The Senate Committee on Health & Human Services met on March 22 to take up interim charges related to DFPS programs, CPS, and opioid and substance abuse.

This report is intended to give you an overview and highlight of the discussions on the various topics the committee took up. This report is not a verbatim transcript of the hearing; it 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.

 

Assess the effectiveness of public and private agency efforts to recruit and retain foster parents. Identify barriers to entry and obstacles that prevent interested families from continuing to provide foster care. Recommend solutions to increase foster recruitment and address non-renewals, especially in first-time foster parents.

Hank Whitman, Department of Family and Protective Services

  • Updates Committee on ongoing lawsuit against Texas foster care
    • Implementation of previous ruling against Texas has been stayed until a decision has been made on Texas’ appeal
  • Link to DFPS presentation
  • 29k children in DFPS care, challenging to find appropriate placement, DFPS strives to place children with relatives
  • HB 4 (85) allowed DFPS to pay kinship caregivers a daily rate while locating placement, expecting kinship use to rise
  • Growing capacity is important, difficult for children with the most complex needs
  • Overall foster homes have increased over the last several years
  • DFPS is partnering with faith-base community to help build capacity, over 1,000 faith communities provide placements, transport, health care, food, etc.
  • Watson – So you completed a capacity needs assessment in 2017, is there a strategic statewide plan being developed from this that is publicly available?
    • In process of developing a plan
  • Watson – Who is included in this?
    • Stakeholders, foster parents, every person in the process
  • Watson – How are you going about creating the plan?
    • Developing process now
  • Watson – Needs assessment will be refreshed this year, so when is the plan going to be ready?
    • Before June
  • Watson – Can you give examples of how you pull faith-based entities into the process?
    • Have specialized personnel in communities to help organize, also regular summits urging members to become foster parents
  • Watson – Are you pursuing strategies to grow these avenues?
    • One part is education about the process and need for care
    • Whitman is also personally engaging with faith leaders
  • Whitman – So the chief strategy is outreach, anything else?
    • This is our main strategy
  • Whitman – Worried about statement that the growth is not enough
    • Not enough for our high needs children, trying to continue to build capacity for this
    • Working heavily with private partners
  • V Taylor – Can you speak to caseloads, staff, pay, etc.?
    • Raise given by legislature has been monumental, turnover rate is much lower; Caseloads have decreased a lot
    • Whitman is riding with caseworkers as well to assess and get feedback
  • Perry – Largest thing I’ve noticed is a new community of support for foster parents
  • Schwertner – Rates have increased, support has increased, this is a multi-pronged approach to an issue that needs to be addressed; These factors were large parts of the lawsuit
    • We have a lot of challenges ahead of us still, have to meet goals in building residency centers, support parental visits, etc.
  • Schwertner – Do we have any numbers regarding how many foster parents have come from faith-based outreach?
    • Can get those numbers
  • Schwertner – Tell me a little about retention of foster families?
    • We haven’t seen an increase in retention, fostering is a difficult prospect
  • Watson – Still not entirely clear how you are going about the needs assessment and rolling it into the strategic plan, would ask that you keep committee aware of progress, especially if there will be an LAR request
    • We need to do this, as any effort like this has a cost
  • Kristene Blackstone from DFPS is called to provide detail on the strategic plan and needs assessment

 

Kristene Blackstone, DFPS

  • Released initial needs assessment last year, compiled a report and discussed needs in each area of state with the provider community
  • Also discussed what was missing in the report
  • Currently looking at data and writing reports in this year, will work with providers in each region to develop a strategic plan
  • Watson – What is the timeframe you envision?
    • Needs assessment planned for May, will begin speaking with communities after
  • Perry – At my church, someone from the foster care system was designated as a liaison
  • Burton – Not familiar with the faith-based specialist in each region, effort is incredible from the faith-based community
    • Whitman, DFPS – Effort has been great, DFPS is meeting with communities to hear concerns as well
  • Schwertner – There is a website called CarePortal designed to connect resources in faith-based communities

 

Denise Kendrick, Embrace Texas

  • Need for more foster parents in Texas
  • Issues/barriers for retaining foster families: negative stigma, difficult recruiting process
    • Solution: retention of active foster parents
  • Care of current foster parents is crucial
  • Need to weed out bad foster parents/bad actors
  • Need to clarify message surrounding foster parents and what the expectations are
  • Use of phrase “foster to adopt” expresses the wrong sentiment
  • HR 4980- need to allow foster parents to care for children in a more similar way to biological parents
  • Better communication with foster parents would help reduce burnout
  • Watson – What are the current barriers to making respite care open?
    • The policies in place, mean that you have to choose providers who are credentialed, or background checked even for babysitting
  • Schwertner- maybe more work needs to happen on the normalcy bill
  • Burton – Where is the blame for the foster parent not given the opportunity to adopt the child?
    • With the child placing agencies
  • Perry – Normalcy and network of support would be beneficial for foster parents, not extending some of those things that biological parents would otherwise be able to do

