Senate Committee on Health and Human Services Publishes Interim Report

Print 🖨

The Senate Committee on Health and Human Services has published their interim report to the 85th Legislature. The report addresses discussions on nine charges. Provided below is a spotlight on the recommendations and/or conclusions; however, for complete details please refer to the full report.

Interim Charge 1 – Fetal Tissue/Wrongful Birth

Fetal Tissue
1. Identify DSHS as the entity responsible for enforcing the prohibition on the sale of human fetal tissue.

2. Criminalize the receipt of any payment made in exchange for human fetal tissue.

3. Incorporate the federal prohibition against solicitation or acceptance of tissue from fetuses gestated for research purposes into Texas law.

4. Increase criminal penalties for buying or selling human fetal tissue.

5. Make it unlawful to offer or provide a woman with incentives to undergo an abortion procedure or donate fetal tissue.

6. Prohibit the donation of human fetal tissue acquired as a result of elective abortions.

7. Limit the receipt and use of donated human fetal tissue to accredited universities that utilize an Institutional Review Board (IRB) process.

8. Require DSHS to develop a standardized consent form to be used by hospitals, birthing centers and Ambulatory Surgical Centers who donate human fetal tissue.

9. Create an annual reporting requirement for hospitals, birthing centers and Ambulatory Surgical Centers that donate fetal tissue.

10. Require records maintenance of instances of fetal tissue donation for a period of seven years or for five years after a minor reaches majority.

Wrongful Birth
1. Eliminate the cause of action known as "wrongful birth" from statute.

2. Direct the Texas Medical Board to continuously track the number and disposition of complaints related to a physician's failure to inform a family of a potential disability in utero or their failure to perform standard testing to detect abnormalities.

Interim Charge 2 – Child Abuse/Foster Care

Recurrence of Abuse and Neglect
1. DFPS should track and utilize additional information including:

Past criminal history of the perpetrator and CPS history in other states.
Recurrence of abuse or neglect tied to the same perpetrator, even if the victim is a different child.

Cases in which another child living in the same home is subsequently victimized.

2. DFPS should continue to pursue efforts to utilize the expertise of forensic investigators and analysts to more accurately assess risk and determine case disposition and the level of services that a family may need.

3. CPS should continue working with CACs to ensure the MEP rollout continues statewide. This program has delivered positive preliminary outcomes and has increased communication between law enforcement, CPS, and CAC staff.

4. DFPS and the Legislature should carefully monitor the launch of an FBSS single broker model of delivering and managing FBSS purchased client services. DFPS should serve a quality assurance role in the pilot and should discern if services offered to families in FBSS are delivering quality outcomes.

5. PEI should utilize predictive analytics to locate areas at high risk of abuse and neglect to target prevention efforts and prioritize service delivery.

PEI should continue exploring and expanding the use of data to target specific risk factors in a community such as violent crime, domestic violence, human trafficking, involvement with the juvenile justice system, low school attendance and readiness, etc. that are correlated with child abuse and neglect.
Using predictive analytics, PEI programs should concentrate on the highest risk areas for abuse and neglect according to the data, including targeting services at the community or neighborhood level rather than county or zip code level, concentrating on the highest risk areas for abuse and neglect according to the data. This data should be used to pinpoint areas to target services and prevention efforts, not specific individuals or families.
PEI should strengthen and grow its partnerships with academic institutions capable of aggregating and analyzing data in these areas to target prevention programs. These institutions should measure outcomes and identify what steps were taken to ensure appropriate services were implemented in high-risk areas.

6. The Legislature should consider the efficacy of targeting more prevention resources to families with prior CPS case history. Only three prevention programs target families with prior CPS involvement, and funding for these programs only accounts for 1.6% of the entire PEI budget, about $1.5 million per biennium.

7. PEI should explore additional outcome measures to determine the effectiveness of targeted prevention programs at improving child welfare and well-being, not just ensuring child safety. DFPS should collaborate with community partners as well as higher education systems to continue evaluating the effectiveness of these programs.

8. DFPS should review its record retention policy and determine if it is adequate to ensure children’s safety with their biological families.

