Mental Health Transformation

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Mental Health Transformation
2
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

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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.

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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.

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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

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TEXAS MENTAL HEALTH TRANSFORMATION
PROBLEMS ADDRESSED BY TRANSFORMATION

• Lack of Recovery/Resilience-focus
• Fragmentation agency silos continuity of care
• Disparities in servicesrace/ethnicity
  geographic
• Lack of adequately trained human resources
• Lack of Coordination of health and MH services
• Use of technology/data not optimal

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Bridging the Quality Chasm
Recovery/Resilience Promising and Evidence Based
Practice Information Technology
The behavioral health care that we know to be
effective
The behavioral health care that Americans receive
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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

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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

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

• www.mhtransformation.org

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Crisis Services Redesign
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Crisis 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 its
  Implementation Phase.

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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

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Crisis Services Funding

• REQUESTED DSHS requested 82 million from the
  80th 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

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Crisis Services Funding, contd.

• 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.

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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

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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

19
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 adults 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.

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• Whats 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.

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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.

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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

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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.

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• 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.

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• 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.

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• 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

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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. 
  

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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

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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.

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Outpatient Competency Restoration Services

• Purpose
• To 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

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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.

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Community Stakeholders Involved

• 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)

• Client representatives
• Client family member representatives
• Child and adult advocates
• Mental health service providers
• Emergency healthcare providers
• Local public healthcare providers
• Law enforcement

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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

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Strengthening Community Control and Consumer
Choice

• Local Planning and Network Development

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The Goal

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

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Todays 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)

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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

38
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

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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

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History

• What happened?

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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 authoritys area or in the county
  where the provision of the services is needed.

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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

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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

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The Committee

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

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The Governors Order

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

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The SolutionA System of Checks and Balances
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The Committees 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

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The Rule

• Where are we going?

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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

51
Stakeholders

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

52
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

53
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

54
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

55
Key Content of the Plan

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

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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

57
Three Opportunities for Input

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

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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

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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

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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

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Implementation

• How do we get there?

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Current Status

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

63
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

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Things to Remember

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

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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)

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You Have a Responsibility

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

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Information

• www.dshs.state.tx.us
• Community Mental Health
• Local Planning and Network Development
• LPND_at_dshs.state.tx.us