 

Jennifer Allmon, Texas Catholic Conference of Bishops

  • SB 11 allowed organization to immediately get to work
  • Created St. Joseph’s Ministry within parishes to provide support for foster families
  • Reviewed written testimony
    • Shows foster need by county based on DFPS data, able to provide additional support to those areas
  • Additional support and information “tool kit” in those areas will enable more people to be proactive in supporting the foster community
  • Spreading information through newsletters, etc.
  • Creation of information created by collaboration with many stakeholders and DFPS

 

Kurt Senske, Upbring

  • Individual family placements are the preferred placement
  • Child centered approach to foster care starts with safety and education
  • Upbring works with 500 foster families
  • Relayed specific personal example of work with a foster family regarding making physical improvements to the home to make it suitable for foster care
  • Capacity challenge is more about retention than recruitment
  • Texas Youth Permanency study conducted with UT-Austin showed the importance of relational permanency
  • Private/public partnership is vital
  • Schwertner- do you track the retention rate?
    • 80% of foster families intend or have adopted
    • 450 are verified but have taken a break from fostering
    • 94-96% success placement rate

 

Review the efficacy and quality of services offered to ensure family preservation while in the Family Based Social Services (FBSS) stage of service at the Department of Family and Protective Services. Make recommendations to better track quality of services and link payments to providers of these services to outcomes for families and children.

Kristene Blackstone, Department of Family and Protective Services

  • Link to DFPS presentation
  • Caseloads have decreased by 30%
  • Turnover has decreased since fall of 2016
  • Discussed services provided by DFPS
  • Rural counties are typically underserved because of lack of available services
    • Considering conducting services study across the state
  • Prior to case close DFPS reviews child welfare
  • SB 11- require performance metrics to be created
    • Partnered with Stevens group to determine these
  • Pilot in El Paso went live last week
    • Performance based contract
    • Started delivering services March 12
    • Increased funds for evidence-based client services
    • Hold contractors to high level of services
    • DFPS will monitor the progress
  • Watson- written testimony shows turnover with an increase in turnover?
    • Slight increase in turnover at the end of last year
  • Watson- why did that occur?
    • positions vacated in region 10
    • additional employee requirements
  • Watson- written testimony indicates caseloads lowering but an 11% increase in referrals, why is that?
    • Better retention of staff overall typically means that case load goes down, have a more stable workforce at present
  • Watson- how many FBSS caseworkers were hired?
    • 150 that were hired as a result of critical needs funding
  • Watson- what is the length of time a case stays open?
    • Currently, 199 days on average
  • Watson- how does that compare to the year before?
    • Believe it is up for the previous year
  • Watson- what is the agency doing to get additional funding for the Family First Prevention Act?
    • Working with stakeholders to see how the bill impacts Texas
  • Watson- service array and availability by region, are you doing any statewide analysis?
    • Trying to figure out how best to survey all of the evidence-based services and where the gaps are
  • Perry- have 199 average days per case, why is that only about 8 months when most case workers are saying that it is usually a 12-month plan? It is time to have a family law and family court discussion? What is your opinion on that?
    • The 199 days is for FBSS cases with very few cases that go to court
    • There are several opportunities in the process that we should be reassessing the plan
    • There are cases that have gone to trial before the 18month mark
  • Taylor- what is driving the number of cases being opened?
    • Agency doing a better job of investigation
    • Better able to assess the factors in a case
  • Taylor- is the number of complaints steady?
    • Number of intakes is up about 4%
  • Taylor why are there so many more cases in the two-year period?
    • with better assessment tools we ere able to better identify cases to open
  • Taylor- do you expect these numbers to keep going up?
    • The number has started to come back down and level off
  • Schwertner- when will the SB 11 evaluation of services will be completed?
    • Working with UT-Austin to figure that out but recommendations will be in place for FY 19
  • Schwertner- where are we on the RFP for the second Pilot Program?
    • Site will be identified in 90 days to be able to put out the RFP
  • Schwertner- what sites have been identified?
    • Staff is compiling list of potential sites

 

John Steven, Stevens Group

  • Made finding similar to Sunset Commission regarding FBSS system
    • Led to support for SB 11 changes
  • Pilot programs is very consistent with federal legislation regarding evidence-based services to keep families together
  • Watson- critical to understand the issue not to avoid having additional issues going into the next legislative session
  • Report on lack of availability of FBSS services shows a need for evidence-based services and to involve the community along with public/private partnerships
  • Working with DFPS staff on RFP for pilot program
    • Considered other states methods
  • Watson- written testimony shows costs of per family costs, does that include case management overlay?
    • Correct
    • That is 2015 data, but similar trends are still there
  • Recidivism rate is about 4%, there will be some upfront costs, if the recidivism rate is lowered there could be a substantial saving for the state through FBSS services
  • RFP was developed with intense review of contract requirements and accountability
  • The evaluation must be thorough to determine if performance measures are being reached
  • RFP outlines that the vendor must: close cases, reduce number of days cases are open, reduce recidivism by 10%, if not met there will be a pay back
  • Need to ensure that the contractor is held accountable
  • Need to ensure that DFPS is monitoring the contract
  • Need to involve the community

