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The Senate Finance Committee met on June 28 to hear invited and public testimony on the following interim charge:

  • Examine the state mental health service delivery system, study the state’s plan for state-funded inpatient mental health services and the statewide behavioral health strategic plan, evaluate existing state mental health services, and recommend improvements.

An archive of the hearing can be found here.

 

This report is intended to give you an overview and highlight of the discussions on the various topics taken up. It is not a verbatim transcript of the discussions 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.

 

Opening Comments

  • Chair Huffman – Over last several years, Texas legislature increase mental health funding significantly; state agencies developed plan; $1.3b dedicated to modify in-patient facilities; COVID exacerbated crisis and long waitlists for facilities; committee committed to prioritize child and adolescent mental health

 

Invited Testimony

Nicole Delaney, Legislative Budget Board

  • Presents overview of Texas mental health crisis
  • First statewide behavioral health plan published 2016; second five-year plan to be posted this year
  • New additional reporting requirements for suicide and suicide prevention
  • Behavioral health funding includes funding for CHIP and Medicaid patients and supplemental appropriations
  • Supplemental appropriations usually budgeted for two years
  • $4.8 billion in funds provided for 26 agencies; HHSC receives majority of behavioral health funding
  • $3.8 billion in Medicaid and CHIP expenditures
  • Total behavioral health appropriations were $8.5 billion
  • Supplemental funding by 87th legislature through SB 2, HB 2, and SB 8
  • THEB also received mental health funding
  • 87th legislature increased mental health funding
  • Huffman – Is the money spent on 1115 waivers included?
    • Yes, it is included under Medicaid and CHIP expenditures
  • Kolkhorst – How much money was directed for waivers?
    • I’m not sure, but HHSC would know
  • Kolkhorst – Who is administering the Permian Basin mental health facility?
    • The local hospital districts
  • Kolkhorst – Is this a state or local facility? How many beds?
    • Local; 100 beds
  • West – How much money do we have in the system for mental health between local and state fundings?
    • Huffman – That’s what we are figuring out
  • Nelson – Why didn’t we have this data prior to the 84th regular session?
    • Before then, we weren’t tracking behavioral health expenditures through all agencies; that year a requirement to submit expenditures was added
  • Nelson – If we could look back 10 or 20 years, would it show a dramatic increase in funding?
    • Yes
  • Hinojosa – Is the federal Covid funding not included?
    • For the most part no; this shows general appropriations funding
    • Hinojosa – We would like to get a breakdown of how federal funding was distributed during the pandemic
  • Perry – We need to focus less on having beds and more on having beds at the right time
  • HHSC responsible for maintaining mental health state hospital system; significant state funding for building and improving state hospitals
  • HHSC partners with institutions of higher education to provide mental health care
  • Funding provided to HHSC to purchase community mental health hospital beds; contracts with local hospitals
  • State hospitals received over 900 million in the last biennium
  • Construction funding at mental health state hospitals increased in last legislative session; HHSC required to submit projects for repairs and bed expansion
  • $1.3 billion provided for construction over last three legislatures
  • Campbell – We need local crisis beds and to use front end dollars; the model should use ARPA dollars
  • Nelson – Are you looking into federal funding for mental health?
    • We are looking into it but not sure how much will come to Texas
  • Kolkhorst – Between 2017, 2019, and 2021, there is $1.3b in construction, correct?
    • Yes
  • Kolkhorst – Was most of that taken from the Economic Stabilization Fund?
    • Yes
    • Kolkhorst – That’s a substantial investment
  • Kolkhorst – Where are we in the stages of rolling out the funding?
    • Some of the facilities have completed construction; the final construction should be completed by May 2025
    • There have been delays due to supply chain issues
  • Kolkhorst – There will be a significant change in our mental health delivery system due to this funding
  • Huffman – The elephant in the room is there are a lot of offline beds due to staffing shortages
  • West – How many local mental facilities are in Texas?
    • I don’t know; there are 39 different facilities managed by the state but I’m not sure about private ones
  • West – Would knowing that give a better picture of state capacity?
    • Yes
  • Hinojosa – How much local funding is going to create more beds?
    • HHSC may know; we track state funding
  • Funding for adult mental health services includes $818m; funding goes to local authorities, Medicaid programs, HHSC grant programs, and other state agency programs
  • $13.4m goes to veterans and $5m supports mental health public defenders
  • Some funding goes toward parolees dealing with mental health and substance abuse issues
  • HHSC received over $100m specifically for child mental health
    • $231.6m goes toward THECB
  • Texas Mental Health Consortium created by 86th legislature to serve children and adolescents; in 2022-2023, received over 200 million in funding
  • Huffman – Yesterday we signed a budget execution order of $100m extra funds aimed for school safety and some will go to mental health
  • Perry – Is the youth empowerment service a gatekeeper? Do they capture these kids?
    • Defer this to HHSC
  • Perry – Do you know how many children YES serves?
    • Yes, we can provide it
    • The targeted number for 2022-2023 was over 1,000 clients per month
    • Perry – HHSC needs to have an age breakdown
  • Perry – If we find a way to help the 3-18 population, we solve the problem for 19+; we don’t have enough ways to help children ten and under
  • West – How much of funds are used for step down programs for after release of a state psychiatric facilities?
    • I don’t have a breakdown
  • West – How are the THECB utilizing these funds?
    • The consortium will be speaking later and can give more details

