is more than can be done to support these families
  • Recommendations:
    • Need to have more complete data on substance use trends regionally through DFPS
    • Need more effective partnerships with OSARs
    • Need better training on best practices for DFPS staff related substance abuse
    • Need more access to specialized treatment
    • Lacking cohesive continuum of care to meet the needs of the state
    • Should encourage family visitation in substance abuse cases
    • Need additional prevention programs
  • Guerra – mentioned the Rio Grande valley regarding the limited resources?
    • There are just fewer treatment facilities in the Rio Grande valley
  • Guerra – what type of outreach would you recommend for the Rio Grande Valley
    • Recommends increasing investment in those types of treatment
  • Frank – mentioned better results in Austin in drug court, can you elaborate?
    • Travis county drug court transitioned into a preservation mindset and keeping families together and graduating them from the drug court program
    • Have data that can be provided to the committee
  • Would like to see more cases are shifted to FBSS, would also mean that the services need to be effective

 

Chris Bryan, Clarity Child Guidance Center

  • Described the organization
  • Have inpatient and outpatient programs
  • At any given time 10% of kids that they see are in the STAR Health program
  • Concerned with early intervention
  • Discussed issue with how many kids are medically cleared for discharge but do not have appropriate placement options upon release
  • Sometimes confusion with reason for extended stays in inpatient psychiatric facility (if it was medical discharge + placement or not) – could create arbitrary view for other placement options
  • Raymond – how long have you been helping this segment of kids?
    • Decades at least
    • Fundraising has had to dramatically increase in the last 6 years
  • Average length of stay was 53 days
  • Described specific example of long term stay for very young child
  • Suggest limiting inpatient stays where possible
  • Minjarez – noted the good work that this organization does

 

Spotlight on Public Testimony

Brandy Howard, Disability Rights Texas

  • Shares experience as attorney ad litem, many foster children have not been treated well and have behavioral health issues that are difficult to manage & have not been treated properly
  • Has worked with Superior to help families get wraparound services, but often families have had no contact with Superior
  • HCS waivers should be increased, children with disabilities are often stuck in RTCs
  • Price – Is what is in the written material over difficulties with Superior accurate still?
    • Still a big issue, there are systemic issues, e.g. caseworker recording incorrect contact number; foster parents often don’t know about different legal and behavioral health

 

Cecilia Hellrung, Attorney

  • Shares experience as an attorney specialized in child advocacy & as attorney ad litem, also worked developing mental health policy for JAG
  • Trauma can often be difficult to detect, trauma is very present in the foster community
  • More legislative work needs to be done on RTC stays, should look into housing and therapeutic homes and alternative placements

 

Michelle Hansford, Certified Peer Support Specialist

  • Substance abuse and untreated mental health issues lead to breakdown of family units and lead to children in foster care
  • Shares experiences at Santa Maria Hostel as a peer support specialist

 

Traci McMurtry, Certified Peer Support Specialist

  • Shares experiences at Santa Maria Hostel as a peer support specialist

 

Stacey Burns, Nexus Recovery Center

  • Regulations surrounding MAT are confusing, pregnant women are often asked to come off MAT that is sustaining recovery after delivery
  • Raymond – Why do they do this?
    • I think it’s a lack of education, perhaps they don’t believe a person should be on methadone
  • Raymond – Asks for someone from the agency to answer
    • Blackstone, DFPS – This shouldn’t be our practice, I don’t think this is our practice
  • Raymond – Asks Blackstone and Burns to discuss

 

Columba Wilson, Self

  • Shares experience with grandchildren in the CPS system after they were taken away from her daughter, has had difficulties obtaining custody
  • Zedler – Suggests Wilson visit with her Representative and Senator

 

Judy Powell, Parent Guidance Center

  • Trauma-informed system should also include parents, not just children; parents are not often treated as well & typically are looked down on and ignored

 

Melinda Picott, Self

  • Shares experience with caring for step daughter with rare disability & difficulties with the biological mother and CPS

 

Lee Spiller, Citizens Commission on Human Rights

  • Up-charting does occur, patients are diagnosed and drugged to make money; we do not have a specific fraud control system for foster
  • Concerned about prescription drug use, mental health diagnosis is stigmatizing & parents need a defense; need to be wary about psychotropics