 

Dan Johnson, Pathways Youth and Family Services

  • Proud to be delivering the FBSS contract
  • Very confident in the program
  • Engaging the community in as many ways as possible
  • Discussed the RFP bidding process
  • Challenges include closing cases within 140 days, which required new case methods for case management
  • Within first 90 days will be providing training to providers
  • Unexpected relationships with FQACs led to new relationship with substance abuse support which will be used across the region

 

Analyze the Department of Family and Protective Services’ progress in meeting statutory requirements related to timely visits to children involved in a reported case of abuse or neglect. Make recommendations to further improve the timeliness of these visits.

Hank Whitman, Department of Family and Protective Services

  • Link to DFPS presentation
  • Lack of timeliness of face to face visits last year were due to lack of staff
    • Timeliness has increased dramatically since last year
  • Special investigators help find families and children to get with case managers
  • If child is not found, they are added to an alert system to help find them
  • Relationships with law enforcement have been very beneficial
  • Watson- many times these cases are high risk and the minimum contact is once a month, what is the average number of visits?
    • More than the minimum, but no specific number available at this time
  • Watson – Requested that information be provided to the committee
    • Will provide that information
  • Watson- majority of visits happen in the residence and the case worker should have the visit in private, how is that tracked?
    • Not sure how that is tracked, although seen the documentation of the visit
    • Described specific example of documentation at a face-to-face visit

 

Audrey Carmical, Department of Family and Protective Services

  • No statutory requirement for tracking those additional visits
  • It is reviewed in internal reviews
  • Watson – Written testimony says “federal requirements”
    • Law requires the one face to face visit, policy of agency requires visit to be conducted in private
  • Watson – Are there any ways to track that?
    • There is a practice to do visits in private
    • The tracking mechanism is not on that scale
  • Perry – When a case worker has an interview there isn’t additional log?
    • There absolutely is
  • Perry – I think it could be more clear, but caseworkers do document
  • Watson – I can see why it would be important to have a mechanism for tracking this important policy provision
  • Schwertner – What are doing in regards to collaborating with federal or international partners
    • We use analysts in other state’s agencies, we go through RSIs and try to track families
    • Need to do more to educate law enforcement about the tools available as well

 

Review services and supports provided to children in Permanent Managing Conservatorship of the state, and the level of preparedness given to youth aging out of state care. Examine the impact of recent legislation related to these populations and make recommendations to ensure youth in care are ready for adulthood and to reduce the likelihood of intergenerational perpetuation of child maltreatment.

Kristene Blackstone, Department of Family and Protective Services

  • Link to DFPS presentation
  • DFPS’s goal is to find permanent placements for youth, but when they cannot DFPS focuses on making productive adults
  • Children aging out of system without a placement face significant problems regarding employment, substance abuse, incarceration, etc.; Though there has been improvement recently
  • Transitional Living Services makes efforts to educate young adults aging out about extended care services, provides opportunities for those aging out to return and receive life skills training, etc.
  • HB 1608 required an internship pilot for teenagers in DFPS, working with Marshall’s as part of the pilot
  • College Tuition & Fee Waiver helps those aging out transition to college; Youth aging out do face difficulties getting to college, but DFPS is working to prepare them
  • Extended Foster Care, Supervised Independent Living, and federally-funded Education & Training Voucher are tools DFPS uses to provide housing for youth aging out
  • Schwertner – Did not realize that the college supports existed, given our foster care liaisons at campuses, etc., there seem to be a whole array of services for youth aging out wishing to go to college
  • Watson – What timeframe are you looking at for a curriculum for live skills for 15 year olds?
    • Looking to have it completed by next year
  • Watson – What does a child need to do to be counted in the completion percentage for life skills courses?
    • Completion of the entire program
  • Watson – Are they assessed for readiness?
    • There are some assessments, but statistics reflect successful completion
  • Watson – Is supervised independent living distributed around the state?
    • They are, but many are in urban areas
  • Watson – Should we be looking at ways to expand this?
    • There are a number of ways we can improve on this service

 

Katherine Barillas, Texas Network of Youth Services

  • We are supposed to be starting life skills education early, designed to begin at age 13
  • We do have systems to check on progress, there are limits and requirements for those caring for them
  • Supervised Independent Living rates did not get an increase last session, currently covers 60-70% of costs, there are waiting lists for these services
  • Even with the various services, many youths do not feel prepared & this has been a consistent trend
  • Recommendations
    • Need to ensure caregivers are prepared
    • Need graduated housing taking steps towards independence

 