 

Michelle Alletto, HHSC

  • Mental health has received significant attention from HHSC and the legislature
  • Presents HHSC funding from state and federal dollars into mental health
  • HHSC given $4b annually for outpatient and in-patient services
  • Established and expanded community based mental health services, built network of state inpatient mental health hospitals, and built partnerships with agencies and academic institutions
  • Partnerships include sitting together on Behavioral Health Coordinating Council
  • Whitmire – Is there a waiting list for facilities?
    • Yes, but it has shrunk
    • Sonya Gaines – Our outpatient waiting list has 400 adults and no children; rural areas have issues with workforce causing waitlists
    • Whitmire – People enter the criminal justice system because they can’t get into mental health facilities; waiting lists are unacceptable
    • Gaines – We also have a 2,000-person waiting list for forensics; 90 individuals for in-patient
  • Huffman – Are the waiting lists because of staffing shortages?
    • Sonya Gaines – Yes
  • West – Asks for clarification on an acronym
  • More than 1.5 billion annually used to support outpatient services
  • Funding served over 11 million patients in FY2021 from outpatient services; primarily served through local authorities that receive HHSC funding
  • Goal of outpatient services to improve health and divert people from inpatient hospitals and jails; work done through crisis system
  • Crisis system built with local mental health authorities; includes crisis hotlines
  • Crisis system resulted of over 15,000 diversions from jail to treatments in second quarter of FY2022
  • 90% of patients receiving outpatient care do not require inpatient
  • Sonya Gaines – Youth Empowerment Program (YES) designed to work with children and families that do not do well in traditional outpatient settings; serves hundreds of children with success
  • Perry – Not many local mental health authorities have programs for young children
    • Gaines – All of our local authorities use evidence-based care; some are more intensive than others
  • Perry – What happens if the local mental health providers can’t care for them accurately?
    • Gaines – There is a lot of interaction with different systems such as public hospitals
  • Perry – How does YES coordinate with children’s mental health services?
    • Gaines – We have a collaborative relationship with the children’s consortia; there are a variety of programs that help to determine care
    • Gaines – Telehealth can be used as well
  • Perry – We have all these systems, but there is a neglect for follow-through; children are limited by time for treatment regimens and must go to different counties for adequate treatment
  • Nelson – What year did we create the coordinating council?
    • Gaines – 2014 or 2015
    • Nelson – That was a very different time; there are very different mental health struggles
  • Nelson – I learned the term first episode psychotic from establishing the coordinating council; it helps us identify children that will have long-term mental health struggles
  • Nelson – We need to train more workers to identify children with mental health struggles, but I would like you to talk about the success we’ve had since 2014
  • Hinojosa – How many pediatric psychiatric beds are available in Texas?
    • Gaines – We don’t have a complete total; there are 560 open community beds in local hospitals
    • A lot of the struggle is associated with the pandemic; large increases in children seeking inpatient care
    • Prior to pandemic decreased number of inpatient beds but had to increase due to new spike
  • Hinojosa – Who cares for children before there are beds available?
    • Gaines – Families or local hospitals
  • West – How are we handling step down programs?
    • Gaines – We’ve been working on step down for adults for the last three years; allows individuals with long histories of inpatient stays to transition
    • Gaines – Children usually move to other programs like the YES program or early onset psychosis program
  • West – What happens when we put people in step down programs and they do not improve? Are there options other than jail?
    • Gaines – We have wrap around services that are available; our goal is diversion
  • Kolkhorst – 1.6 billion per year is non-Medicaid funding?
    • Yes
  • Kolkhorst – When we say non-Medicaid, is there no federal match for it?
    • Gaines – This list shows both federal mental health block grant dollars with no match and general revenue state dollars
  • Kolkhorst – Are there problems with allocating beds under SB 454?
    • Gaines – 454 allowed us to engage with local authorities to better collaborate; we are doing a pilot program for diversion
    • 454 has been extremely beneficial; it allows us to keep people closer to home
  • Kolkhorst – There is a mental health crisis of anxiety and depression across the state; the crisis increased because of Covid
  • Perry – What would you change in state funding?
    • Gaines – There have been great strides in creating a wonderful foundation; not all states have a comprehensive mental health system with applied evidence-based practices at work
    • Most local authorities are certified mental health clinics; we are the only state that has this
    • Investment in crisis services and state hospitals has been critical; we’ve expanded the state mental health service capacity
    • Need to focus on inflation and continuing to serve population as it grows; need more funding
    • Could build on crisis services to serve children; recommends child focused crisis team
  • Perry – Do you work with TEA on their mental health initiatives?
    • Gaines – Yes, they sit on the coordinating council; we work with them heavily on several projects
  • Provides map of state hospital locations; 1700 beds currently
  • Ability to open beds dependent on staffing
  • Covid heavily impacted state hospital operations
  • Local mental health authorities can refer patients to state hospitals; criminal justice system sends individuals as well
  • Competency restoration for individuals charged with a crime
  • Partnered with academic institutions to build new hospitals in Houston and Dallas; will increase state beds to 2900 but issues with staffing
  • Huffman – Where are the staffing shortages located?
    • Across the system; we compete for employees
  • Huffman – Does the private sector experience shortages?
    • I’m not sure
  • Maximum security waitlist increased since 2020
  • Staffing shortages impact all aspects of the mental health continuum
  • Huffman – So the state has funded the services, but staffing is preventing people from receiving care?
    • Yes, we compete with even Target and Buckees for staff
  • Whitmire – Could you come back to us with a plan for staffing shortages?
    • Yes, we have been testing ways to address the shortage
  • Hinojosa – The workforce shortage is across the entire country; there is a lack of skilled labor
  • Kolkhorst – We need to move beyond the pandemic and get people back to work
  • West – What happens in parts of the state where there is not a public hospital system?
    • Scott Jackson – We have so many offline beds so people get stuck in emergency rooms until a bed can be found; sometimes we can do emergency admissions to hospitals
  • West – Is this issue worse in rural areas?
    • Jackson – I think it’s in both, but I would guess it’s worse in rural areas
  • Kolkhorst – Do we have private forensic beds?
    • Jackson – the hospitals have a contract with Palestine and Montgomery County for forensic beds; generally, they are in state hospitals
  • Kolkhorst – Is the crisis in forensic beds?
    • Jackson – Yes, we have a large forensic population and a lengthy waitlist
  • Bettencourt – What happens to mass shooters that are found mentally incompetent?
    • Jackson – They will come to us and we perform competency restoration services; either they are fine or still incompetent and stay with us
    • They go to maximum security beds if they are found not guilty by reason of insanity
  • Huffman – Does the backlog come from people waiting to have their competency restored?
    • Jackson – Are waitlist is mainly people needing competency restoration
  • Huffman – We need to make this process more efficient
    • Jackson – We are looking for ways to interfere before people get into the criminal justice system; a lot of people on our waitlist are homeless or addicts and don’t need mental health services
  • Whitmire – How long do people sit on the waitlist?
    • Jackson – The average wait for a maximum security bed after we are notified is 499 days; non-maximum-security beds is 237 days
  • Whitmire – What can we do after people in jail are stabilized and released?
    • Jackson – This is something we are looking at going forward; it’s a piece in the system that we are missing
    • Gaines – We need more of our effective programs; home and community based services works significantly we just need more
  • Perry – Are the 900 waiting MSU candidates for forensic beds?
    • Jackson – Yes
  • Perry – If workforce wasn’t an issue, would we need more bed space?
    • Jackson – We do need bedspace
  • Perry – How many forensic beds do we need? Do we have existing buildings that can be repurposed?
    • Jackson – We have looked at using existing buildings especially from a step-down perspective