High Acuity Foster Kids
1. Develop a clear, uniform definition of children with “High Needs"

Develop a definition that captures not only children currently in crisis, but also those at an elevated risk of experiencing a future crisis without appropriate and timely services.
Create a system to identify high needs children as soon as they enter the system to enhance care planning and preventative services and supports.

2. Expand Services for Children and Families

Encourage more collaboration between CPS and LMHAs to increase utilization of available services such as Targeted Case Management and Psychosocial Rehabilitation.
HHSC and DSHS should work collaboratively to ensure training and support is available to all interested providers who have the capacity to become credentialed and contracted to deliver targeted case management and mental health rehabilitative services.
Continue expansion of Superior's Turning Point Program statewide, beginning with areas of the state with the greatest number of high needs foster children.
DFPS and Superior should continue expansion of Foster Care Centers of Excellence statewide and facilitate relationships regionally with providers.
Ensure all foster and adoptive parents, caseworkers, and providers receive evidence-based trauma informed training, especially if they will be caring for a child with high needs.
Ensure all foster care children receive their EPSDT screening within 30 days of entering care, and impose financial sanctions on Superior and CPAs who fail to meet the 90% benchmark by the end of FY 2018.
Direct DFPS and HHSC to develop a triage assessment to occur within 3-5 days of entering care to identify high needs children and expedite services and supports for those children.

3. Develop Statewide Capacity

DFPS should require every catchment area to create and implement a local plan to develop, monitor and maintain capacity based on DFPS' Occupancy Analysis. The local plan should be developed by regional leadership in collaboration with local providers, faith-based entities and other stakeholders and should be updated annually.
The agency should consider the use of technology to monitor changes in capacity and placement needs on a real-time basis.
Focus capacity efforts for high needs children on the development of treatment foster homes, wrap-around services, and in-home supports to provide a continuum of services. Consider enhanced funding for these types of placements, including paying CPAs an enhanced rate for the development of capacity in therapeutic foster homes comparable to the rates paid to RTCs. DFPS is pursuing a pilot to test this model. The Legislature should carefully monitor the results of this pilot and consider expanding if it is successful.
Better utilize the faith-based community to recruit foster homes and therapeutic foster homes for high needs children. More of the agency's efforts will be discussed in the Strengthening Adoptions section of this report, but DFPS should continue to better understand the need for foster and adoptive families by region, and partner with faith-based entities to recruit needed levels of foster and adoptive families in those areas. The state should also ensure that faith-based entities' First Amendment rights are upheld and any barriers to partnering with these entities are removed as the agency works to build and grow these collaborations.

4. Build an integrated and accountable case management system

Implement the Stephen Group Pilot which will establish a lead agency in a single region to implement integrated case management services for children in foster care who represent the population of children with the most acute medical and behavioral health needs. The lead agency should coordinate the activities of all entities responsible for a child's medical, placement, and behavioral health case management and ensure all components are utilized effectively without duplication to achieve quality outcomes. This lead entity should receive a separate rate for placement and be held accountable through their contract to:
- assume greater service coordination and risk for children they agree to serve;
- accept increased placement responsibility by implementing a no eject, no reject policy;
- be responsible for ensuring the provision of all the services a child needs, including intensive wrap-around services; and
- be responsible for ensuring children move from RTCs and psychiatric hospitals to lower level placements.

The entity should be paid in part based on outcomes, including:

Improvements in safety, placement stability and permanency;
Decreases in RTC placements and length of stay; and
Decreases in inpatient psychiatric placement and length of stay.

Continue rollout of the Single Child Plan of Service initiative sought to change the practice of separate case planning and bring all parties together to develop one plan for the child. Ensure providers are involved in developing a Single Child Plan of Service.

5. Hold CPAs Accountable and Pay them for Performance

Expand the performance-based demonstration to apply to all contracted providers across the state.
Develop additional outcomes related to child health and behavioral health.
Tie payments to outcomes, including penalties for poor performance and incentives for high performers, beginning in FY 2018.
Reform the current level of care system in order to incentivize more appropriate treatment and placement decisions.
Consider increasing rates to adequately cover the costs of caring for high needs children.