Susan McDowell, LifeWorks

  • LifeWorks is primarily trying to solve barriers to self-sufficiency
  • Maintains contracts with DFPS for housing, prevention and intervention, transition centers, etc.
  • Reiterates that statistics for foster care involved youth are troubling, housing, substance abuse, incarceration, etc.
  • Usage of data needs to improve across all providers, need to align around evidence-based practices
  • Need to look at how we are aligning CPS systems with state and federal systems targeting homelessness, education, and health
  • Need to also consider rural partners and support from state and philanthropic partners
  • Perry – Time to revisit if our public system is properly preparing children, rural areas also have some unique programs focusing on job preparedness and leadership skills; Could be collaboration both ways where rural programs are leveraged for urban areas
  • Kolkhorst – There are some advantages in rural programs, though we are working through deficiencies; Some of my counties don’t have a foster family available, what do you suggest we do for these communities?
    • Not so worried about youth that is either urban or rural and is stable
    • Can do a lot of work in getting community-based care moving

 

Review substance use prevention, intervention, and recovery programs operated or funded by the state and make recommendations to enhance services, outreach, and agency coordination. Examine the adequacy of substance use, services for pregnant and postpartum women enrolled in Medicaid or the Healthy Texas Women Program and recommend ways to improve substance use related health outcomes for these women and their newborns. Examine the impact of recent legislative efforts to curb overprescribing and doctor shopping via the prescription monitoring program and recommend ways to expand on current efforts.

Sonja Gaines, Health and Human Services Commission

  • Link to HHSC presentation
  • Estimate that 1.6 million Texans have a substance abuse disorder, means recurrent use of drugs and alcohol that leads to health problems or disruption of responsibilities
  • HHSC strategic plan contains goals for HHSC response to substance abuse:
    • Enhancing service coordination and delivery
    • Enhancing prevention and intervention services
    • Increasing data collaboration
  • Major barriers to treatment for these issues, including provider shortage and waitlists
  • Statewide Behavioral Health Coordinating Council survey of agencies showed 30 different programs focused on substance abuse treatment
  • Outreach, Screening, Assessment, and Referral Centers (OSARs) are located throughout the state, 30,000 people treated through these offices @$7 million annually
  • Many screened through OSARs are screened by phone, can also visit individuals directly
  • HHSC also created the mentalhealthtx.org website for outreach and education, contains a service locator tool
  • Non-Medicaid indigent care services programs cover an array of areas – youth prevention services, resource centers, pregnant and postpartum services, HIV services, etc.
  • $27 million opioid funding added last session, >$200 million in treatment services across Texas, 76% of this is federally funded
  • There is also a Medicaid benefit, $9.7 million, includes assessment, detox, residential treatment, outpatient treatment, screening, etc.; Close to 6,000 individuals receive annually
  • 56 substance abuse related 1115 waiver projects exist across Texas, partnership between substance abuse providers, LMHAs, hospital districts, etc. is high
  • $400 million in first 6 years of 1115 waiver through DSRIP, CMS has extended through Sept. 2022
  • Kolkhorst – Of that money, on the first waiver $2.9 billion had to go to mental health, are these services a subset?
    • Believes it is
  • HB 13 (matching grant) and SB 292 (reducing recidivism) were great funding measures passed, allowed for a large expansion of substance abuse services
  • Schwertner – Calls Stephanie Stephens from HHSC provide info on 1115 waiver funds
    • Stephanie Stephens, HHSC – There was a 10% set aside for 1115 funds for mental health, can get the substance abuse breakdown numbers later
  • Kolkhorst – Not sure we have a global view of mental health funding, need to track dollars devoted to these areas
  • Schwertner – Asks after provider allocations under the new waiver
    • Have continued the allocations, specific programs will be outlined in transition plans
  • Kolkhorst – Did we ever have a good look at what the $29 billion 1115 money went to?
  • Schwertner – With DSRIP, the thought was innovative programs would lead to savings and better programs; Whether the waiver has been successful at this or whether the overall health care pipeline has just been expanded is worth considering
  • Buckingham – Asks after metrics or outcomes tracking?
    • Gaines, HHSC – There are several measures, can get this to you

 