 

Tim Regal, TEA

  • Since 2017, TEA active in building mental health capacity
  • Federal government awarded TEA grants for mental health services
  • New division to bring mental health experts together
  • Statewide plan for mental health developed to increase student and family access to mental health services; progress report on plan to be available soon
  • Task force on public school mental health services established in 2019; makes recommendations to the legislature

 

Julie Wayman, TEA

  • After statewide behavioral health coordinating council, developed workforce to evaluate mental health services in schools
  • Presented student discipline data; because of Covid, levels down
  • Limits on TEA data; schools have different approaches to discipline
  • Over ten years, students expressed feeling sadder and more hopeless; warning sign for potential mental health concern
  • Increase in students contemplating suicide
  • Goal of college and career readiness to engage students; when students unengaged, more mental health struggles
  • 37% of students reported mental health struggles during Covid
  • 44% of students reported persistent sadness and hopelessness
  • In 2020 began tracking youth mental health in emergency rooms; increased significantly
  • School counselors a base in schools; do prevention, intervention, and referrals
  • 394:1 average student to counselor ratio; recommended 250:1
  • Legislation allowed for licensed professional counselors in schools
  • 2090 school psychologists
  • Data does not include some scenarios such as partnerships between schools and local mental health authorities, faith-based groups, and other prevention staff
  • Increased school counselors, social workers, and psychologists throughout the state
  • Admissions to counselors preparation programs has decreased
  • Certifications and completions are down a bit, need to keep an eye on the pipeline
  • Overviews the following partnerships and programs: school/community, TCHATT, LMHAs, and trauma-informed counseling
  • Stood up Project AWARE to support school-based mental health programs and services
  • 2 hours before the Uvalde Shooting stood up a new online database to connect community health resources
  • Bettencourt – Director McCraw noted there was no official complaint filed for the shooter before Uvalde; way to tie this to a reporting environment? How do you reel those who are truant back in?
    • For Safe and Supportive School Program need teacher referral or those who are working with the child to notify parents and make an intervention program
  • Bettencourt notes that there are patterns of behavior that should be reported early on
    • Is a part of the top three priorities of the Commissioner; working on plans and proposals about the reporting element
  • Bettencourt – Large decrease in ISS?
    • In a place to re-frame strategies and to use resources in the community; thinking data has decreased because of COVID
  • West – Strategy to get ratio of counselors to the national 250:1?
    • Have a recommended model adopted in the 86th which was 1:350 and are near that
    • Will take that note back to the agency and report back to the committee
    • West – Let us know if there is
  • Perry – How many districts have access to TCHATT? Concerned some districts are doing their own thing
    • Is rolling out, 337 were online in May; heard anecdotally that the service has been turned down by districts
    • Perry – Need to ensure districts are using this
  • Perry – Database tracking mental health encounters by students around the state?
    • No; will learn that through the recently started Safe and Supportive Schools Program
    • Will hear from the Mental Health Task Force in November on this
  • Perry – Need to track this to ensure we are being successful; is a broad gap between DEAP/JJAEP need something between the middle of these two
  • Hinojosa – Have spent $300m to identify those who may be suicidal/hurt others; Uvalde shooter had signs he was violent, if we had consortium at that time, situation could have been averted?
    • Takes a long time to get these supports/programs set up; school districts are to have policies in order to report these types of students
    • Hinojosa – Need proactive awareness
  • Nichols – Was amazing during 2020-2021 the consortium was able to reach the schools it did; anticipation how fast the access will ramp up?
    • Not sure, will monitor that
  • Nichols and Wayman discuss the issues with workforce
  • Nichols – Previously passed legislation that has protected truant students, but has lack the ability to enforce truancy; schools not reporting discipline versus “code of conduct?”
    • Truancy legislation required a lot of work/effort from the districts
    • Nichols – Would appreciate recommendations from TEA to give schools more authority concerning truancy

