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Below is the HillCo client report from the August 15 Senate Health and Human Services Committee hearing.
 
The committee met to consider the following interim charges:
 
Monitor the implementation of programs that were created or expanded by the 83rd Legislature to improve mental health and substance abuse services and assess these efforts' contribution to improved outcomes such as reduced recidivism in state hospitals, diversion from emergency rooms and county jails, and access to permanent supportive housing. Identify and address gaps in the current mental health and substance abuse system and make recommendations to better coordinate services across agencies and programs.
 
Evaluate the current state of prescription drug abuse and strategies for reducing prescription drug abuse in Texas. Make recommendations on how these policies can be improved or modified to enhance the State of Texas' handling of services, treatments and education related to prescription drug abuse and to reduce the overall prevalence of prescription drug abuse.
 
Evaluate the Temporary Assistance for Needy Families (TANF) program structure. Make recommendations to improve the program's operations and ensure the program achieves outcomes that allow TANF recipients to find employment and achieve self-sufficiency. Recommendations should seek to ensure Texas is using the most effective work-related requirements and drug testing protocols.
 
 
Mental Health and Substance Abuse
 
Chairman Charles Schwertner noted the legislature has shown a commitment to these issues by appropriating an additional $300 million for mental health and substance abuse services; also, 1115 waiver projects for mental health and substance abuse have been funded at around $825 million.
 
Lauren Lacefield Lewis, Assistant Commissioner for Mental Health and Substance Abuse, Department of State Health Services (DSHS)
Presentation

  • There are still gaps in the system and things that need to be improved next legislative session
  • 2% of the adult population in Texas has a persistent or severe mental illness
    • DSHS currently serves about 31% of that population
  • 5% of the child population in Texas has a severe emotional disturbance
    • DSHS currently serves about 27% of that population
  • 3% of adults with chemical dependency are served by DSHS
  • 4% of children with chemical dependencies are served by DSHS
  • In 1994 there were 3,343 state psychiatric hospital beds, now there are 2,900
  • Schwertner asked what the optimal capacity is
    • That is being determined right now
  • In 1994 there were 18.2 beds per 100,000 people in the state; there are now 10.8
  • The 14-15 biennium appropriations saw over $20 million in increased funding for the NorthSTAR program
  • Sen. Jane Nelson noted the state needs to be funding solutions not problems; would like to see a shift toward focusing on investments made and measuring outcomes
  • Last session DSHS received additional resources to meet to unmet need in mental health services
  • Funds were distributed through LMHAs based on numbers of people waiting for services
    • By May 2014 waiting lists had gone from 5,321 adults and 194 children in February of 2013 to 285 adults and zero children
  • DSHS was appropriated $43 million to expand and improve community mental health services for those who were underserved
    • As of March 2014, 1,435 adults had been moved into the appropriate levels of care
  • For substance abuse services capacity expansion, funding for an additional 948 clients was requested last session; DSHS served an additional 1,183 clients with that funding
  • In July 2013 rate increases for substance abuse treatment were approved and are now fully implemented
  • Sen. Carlos Uresti asked how many adults are not receiving substance abuse treatment
    • Services are reaching a relatively small portion of those with substance abuse issues
  • David Lakey, DSHS commissioner noted a pilot program with the Department of Family and Protective Services (DFPS) recently began in order to allow parents to maintain custodial rights of their children while receiving services; the collaboration resulted in 6 children able to access other services; will be looking for additional funds to expand that pilot next session
  • Sen. Judith Zaffirini asked how many beds will be requested
    • 30 beds; 10 are funded now
  • DSHS received an additional $10 million for substance abuse treatment and intervention services for individuals referred by DFPS; on track to meet annual goal for this program
  • DSHS was appropriated $5 million to expand mental health first aid training; goal is to reach over 12,000 educators; 11 trainings have been held to date
  • YES waiver expansion was appropriated $24 million; still working to expand that program
  • Zaffirini asked what progress has been made
    • Expansion is contingent upon CMS approval so the timeline is hard to estimate; trying to expand to all rural regions
  • Also received funding to support local mental health efforts
    • Harris County has added 6 long term beds
    • Harris County is implementing a state match program to serve at least 200 frequent recidivists  per year with serious mental illness
    • Rules for a jail based competency restoration program are in progress of being adopted; will start this fall in Dallas
  • $4 million was appropriated to the veterans mental health program to increase capacity and reach of services; working to train clinicians, volunteer coordinators
    • Program is mostly on track with goals
  • Zaffirini asked about the contract between Texas A&M and Veterans Commission
    • Very close to resolution; confident there will be a contract in place by September 1
  • Zaffirini noted if the contract is not in place by September 1 the peer to peer program is expected to end
  • The health community collaborative project received $25 million in funding; the project is a 100% match for municipalities in counties over 1 million in population; all five eligible communities were awarded grants; contract execution is expected this fall
  • The public awareness campaign, supportive housing project and Oxford House expansion are all either meeting or close to meeting target goals
  • The psychiatric residency program expects to see 19 residents rotating through 7 state hospitals and 3 LMHAs; 75% of those participating will remain in public sector practice
    • Lakey noted DSHS will be asking for additional resources to expand this program next session
  • Psychiatric nursing assistants received a 10% pay increase effective last year; have not seen a significant change in turnover rates yet
  • On track to meet deadline for state hospital ten year plan; plan is due December 1, 2014
  • Zaffirini asked about the plan
    • The system is very outdated and the whole system needs to be improved; analysis is being done on what communities people are coming from and where capacity needs to be added; will also be studying who is willing to sell capacity to the state to go along with additional capacity built out by the state
  • Zaffirini asked if any new best practices have been identified
    • Looking at best, most efficient and clinically appropriate methods for providing treatment to specialized populations
  • Zaffirini noted she would like to see veteran programs addressed in that plan
  • Nelson asked about the 10% withhold for LMHAs; right now outcomes are only being captured for people receiving services for LMHAs; how can we address that problem so that there is accountability across all communities
    • That is one of the issues being addressed throughout DSHS as a whole; measures for determining outcomes are also being studied