Lisa Ramirez, Health and Human Services Commission

  • Our system uses national outcome measures
  • Perry – Does our system track recidivism or repeats? Also asks after neonatal tracking measures and if it includes neonatal abstinence syndrome (NAS)
    •  Neonatal tracking measures look at fetal withdrawal symptoms, NAS is tracked at a state level
  • HHSC runs various programs and studies focused on maternal care, includes NAS initiative working to promote awareness and increase identification
  • Seeing lowered needs of NICU use for NAS patients, leading to lowered costs
  • V Taylor – Where do our maternal mortality numbers come from?
    • Evaluated and analyzed by HHSC through the Maternal Mortality group
  • V Taylor – So they come from the counties?
    • Can get back to you with more specifics, statistics are from 2016
  • Kolkhorst – I know there have been disputes as to death certificates, etc., are our numbers accurate?
    • Gaines, HHSC – Yes, our numbers are recent and DSHS has been looking at improvements recently regarding accuracy
  • V Taylor – TX needs to do a better job on how it collects data on a county-by-county basis, flu death numbers were off, for instance
  • Kolkhorst – How do we address this? Maternal mortality is an area where we need accuracy
    • Ramirez, HHSC – We are working closely with Vital Statistics, polling local personnel on data now, particularly concerning overdose deaths
  • Kolkhorst – And part of this was directed by SB 17 during 85 (1)
  • Miles – And you’re not questioning the validity of the prevalence of overdose, just asking after data collection, correct?
    • V Taylor – Have misgivings about a non-standard data set; Agrees overdoses are an issue, but not convinced it is the major cause
    • Gaines, HHSC – We do recognize that we need a closer look at data, DSHS is looking at this
  • Kolkhorst – I think SB 17 and the Maternal Mortality Task Force is verifying deaths by medical record
  • Miles – SB 1599 contained better guidelines for maternal mortality data, need to abide by it
    • V Taylor – Appreciates the work done on this, need to make sure all of data is accurate
  • Majority of Texas’ targeted opioid response funding is dedicated to treatment and recovery services, medication received during treatment significantly improve outcomes
  • HHSC also has targeted services for housing, employment, etc.
  • Tend to only go after substance abuse disorders after they have become severe, preventative treatment can drastically increase outcomes and decrease overall cost
  • Kolkhorst – One of the alarming statistics from Medicaid and CHIP services details how recipients are prescribed dangerous substances at higher rates and have much higher rates of overdoes (3-6x), do you have an explanation for that?
    • Texas Targeted Opioid Response (TTOR) initiative is working on preventative and education measures to keep recipients opioid naĂŻve and to deter overprescribing
    • Stephens, HHSC – Other measures are guiding MCOs on this issue, a work goup will be meeting next week to help address this issue
  • Kolkhorst – Some stats and trends are promising, but the age of death from overdose is decreasing too
    • Gaines, HHSC – We are also concerned with tracking our efforts, not just putting money out there

 

Lynnette Watkins, Baptist Health System, Texas Hospital Association

  • This is a multidisciplinary effort, many things need to be done to tackle a complex issue
  • CDC reported opioid overdose visits increased 30% from July 2016 to Sept. 2017, significant increase
  • V Taylor – And these numbers are state numbers?
    • These are national numbers from the CDC report
  • CDC also broke down regions, in the South West it was 7% per quarter or 20% over this same period
  • When patients are stable, we try and find a treatment facility to continue care; Many patients with psychiatric issues also have substance abuse disorders
  • Recommendations
    • Allowing physicians flexibility to care for patients
    • THA has adopted opioid prescribing guidelines for ERs, could be used as a model
  • Baptist Health System is proud of its NAS program
  • Schwertner – Regarding the ER opioid guidelines, prior protocols for pain identification required more medication and increased inpatient use, have these been looked at?
    • While the guidelines focus on the ER, we have had discussions across the spectrum
  • Schwertner – Are we still using the face diagram to gauge?
    • Yes, but we are having conversations about how we look at and manage pain
  • Schwertner – Can be difficult given CMS involvement and metrics for pain management
  • Campbell – Have heard this same thing, but that it is more of a legislative initiative
    • Joint Commission came out with new guidelines in 2018, looked at to the pain management metrics in the patient experience
  • Schwertner – Oftentimes, first introduction to opioids happens in a surgical environment, pain management metrics that measure ease or comfort can complicate the opioid problem

 

Amy Granberry, Charlie’s Place Recovery Center

  • Heroin surpassed alcohol in our facilities as largest treatment substance 2 years ago, also seeing increases in methamphetamine and synthetic drugs
  • V Taylor – Nationally, we’ve seen states move towards legalizing marijuana, do you see a correlation between legalization and opioid deaths
    • Hadn’t looked at this before, but can
  • V Taylor – Opioid death rates are skyrocketing, wondering if one is leading to the other
    • The majority of patients are using multiple substances, but would need to look at this
  • As a provider, required to follow-up with every patient 60-90 days after treatment, have very good metrics; Though we do see some patients return multiple times
  • Regarding competitiveness, we apply for the services we believe we will need, there is also a 5% community match required
  • Charges with serving HHSC region 11, we have 36 beds for indigent contract, actual capacity is 155 beds split between different sources; Waitlists are primarily for indigent beds
  • Work very closely with LMHAs and OSARs, hospitals, CPS, etc.
  • ~65% of patients have some sort of co-occurring mental health and substance abuse disorder
  • Perry – Regarding outcomes, do you track patients past 90 days, readmissions, etc.?
    • Just finished a 3-year project tracking everyone, have a significant readmit, 12-15% stay out
  • Perry – Does this become a baseline budget item for every taxing district to deal with, or not? 85% come back
    • When we talk about the number it is difficult to track patients consistently
  • Perry – Regarding beds, we see that we have capacity, but because of specific program requirements we can’t you use it; Did you have beds available for the indigent waitlist that you couldn’t use?
    • With funding, all of them
  • Perry – But you get funding for the others
    • We get paid fee-for-service, so unused beds do not have funding attached
  • Schwertner – Do you track how patients are first introduced to opioids?
    • Not with specificity, it is discussed during assessment
  • Schwertner – Do you have thoughts on the most common mechanism?
    • We treated >200 that were prescription opioid abusers that began with valid prescriptions

