The Senate Committee on Health and Human Services has published its report to the 82nd Legislature. Below is a summary of the recommendations.
In regards to interim charge 1 which reviews the passage of Federal Health Reform and its impact on Texas, implication discussions are dispersed throughout the committee report.
Interim Charge 2—Prevention and Early Intervention—Study the benefits, efficiencies and costs, and effectiveness of the social service related prevention and early intervention programs at the health and human services agencies, the juvenile and adult criminal justice agencies and other government agencies that have programs that address mental illness, substance abuse, child abuse and neglect, domestic violence, single-parent families, absentee fathers, early pregnancy, and unemployment. Study other states’ prevention programs and efforts to administer these programs through a merged prevention department. Make recommendations to improve the efficiency and effectiveness of these programs.
Interim Charge 2 Recommendations:
1) Texas Sunset Commission should review the program evaluation mechanisms used to measure outcomes in Prevention and Early Intervention programs across state agencies.
2) Include Prevention and Early Intervention in relevant agencies’ Strategic Plans.
3) Encourage agencies to use the Texas State Needs Assessment to determine the areas of the state with the greatest levels of need for Prevention and Early Intervention services.
Interim Charge 3—HHS Eligibility System—Review the timeliness and efficiency of the Health and Human Service Commission’s eligibility system. Include a review of staffing levels and staffing distribution; implementation of Rider 61; and the increased demand on the system. Make recommendations to improve the efficiency and effectiveness of the system, focusing on policy changes that will not create a large financial burden for the state.
Interim Charge 3 Recommendations:
1) The Health and Human Services Commission (HHSC) should continue current efforts to review existing policies and procedures; rebuild and retain its eligibility workforce; and complete statewide transition to TIERS.
2) The Legislature should limit eligibility policy changes, when feasible, until statewide transition to TIERS is complete.
3) HHSC should work to ensure that applicants have access to the TIERS “self-service” portal in their communities.
4) HHSC should continue to strengthen partnerships with community-based organizations to increase options available to Texans in need of assistance.
Interim Charge 4—Health Information Exchange—Study and make recommendations on the state’s role for facilitating the exchange of health care information in the future, including using the Medicaid exchange as a framework for the statewide exchange of health information between health care providers to improve quality of care; what information the state would provide; how to use this information to improve care management, prevent medical errors, and reduce unnecessary services; and policies and statutory changes needed to ensure that privacy is protected. Study the feasibility of developing multiple regional health information technology exchanges in Texas.
Interim Charge 4 Recommendations:
1) The Texas Legislature should work with the Texas Health Services Authority (THSA) to move forward with implementation of a statewide health information exchange infrastructure.
2) THSA should leverage existing state infrastructure when possible to take advantage of economies of scale.
3) THSA and the Texas Legislature should work together to ensure that the exchange of health information is secure and patient privacy is protected.
4) Patients should have explicit right to their electronic health data.
5) Health care providers, relevant state agencies, and pharmacies should work together to resolve remaining challenges related to e-prescribing.
Interim Charge 5—Health Care Workforce—Study the state’s current and long-range need for physicians, nurses, dentists and other allied health and long-term care professionals. Provide recommendations for ensuring sufficient numbers of health care professionals, focusing on medically underserved and rural areas of the state as well as the border region. Consider health care delivered by Advanced Practice Nurses in terms of access, cost and patient safety and include an assessment of independent prescriptive authority with those states in which prescriptive authority is delegated by a physician. Make recommendations to enhance the efficient use of Advanced Practice Nurses in Texas.
Interim Charge 5 Recommendations:
Primary Care
1) The Legislature should place responsibility on medical schools and residency programs to produce more primary care physicians, especially those that will practice in rural areas.
2) Medical schools should consider “fast-track to physician” programs for physician assistants and advanced practice registered nurses with an abbreviated medical school curriculum based on prior education, training, and skills.