6. Expand foster care redesign

Foster care redesign is working in Region 3b and should be expanded. Expansion to Region 2 is currently underway. CPS should consider strengths, weaknesses, and lessons learned from past and current foster care redesign contracts when developing new contracts with a Single Source Continuum Contractor.
New SSCCs should be required to be non-profit entities.
An extensive readiness review should be conducted prior to expanding to a new region, and prior to moving into a new phase of a contract.
DFPS and HHSC should work to develop rates that accurately reflect the cost of care and the transfer of risk to the SSCC over the three phases of implementation.
SSCCs should be allowed to transition to phases two and three more quickly if they pass a comprehensive readiness review.
Conservatorship case management should be fully transferred from DFPS to the SSCC in Phase 2, but CPS should maintain contract oversight and quality assurance roles.

7. Strengthen collaboration and communication between providers, CPS, families, and
children

Continue building networks between CPS well-being specialists and caseworkers to ensure caseworkers are educated about the services and supports available for high needs children, and ensure caregiver knowledge of services and trauma informed care.
Improve the Health Passport to make it more accessible and less time-consuming. DFPS and Superior should consult with medical and behavioral health providers, CPAs, families, CASA, etc. to gather feedback and recommendations on how to improve this tool.

Adoption Disruption
1. Increase collaboration with faith-based organizations and congregations to recruit, train, and support foster families.

Starting in July 2016, DFPS began working to strengthen its partnerships with faith-based entities and better track its partnerships with them. This work should continue, and the state should explore ways to further develop faith-based partnerships to recruit foster and adoptive families.
As of July 2016, DFPS is collecting and tracking data on how many faith-based partnerships involve foster/adoptive recruitment, how many partner with the CARE portal, and how many provide services such as respite. The Committee supports this effort and encourages the agency to continue to better understand, by catchment area and region, where partnerships are needed and how they can be reinforced and better utilized.
The Committee supports the Lieutenant Governor's Adoption Summit on November 2, 2016, as an opportunity to foster additional collaboration and communication between faith-based entities, the agency, stakeholders, and the Legislature on how to better recruit foster/adoptive parents and ensure foster children find permanency in safe, loving homes.

2. DFPS should ensure adoptive families are given a full and complete history of the child. DFPS should review the information that is redacted from children's records and ensure that the child's history is portrayed accurately to a potential adoptive family. DFPS should ensure potential parents are given these records in a timely manner.

3. DFPS should focus on ensuring families and caseworkers receive appropriate training.

All adoptive families should receive trauma-informed training.
The agency should ensure statewide availability of adoption-specific training for caseworkers and supervisors and should utilize the Best Practices Guidelines created in 2013 as a starting point for this training. Training should include recruitment efforts and matching and selection processes for adoption workers and training for families.
The agency should also establish minimum requirements for adoption worker performance.

4. DFPS should review its adoption process to ensure children are placed in suitable, supportive homes in a timely manner.

DFPS should ensure children are involved in the pre-placement process and are ready for adoption.
DFPS should ensure that while its focus is on permanency, it is certain that the child is ready for adoption and understands that they will be adopted.
DFPS should identify children most likely to experience an adoption dissolution or disruption and provide individualized services.
Triggers should be created to alert caseworkers, agencies, and post adoption service providers of children and adoptive families who are more likely to experience problems.

5. Post adoption service contracts and performance measures should be evaluated and measured using quality metrics and outcomes.

Targeted funding for in-home, wrap-around services and supports should be considered for children with a higher disruption risk.
DFPS should review and reform its performance measures for post adoption contracts to ensure the contracts and outcomes incentivize providers to offer high quality, preventative services, and make data regarding the quality of services available to CPAs, caseworkers, and adoptive families.

6. DFPS should implement recommendations from the internal adoption audit related to recruitment. Specifically:

Ensure recruitment occurs while simultaneously preparing the child for adoption.
Develop and monitor regional outcomes for targeted recruitment efforts.
Update TARE by ensuring children's profiles are posted and photos are updated in a timely manner, and require information and inquiries to be reviewed promptly to ensure outdated information is excluded from the website.
Ensure inquiries outside of TARE are tracked and performance metrics are established to ensure responsiveness to potential adoptive families.
Develop minimum documentation requirements for a child's recruitment activities and matching and selection decisions.

