Assessing and Planning for Behavioral Health Transformation

1. Assessing and Planning for Behavioral Health Transformation Texas Mental Health Transformation Grant An Overview of the Assessment and Comprehensive Plan Dave Wanser Ph.D., Deputy Commissioner Texas Department of State Health Services

2. Transformation Drivers:Assessment of Texas BH indicators • Prevalence of behavioral health disorders: 2,578,424 • SMI and SED in the population: ~1,552,543 (57% adults) • Substance Abusers who would seek treatment: ~ 1,025,881 (2005) • 2,149 Texans committed suicide (2002) • 9,992 Texas were hospitalized for attempting (2002) • Economic Cost to Texas of Behavioral Health Problems: • Mental Illness: $16.6 billion(2003) • Alcohol and Drug Abuse: $25.9 billion(2002)

3. Transformation Drivers:Assessment of Agency BH indicators HHSC: • 1/3 of all Texas children were enrolled in Medicaid in 2005 (~2.1 million). • Mental health needs are the most frequent reason children and youth are referred to local CRCG interagency planning teams. DFPS: • 38,522 investigative cases were confirmed abuse and/or neglect. • Parental substance abuse contributes to an estimated 1/3 – 2/3 of cases. DADS: • 22% of older adults have mental disorder that is not part of the normal aging process • ~17% of older adults abuse alcohol or drugs. • Older adults have the highest suicide rates. DARS: • Percentage of people served in Vocational Rehabilitation with disabilities that interfered with their employment: 19% mental/emotional; 16% cognitive; and 7% substance abuse.

4. Transformation Drivers:Assessment of Agency BH indicators DSHS: • Current system able to serve ~10% of those in need. • State Mental Hospitals have had a 55% increase in admissions since 1996, with shorter lengths of stay. Forensic commitments are increasing. • 25% in MH and 20% in SA services had a Co-occurring Disorder. TJPC/TYC: • 26.5% of juveniles supervised by probation departments were mentally ill.. • High risk youth comprise 43% of TYC population (4% chemically dependent; 48% serious emotional disturbances; 11% were sex offenders; 17% capital and serious violent offenders; 1% mental retardation) TDCJ/TCOOMI: • Typical adult offender is 36.3 years old; has IQ of 90.7 (normal = 100); a history of academic failure; an average schooling of 10th grade but tests at grade 7.6; low self-esteem including no confidence about finding employment; no vision for a productive future; has compulsive behavior; is defensive or has a negative attitude; has difficulty with relationships and difficulty controlling anger; and, escapes from reality through drug or alcohol abuse before and after incarceration.

5. Transformation Drivers:Assessment of Agency BH indicators TEA: • Annual student drop out rates for African-American were 5.4%, Hispanic were 6.1%, and White were 2.5%. • In high school, more than 1 in 5 African-American (21.9%) and Hispanic (23.5%) students in 9th grade did not advance to 10th grade. • In elementary school, African-American and Hispanic students were almost twice as likely to be retained in a grade level as White students. TWC: • 15,013 adults and 190 youth were served by the Project Re-integration of Offenders work program. ORCA: • Hispanic population doubling in nonmetropolitan/rural areas by 2040. • More aged 65 and older in rural vs. urban counties (15.5% to 9%). • Higher poverty rates and lower income levels in rural vs. urban counties. • Health care professional shortages in rural areas.

6. Transformation Drivers:Assessment of Agency BH indicators TDHCA • 25% of homeless individuals suffer from a serious mental illness. • More than 65,000 persons with disabilities did not have predictable means of shelter in 1999. • An SSI recipient would have to pay 98.3% ($536) of his/her $545 monthly payment to rent a one-bedroom apartment in Texas. VHA • 27,000 Texas Reservists have fought in Iraq or Afghanistan. • In 2005, 1,667,370 veterans resided in Texas, 22.49% had accessed VHA services. • If trends continue, half of all returning vets will have a brain injury. • About 25% of returning veterans asked for help for mental health disorders. • 485,092 patients in the VA health system had substance use disorder (2002). • Veterans with substance use disorders accounted for approximately 12% of VA patients and about 25% of total expenditures - $4.2 billion.

7. Driving Transformation:Client Matching • Agency collaboration has allowed investigation into shared clients. • TDCJ and DSHS • Matches TDCJ data to Mental Health CARE System • Co-Occurring Children’s Policy Academy • Matched children in HHSC (Medicaid), Mental Health, Texas Youth Commission, Texas Juvenile Probation Commission. • Matched children in the Department of Family and Protective Services and the Texas Education Agency.

8. TDCJ and Mental Health Matching These numbers reflect offenders who have received services in the public mental health system and does not include those not diagnosed or who have not received care in the public system. A recent study indicates 40% of offenders have a mental health disorder.