3) Health professions schools should be encouraged to hire faculty with primary care experience.
4) Encourage nurse-midwifery education programs in areas where none exist.
5) Advanced practice registered nurses and physicians should partner to find a policy solution to address the state’s primary care shortage.
Medicaid
6) The Legislature should ensure that funding for Frew initiatives is maintained.
Rural and Border Areas
7) Texas should require individuals using a H-1B visa to practice in Texas to fulfill a service requirement in underserved areas of the state.
8) The Statewide Health Coordinating Council should consider appointing an ad hoc advisory committee under its current statutory authority that will act as a steering committee for the Health Professions Resource Center.
9) Health professions schools should be encouraged to devote faculty time to coordinate rural health curriculum and community-based rotations, provide rural health courses, reserve admissions slots for rural candidates, provide rural tracks for professional and graduate students, and provide rural community-based clinical experiences for academic credit.
Interim Charge 6—Aging Texans/Guardianship
A) Explore strategies to support the needs of aging Texans, including best practices in nursing home diversion, expediting access to community services, and programs to assist seniors and their families in navigating the long-term care system with the goal of helping seniors remain in the community.
B) Study the guardianship program implemented by the Department of Aging and Disabilities and the Department of Adult Protective Services, including the efficiency and effectiveness of the program, the relationship between the two agencies, the appropriate rights for parents, and whether clients and their assets are adequately protected to ensure the state is appropriately identifying seniors in need of protection.
Interim Charge 6 Recommendations:
A.
1) Direct HHSC and the Department of Aging and Disability Services (DADS) to conduct a study to determine how individuals arrive at a nursing facility’s “front door,” what services the individual has received, where services were provided and by who, what community supports are currently available and how to expedite access to services for which the individual would be eligible but for which an interest list exists.
B.
1) Direct DADS and the Department of Family and Protective Services to further streamline the guardianship process to prevent unnecessary duplication of efforts.
2) Upon the removal of a parent or family member as the ward’s guardian, direct courts to immediately notify former guardians of their removal and give them 30 days to seek reinstatement.
3) Upon the removal of a parent or family member as the ward’s guardian, make the court’s appointment of a successor guardian temporary in order to allow other family members to step forward and serve as the ward’s guardian.
4) Direct probate courts to provide family members notice of hearings to determine whether guardianship of a loved one is appropriate, or to determine changes in guardian or guardianship status.
5) Limit the individuals who may request or contest a guardianship to (1) the proposed ward, (2) DADS, or (3) an individual interested in the proposed ward’s welfare.
6) Allow a ward to retain an attorney; appeal or contest any action by the guardian ad litem or the court, including fees or expenses ordered to be paid from the ward’s estate; change a will; associate with particular person(s) and give effect to a previously executed durable power of attorney.
7) Direct Adult Protective Services to alert law enforcement after removing an individual pursuant to an emergency order authorizing protective services if the individual’s home is left vacant in order to allow law enforcement to monitor the home.
8) Encourage the use of volunteers to assist with DADS guardianships.
Interim Charge 7—Obesity and Second-Hand Smoke—Examine how the state could enact policies to improve the overall health of Texans, focusing on programs that compliment individually-based prevention with community-based prevention to reduce obesity rates by increasing physical activity, improving nutrition, and improving self-management of chronic diseases such as diabetes. Examine obesity-related health disparities between different ethnic groups and ways to narrow these gaps. Consider the fiscal and health impact of second-hand smoke on businesses and service sector employees. Study state level initiatives to incorporate these individual and community-based prevention strategies, including initiatives pursued in other states.
Interim Charge 7 Recommendations:
1) Utilize unleased state property to cultivate community gardens.
2) Increase reporting requirements for schools and SHACs on compliance with requirements related to Coordinated School Health, nutrition, and physical activity.
3) Require daily physical activity for all public school children.
4) Create a Healthy School recognition program for campuses that excel in comprehensive school health.
