Mental Health Transformation

A Long History of MH Transformation in Texas

  Prior to HB 2292   COPSD Jail Diversion  Benefit Design Post HB 2292   Resiliency and Disease Management Consolidation of MH, SA and PH    MH Transformation Grant and TWG POLR Crisis Redesign

MENTAL HEALTH TRANSFORMATION THE FEDERAL VISION We envision a future when everyone with a mental illness will recover, mental illnesses can be prevented or cured, mental illnesses are detected early, and everyone with a mental illness at any stage of life has access to effective treatment and supports – essentials for living, working, learning, and participating fully in the community.

MENTAL HEALTH TRANSFORMATION THE PROBLEM  In any given year, one in 4 Texans suffer from a diagnosable mental disorder.

 Mental disorders are the leading cause of disability for ages 15-44.

 The number of suicides in Texas has increased by 15% in the last 5 years. This number is 55% higher than homicides and 134% higher than those who died from HIV.

 People with serious mental illness served by the public mental health system die, on average, 25 years earlier that the general population.

 75% of all persons with mental illness smoke; persons with mental illness consume 44% of all cigarettes nationally.

BEHAVIORAL HEALTH ISSUES IMPACT OTHER SYSTEMS  75% of children placed in foster care have parents with behavioral health problems  30% of adults in correctional institutions have received mental health services  26% of persons served through vocational rehabilitation have behavioral health problems  48% of youth served by TYC have serious emotional disturbances  26% of all hospital discharges are related to mental health or substance abuse problems  46% of all ER visits have behavioral health issues as a basic or contributing factor

TEXAS MENTAL HEALTH TRANSFORMATION

PROBLEMS ADDRESSED BY TRANSFORMATION

 Lack of Recovery/Resilience-focus  Fragmentation; agency “silos”; continuity of care  Disparities in services……race/ethnicity; geographic  Lack of adequately trained human resources  Lack of Coordination of health and MH services  Use of technology/data not optimal

Bridging the Quality Chasm

The behavioral health care that Americans receive

Recovery/Resilience Promising and Evidence Based Practice Information Technology

The behavioral health care that we know to be effective

Information Technology: The Electronic Bridge

 Collaborative planning and record sharing across service systems  Increased access to services in underserved areas  Reduced fragmentation of services  Workforce development  Public information and education

 TRANSFORMATION INITIATIVES Consumer voice – Policy, Practice, Evaluation  Partnerships - state agencies, local entities, consumers and family members  Special initiatives – peer support, housing, employment, school-based services, criminal and juvenile justice, older adults  Workforce development  Technology / data  Community Collaboratives

Community Collaboratives

West Texas Community Coalition Tarrant Transformation Project Dallas County Unified Public Mental Health Initiative Nacogdoches County Mental Health collaborative Terrell County Behavioral Health Collaborative Bexar County Safety Net Community Collaborative Selected Urban Communities Selected Rural Communities Selected Border Communities Williamson County Mental Health Task Force Coastal Bend Rural Health Partnership

Mental Health Transformation Website

 www.mhtransformation.org

Crisis Services Redesign

C risis Services Redesign Committee

Last year a Committee was formed which included representatives from:  NAMI     Advocacy Groups State and Private Hospitals Mental Health Professionals, Mental Health Support and Related Prevention Groups.     Physicians Law Enforcement and Judiciary DSHS Community Mental Health Centers The recommendations from that group are guiding the course for Crisis Redesign now in it’s Implementation Phase.

Goals of Crisis Redesign

A state-wide system of crisis services with the goal of improving:       Accessibility Standards of care Community involvement Consumer choice Less restrictive treatment environments Lessening burden on hospitals, jails & law enforcement

Crisis Services Funding

 REQUESTED : DSHS requested $82 million from the 80 th Legislature to make significant progress toward improving the response to behavioral health crises  AWARDED : Through the Legislature and Rider 69, the full $82 million was granted over Fiscal Years 2008/2009 to redesign and improve the mental health crisis system across Texas

Crisis Services Funding, cont’d.

 $27.3 million will be allocated in FY 08  $54.7 million will be allocated in FY 09  Additional funds will be requested from the 81st Legislature  It is required that new crisis redesign general revenue funds will be used to improve crisis services provided and not replace the current crisis services.

Standards

Standards are set for all services in the crisis service array. Standards address:        Description of service What acuity is served in each service Plant/facility requirements Staff credentials and training requirements Assessment parameters Services provided and time frames for delivery Continuity of care

Initial Crisis Services: Hotline

 Every LMHA will be required to provide a continuously available telephone hotline staffed by specially trained crisis counselors that provides information, screening and intervention, and support to callers 24 hours per day, 7 days per week.

 Hotlines must be accredited by the American Association of Suicidology (AAS)  All callers to the hotline will be evaluated by a trained Qualified Mental Health Professional

Initial Crisis Services: Mobile Outreach

 Mobile Outreach Services are a combination of crisis services that provide emergency care, urgent care, and crisis follow up to children, adolescents, or adult’s in the community. The Mobile Crisis Outreach Team will respond to individuals experiencing a mental health crisis in their homes, schools or other public areas.