 

Judge Nancy Tanner, Potter County

  • Not sure why in 2022 we have a workforce problem
  • Do the mental health hearings for county and those surrounding counties
  • Need a mental hospital in Amarillo that would serve the entire panhandle
  • Have land already donated; ask the legislature to consider this proposal
  • Huffman – If had a state hospital, what is the greatest need?
    • Greatest need would be to put those who need to be in a state hospital to immediately go; currently they are just being let go
  • Perry – A hospital in that area would make sense geographically

 

Brian Thomas, Potter County Sheriff

  • Have a 599 bed jail and 540 are in jail; 24 inmates have been court ordered to a state hospital
  • Cost of mental health inmates is more expensive than other inmates; falls back on county taxpayers
  • Are dealing with workforce issues; part of issue is private businesses

 

Dr Richard Jordan, Amarillo Texas Tech

  • Need a state hospital in the area; number of patients who need long-term care is dire
  • Through which would be able to create a psychiatrist residency program
  • Huffman – Think Texas Tech Amarillo could help?
  • Nelson – Difficult to have residents choose psychiatry as a career? Difference now?
  • Perry – Tech has never had the final piece to the psychiatry program
    • Pros are lifestyle is different than other physicians and higher reimbursement rates

 

Dr. Amy Stark, Self

  • Number of Texans with mental illnesses are increasing; need more intensive care from state hospitals
  • When there are not enough beds, patients languish in the community; happens in especially in the panhandle
  • Need a state hospital in the area to train future psychiatrists as well

 

Andy Keller, Meadows Mental Health Policy Institute

  • Does not like mental health rankings by state; are supposed to be used to create policy not to compare mental health response by states
  • Texas is ranked so low due to the weight of certain indicators
  • Cross sector partnerships have offered the opportunity to move quicker concerning the state hospital redesign
  • Is a workforce emergency; will need directive action by the legislature to assign a deadline for a plan
  • Panhandle is positioned well for a state hospital
  • Waitlist and the beds offline is the biggest issue right now
  • Need to look at the populations that are in the hospital; could consider taking Class B misdemeanors out of that and look at long-term stays
  • Need to do more on jail diversion; SB 292 back in 2017 good start, but need to do more
    • Dallas County was able to expand multi-disciplinary model has been expanded city-wide and are diverting 97%
  • Focus on children is relatively new and have not invested as much; need to expand infrastructure
  • Overviews legislature’s previous commitments including MST Teams
  • Need more hospital capacity for children, but propose pediatric crisis teams for early intervention
    • Estimate 7k students need early intervention
  • TCHATT was stood up quickly, but need common standards and targeted programs to educate/provide resources
  • Need more professionals, but biggest crisis is competition with salary with private businesses; need to do drastic work on this
  • Nelson – Was previous stigma around mental health; expand on the misreporting?
    • Need to not be distracted by news reports that pick and choose certain statistics
  • Nelson – Turned a corner how we see mental health?
    • Have more going into psychiatry than ever and other mental health professions
  • Nelson – Discusses Schwertner 2015 state hospital bill and other Senators’ mental health work
  • People with mental health issues are not violent
  • Hinojosa – Need continues to grow in our state, especially in South Texas
  • Kolkhorst – You mentioned we need seven teams, what type of teams?
    • Multisystemic therapy teams; they work with all the community adults in a youth’s life
    • The average hours of mental health services you will get is 20 hours a month; multisystemic therapy teams will give 100 hours in the first month
  • Kolkhorst – Superintendents agree we need parents to be involved in their children’s lives
  • Kolkhorst – How much do multisystemic therapy teams cost?
    • $600,000 a month per team; recommends adding it to Medicaid program
    • The average cost per youth is around $12,000; takes three to seven months
  • Kolkhorst – Is TCAT the only program of its kind in the country?
    • We think so; it is an organized system of the best mental health experts
  • Kolkhorst – Is social capital decreasing in our society?
    • Children today have less community support around them in our natural communities; this is the case in faith, community service, and other parts of our world
    • Wasn’t concerned about social media initially, now is
    • Social media insufficient substitute for community engagement
  • Kolkhorst – How much would you need for multisystemic therapy?
    • 80 million a year, but hopefully some would be funded by Medicaid
  • Kolkhorst – Discusses the different outcomes of mental health struggles between boys and girls
  • Neighboring states ramped up multisystemic therapy, but implement it after criminal justice encounters and don’t pair it with a program like TCHATT
  • Huffman – Are multisystemic therapy programs available under Medicaid?
    • In 2019, SB 2277 added it as an in lieu of service; recommends making it a Medicaid service
    • Capacity needs to be built overtime
  • Huffman – How would cost be broken out to state if it was a Medicaid benefit?
    • We can provide that
  • Perry – Is the program 100% outpatient?
    • Yes unless there is a situation in which a child needs to be transported to a short term facility
  • Perry – Are candidates contingent on parental involvement?
    • Before justice system involvement, there needs to be parental engagement
    • The team can begin to engage with parents before engaging with the child
    • Justice system involvement would occur if parents don’t want it; if there was an incident then they can come in
    • Service designed for parents who don’t want to do other programs
  • Perry – What about the people who can’t be helped by the program?
    • 1/3 of children won’t see results; they need to go to other programs but often they don’t receive adequate help
    • Implementing this program would probably free up space in inpatient facilities
  • Perry – How do you dispatch the teams?
    • There is a triage system; investments made from TCHATTwould ramp up existing providers
    • For the multisystem therapy, we could get 20 teams quickly, but it needs to be built over time