Interim Charge 3 – Aging

Healthy Aging
1. HHSC should better utilize universities to study the effectiveness of existing state programs focused on preventing and controlling chronic diseases.

2. Establish a collaborative leadership council to bring together universities with research programs focused on healthy aging in order to increase collaboration and share best practices.

This Council would bring together state leaders in aging research and clinical care to better understand the determinants of healthy aging in older adult populations, expand interventions that promote healthy aging, and translate the state's investment in healthy aging research into sustainable community-based programs and interventions.

3. Require the Executive Commissioner to appoint a Statewide Aging Coordinator to coordinate efforts on healthy aging and to lead the development of a comprehensive strategic state plan.

Require state agencies that receive funding for aging-related research, clinical care and community programs to report expenditures to the Aging Coordinator in order to identify areas where more collaboration could improve program effectiveness, and areas where the state may be duplicating efforts. The Coordinator should spearhead efforts to eliminate duplicative programs, committees, reports, and campaigns.
The Coordinator would facilitate the creation of a comprehensive state wide Strategic Plan on Healthy Aging, beginning with the federally-required State Plan on Aging, and adding additional elements as appropriate.
The Coordinator would also be required to promote collaboration within the enterprise, across all state agencies, and between state and local entities.

4. Expand veteran specific supports to the state's aging veteran population through ADRCs.

HHSC should assist in the expansion of veteran-specific services from 17 ADRCs to all 22 ADRCs.P35F36P The agency should consider requiring a collaborative link between ADRCs that do not provide these services with those that do in order to maximize the efficient use of existing resources.
HHSC should assist in the expansion of Veteran-Directed Home and Community Based Services (VD HCBS) programs by examining what areas of the state would benefit most from the program. Since these programs are federally funded, the agency should assist ADRCs in pursuing grant opportunities.

5. Remove the Legislative Committee on Aging from statute.

Given the multitude of plans, advisory bodies, and programs focused on healthy aging, and the work of standing committees in the House and Senate on this issue, a separate Legislative Committee is no longer necessary.

6. Require the revamped Strategic State Plan on Aging to contain outcome data for disease prevention and management programs.

HHSC should use this data to compare programs and examine ways to support the most successful programs.
As mentioned above, HHSC should also utilize the expertise of university aging experts to analyze the effectiveness of current programs.

7. Support respite services for caregivers.

The Legislature should consider expanding the Texas Lifespan Respite Care Program to additional areas of the state.
HHSC should also engage with our federal partners to expand the availability of respite benefits for caregivers of Medicare-eligible individuals who do not qualify for hospice but have a serious chronic serious health condition and requires assistance for at least two activities of daily living.

Long-Term Care Quality and Oversight
Enhancing Regulatory Tools:
1. Where appropriate, increase administrative penalty caps. Specifically:

Remove per inspection caps on ICFs/IID penalties;
Increase ALF penalty caps to $5,000 for the most serious violations;
Increase the penalty cap for HCSAAs to $5,000 for the most serious violations. The highest level violations should be delineated to ensure only those violations that result in actual harm or serious jeopardy are subject to the higher penalty cap.

2. Remove right to correct for violations that cause actual harm to clients.

3. Direct DADS, through rule, to create a matrix of progressive sanctions based on scope and severity of violations for each provider type.

4. Increase transparency for dementia related care by requiring all nursing facilities to inform residents and potential residents whether or not they have Alzheimer's certification.

Reducing Administrative Burden on Providers:
5. Require that, unless they are issued in response to an emergency situation or at the request of the federal government or providers, informational letters, policy changes, and policy clarifications must be issued to providers in a monthly or quarterly packet in a streamlined and coordinated fashion. All such documents should clearly explain the objective, how to implement the changes, and what existing policy, if any, is being altered.

6. Consider allowing a three year licensure period for all long term care providers, while maintaining current survey schedules.

