Advancing Texas Behavioral Health Policy: Building on Progress and Early Intervention

1. MMHPI Policy Briefing:Opportunities to Advance Texas Behavioral Health Policy Andy Keller, PhD | Nelson Jarrin, JD | January 14, 2019

2. Meadows Mental Health Policy Institute

3. Opportunities to Advance Texas Behavioral Health Policy • Build on our accomplishments. • Intervene early to address the mental health needs of Texas children. • Fight mental illness like we fight cancer.

4. 1. Build on our accomplishments

5. Build on Our Accomplishments • The Texas Legislature has worked systematically to eliminate waitlists, maintain a minimum hospital safety net, redesign our crisis systems, and make investments for targeted populations (e.g., homeless, veterans). • The 85th Texas Legislature increasedbehavioral health funding by $749.3 million (AF). • The 2018–19 General Appropriations Act appropriates over$7.6 billion (AF) for behavioral health. • We must maintain and build on the work of the Texas Legislature and Texas communities to strengthen and transform our mental health system.

6. 85(R) SB 292 • SB 292 (Huffman, Nelson, Schwertner) created the Mental Health Grant Program for Justice-Involved Individuals. • GOAL – to reduce: (1) recidivism rates, arrests, and incarceration for people with mental illness; and (2) the wait time for forensic commitments of people with mental illnesses to a state hospital. • FUNDING – $12.5 million in fiscal year (FY) 2018 and $25 million in FY 2019, plus $5 million per fiscal year for Harris County. • APPLICANTS must be a county-based community collaborative consisting of a county, a local mental health authority serving the county, and each hospital district, if any, located in the county.

7. 85(R) HB 13 • HB 13 (Price) created the Community Mental Health Grant Program. • GOAL – to support community mental health programs that provide services and treatment to people experiencing mental illnesses. • FUNDING – $10 million in FY 2018 and $20 million in FY 2019. • APPLICANTS must be a nonprofit or governmental entity (e.g., city, school district, institution of higher education).

8. Progress Thus Far – SB 292 (Urban)

9. Progress Thus Far – SB 292 (Rural)

10. Progress Thus Far – HB 13

11. 84(R) SB 55 • SB 55 (Nelson) created the Texas Veterans + Family Alliance Grant Program. • GOAL – to support community mental health programs that provide and coordinate mental health services and treatment for Texas veterans and their families. • FUNDING – $20 million in FY 2018 with authority to carry forward unexpended balances to FY 2019. • APPLICANTS must be a community program thatdemonstrates a commitment to addressing mental health needs of veterans and their families.

12. 86(R) Grant Funding Opportunities • Fund 85(R) SB 292 at $60 million for the FY 2020—21 biennium:$25 million for each fiscal year, plus $5 million per fiscal year for Harris County. • Fund 85(R) HB 13 at $40 million for the FY 2020—21 biennium:$20 million for each fiscal year. • Fund 84(R) SB 55 at $20 million for the FY 2020—21 biennium.

13. State Hospital System • We need to replace aging state hospitals with state-of-the-art medical facilities optimally positioned to serve people well and support transitions out of care back to where they live.

14. State Hospital Catchment Areas

15. State Hospital System Transformation • The 85th Texas Legislature appropriated $300 million for new state hospital planning and construction. This is Phase Iof a three-phased approach to improve the state hospital system in the current and future biennia.

16. Phase II Transformation Opportunities • Fund Phase II of the state hospital system transformation at an amount to be determined (at least $300 million). • Potential Opportunities • Austin State Hospital construction • San Antonio State Hospital construction • Planning for a potential hospital in the Dallas area • Planning for a potential hospital in the Texas Panhandle • Construction of a 100-bed unit at Rusk State Hospital

17. 2. INTERVENE EARLY TO ADDRESS THE MENTAL HEALTH NEEDS OF TEXAS CHILDREN

18. Needs Among Texas Children and Youth

19. The Progression of Mental Health Conditions • Half of all mental health conditions manifest by age 14; interventions work best at this early stage when symptoms are less severe, more treatable,and more readily prevented from escalating to more dangerous conditions that increase risk. • By young adulthood, 75% of lifetime cases have presented. Early Detection, Intervention Appropriate Treatment

20. The Ideal Mental Health System for Children • THREE KEY COMPONENTS: • Helping local schoolsidentify needs and link to help: • Early, before situations become harder to treat;and • Fast, when a severe need arises and expertise is essential to maintain safety and functioning; • Helping pediatric primary care providersfindand treat mental illness early when it is mild to moderate; and • Making intensive treatment available to children and youth with the most severe needs, quickly, when needs emerge.

21. 1. Helping Local Schools Get Expert Evaluation • All schools need someone to coordinate identification and linkage(“liaisons”). This role can be filled by school counselors with dedicated time to address mental health concerns, school-based clinics, Communities In Schools, and others. • When a severe need arises,schools must be able to get expert evaluation on the scene quickly, and teachers and staff need rapid access to reliable advice and care. • A few Texas schools have mental health experts on site, but that solution is not feasible for most schoolsand no single expert can answer every question. • Telemedicine offers the infrastructure to fill the gaps in expertise.