 

Dr. David Lakey, Texas Child Mental Health Care Consortium

  • Works with local mental health authorities
  • Offers child psychiatric fellowships
  • CPAN number activated two years ago; first child in TCHATTentered two years ago
  • ARPA funds haven’t been used yet; to be used this summer
  • Provides overview of Texas Child Mental Health Care Consortium budget and expenditures
  • 42% of budget to CPAN
  • Expenditures increasing as hiring staff and offering more programs
  • 8,422 CPAN providers; 10,000+ patients through program
  • Each provider receives $760 from Consortium; each consult $1000
  • Using this model for pregnant women
  • Largest challenge is staffing
  • TCHATT serves over 40% of Texas student body; need to expand into rural areas
  • Spends $3350 per campus; will increase
  • Provided TCHATT services to 6,000 students
  • Survey data indicates TCHATT and CPAN data helps
  • Completing pilot programs with substance abuse and school mental health education
  • Challenges with physical space, infrastructure, and internet in rural areas
  • Estimates ability to implement statewide next legislative session
  • Involvement well received by local mental health authorities; exposes residents to public health
  • Want to expand services to all mental health authorities and providers that want it
  • Recommends expanding number of mental health and child psychiatric fellows
  • Created new fellowship programs throughout the state
  • Working with emergency rooms and hospitals to gather information
  • Established networks for depression and suicide and childhood trauma
  • Two types of program evaluation; works with UT Austin School of Social Work routinely and Rice University completing formal evaluation
  • Need to grow mental health employees from Texas
  • Recommends partnering with minority serving universities to recruit mental health workers; could offer scholarships or tuition reimbursement
  • Recommends developing a mentoring system that would pay for and provide clinical supervision
  • Need to streamline licensure between other states and Texas
  • Evaluating alternate models of triple care
  • State work does not replace strong local mental health authorities
  • Nelson – Do you believe the funding Governor Abbott approved today was sufficient to expand TCHATT entirely statewide?
    • Looking at our current expenditures, we have enough money due to ARPA and carry-forward dollars
    • It’s enough funds to get through the next biennium
  • Nelson – What is the process to increase school buy in? Why don’t they want these resources?
    • Laurel Williams – More say yes than no; when they say no it often has to do with a lack of school resources
  • Nelson – What is the plan to expand TCHATT statewide?
    • Every other week, we have conversations with peers on how to move these programs forward
  • Perry – What is a complete consult?
    • Laurel Williams – CPAN is a psychiatric consult line; the work they do changes on a case-by-case basis
  • Perry – Is the consult complete when a referral is done?
    • Williams – CPAN is not a direct care service; we give guidance to physicians and are working on upskilling
    • We will begin doing one-time direct care consultations in the fall
  • Perry – For TCHAT, when is your work done?
    • Williams – It is dependent on the conversation with the family; care will be continued until no longer necessary
  • Perry – Do you keep data on TCHATT encounters?
    • Williams – Yes, we record who children are referred to any why TCHATT ended
    • Working to connect CPAN and TCHAT
  • Perry – All districts need to use TCHAT; TEA must report who isn’t using it
  • Hinojosa – Concerned with workforce shortages
    • Will take a continuum of strategies to address; recommends reimbursement or elimination of student debt
    • Recommends paid internships in public mental health and addressing clinical supervision requirements
  • Hinojosa – Concerned with implementation of TCHATT in rural areas
    • TCHATT conversations can occur in the home or families can find spaces with internet connection
  • Kolkhorst – What kind of research do you do?
    • One study focused on childhood trauma, one on childhood depression
    • UT Southwestern leads depression network
    • Trauma study led by UT Austin
    • Studies inform what services are needed
  • Kolkhorst – Have the children agreed to be in the research?
    • Yes, there is parental consent
    • There are 1,000 children participating; they receive slight reimbursements
  • Kolkhorst – How do you decide how much to allocate to research?
    • SB 10 allocated 10% toward research; we would like to allocate 10% again
  • Kolkhorst – Local superintendents acknowledged usefulness of TCHATT and CPAN
  • Kolkhorst – Do rural mental health employees tend to stay rural?
    • We help supplement rural providers where we can; need more training in rural areas
    • Important for individuals to be exposed to public mental health
  • Kolkhorst – Is there overlap between TCHATT and private vendors of mental health services?
    • No
  • Kolkhorst – Are you researching the impacts of social media?
    • We don’t have a social media study, but look holistically at things impacting children in the studies
  • Nelson – The last time an interim study on statewide health related workforce needs was completed was in 1999; recommends completing an updated study
    • The coordinating council would be a helpful tool; they created an analysis of the mental health workforce