Survey Consistency:
7. Consider requiring surveys that result in administrative penalties to be signed off on by individuals with expertise in the area in which the violation occurred.

Staffing:
8. Encourage partnerships between nursing facility and long term care providers, and medical and nursing schools to increase interest in entering the field of caring for geriatric patients and individuals with intellectual or developmental disabilities.

9. The Legislature should consider increasing funding for the nurse staff enhancement and the community-based provider wage enhancement program. If funding is appropriated for this purpose, payments to providers should be based on the achievement of performance measures tied to quality.

10. Continue efforts to leverage expertise at SSLCs to support clients in the community.

DADS plans to implement a pilot in the fall of 2016 to provide dental services to HCS clients at the Austin and Richmond SSLCs. The benefits of this pilot should be monitored to determine additional ways to leverage appropriations that are allocated to SSLCs to ensure the most efficient use of resources as the SSLC census continues to decline.

Interim Charge 4 – Medicaid Reform and the 1115 Transformation Waiver

1. HHSC should aggressively pursue a longer term renewal of the 1115 Transformation Waiver.

2. HHSC and the Legislature should continue to have a clear focus on bending the cost curve in the Medicaid program.

3. During negotiations, HHSC should pursue a streamlining of DSRIP project outcome measures to ensure that CMS and the state can accurately measure the cumulative impact of DSRIP projects on health outcomes and cost savings.

Interim Charges 5 & 6 – Inpatient Mental Health Reform/Diversion and Forensic Capacity

1. Protect the investment the Legislature has made in developing the state's mental health system. State budget writers will face serious budget constraints in developing the budget for the next biennium, and difficult decisions will have to be made in order to live within the state's means. However, the Committee recommends that the Legislature should prioritize protecting past investments in mental health. If not, Texas will lose capacity in both forensic and community based settings, compounding the issues that are currently facing the state.

Expand Capacity:
2. Address the inpatient forensic wait list by expanding capacity in the current system.

State Hospitals:
- Fund additional maximum security beds at Rusk and/or Vernon. This would reduce the MSU waitlist and increase the current MSU capacity in the state.
- Begin plans to replace ASH on its current campus, including residency or operational agreements with UT's Dell Medical School. ASH's situation is unique when compared to other state hospitals because of its location in an urban center less than four miles from a medical school. The state should research opportunities for external funding partners, including philanthropy.
Community Beds: In addition to growth within the state hospital system, the state should consider options for contracting forensic beds in the community. The benefit is twofold: community beds allow individuals to receive services closer to their home and are often cheaper than state hospital beds. While the committee recognizes the budget constraints facing the state, we recommend prioritizing the following:
- Contract for additional forensic capacity with University of Texas Health Science Center Tyler (UT HSC-Tyler). The State currently contracts with UT HSC-Tyler to operate 30 residential inpatient beds and has the capacity to expand from 30 to 60 civil and/or low risk forensic patients. The capacity is already in place and can be operational as soon as funding is available.
- Contract for additional forensic capacity with Harris County Psychiatric Center (HCPC). There is significant outstanding need for inpatient capacity in Harris County. Harris County falls within the catchment area of Rusk, meaning that if an individual is found incompetent to stand trial in Harris County and no beds are available at HCPC or Montgomery County Psychiatric Center, they must be transported to Rusk three hours away. There the individual is restored to competency and transported back to Harris County. Treating individuals closer to home is not only better for long term recovery and continuity of care, it reduced costs and burdens on staff, often law enforcement, who have to transport individuals over long distances.
- Strongly Consider Options For Contracting with other University Health Science Centers to operate facilities similar to UT HSC-Tyler and UT Health at HCPC. The University of Texas Southwestern Medical Center (UTSW) provides another unique opportunity for the State to contract with a university health science center for the operation of a psychiatric facility that treats forensic and civil patients. This would allow the state to reduce state hospital capacity by moving civil capacity from Terrell State Hospital to this new facility along with opportunities to care for low risk forensic patients, while at the same time provide training opportunities for psychiatric residents and other mental health care students at UTSW.