 

Andy Keller, Meadows Mental Health Policy Institute

  • Need to recognize that these are chronic illnesses, 28-day treatment funding period is an arbitrary cutoff that does not reflect reality of years-long treatment
  • Discrepancies in opioid deaths is important to look at, critical to get these counts correct to ensure federal dollars continue to be leveraged
  • We have seen trends grow from the 90s, not only do we need to treat pain, we also need to treat addiction at the same time
  • Cutting access to medications and opioids will just lead to more heroin deaths, medically assisted treatment can help
  • Right now the 5-year contracting process is not sufficient to meet local needs, need to explore local option
  • Need to focus on integrated care and rethink sending OSAR dollars to LMHAs
  • Schwertner – You’d think colocation of mental and behavioral health services would be good
    • It is, need to think more on who is in the lead, OSAR dollars without planning dollars could be problematic
  • V Taylor – Data is not adequate, is there a way to fix this? Have had problems in Tarrant County
    • There are Medical Examiner’s Offices in larger counties where the specificity of local data isn’t preserved; Reconciliation of data between large counties and DSHS would take us most of the way
    • Likely also need training and assistance for JPs
    • Need personnel to crunch the numbers, Committee could likely request reconciled data
  • V Taylor – What is medically assisted treatment? Is that methadone?
    • There are new substances aside from methadone, can be very helpful coupled with long-term counseling
  • Schwertner – What are states like West Virginia doing differently from Texas to see such a larger amount of opioid deaths?
    • We believe Texas started on pill mill monitoring earlier, started tracking prescriptions, etc., have not done a state-by-state comparison though
    • But need to be concerned about rise of heroin addiction as well
    • Need to also consider that parts of Texas are more like these other states, county-by-county breakdown can be provided
  • Schwertner – Would like more data on this and data on when individuals are first exposed

 

Andrea Richardson, Bluebonnet Trails Community Services

  • OSAR outreach focuses on those surrounding individuals with substance abuse issues, also look to education of hospitals, etc.
  • Would hope we can dig deeper into 1115 waiver and programs started as a result; Knocked down barriers to operation and opened doors to other providers
  • Data collection is definitely a challenge, difficult for OSARs to move to areas in need without accurate information
  • Funding for treatment providers will be critical for future success, needs to be an intentional system of care devoted to improving outcomes

 

Laurie Vanhoose, Texas Association of Health Plans

  • Many health plans are implementing self-imposed goals
  • Plans have noticed that regionally there are combinations of drugs being overprescribed, able to target these regions and decrease utilization; Superior saw good results in Houston
  • Majority of people receiving services were women, half were of childbearing age; Important to tackle this issue
  • Plans have the ability to identify clients’ prescription activity, allows for hard stops at pharmacies for dangerous prescriptions, identification of first opioid fills for education intervention, etc.
  • On the commercial side, seeing plan implement alternative to opioids, these benefits may not be covered in Medicaid today & should be looked at
  • Substance abuse disorder services usage has increased recently
  • System does not have enough providers for pregnant women
  • Need flexibility in the Medicaid program to implement the CDC recommendations
  • There is a lock-in program, but would like expanded ability to oversee personnel and follow-up
  • V Taylor – Your data says we have a $1 billion opioid abuse program, how did you get this number?
    • National statistic from American Enterprise Institute
  • V Taylor – Can you speak to the PMP?
    • Would like to work with state to expand use of this
  • V Taylor – Have heard of difficulties in PMP to handle national data, Texas has many borders, can you speak to this?
    • Cannot, but would be a useful tool
  • V Taylor – Asks after Narcan, Naloxone
    • There is a question under current rules on whether this is fillable without a prescription
  • V Taylor – But your concern is if this is billable under Medicaid?
    • Correct, also wondering if a family member of a client could fill this prescription
  • Schwertner – Lock-in still requires IG approval?
    • Correct
  • Schwertner – Still need to look at this, have seen a report alleging that Medicaid feeds into this, do you have any comments on this?
    • Have seen questions regarding the validity of that report

 

Richard Dutton, Texas Medical Association

  • Opioids are part of many drugs used in anesthesia
  • Interested in developing metrics for how many people are exposed to opioids and how quickly they are taken off
  • Seeing reduction in standard dose prescriptions of opioids, trending towards a more tailored approach for individual patients
  • Hospital physicians would benefit from PDP built into electronic records keeping systems