 
Sonja Gaines, Associate Commissioner for Mental Health Coordination, DSHS

  • With SB 58, HHSC was asked to include covered mental health rehab and targeted case management into managed care
  • A lot of work has been done with this project to ensure MCOs are on the same page
  • Will create increased choice and access for Texans
  • Zaffirini asked if the provider base is adequate
    • There are a small number of providers who have signed on and many more who are interested and working to make that happen; many have to apply for Medicaid billing authority as well
  • Also developing two health home pilots for integration of behavioral and physical health; advisory committee is working on that project
  • Lakey noted priorities for next session which need to be addressed
    • New models of care for inpatient psychiatric facilities and adult crisis mental health
    • Mental illness and substance abuse prevention
    • Addressing babies born with drug reliance through provider education
    • Individuals with mental illness in nursing facilities
  • Nelson likes the idea of buying capacity from other entities rather than investing in bricks and mortar

 
Andy Keller, Meadows Mental Health Policy Institute

  • There has not been an effort in any state to expand mental health and substance abuse services similar to what Texas implemented last session
  • Zaffirini asked if Meadows is doing anything to address the inadequate workforce issue
    • Have not weighed in yet; trying to determine where the gaps are
  • Three main policy suggestions
    • Primary care and behavioral health integration should be talked about more
      • People with mental health issues are dying three years earlier in Texas than in other states; need to address chronic illness in the mental health population
      • Can be a significant way to decrease inpatient costs and ER use
    • Cross payer coordination
      • There is a very high number of patients will mental illness who are served by Medicaid
      • 1115 waiver is a big part of this; making sure Medicaid eligibles are utilizing Medicaid services for mental health
    • Improving accountability and effective purchasing
      • Increasing reporting requirements for providers and decreasing reporting requirements for DSHS will go a long way to standardizing metrics and getting more useful data
      • Metrics have to be aligned with incentives
      • Nelson believes too many metrics are being used to evaluate mental health outcomes; which are the most important
        • Use of jails in mental health services, time it takes to get a patient services, for people with substance abuse issues it is important to track recovery measures

 
Gaines continued her presentation

  • When Gaines started in her new position, she began travelling around the state to get an idea of how collaboration across entities is working; there is lots of opportunity in that space
  • Need to look at a system that ensures Texas has a unified approach for delivery of behavioral health services that allows Texans to have access to care at the right time and in the right place
  • Zaffirini asked what the agency is doing to inform the public about crisis centers and the services they provide
    • Those services are distributed through LMHAs and many are publicizing their programs in their own ways
  • Nelson asked what is being done to erase the stigma on mental health
    • Lakey noted there was funding from last session that is going toward that effort; especially education at the youth level
  • Lots of work has been done in partnership with the Texas Education Agency to address issues with school-age children; continuing education credits for mental health first aid is a big part of that partnership
  • Zaffirini asked about suicide prevention skills training
    • Lacefield Lewis noted work is being done to further train DADS and DSHS staff in that regard
  • Challenges
    • The current system lacks a unified vision across state agencies; long range planning in particular
    • Absence of mental health screening training in professions where it would help the most
    • Need more continuity between agencies when considering transfers of patients
    • Need more uniform measures across all systems
    • Current mental health funding is diverted through 12 agencies and that creates a disconnect
    • In Texas, there is no single source to access mental health resource information
    • Access to mental health resources in rural areas
  • Nelson noted the statewide portal for mental health services needs to be developed as soon as possible; would not take any legislation or rules