3. Expand successful Outpatient Competency Restoration Programs. This would allow additional individuals to be served in a more appropriate and less restrictive setting, while taking pressure off the state mental health hospital system.

4. Consider restricting where an individual charged with a Class B Misdemeanor can be committed for care. Modify Chapter 46B of the Code of Criminal Procedure to prevent an individual found incompetent to stand trial and charged with a Class B Misdemeanor from being committed to a state hospital. Instead, the individual could be committed to an inpatient facility other than a state hospital or released on bail for outpatient restoration if the individual is not a danger to others.

Building a Continuum of Care for High Utilizers:
5. Remove unnecessary process measures from LMHAs to allow them flexibility to appropriately and effectively serve high utilizers. Contract requirements with local LMHAs prevent effective outreach to individuals in need of service. Building flexibility in contracts would allow local providers to better serve their population. Funding flexibility should be tied to reduced recidivism rates in the LMHA service area. General Revenue funded ACT teams should have the same flexibility as non-GR funded ACT teams, such as the Housing First ACT team at Austin Travis County Integral Care.

6. Expand the Harris County Jail Diversion Program to other areas of the state, with a local match requirement and local option to utilize funding to address other capacity issues such as forensic waitlists. The successes of the Harris County Jail Diversion Program should be expanded to other areas of the state that could benefit from such a program. However, it may not make sense to expand the exact same program in certain areas of the state, so flexibility needs to be built in to allow local communities to create programs for the purpose of achieving specific outcomes related to recidivism and forensic commitments.

7. Consider piloting a psychiatric step-down program as proposed by HCPC. The program should include ongoing case management, supportive housing, and substance abuse treatment and should focus on individuals with multiple psychiatric inpatient stays. The pilot should be required to closely track outcomes such as recidivism rates and cost savings.

8. Apply recommendations made as a result of Rider 80 related to crisis intervention. Make any changes necessary to fully develop and maximize capacity in the crisis intervention system.

Addressing Workforce Issues:
9. Address major staffing issues in our state hospitals and local mental health system by partnering with universities. Continue funding the Psychiatric Residency Stipend Program which provides for residency rotations at a number of LMHAs. Pursue additional residency training programs between state mental health hospitals and university health science centers, such as the contract between the UT Health Science Center at Tyler and Rusk State Hospital. The state should also track the number of residents who decide to remain working in the public mental health system.

10. Require the Texas Medical Board to create an expedited licensure process for out-of-state psychiatrists. A psychiatrist applying for expedited licensure in Texas would need to be board certified; possess a full and unrestricted license to practice in another state that has no disciplinary action, suspension, or restrictions; have never been convicted or received adjudication; and not be under active investigation by a licensing agency or law enforcement in any state, federal, or foreign jurisdiction.

11. Expand the Mental Health Professional Loan Repayment Program. Continue funding and expand the Mental Health Professional Loan Repayment Program. Examine opportunities for additional funding options, such as federal matching programs.

Interim Charge 7 – Telehealth

1. Any further expansion of telemedicine should fall within the standard of care.

2. Increase the use of telemedicine and telehealth across state health agencies.

DSHS: Ensure Telehealth capability in all state hospitals. Only four state mental health hospitals currently utilize telehealth services. DSHS should report on the use of telehealth services in the state hospital system and determine if expanding telehealth services system wide would be beneficial, the cost associated with expanding telehealth to additional state hospitals, and the potential impact expanding telehealth services would have on length of stay, cost containment, and capacity.
DFPS: Ensure children with high medical and mental health needs are more quickly connected to necessary services and supports by allowing CPS case workers to be authorized patient site presenters. The Texas Medical Board and DFPS should create an education and certification process for CPS case workers to be telepresenters. The process should teach case workers how to perform a triage survey in order to identify children who need higher levels of care and how to properly use telemedicine equipment. This should not take the place of an in-person medical visit, but should be used to better triage children with high levels of need.