 

Adam Bruggeman, Texas Medical Association 

  • Maternal and fetal medicine is very important in regard to this issue
  • Need to discuss people who are living with this issue
  • Need to focus on treatments that work
  • Need to get data to show that our chosen solutions work
  • Need information sharing integrated to make it easier for doctors to determine if that particular opioid is appropriate for them, would also help with identifying those who are taking drugs out of state
  • This is a medical problem and needs a medical solution
  • Watson- there is now a certification in addictive medicine?
    • It is now recognized at the national levels as a board-certified medicine
  • Watson- how to do describe an addiction medicine doctor?
    • Encouraging treatment from a medical perspective
  • Schwertner- medication assisted treatment provider has to be an addictive medicine certification?
    • There are individual regulations for certification of specific medication treatments
  • Schwertner- appears to be a discrepancy in opioid abuse between the northeast and southwest, can you touch on that?
    • There is a high percentage of “pill mills” setup in north east and tends to be a more rural issue

 

Allison Benz, Texas State Board of Pharmacy

  • Prescription monitoring program transferred in 2016
  • Began connecting information with 20 other states
  • HB 2561 added new requirements to the program
  • 20 million prescriptions have been reported to the program in 2017
  • 2.7 million searches within the system in 2018
  • Would like to add two features to the program
    • Clinical alerts
    • Integration to the PNP
  • Watson- what was the note about electronic prescriptions?
    • Would recommend e-proscribing for controlled substances
  • Watson- what would we hear from the physician community regarding this?
    • Bruggeman- there are DEA requirements to e-prescribe, but it allows prescriptions to be cancelled
  • Watson- it does make it more difficult to do the prescription
  • Watson- the e-prescription issue, is that something that would require legislation?
    • It would require legislation to require that
  • Perry- have you thought about less that 7 days for the reporting from the pharmacy in the PNP?
    • They have 24 hours to report it
    • Bruggeman- in support of this because people don’t doctor shop over the course of a few days, they do it in one day. Might be concerned about which medications are required to be reported

 

Spotlight on Public Testimony

Matt Boutte, Texas Academy of Physician Assistants

  • Need the ability to let PAs prescribe opioids for treatment
  • Schwertner- how many PAs in Texas?
    • 8,911

 

Dennis Borrel, Coalition with Texans for Disabilities

  • Part of the solution could be to disrupt the initial opioid prescription
  • Need to add opioid analytic to HHS study

 

Reginald Smith, Communities for Recovery

  • Recovery for substance use disorder required long term maintenance and support similar to diabetes
  • Recovery homes are effective because they provide a level of support
  • Recovery community organizations are also very important area of support

 

Craig Benton, Texas Chiropractic Association

  • Chiropractic care is a large factor in opioid abuse care/recovery, the majority of prescriptions are written to treat chronic pain
  • Those who are referred chiropractic and acupuncture are 55% less likely to be prescribed opioids

 

Anthony Guerra, Self

  • Acute treatment can be part of the process but there are many different options
  • Recovery is a long-term plan requiring many support mechanisms

 

Kayla Soms, Social Work Student

  • Under Healthy Texas Women Program, there are no substance use treatment or services available
  • 2/3 of Maternal deaths happen after kicked off Medicaid with the majority due to overdose
  • Recommend expanding Medicaid to women for 12 months postpartum

 

Carol Pereira, Nurse

  • Current case load of 30 NFP clients, 5 have opioid addiction issues
  • Relayed personal experience clients with opioid abuse relating to family history leading to addiction

 

Ricchard Hurley, Texas Pain Society

  • 65% of addicts were introduced to a drug that was not prescribed
  • Doctor shopping, need to enforce current laws regarding this issue
  • Recommend 6 hours of CME for every physician that proscribes opioids regarding risk mitigation
  • Medicaid is so heavy into opioids because of costs
  • All schedule 2 drugs should have to be e-prescribed
  • Taylor- is there a law against doctor shopping?
    • There is a law
    • Called the police on multiple situations with no effect

 

Adriana Kohler, Texans Care for Children

  • Overdose is leading cause of maternal death in Texas
  • Untreated substance abuse disorders have health effects on unborn children
  • 52% of child abuse includes substance abuse
  • 66% of child abuse removals involve substance abuse
  • Family specialized treatment works and improves health for mothers and children

 

John Ingham, Self

  • Supports incorporating the family into the recovery process
  • University High School affiliated with UT-Charter has been open for 4 years
  • Needs based program fee
  • School provides recovery in combination with education
  • Schwertner- where did most of the kids get introduced to the medication?
    • Many ways, including improperly disposed of or over prescribed prescriptions
    • Mostly friends and family

 

Laura Guerra, Children’s Defense Fund

  • Discussed parental substance abuse and its impact on childhood development and health
  • Recommends finding ways to expand Medicaid coverage to more people
  • Medicaid could provide more stable funding for our state