What’s new about

Mobile Outreach?

 Greater accessibility to Mobile Crisis Outreach Teams (MCOTs)  Specific MCOT standards regarding the delivery of services and the training & experience required of Mobile Outreach Staff.

Roll Out of Crisis Redesign

Initial Services to be Implemented   Hotline Mobile Crisis Outreach Team Will be brought up to new DSHS standards first. Any remaining funds will be available to LMHAs to spend on the following “Enhanced Services”.

Enhanced Services

 Walk-In Services  Extended Observation Services (up to 48 hours)  Crisis Stabilization Units (CSUs)  Crisis Residential/Respite (Child or Adult)  Crisis Respite (Child or Adult)  Mental Health Deputies/Crisis Intervention Teams  Transportation

Enhanced Crisis Services Walk-In Services

Office-based outpatient services for adults, children and adolescents providing immediate screening and assessment and brief, intensive interventions focused on resolving a crisis and preventing admission to a more restrictive setting such as a hospital or juvenile detention.

Extended Observation Services (up to 48 hours) Emergency and crisis stabilization services provided to individuals in a secure and protected, clinically staffed (including medical and nursing professionals), psychiatrically supervised treatment environment with immediate access to urgent or emergent medical evaluation and treatment. Crisis Stabilization Units (CSUs) Short-term residential treatment (up to a stay of 14 days) designed to reduce acute symptoms of mental illness provided in a secure and protected, clinically staffed, psychiatrically supervised treatment environment.

Crisis Residential (Child and Adult) Crisis residential services treat individuals with high risk of harm and severe functional impairment who need direct supervision and care but do not require hospitalization. Length of stay is generally less than one week. Crisis Respite (Child and Adult) Treats individuals with no risk of harm, who have functional impairment and are in need of supervision but not hospitalization. Appropriate for individuals with stressful and/or unsupportive recovery environments and those who have had limited response to prior treatment. Length of stay is generally less than one week.

Mental Health Deputies/Crisis Intervention Teams Funding used to assist local law enforcement agencies in providing specialized training for deputies on the recognition of mental illness and de-escalation of volatile situations Transportation Funding used to help pay for transportation costs incurred by local law enforcement agencies related to behavioral health crises

Additional Projects

 Community Investment Incentive Approximately 30% of the new crisis funds will be offered through a competitive process to communities willing to invest local resources in the development of:  Psychiatric Emergency Services Center OR  Other community-based projects that focus on diverting individuals from incarceration or providing alternatives to State hospitalization.

Psychiatric Emergency Service Centers  All LMHAs or communities will be eligible to apply for funds to establish “PES Sites”  Up to 6 sites will be funded and selected at the end of this year; operational by next summer  Elements of PES Sites will include:  Extended Observation Services (up to 48 hours)  Inpatient services in a Crisis Stabilization Unit (CSU) or hospital for up to 14 days

Outpatient Competency Restoration Services Senate Bill 867

Allows for development of an Outpatient Competency Restoration program to help communities provide effective treatments and competency restoration to appropriate individuals with mental illness identified by the courts as incompetent to stand trial.

Outpatient Competency Restoration Services

P urpose  T o treat mentally ill individuals accused of a crime in a less restrictive, more clinically appropriate setting than in jail or State Hospital. Services Include    Psychiatric stabilization Legal education and courtroom “practice” Housing assistance

Crisis Service Local Planning Community stakeholders are a vital part of the local planning process and will be key in successful implementation of crisis services.

Community Stakeholders Involved

       Client representatives Client family member representatives Child and adult advocates Mental health service providers Emergency healthcare providers Local public healthcare providers Law enforcement  Probation and parole department representatives  Judicial representatives from each county  Outreach, Screening, Assessment and Referral (OSAR) provider(s)  Substance abuse service providers  Others deemed appropriate by the LMHA (such as concerned citizens, private sector)

Measuring Accountability

 DSHS must report to the Legislative Budget Board (LBB) and the Governor on the implementation of crisis services *************************************************  DSHS is adding Performance Measures to the Performance Contracts for all LMHAs

Strengthening Community Control and Consumer Choice

Local Planning and Network Development

The Goal

 Develop a local network of services to  Meet local needs and priorities  Maximize consumer choice  Improve access to services

Today’s System

  Single State Authority: DSHS  Board members appointed by the Governor  State Advisory Committee members represent LMHAs 37 Local Mental Health Authorities (LMHAs)  Board members appointed by local government  Local Planning and Network Advisory Committees (PNACs)

Characteristics

      Community provides input during local planning process PNAC makes recommendations LMHA provides most services LMHA chooses whether or not to contract with private providers for services LMHAs not accountable to stakeholders for decisions No consumer choice of providers

   

What Has Changed

State Advisory Committee members represent many stakeholder groups, including consumers Consumers have a choice of providers LMHAs provide services “as a last resort” under limited, defined conditions LMHAs must justify contracting decisions

Local Planning and Network Development

  What it is NOT  An effort to wholesale privatize MH services What it IS  A standardized, transparent process for planning and developing a network of MH service providers.