 

Mary Dale Peterson, Driscoll Children’s Health System & Childrens Hospital Association of Texas

  • Increase in youth ER visits due to mental health
  • Suggests a system to allow access to available health bed information
  • Recommends putting a state plan amendment for partial hospitalization and outpatient treatment
  • Lack of residential treatment facility beds; 20% of kids continue to revolve in and out of facilities and depend on residential treatment facilities
  • Created pediatric mental health task force that meets monthly; works with hospitals and police departments
  • Corpus Christi ISD has 11-12 mental health professionals; separate from school counselors
  • Having TCHATT available invaluable for families and schools
  • Corpus Christi ISD requested more staff, training, and resources
  • Working on pilot program to fund four mental health professionals across Nueces and Hidalgo service areas
  • Recommends more preventive care services; designed program to help parenting skills and improve child outcomes
  • Program funded by Medicaid in North Carolina; could be funded in Texas
  • Attempting to target families of children with learning disabilities
  • Hinojosa – How do you handle children in ERs?
    • The average wait for transfer to a mental health facility is 9 hours but it may vary
    • Looking to purchase specialized ambulance to increase ease of transports
    • Most of the children who come in are transported over 150 miles away
  • Hinojosa – What type of team have you put together in the task force? Does it vary by situation?
    • There is a partnership between 12 specially trained police officers and the crisis unit; they go out on mental health calls
    • On the field, there is access to mental health physicians
  • Hinojosa – A lack of mental health training in police officers causes tragedies
  • Hinojosa – How much does your program cost?
    • It’s funded by the health plan but it’s not very expensive

 

Beth Lawson, StarCare Specialty Health System

  • Local mental health authority; charged with creating access to a diverse array of specialty healthcare services
  • Wellbeing at risk due to environmental factors such as Covid, inflation, and workforce shortages
  • StarCare serves over 9,000 patients a year; 5 counties hubbed in Lubbock
    • Delivers $48m worth of care
  • Local mental health authorities great investment for state; diverts cost from jails and state hospitals
  • Only local mental health authority in Texas that runs its own community-based hospital called Sunrise Canyon; offers care from outpatient services to most intensive inpatient care
  • Sunrise Canyon has lower costs and shorter stays than state mental health hospitals
  • Hospital partners with institutions of higher education for community-based training
  • Sunrise Canyon has no waiting list; network of five hospitals
  • Model of Sunrise Canyon would not work everywhere, but should be implemented in some places in Texas
  • Hospital offers walk-ins
  • Prevention just as important as treatment
  • Partners with Consortium to address children’s mental health
  • Early adopter of jail-based competency and outpatient competency restoration
  • Partnerships responsible for system’s success
  • Transitioning away from 1115 waiver
  • West – How do you handle people that don’t know they have a mental health problem?
    • Emergency detention and magistrate orders can put someone in front of a psychiatrist; there is roughly 72 hours to complete this
  • West – Does the doctor decide if they need continued help?
    • Yes, if they need inpatient treatment with a court order
  • West – What about out-patient?
    • Yes, but it is their choice to accept the treatment
  • Covid-fatigue impacting workforce in addition to inflation and other issues; StarCare raised minimum wage to $15 an hour
  • Minimum wage increase causes wage compression

 

Sheriff Kelly Rowe, Sherriff’s Association of Texas

  • Staffing affecting police departments as well; at county jail level, no ability to find a release
  • Commission anticipates jail overcrowding across Texas state
  • Average length of stay in county jails is 27 days for no mental health issue, 36 days for those with mental health struggles
  • Overcrowding and staffing affecting all sectors of economy

 

Sheriff Brian Hawthorne, Sherriff’s Association of Texas

  • State legislature significantly helped mental health providers; encourages continuing to increase funding, especially in rural counties
  • Recommends committee examine and encourage use of in jail based competency restoration
  • In jail-based competency allows people to move through the system faster
  • Requests earmarking money for 292 program and jail based competency restoration
  • Huffman – Requests Hawthorne come up with a plan and bill for funding

 