 

Josh Cuddy, Texas Criminal Justice Association

  • Diversion from jail and into treatment is shown to be effective
  • Only a small amount of cases are being diverted
  • Diversion works well for people with support, but not for individuals with high levels of need
  • We recommend decreased penalties for offenses which would increase TX’s capacity to help other Texans

 

Chad Richards, Quest Diagnostics

  • We have partnered with state governments to tackle the opioids abuse issue
  • Need to reduce number of prescriptions written each year
  • CDC recommends urine testing before and during opioid treatment

 

Judy Powell, Parent Guidance Center

  • Relayed personal experience with a specific person regarding substance abuse and its effect on working with CPS
  • People need more training on what a substance abuse case looks like especially in CPS

 

Janet Realini, Healthy Futures of Texas

  • Presented written testimony
  • Support Healthy Texas Women Program
  • Women with substance abuse have high rate of unplanned pregnancy
  • Need to use preventative care programs to greater degree
  • Need effective screening and referral programs for substance abuse

 

Greg Hansch, NAMI Texas

  • Primary care offers unique and underutilized option for substance abuse care
  • Collaborative care models show very positive results when used in primary care settings

 

Michael Redden, New Horizons Ranch

  • Community organizations are heading the call for supporting Texas youth

 

Lanna Switzer, New Horizons Ranch

  • Described personal experience with a youth suffering from PTSD
  • CPS case workers do not have offer a person that has daily contact with a child

 

Marline Claros, Self

  • Described personal experience being in the foster care system, and the benefit of community programs

 

Annie Atwood, Benchmark Family Services

  • Child placing agencies need to
    • Recruit the right people to foster children
    • Train foster parents, TBRI is an especially effective training method
    •  Supporting placements with counseling and crisis management
  • Have not had to close any foster homes after implementing TBRI training

 

Gary Buff, Our Community Our Kids

  • Implements community-based care in Region 3B
  • Developing home-based care model for parents and providers based on other states but will be unique in Texas
  • Put out RFI to providers to help determine what a system like that would look like
  • Expecting to implement home-based care in April/may

 

Patricia Hogue, Self

  • Need to offer mental health support to children in foster care
  • Need to focus on addressing that trauma
    • Often times is misdiagnosed
  • Over and mis-medicating traumatized children
  • Recommend requiring DFPS to be properly trained in techniques to identify trauma and mental health issues

 

Brandon Logan, Texas Public Policy Foundation

  • Family preservation has evidence of being very impactful through FBSS
  • Reunification rate is less than 30%
  • CPS should track reasons that children are removed

 

Pamela McPeters, TexProtects

  • Trauma leads to long lasting negative effects including foster youth pregnancy
  • Recommends
    • Provide pregnant youth access to homebased parenting education and training
    • Ensure expecting youth remain with their children in care
    • Collect data regarding this issue

 

Thomas Mulnar, Divinity Family Services

  • Deals with relative placements
  • 2008 38% relative placement in CPS care
    • 2017 above 50% for first time
  • Relative care is a faster placement process and more long lasting

 

Cindy Mericle, Love Fosters Hope

  • Working with teenagers that age out of foster care
  • Discussed the benefit of TBRI
  • Trauma is very prevalent in foster care youth

 

Jeffery Morgan, Self

  • $770 million for foster care adoption
  • Glad to be hearing testimony regarding family preservation
  • Grandparents play a huge role in the foster community, stressed the importance of grandparent laws allowing visitation to support family structure

 

Katie Olson, Alliance Members

  • Legislature seems to want to reform the system as a whole
  • Need to provide support for those involved in the foster care and CPS systems

 

Dimple Patel, TexProtects

  • Supports home-based treatment services
  • Home visiting programs can offer more intensive services
  • FBSS cases often involve substance abuse

 

Deidre Robinson, Previous Foster Parent

  • Relayed personal experience as a foster parent
  • Chose not to continue being foster parents due to multiple reasons
    • Not trained on how to navigate the foster system
    • Changed case workers frequently
    • Lack of communication with CPS
    • Efforts were considered a hinderance
  • Taylor- have heard similar issues to those raised

 

Kate Murphy, Texans Care for Children

  • Foster children are at a high risk of becoming pregnant
  • Will be releasing a full report regarding this issue
  • Lacking provider with training on reproductive issues
  • Recommend training on preventing pregnancy for those who work in the foster care system
  • Incentivize placements to keep youth with their child during foster care

 

Audra Simpson, We Will Speak

  • Most placements worked with
    • were emergency placements
    • Have had a minimum of 7 case workers
    • were on medication while in care
  • need for a consistent adult to work with for most foster youth

 

Matthew Trail, Disability Rights Texas

  • lack of community supports and services for children that need it the most including mental health care
  • need for therapy to foster homes to support mental health
  • department has over-reliance on residential based care
  • this leads to a lack of preparedness for life after foster care