5) Require schools to report de-identified individual Fitnessgram results to the Texas Education Agency (TEA) to facilitate more accurate correlations.
Interim Charge 8—H1N1 Influenza Pandemic and ImmTrac—Study the state’s ability to appropriately respond to the H1N1 influenza pandemic by examining issues related to vaccine distribution and capacity. Consider the benefit of providing the state’s independent school districts and various health authorities with standardized protocols for issues including, but not limited to, vaccine administration, absenteeism and the cancellation of school and other school-related events. Assess the state’s ability to track and record H1N1 vaccinations through the ImmTrac registry, and review statutes governing ImmTrac to increase the effectiveness and efficiency of immunization information systems.
Interim Charge 8 Recommendations:
1) Replace current ImmTrac system technology to facilitate data exchange between ImmTrac and Electronic Medical Records (EMRs).
2) Implement improvements to the user interface for ImmTrac to improve data input and lookup for records.
3) Build best practices tools into the ImmTrac system.
Interim Charge 9—Health Care Quality and Efficiency—Study current state health care quality improvement initiatives in Texas, including statewide health-care associated infection and adverse event reporting, reimbursement reductions in the Texas Medicaid program for preventable adverse events, potentially preventable readmissions identification, health information technology implementation, pay-for-performance programs, and other initiatives aimed at improving the efficiency, safety, and quality of health care in Texas. Identify statutory changes that may build upon efforts to improve quality of care and contain health care costs in Texas. Study policies that encourage and facilitate the use of best practices by health care providers including the best way to report and distribute information on quality of care and the use of best practices to the public and to promote health care provider and payment incentives that will encourage the use of best practices. The study/recommendations could also include assessing the best way to bring provider groups together to increase quality of care, the use of best practices, and reduce unnecessary services.
Interim Charge 9 Recommendations:
1) HHSC should develop outcome measures that promote safe and efficient health care behaviors by health care providers and patients. Once fair and objective outcome measures are developed, the Commission should apply them to Medicaid and CHIP payment systems.
Unnecessary Emergency Room Visits
2) HHSC should establish a health home initiative in which payments are based on a provider’s performance on a set of measurable wellness and prevention criteria and use of best practices. Providers would be able to receive a shared portion of any savings achieved by the health home.
3) HHSC should develop and implement Medicaid copayments for unnecessary emergency room visits.
Unnecessary Hospital Admissions
4) Existing hospital discharge reporting exemptions should be eliminated.
5) HHSC should study the feasibility of expanding a pay-for-performance program to long-term care facilities such as intermediate care facilities for individuals with mental retardation and home and community-based providers.
6) HHSC should develop a program in which Medicaid recipients receive credits in a “healthy rewards account” based on cost savings resulting from successful management of chronic condition(s). Medicaid enrollees could use the credits to obtain enhanced health care benefits and health care products.
Potentially Preventable Readmissions
7) HHSC should develop and implement a payment methodology, using outcome and process measures, to adjust Medicaid reimbursement for potentially preventable readmissions.
8) The Department of State Health Services should publicly report potentially preventable readmissions performance across all payers.
Potentially Preventable Complications
9) HHSC should report to hospitals on potentially preventable complications performance and develop outcome measures to adjust Medicaid reimbursement for preventable complications after hospitals have had time to improve practices.
Unnecessary and Duplicative Services, Diagnostic Tests, and Medications
10) HHSC should implement a quality-based payment initiatives program with an emphasis on efficiency, use of best practices, and outcomes.
Medicaid Fraud
11) Policymakers should continue to aggressively pursue individuals who defraud the Medicaid program.
12) HHSC should create a Medicaid transparency website.
Interim Charge 10—Texas Medical Board—Study current practices of the Texas Medical Board relating to the disclosure of complaints.
Interim Charge 10 Recommendations:
1) Prohibit the Texas Medical Board (TMB) from accepting anonymous complaints.