9. Children’s Policy AcademyHHSC, MH, TYC, and TJPC Matching Reflects the number of shared clients among the four agencies. Of 213,427 total children in the agencies, at least 12% are served by two agencies, 2% by three agencies, and about 1% by all four agencies. It is entirely possible that any or all of those 165 children are each a $1 million dollar child.

10. A Greater Percentage of Victims of Child Abuse/Neglect with Juvenile Justice Contact had Criminal History in their Family, had a Behavior Problem, and/or had a Substance Abuse Issue > > > Source: DFPS Child Protective Services and TYC client databases, from Ruggiero, K.M., and Mason, M. (2006). The role of behavioral health services among youth in Texas at risk for juvenile justice involvement: Multi-agency data-matching project for the Policy Academy on Co-Occurring Substance Abuse and Mental Health Disorders. Austin, TX.

11. But Less Than Half Received Behavioral Health Services Funded by the State Source: DFPS Child Protective Services, DSHS Mental Health and Substance Abuse, HHSC Child Medicaid, and TYC client databases, from Ruggiero, K.M., and Mason, M. (2006). The role of behavioral health services among youth in Texas at risk for juvenile justice involvement: Multi-agency data-matching project for the Policy Academy on Co-Occurring Substance Abuse and Mental Health Disorders. Austin, TX.

12. A Greater Percentage of Victims of Child Abuse/Neglect with a Behavior Problem had an Earlier Disciplinary Problem Identified by TEA - Mostly Student Misconduct Source: FY2003 DFPS-TEA Data-Match, TEA, October 2006.

13. Driving Transformationin the Current System: Challenges Stigma Lack of Public Understanding Lack of Provider Understanding Employment and Housing Education and Training Needed Veterans and Families Large numbers in Texas BH problems high after return Need for PTSD services/training Coordinated approach for families Rural Needs Access to Care Difficulty Workforce Shortages Housing Shortages Transportation Issues Older Population Increasing More Rural Complex Medical Needs Undiagnosed Mental Disorders Substance Use Increasing Allow to Age at Home Family Involvement in Care Children and Youth Increasing Changing Demographics Justice and Protective Services Medicaid Increases Dropouts Need Systems of Care Family Involvement in Care Demographic Shifts Hispanic Majority by 2040 Culturally Appropriate Services School Dropout Rates Less Education = Less Income More Un- and Underinsured Multilingual Workforce

14. Driving Transformationin the Current System: Needs Under-funded System 47th in per capita Funding Need exceeds Service Supply Operating Costs Increasing Transportation Cost Medicaid Reimbursement Lack of Service Coordination Crisis Services Redesign Improve Jail Diversion Evidence Based Practice Use? Coordinate Services in the State Earlier Identification of Need Workforce Issues Training Needed Recruit to rural areas College/University collaboration New service delivery models Multilingual workers needed Fewer Entering the Field Ability to Screen, Assess, Refer Consumer Oriented Define Consumer Driven Different Agency Rules System Difficult to Navigate Support for Peer Models System that works for Youth Use of Technology Agencies Share Clients Data Sharing/Integration Expand Current Use Use of EHRs HIPAA translation

15. Transformation Objectives Current System Transformed System Population-based; early intervention Persons receiving services Coordinated care; “no wrong door” Agency “silos” Piecemeal, fragmented training Well-defined workforce development / training infrastructure Data Compartments Data – sharing and coordination Consumer and family member involvement Consumer and family driven - system Persons falling through agency “cracks” Seamless continuity of care

16. Recognizing that Transformation … • is an evolving process which takes time • will focus on pivotal issues and opportunities • will be based on a learning process, requiring adjustments and refinement • requires major shifts in organizational “cultures” • will be based on partnerships - consumers, family members, providers and local, state, federal levels of government

17. New Freedom Goals - Texas Goal 1 Mental Health is Essential to Health Goal 4 Early Screening, Assessment, Referral Goal 2 Care is Consumer and Family Driven Goal 5 Excellent Care is Delivered Goal 3 Eliminate Disparities in Services Goal 6 Increase Use of Technology

18. NFC Goals and Strategies

19. NFC Goals and Strategies

20. NFC Goals and Strategies

21. NFC Goals and Strategies

22. NFC Goals and Strategies

23. What’s Next? • Continue Dialogue and Inclusion of Voices • Four Initial Workgroups Developed: Adults, Youth, Technology, Workforce • Leverage Immediate Opportunities • Research and Evaluate Longer Term Activities • Prioritize Efforts

24. The Present System Fragmented, confusing to navigate, inadequate services that frustrate recovery…. A Transformed System Consumer-driven, coordinated ‘no wrong door’ quality services supporting recovery …