 Emphasizes choice of providers, whenever possible  Allows for local control through stakeholder input  Requires the network to be managed by LMHA

History

What happened?

The Law in 2003

“The local authority shall consider public input, ultimate cost-benefit, and client care issues to ensure consumer choice and the best use of public money in  assembling a network of service providers; and  making recommendations relating to the most appropriate and available treatment alternatives for individuals in need of health or mental retardation services.”

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New Provisions of HB 2292

“In assembling a network of service providers, a local mental health and mental retardation authority may serve as a provider of services only as a provider of last resort and only if the authority demonstrates to the department that  the authority has made every reasonable attempt to solicit the development of an available and appropriate provider base that is sufficient to meet the needs of consumers in its service area; and  there is not a willing provider of the relevant services in the authority’s area or in the county where the provision of the services is needed.”

The Question: Does HB 2292 Apply to Mental Health?

    Extended controversy May 2005: Governor issues Executive Order RP 45 March 2006: Attorney General rule that HB 2292 applies to MH June 2006: HHSC orders DSHS to conduct negotiated rulemaking per RP 45

The Process

   October 2006: Negotiated Rulemaking Committee convenes March 2007: Draft rule proposed for public comment (none received) June 2007: Final rule adopted with no change

       

The Committee

LMHAs Clients Family members Advocates Private providers Local government DSHS Other stakeholders

The Governor’s Order

     Protect and prioritize consumer choice Strengthen and maintain safety net Ensure local involvement in system development Recognize local differences Protect funds for services

The Solution: A System of Checks and Balances

DSHS LMHA Local Stakeholders

The Committee’s Framework

      A public and transparent process Flexibility to respond to local needs and resources Boundaries for LMHA decision-making Multiple opportunities for stakeholder input LMHA accountable for how it responds to community input DSHS monitors LMHA decisions and response to stakeholders

The Rule

Where are we going?

The Content of the Rule

     Consumers choose from two or more providers of a service when possible Conditions under which LMHA can provide a service are limited and defined LMHA develops 2-year local plan for developing external provider network Consumers and other stakeholders participate in planning DSHS provides oversight

Stakeholders

       Consumers, current and former Family members Advocacy organizations Providers (external) Community organizations Local officials Interested citizens

Consumer Choice Defined

   Two or more qualified provider organizations for each service package AND Two or more qualified individual practitioners for specific services Exceptions may be made if it would be too expensive to have multiple providers Choice may be limited by provider availability

The Process

     DSHS provides website for private providers to express interest LMHA obtains community input LMHA publishes draft plan for public comment LMHA publishes final plan and submits to DSHS with summary of response to public input DSHS reviews and approves plan

The Process, cont.

    LMHA publishes draft documents used to purchase services from external providers for public comment LMHA conducts formal service procurement LMHA provides consumers with information about all service providers Consumers choose their providers

Key Content of the Plan

     Community stakeholder input Assessment of available service providers Local plan for network expansion with LMHA’s rationale Services to be provided by one provider due to economic factors How consumer choice and access will be addressed

Key Content of the Plan, cont.

     Past efforts and results to expand network Barriers to network expansion and efforts to address them How service dollars will be preserved Procurement plans, addressing specific service packages and populations Future plans for network expansion

Three Opportunities for Input

   Before LMHA develops local plan When LMHA publishes draft plan When LMHA publishes draft procurement tools

When Can an LMHA Provide Services?

    No qualified providers Insufficient consumer choice (must have two or more providers) Diminished access to services (DSHS to determine baseline) Insufficient capacity in external network

When Can an LMHA Provide Services?

  Need to protect critical infrastructure  Phased transition permitted  LMHA judges capacity of external providers to re-establish lost capacity Existing agreements limit ability to contract or circumstances that would result in substantial source of revenue to support services

Consumer Selection of Providers

    LMHA maintains standardized list of basic information about each provider List given to consumers with options Provider assigned on rotating basis if no choice made within specified timeframe Consumers offered choice at every treatment plan review

Implementation

How do we get there?

Current Status

   DSHS is ready to launch the website  Stakeholder information  Forms for service providers to sign up LMHA planning process begins Nov 1 st   Three groups of LMHAs Staggered planning period  6 month planning cycle Stakeholder training conducted with initiation of the local planning process

Planning Timelines

    November 2007: Cohort 1 (East Texas, including Harris County) January 2008: Cohort 2 (South/Central Texas, including Austin and the Valley) February 2008: Cohort 3 (North/West Texas, including Ft. Worth, El Paso, and the Panhandle) July - September 2008: Plans approved by DSHS

Things to Remember

   Changes will happen gradually Every local service area will evolve differently Implementation will be a learning process for all parties

You Have a Voice

   Direct input during planning Local Planning and Network Advisory Committee representation (50%) State Advisory Committee representation (2 consumer and 2 family members)

You Have a Responsibility

  Local stakeholders, LMHAs, and DSHS share responsibility and control System of checks and balances relies on stakeholder participation

Information

  www.dshs.state.tx.us

 Community Mental Health  Local Planning and Network Development [email protected]