2) Maintain confidentiality of complaints, except those made by a pharmaceutical or health insurance company or its agent (acting in his/her official capacity).
3) Increase the time for physicians to respond to a notice of complaint.
4) Establish an option for TMB to respond to complaints that is more corrective than punitive so that the process is less adversarial.
Interim Charge 11—Stem Cell Data—Review the types of human stem cell and human cloning research being conducted, funded, or supported by state agencies, including institutions of higher education. Make recommendations for appropriate data collection and funding protocols.
Interim Charge 11 Recommendations:
1) Require the Texas Higher Education Coordinating Board to include questions in the Annual Research Expenditure Report on the type and funding source of research being conducted on human stem cells.
a. Collect this data from state-sponsored institutions of higher education, including health-science centers, as well as from non state-sponsored institutions that receive state funding.
b. Ensure that amounts of funding are not over or under reported due to duplication.
Interim Charge 12—Medicaid Home and Community Based Services Waivers—Review the Medicaid HCBS waivers (CBA, STAR Plus, CLASS, MDCP, DBMT, TxHmL) and develop recommendations to assure that people with significant disabilities, regardless of disability label or age, receive needed services to remain in or transition to the community. Review should look at the delivery system, eligibility, service packages, rate structures, workforce issues and funding caps. Examine options for the provision of services for children aging out of the Medicaid system. Make recommendations for streamlining/combining these waivers, ensuring that these waivers are cost effective or create cost savings, and developing policies that contain costs in an effort to increase access to the services. The review should examine other states’ community care waivers and provide recommendations relating to efforts that have been successful in other states.
Interim Charge 12 Recommendations:
1) Direct HHSC to implement Medicaid capitated managed care services in the urban counties of El Paso and Lubbock and expand Medicaid managed care in South Texas.
2) Direct DADS to require Home and Community-based Services waiver program providers to convert existing 3–4 bed residential models to 6 bed models.
3) Direct DADS to require Medicaid 1915(c) waiver program consumers to access attendant services through the Primary Home Care, Community Attendant Services or Personal Care Services Medicaid entitlement programs and access attendant services through a Medicaid waiver program only if the consumer requires services not available in the Medicaid entitlement programs or requires more service hours than are currently allowed under the Medicaid entitlement programs.
4) Develop a media campaign to publicize Home and Community based Services programs and the various delivery options such as self-determination, consumer direction and traditional agencies.
5) Direct DADS to ensure that local Mental Retardation Authorities are counseling consumers about all available service delivery options, including 6 bed ICFs/MR.
6) Direct DADS to post on the department’s public website the historical enrollment rate for each Medicaid 1915(c) Home and Community Based Services waiver program.
7) Direct DADS to develop a more comprehensive utilization management and review process in all Medicaid 1915(c) Home and Community Based Services waiver programs by including targeted reviews and random sampling; prospective, concurrent and retrospective reviews as appropriate; and face to face visits with consumers.
8) Direct HHSC and DADS to jointly explore additional opportunities to further streamline licensing and contracting activities associated with Medicaid 1915(c) waiver programs.
9) Direct HHSC to consider developing risk management protocols to include in all Medicaid 1915(c) Home and Community Based Services waiver programs.
10) Direct DADS to require home and community support services agencies to apply for a certificate of need before applying for a license.
11) Direct DADS to require home and community support services agency administrators to be licensed.
12) Direct DADS limit the number of home and community support services agencies an administrator can oversee to no more than two licensed agencies.
13) Require a state entity or entity that HHSC or DADS contracts with to conduct independent assessments of individuals before they may begin receiving services from a home and community support services agency.
Interim Charge 13—CPS Mental Health Services—Study the type, duration, frequency and effectiveness of mental health services available to and accessed by abused and neglected Texas children. Recommend strategies to address the impact of the trauma, and enhance therapeutic services available to this population in an effort to eliminate the cycle of abuse and neglect.