Steve Glazier, UT Health Behavioral Sciences Department

  • New psychiatric center; partnership between UT and HHSC
  • UT partnered with Harris County for 36 years to evaluate county psychiatric center
  • Patients can be stepped down through care
  • Housing available upon discharge from hospital
  • Significant outcomes from patients in program; less likely to be readmitted and arrested
  • HHSC owns building; UT provides care
  • HHSC contracts beds for patients; rest of beds used privately for UT
  • Once UT receives enough funds from patients, funds will be used to pay for facility and allows UT to contract beds at low rates to HHSC
  • Providing quality care at competitive prices
  • UT Health owns business and risk; serves as governing board of hospital
  • HHSC maintains a board spot
  • UT Health follows some HHSC guidelines; incorporated them into contract and UT Health guidelines
  • Model can be replicated with other providers
  • Challenges with governance
  • Seeks to fill gaps in the continuum of care
  • Started recruiting staff in November to open in March; hired enough and opened two units
  • Looking to open two more units in August
  • Easier for academic centers to recruit
  • Due to inflation, had to complete a salary market adjustment; at mid-point in the market
  • Facility allows for unique treatment
  • Using the same economic drivers that are used for Houston hospitals
  • Challenge in ensuring building represents key stakeholders
  • Huffman – How does your facility enhance the behavioral health workforce?
    • Allows for clinical supervision, recruiting from out of state
    • Academic institution involvement attracts people to the field
  • Huffman and WHO discussed salaries; are at the mid-point in the market
  • Are using the same economic drivers of other privately owned hospitals to run capitol upkeep and indigent care to create an incentive to keep costs down
  • Overviewed HHSC contract negotiations and governance conversations
  • Huffman – Talk about your additional education capacity for behavioral health workforce?
    • Have recruited a lot outside of the state, tuition reimbursements; many want to work for an academic institution

 

Dr. Sarah Wakefield, Texas Tech Health Science Center and Texas Child Mental Health Consortium

  • Have a crisis of access to adequate care for those in crisis, and have a lack of resources to prevent people from reaching crisis
  • 4 to 7 ROI in investing in mental health
  • Must reimagine healthcare; need to take assessment and care to where they are
  • Must treat the pathology of mental illness as early as possible
  • Provides personal anecdote of the difficulty in providing service in rural areas
  • Consortium focuses on using a multi-disciplinary team
  • Are focusing on “middle services” before someone reaches a crisis
  • TCHATT deals with the seriously mentally ill; those who need intervention
    • Was rolled out during the pandemic
  • MOUs in place for 130 ISDs; at the beginning might not have that may referrals
  • Are implementing plans of comprehensive care for ARPA funds
  • Overviews CPN expansion and enhancement programs
  • Implemented a software for the screening process which includes recommended
    • Find the 57% of those who are screened meet clinical depression criteria
  • Perry and Wakefield discuss the child psychiatrist program and child psychology internship/post-doc programs at Texas Tech
  • Perry – Training with the IDD population?
    • Yes
  • Perry – Should districts move from CATR to TCHATT?
    • Yes, they should and they did; consolidated under TCHATT

 

David Criner, Sheriff Midland County

  • Highlights the costs associated with inmates with mental health issues and the overcrowding of Midland County jail

 

Russell Meyers, Midland Health

  • Meadows assessed Permian Basin in 2016; documented the communities “massive” need
  • Made the request last fall and were given $40m to go towards an $86m comprehensive care hospital; most of focus was adults and adolescence
    • Are looking to expand care to children and add services due to recent events
    • Will not be open until about 2024; philanthropy will meet the remaining need
  • Have workforce shortages across industry and need the ability to grow own workforce particularly psychiatrists
  • Some additional state beds to serve the region would be helpful to the community

 

Terry Crocker, Tropical Texas Behavioral

  • Will serve more than 33k different people this year
  • 1,400 budgeted employees and 936 positions are filled
  • Vacancy percentages is gradually improving due to compensation modification and other modifications
  • Need to bring more people into the mental health services field through higher education incentives
  • Inpatient mental health services; only have about 30 beds for adult use only
  • No child or adolescent state hospital bed in the RGV and the closest is in San Antonio
  • Greatest weakness in the Valley is the lack of bed availability
  • Those who are acutely ill need the services of a state hospital; private providers often cannot provide and cannot admit them
  • Kolkhorst – Will be taking on the workforce charge in Health and Human Services; are funded through Medicaid/Medicare and state funding?
    • Have over 55 different funding streams including school districts who contract with us
    • Majority of budget is contract with HHSC
  • Hinojosa – Support building a state hospital in the RGV?
    • Yes; no child or adolescent state hospital bed in the RGV and the closest is in San Antonio
    • Hinojosa – Notes babies and children is the biggest population is growing in the RGV

 

Invited Testimony Closing Comments

  • Huffman – Would like HHSC to come back to the committee to report/provide the committee with a plan for the following: updated roadmap for long-term and short-term, capacity needs statewide, workforce challenges, community readiness
  • Huffman – Will be helpful in budget discussions/decisions

 

Public Testimony

Margie Netherton, NAMI Texas Panhandle

  • Support the proposed building of a state hospital in the panhandle; only region in Texas that has no state psychiatric hospital

 

Andrew Lopez, Colorado Co. Sheriff’s Office

  • Seen an increase in mental health consumers, but many are released after a short stay and often become part of the criminal justice system
  • Ask for rural counties to get a grant to provide training to deputies to prevent mental health consumers from entering into the jail system
  • Concerned that TCOLE has recently reduced training hours mental health officer course
  • Huffman – Mental health call, you respond with backup?
    • Yes and provide them with additional support
  • Huffman – Did not know TCOLE reduced those training hours, thanks for bringing to our attention