3. Work with Congress and the Drug Enforcement Agency to allow psychiatrists registered with the DEA to prescribe controlled substances via telehealth. The Ryan Haight Online Pharmacy Consumer Protection Act requires that any prescription of a controlled substance must be obtained by a practitioner who has conducted at least one in-person medical evaluation. There are some exceptions, including an instance in which the patient is located in a facility registered with the DEA and is being treated by a DEA-registered provider.P42F43P Since an in-person visit is not required for telehealth services, the requirement that the patient be in a DEA registered facility should be removed. However, due to the prevalent issue of prescription drug addiction, the prescribing psychiatrist should be allowed to prescribe all necessary medications to treat a mental illness, excluding opioids and other pain medications with a high risk of dependency.

4. Expand the University of Texas's Virtual Health Network (UT-VHN) to other health institutions. In February 2016, the UT Board of Regents approved $10.8 million over four years for the development of a Virtual Health Network, building on current telemedicine services used in the system.P43F44P This recommendation would allow different university health systems to share resources and expertise across the state. Other university health systems would then be able to connect to other health care settings in their region, increasing access to all levels of care statewide.

5. Expand the use of telemedicine to ensure timely access to trauma services. Allow telemedicine to satisfy certain trauma facility designation requirements for facilities located in rural counties. Additionally, the Legislature should monitor the success of the Next Generation 911 Telemedicine Services Pilot in West Texas to determine the success of the program in connecting more rural Texans to EMS and trauma services, and whether an expansion of the pilot is warranted.

Interim Charge 8 – Refugee Resettlement

1. Require HHSC to consider the creation of a state license for local refugee resettlement agencies. The state has a vested interest in ensuring the security of Texans and in protecting vulnerable refugees from exploitation once they arrive in our state. The Legislature chooses to regulate certain industries that work with vulnerable populations through licensure, such as Child Placing Agencies that are licensed by DFPS. This allows for oversight and maintenance of minimum standards. Currently, the only oversight the state has over local refugee resettlement agencies is contractual, but that will end once the state is no longer the federally designated state coordinator, effective January 31, 2017. The legislature should consider licensure for local refugee resettlement agencies to ensure adequate security measures are taken prior to relocating refugees to Texas, to ensure refugees are being cared for in accordance with state laws, and to provide the legislature and local entities with more information on when and where refugees are entering Texas. This would also allow the state to evaluate the success of programs provided to refugees by local agencies.

2. Explore options to require refugees to default into Refugee Medical Assistance program instead of Medicaid/CHIP. Currently, the RMA is the payer of last resort, and refugees default into Medicaid or CHIP, as applicable. This arrangement is unique to the refugee program because Medicaid and CHIP are typically the payer of last resort. This leads to higher costs for the state and reduces the financial burden on the federal government.

3. Petition Congress for a higher FMAP from the federal government for refugees enrolled in Medicaid/CHIP. The federal government currently uses the standard Federal Medicaid Assistance Percentage (FMAP) to determine what percentage of Medicaid costs attributable to refugees are borne by the federal versus the state government. Since the state has no power to determine how many refugees are
resettled in our state or what services they are entitled to, there should be an enhanced FMAP for refugees.

4. Direct HHSC to work with local communities who are disproportionately impacted by the refugee program to submit an annual fiscal impact report to ORR. The state has an interest in protecting the financial stability of the state and local communities from unfunded mandates by the federal government. The federal government chooses to send refugees to the state with little to no input from the state and local communities, and fails to recognize the full costs of accommodating those refugees. HHSC should assist local communities with calculating the full costs of refugee resettlement to local governments including local ISDs, healthcare systems, Emergency Medical Services and law enforcement, and reporting those costs annually to ORR to provide a more accurate picture to the federal government of the financial burden placement of refugees will have on local communities.

Interim Charge 9 – Implementation of Legislation

DFPS Sunset Implementation
1. The state should continue to monitor implementation of all Transformation initiatives currently in progress, understanding that culture change and better outcomes are long-term goals that will not happen within a year.

CPS initiatives should be looked at in tandem with redesign to ensure that collaboration occurs between pilot programs and redesign, and that pilots introduce elements of the FCR model to providers and caseworkers in the legacy system.
DFPS must continue to push forward with key initiatives, but should prioritize roll out of these endeavors to ensure caseworkers are not overburdened.
Increased accountability should continue to be a focus of all Transformation efforts. Tying incentives to provider performance in all contracts should be a priority for the agency.
The Legislature should continue to monitor IMPACT Modernization to ensure it is completed by the end of Fiscal Year 2017 and includes all components funded during the 84PthP Legislative Session.