Interim Charge 13 Recommendations:
1) Direct the Department of Family and Protective Services (DFPS) to provide Child Protective Services caseworkers and supervisors annual refresher training in trauma-informed care.
2) Direct DFPS to offer trauma-informed care training to CASA volunteers, Child Advocacy Center staff, MHMR Center therapists, and domestic violence shelter staff.
3) Direct DFPS to include trauma informed care training in the department’s parenting class curriculum for parents who have contact with Child Protective Services.
4) Direct DFPS to study the effectiveness of trauma-informed care training for Child Protective Services caseworkers and supervisors, foster parents, adoptive parents, kinship caregivers, and others receiving this training.
5) Encourage HHSC to require STAR Health mental health providers (e.g., psychiatrists, psychologists, licensed professional counselors) to receive training in grief and loss therapy, sexual abuse therapy, physical abuse therapy, and trauma-informed care.
6) Require STAR Health to ensure that children receive a timely THSteps checkup and require contracted providers to screen children for depression and other common mental illnesses during the child’s THSteps checkup.
7) Encourage STAR Health providers to offer appointments after hours and on weekends.
8) Encourage HHSC to undertake additional efforts to increase awareness of community MHMR Centers are a resource for children in STAR Health. In addition, whenever possible and practicable, HHSC should encourage greater use of local MHMR Centers and substance abuse clinics.
9) Encourage HHSC to commission a subsequent report evaluating the quality of care in the STAR Health managed care program.
10) Direct HHSC to reduce costs associated with private duty nursing.
11) Direct HHSC to reduce costs associated with certain non-mental health therapies, including physical therapy, occupational therapy, and speech therapy.
12) Require a state entity or entity that HHSC or DADS contracts with to conduct independent assessments of individuals before they may begin receiving services from a home and community support services agency.
13) Direct DFPS to restructure its Level of Care based reimbursement system to reward improvements in children’s well-being.
14) Direct HHSC to develop a plan to increase STAR Health providers’ use of telemedicine.
15) Encourage DFPS to contract with providers that can provide individualized continuums of care, particularly as children transition from residential environments to foster home settings.
16) Encourage HHSC to require STAR Health providers to receive training in post-traumatic stress disorder and attention deficit hyperactivity disorder under contract requirements.
17) Require the child’s medical consenter to inform the parties involved in the case when a child is placed on a psychotropic medication.
Interim Charge 14—Monitor the implementation of legislation addressed by the Senate Committee on Health & Human Services, 81st Legislature, Regular and Called Sessions, and make recommendations for any legislation needed to improve, enhance, and/or complete implementation.
A) Fostering Connections Act – Monitor Department of Family and Protective Services’ implementation of the U.S. Fostering Connections Act, including the new Kinship Care program. Include recommendations on how to optimize the use of monetary assistance to qualified relative caregivers.
B) State Supported Living Centers – Monitor the Department of Aging and Disability Services (DADS) implementation of SB 643, relating to Texas’ state supported living centers (SSLCs), implementation of Special Provisions relating to All Health and Human Services Agencies, Section 48. Contingency Appropriation for the Reshaping of the System for Providing Services to Individuals with Developmental Disabilities, and implementation of the United States Department of Justice (DOJ) Settlement Agreement terms.
Interim Charge 14 Recommendations:
A.
1) Direct the Department of Family and Protective Services to apply for a waiver allowing the department to reduce benefits to kinship caregivers who remain in paid foster care long term.
B. Conclusion:
Many of the 81st Legislature’s sweeping reforms will be gradual and incremental. There are encouraging signs of progress, but there is still a long way to go to make the service delivery system for individuals with intellectual and developmental disabilities the best it can be.
A copy of the complete report can be found by visiting:
http://www.senate.state.tx.us/75r/Senate/commit/c610/c610.InterimReport81.pdf