 
Katharine Teleki, Senior Policy Analyst, Sunset Advisory Commission

  • During Sunset review, DSHS was asked how well they were able to integrate mental health and substance abuse systems; there are still many barriers to consolidation especially front door services
  • There is room for improvement and modernization in how services are contracted and in reporting/ measures
  • The state hospital system will be another big issue during the Sunset review
  • Significant pressure coming from the criminal justice system to address mental health populations in jails is a newer trend; system creates significant legal and financial issues
  • Recommendations will focus on the following areas
    • Improved training, resources and coordination with the goal of improving understanding of what alternatives exist for the mentally ill population
    • Need for more capacity in the system; to buy, when possible, in the community
    • Revamping how DSHS allocates state funded beds to local regions; providing incentives for appropriate use
  • Sen. Larry Taylor has heard concerns from constituents surrounding community homes; need to look less at shutting them down and more at how these types of services can be maintained
  • Taylor asked what happens to people who are found not guilty by reason of insanity or those people who do not stand trial because of mental health issues
    • Lacefield Lewis noted it is a complex system; sometimes the judge determines they are fit to reenter society, sometimes they go to state hospitals; it depends very much on the particulars of each case and what the justice system decides to do with input from DSHS

 
Prescription Drug Abuse
 
Lauren Lacefield Lewis, DSHS
Presentation

  • Texas is below the national average in prescribing opioids and benzodiazepines
  • Of those who report heroin use, 80.5% admit to nonmedical use of prescription drugs
  • Some of the more prevalent prescription drugs used non-medically by secondary school students include codeine cough syrup, oxycodone and hydrocodone
  • Nonmedical use of prescription pain relievers is highest among 18-25 year olds
  • Texas received $116.8 million from the substance abuse prevention and treatment block grant in FY14
    • 60% of funds used for treatment; 40% for prevention and intervention
  • Specialized projects for substance abuse interventions include: pregnant and post-partum intervention, parental awareness, rural/border intervention and HIV programs
  • Programs include residential treatment, outpatient treatment, detoxification, opioid substitution and specialized treatment programs
  • Alcohol and marijuana are the two highest utilized substances by people who seek treatment through DSHS; nonmedical prescriptions and heroin combine to represent a significant portion of that population as well
  • Neonatal abstinence syndrome is becoming a larger focus for DSHS; Bexar, Harris and Dallas Counties have the highest incidence of the syndrome
  • Schwertner asked where emphasis will be going forward
    • Lakey replied that neonatal abstinence is definitely one of the major efforts; addressing physician induced prescription use without birth control will be a large part of that effort moving forward

 
Mari Robinson, Executive Director, Texas Medical Board

  • Texas has been dealing with this epidemic for many years now
  • In the last few years legislation was passed implementing regulations on pain management clinics; regulation is going well; many enforcement actions have been taken
  • Working with the pharmacy board and the DEA to get the issue under control
  • The issue is being addressed at the federal level as well
  • Some of the regulatory efforts are working; Texas is now 44th among the states in drug overdose deaths
  • Texas is down to 33rd in prescribing these medications as well
  • There is a national prescription drug monitoring program that Texas is not currently a member of; Texas should be using that resource
  • Prescription monitoring program data needs to be integrated with health information exchange (HIE) systems
  • Nelson asked if there are any statutory obstacles to using the federal prescription monitoring program
    • Would have to address statute to allow interoperability with a nationwide system; probably a few other necessary tweaks

 
Gay Dodson, Executive Director, Texas State Board of Pharmacy

  • Have been concentrating on getting pharmacists away from being drug dealers; there are doctors who write the bad prescriptions as well as bad pharmacies who fill them
    • Probably less than 1% are problem pharmacists
  • Working very hard to educate pharmacists about this issue to further fix the problem
  • Pharmacy board would like to have the purview of the prescription monitoring program moved  from DPS to the pharmacy board
  • Schwertner asked if it seems like DPS would like to be freed of that responsibility
    • Those discussions have not taken place

 
RenEarl Bowie, Assistant Director of Regulatory Services Division, Texas Department of Public Safety (DPS)