2. Recruiting the right workers, ensuring that new workers understand their job role, and retaining workers should continue to be a focus of the agency and the Legislature.

The Legislature should evaluate locality based pay increases for areas of the state with high turnover and high cost of living.
The agency should evaluate repurposing tenured investigators for after-hour shifts.
The new CPD model is working and should be rolled out to supervisors as planned in early 2017.
The agency should ensure upper level management including Program Administrators, Program Directors and Regional Directors are well-trained and able to adequately support their staff.

3. Redesign is working and is the future of the foster care system. However, rate setting and contract design issues must be addressed in the current catchment areas before the model is expanded to new areas of the state.

Moving forward, the agency should transfer case management functions to Single Source Continuum Contractors in Phase 2 of implementation.

OIG Sunset Implementation
1. Require the IG, in conjunction with MCOs, to develop outcome measures related to cost avoidance. As the state phases out of the fee-for-service model of health care delivery to the managed care model, it is necessary for the state to adapt performance measures accordingly. In addition to evaluating SIUs and other efforts to detect fraud, waste and abuse and recover overpayments, the IG should focus on ways to determine the effectiveness of MCOs efforts to prevent fraud, waste and abuse in order to gain a more complete picture of MCO performance.

2. Require the IG to audit and monitor the eligibility system in place for safety net programs at HHSC. For the IG to transition its method of preventing fraud, waste and abuse from the fee-for-service model to the new managed care model, more attention should be paid to prevention efforts and not just back end recoveries related to fraud, waste and abuse. This begins with the state's determination of eligibility for Medicaid, SNAP, TANF and WIC. Chairman Schwertner requested this audit prior to publishing this report to ensure that all individuals receiving these benefits are truly eligible. This will protect the viability of these programs for those who truly need them, and will assist HHSC in preventing fraudulent payments or services to beneficiary recipients.

3. Require the IG, in concert with HHSC and with input from MCOs, to develop more clear guidelines for SIUs. Although the Committee would recommend against requiring a minimum investment in SIUs by MCOs, the variance in the level of SIU investment and activity indicates that MCOs may need additional guidance on how to structure and utilize these entities.

4. Require HHSC to change their rules to allow the IG to recover overpayments they detect. HHSC created rules that require all funds recovered from an MCO's referral to go to the MCO even if the IG played a role in the recovery. This requirement was made through rule and is not reflective of state statute. Giving all the recovered money, less expenses, to the MCO reduces the incentive for the IG to recover funds when a case is referred from an MCO. To ensure the IG and MCOs are appropriately incentivized, the IG should collect all funds they recover without MCO support and the MCOs should collect all funds they recover independently.

5. Require HHSC, in conjunction with the IG, to create rules to define when a provider, "presents an ongoing significant financial risk to the state and a threat to the integrity of Medicaid." The above language was added in SB 207 as a way to stop the IG from overusing CAF holds for inappropriate reasons. P20F21 P The IG is concerned the language is too restrictive. The intent of the new statutory language was not to prevent the use of CAF holds, which is required by federal law. To address this confusion, HHSC, in conjunction with the IG, should develop rules to further clarify situations in which CAF holds can be used.

Women's Health Recommendations
1. Continue to prioritize funding for women's health programs.

2. Ensure access to women's health programs across the state. HHSC should work to proactively identify and quickly remedy any access to care issues that arise in the state-funded women's health programs.

3. Increase access to Long Acting Reversible Contraceptives. This should include expanded, statewide training opportunities for the insertion of LARCs, including for mid-level practitioners practicing under the supervision of a physician.

4. Pursue policies to reduce maternal and infant mortality rates. This should include careful consideration of the Texas Maternal Morbidity and Mortality Task Force's recommendations, outlined above, and leveraging Healthy Texas Babies funding to better support the Task Force and create a collaborative approach to improve maternal and infant health.