 

Jay Johannes, Colorado Co. DA

  • Number one issue is the amount of forensic beds
    • Huffman – Will need to take up the forensic bed issue

 

Dr. Mazey Leftwitch, Greater Colorado Valley Task Force

  • Issues of lack of local beds, not having local crisis centers, mental health professionals, etc.
  • Need to go back to high school and pull more people into mental health services
  • Need to do more to find mental health staff
  • Have a lot of funds and efforts going out, still have a large problem
  • Appreciate funds for mental health authorities; regulations stop them from serving those with certain diagnosis
  • Huffman – What can we do to help rural counties that do not have the beds?
    • Have raised about $300k in private funds due to lack of state funding
    • Is a lack of follow-up after they leave; constant repetition of crisis
    • Would like to see funds directed to rural counties to develop their own plan
  • Kolkhorst – Noted they have been talking about reforming the mental health system for years; do not typically give funds straight to counties, but currently are not getting enough funds to services
  • Kolkhorst – Have “played by the rules” and “about done with the rules if we do not get the services out there”

 

Lori An Gobert, Mayor of Columbus

  • Have 1 mental health specialist for 5.3k residents
  • Mental health responses by a small number of citizens cost the city millions of dollars
  • Could be avoided by having availability of facilities and services in this area
  • Ask the legislature to increase funding to communities across Texas for this

 

John Kaspel, Texas Police Chief’s Association Mental Health Pathways Committee

  • TPCA asks the legislature to consider consider pre-incarceration mental health needs
  • Need to supply officers in the field the appropriate training or resources/supplies to refer such persons into services or diversion centers
  • Funding could go toward brick-and-mortar regional service centers
  • Perry – Learned is a very inconsistent mental health component in the academy; need your association to not “run” or “manipulate” TCOLE and get academies right
  • Perry – All officers should have the full spectrum of training for mental health
    • Believe the training mentioned earlier that has been reduced should be increased back to 40 hours and should be mandatory
  • Kolkhorst – TCOLE training is important to talk about; need to double down on investments before we cycle down on the effects COVID had on us
  • Perry – Notes in other committee hearings heard police/schools saw signs of concern in students who ended up committing mass violence

 

Claudette Fette, Occupational Therapy Texas Woman’s University

  • Mental health advocate; overviewed barriers to occupational therapists working as primary mental health providers
    • Are not in the list of mental health providers and do not diagnose
    • Texas Medicaid does not have a place for skilled professional staff that do not diagnose
    • Funding is the third barrier
  • Funding needs to be increased for direct care staff
  • Need to create a recovery workforce designation and OT belongs within those roles
  • OTs could be part of the workforce solution; currently are losing them to other states

 

Angelie Parte, TOTA

  • Occupational therapist; face barriers such as lower reimbursement rates
  • Ask for increased financial support for existing and developing behavioral health programs

 

Greg Hansch, NAMI Texas

  • Legislature’s commitment to the mental health – effect on quality of life for those with mental heath issues has been profound
  • Are still gaps in provision of services; have recent closures of crisis facilities and lack of housing
  • Have a partner in the judicial system with AOT and mental health courts; should be investing in these court services
  • Legislature’s investment in coordinated specialty care will only get us 45% of the way there, need continued investment/focus
  • Huffman – Safer Communities Act funding could go to those courts

 

Kurk Noaker, Arc of Texas

  • Will overview 2 of 5 recommendations; rest are in written testimony
  • Need more equity among LMHAs and local IDD authorities
  • Would like to see establishment of mental health triage centers

 

Russell Schoffner, Assistant County Administrator Tarrant County

  • Appreciates the discussion about the issues with forensic beds; current inmate waitlist for a forensic bed is 158
  • Tarrant County has used ARPA funds with local partners to open a diversion center
  • Committee should consider next session for a grant program or funding streams for these community partnerships
  • Ask for reimbursement from the state to cover the costs of inmates on the waitlist
  • Notes the workforce shortages in the jail and diversion center
  • Need to keep urban access for mental health in mind

 

Josette Saxton, Texas Care for Children

  • Agree with testimony provided today; appreciated additional mental healthcare funding
  • Need to ensure parents and families have the options when their kids are in crisis and to have upstream services
  • Schools are not clinicians, but should promote the social/emotional/academic wellbeing of kids
  • Should provide funding stream to districts providing those services and need to shore up community mental health centers

 

Shelia Hemphill, Texas Right to Know

  • Discusses the governments involvement/overreach during the pandemic

 

Margie Barilla, Elevate Healthcare

  • Overviews the lack of mental health providers in the panhandle/north Texas
  • Need an immediate facility in this region of the state

 

 Sonia Burns, Self

  • Family member has been a part of the mental health system
  • Need to address those on the waitlist who have already been competency evaluated
  • State hospital redesign funding did not address those with most complex needs and highest utilizers
  • Recommends expanding eligibility criteria SSLCs
  • Asks to meet with the members on the committee with the COS
  • Huffman – Cannot promise that
  • Perry – We should this has been informative; SSLC use is helpful for kids who need intermediate care that have unengaged parents

 

Closing Comments

  • Perry – Thought we would have testimony from private vendors; is the insurance that is limiting the amount of days they are in the facilities