  • Working to implement SB 1643 (83R) by setting up a process for the vendor to transmit data through the HIE so that only authorized individuals can view the prescription information
  • Schwertner noted there will be future discussion about  the best agency to house the prescription monitoring program

 
Temporary Assistance for Needy Families (TANF)
 
Kyle Janek, Executive Commissioner, Health and Human Services Commission

  • Welfare as an entitlement was ended in 1996 and more authority was given to the state in the form of block grants and certain requirements to establish the TANF program
  • For TANF, unless exempt, recipients are required to be involved in some work activity; 50% of all families and 90% of two-parent families must be participating in work activities; there is a financial penalty if states do not meet those targets
  • For FY14, $495.3 million in block grant funding was appropriated to TANF; $26.8 million was allocated for TANF cash assistance
  • Two TANF programs that provide monthly cash assistance
    • Program for two-parent household
    • Program for child-only or one-parent families
  • Medicaid, CHIP, SNAP and TANF are all accessed through a single application for Texans
  • The most common form of TANF assistance is the monthly cash grant
  • In June of 2014, the average monthly benefit for TANF recipients was $73; amount will vary based on size of family, number of parents, etc.
  • TANF is easily the most complicated application and eligibility system of all assistance programs
  • Nelson discussed drug testing for TANF eligibility
    • Drug testing is very expensive, especially when testing all recipients; courts have also struck down non-suspicion drug testing for TANF
  • Uresti asked what the average TANF recipient looks like
    • The typical recipient is a single female around 30 years old with two kids; the maximum  income level would be $188 per month
  • Uresti noted the idea behind the program is to give someone a boost so they can stabilize and try to find work

 
Public Testimony
 
Katharine Ligan, Center For Public Policy Priorities

  • In state correctional facilities, 35% of inmates have previously received public mental health services
  • Incarcerating individuals rather than treating comes with a high fiscal and human cost
  • Peer support services are a good way to help people transition from jail to normal life and reduce recidivism

 
Colleen Horton, Hogg Foundation for Mental Health

  • Gaps in the system
    • What will go into effect on September 1 is not integrated health care, it is essentially integrated payment structures for behavioral health services
    • Reiterated the benefit that can come from peer support services
    • Kids in CPS custody are not eligible for the YES waiver but should be

 
Sarah Paul, Texas Criminal Justice Coalition

  • People, youth especially, will receive much better treatment for mental health and substance abuse issues in diversion programs rather than incarceration
  • Recommends expansion and strengthening of diversion programs
  • Schwertner asked what could be done as far as judicial training
    • There is a lot of room for improvement in that area

 
Tanya Lavelle, Easter Seals of Central Texas

  • The cornerstone of independent living is successful housing
  • The housing program initiated last session has been successful so far
  • Improvements can still be made; vouchers should be made for a longer term

 
Amy Granberry, Association of Substance Abuse Programs

  • Only a small percentage of the need for substance abuse services in Texas are being met
  • Increased funding is greatly appreciated however providers are having a hard time meeting the increased demand for services
  • Schwertner asked about the current state of integration of substance abuse and behavioral health services
    • Some LMHAs are working very well to that end

 
Josette Saxton, Texans Care for Children

  • The role of prevention and early intervention in mental health and substance abuse disorders must have a higher focus

 
 
Lee Johnson, Texas Council of Community Centers

  • There are still gaps in services and integration
  • Local law enforcement training is a large part of improving community mental health services
  • There is a high need for funding of jail diversion programs

 
Jill Switzer, Mental Health America of Texas

  • The investment in mental health services made last session is much appreciated
  • Data is not available to the public in a user friendly format
  • Zaffirini asked what needs to be done for suicide prevention education
    • MHAT does a lot of outreach and suicide prevention programs or resilience building programs; more effort needs to be given for the middle aged group

 
Carly McConnell, Texans Standing Tall

  • Pill mills and illegal prescribing are a problem but most people who abuse get pills from family or friends
  • Drug take back days are a good way to prevent youth from getting pills in their medicine cabinets that aren’t being taken medically anymore
  • Would like to see the DSHS school survey expanded to all school districts

 
Amy Granberry, Association of Substance Abuse Programs

  • Both the supply and demand sides of prescription drug abuse need to be addressed

 
Rachel Cooper, Center for Public Policy Priorities

  • Concerned that the primary goal of the TANF program is failing
  • More and more children are living in poverty at the same time TANF roles are drastically being reduced
  • There are so many rules within the program it has become hard to qualify for and administer the program
  • More is being spent on eligibility services than on benefits to recipients