22. 86(R) Funding Opportunities • The Texas Education Agency (TEA) Legislative Appropriations Request (LAR) proposes the Safe and Healthy Schools Initiative as their highest priority exceptional item. • $52.5 million in grant funding is requested for FY 2020. • The Initiative is grounded in four primary pillars: 1) Mental Health Supports; 2) Positive School Culture; 3) Facility Safety; and 4) Emergency Response Coordination. • 85(R) HB 13 (Community Mental Health Grant Program) supports community mental health programs that provide services and treatment to people experiencing mental illness. School districts may apply.

23. 86(R) SB 63: Texas Mental Health Care Consortium • Senator Nelson filed SB 63 on November 12, 2018, the first day to pre-file legislation for the 86th Legislative Session. • ESTABLISHES a consortium of state-funded medical schools. • GOAL – to coordinate the expansion and delivery of mental health care services by using the infrastructure and expertise of state-funded medical schools and community providers. • FOCUS – children and youth with behavioral health needs. • 86(R) SB 63 proposes the use of telemedicine and telehealth programs to identify and assess behavioral health needs and provide access to mental health care services.

24. 2. Leveraging Pediatric Primary Care Providers • 75% of children with mental health issues who receive care are treated in a primary care setting (family doctor, pediatrician). • With the right early support, most would not need a specialist. • In addition to routine care, pediatric primary care is key to early identification, referral, & coordination for higher risks. • Over a decade of research demonstrates that primary care providers can treat behavioral health issues as they would any other health issue – treating mild and moderate cases and detecting the more complex or severe cases for specialists.

25. Leveraging Primary Care: Child Psychiatry Access Programs (CPAP) • Nearly 30 states have implemented CPAP programs. • The Massachusetts Child Psychiatry Access Program, established in 2004, is the longest-running program.

26. CPAP Opportunity • In response to Hurricane Harvey, local philanthropy funded CPAP prototypes in Harris County and the surrounding region that were developed by Baylor College of Medicine, UTHealth Houston, Texas Children’s Hospital, and Harris Health. Children’s Health in Dallas also has a long-standing project. • Philanthropy alone cannot sustain this initiative. • 86(R) SB 63 (Nelson) establishes a network of CPAP hubs across Texas through state-funded medical schools. • Fund the network at $5 million in FY 2020 and $10 million in FY 2021.

27. 3. Making Intensive Treatment Available • About 20,000 children and youth each year need intensive treatment because of severe behavioral dysfunction. • They do not all need the same treatment. • Highest risk of harming others: About 900 Texas youth who first experience an episode of psychosis (FEP) each year. • Psychosis is characterized by hallucinations and delusions. • Those with untreated psychosis are 15 timesmore likely to commit homicide. Effective treatment decreases the risk. • They also have a dramatically elevated risk of suicide and other mortality: 24 times the risk for their peers. • Today, treatment is delayed for five years post-onset.

28. Treating Psychosis: Coordinated Specialty Care • Coordinated Specialty Care (CSC),a team-basedapproach, starts assertive and intensive treatment as soon after the initial psychosis as possible. • Texas currently has 12 Coordinated Specialty Care teams located at 10 community centers across the state. • Expected caseload for each team is 30. • Texas should at least expand Coordinated Specialty Care programs for all youth ages 14 - 18 (900 new cases a year).

29. CSC Expansion Opportunity • Last year, the Substance Abuse and Mental Health Services Administration increased the Mental Health Block grant award to the Health and Human Services Commission (HHSC). • HHSC is using $3.7 millionof this increase to fund Coordinated Specialty Care expansion in FY 2019. • Teams will be located at 22 community centers in FY 2019. • The HHSC Legislative Appropriations Request (LAR) is seeking $7.9 million in both FY 2020 and FY 2021 (GR) to fund Coordinated Specialty Care expansion (Item 19). • These appropriations are scalable as each new team would cost approximately $400,000 per year.

30. 3. FIGHT MENTAL ILLNESS LIKE WE FIGHT CANCER

31. Texas Mental Health Research Framework • MMHPI prepared the Texas Mental Health Research Framework upon the request of the chairs of academic departments of psychiatry and behavioral health leaders in state government. • OBJECTIVE – to promote synergistic collaborations in mental health and substance use disorder research across Texas university systems and to advance the research component of the Texas Statewide Behavioral Health Strategic Plan.  • FOCUS AREAS – (1) depression;(2) first episode psychosis;(3) substance use disorder; (4) bipolar disorder and schizophrenia; and (5) community systems research.

32. 86(R) SB 63 Texas Mental Health Care Consortium • 86(R) SB 63 (Nelson) also includes a research component. • The Consortium is directed to: • Develop and implement a mental health research plan; • Create an aggregated inventory of mental health and substance use disorder research completed by institutions of higher education in Texas; and • Coordinate mental health and substance use disorder research efforts by state-funded medical schools to ensure those institutions engage in effective and targeted research, which can be used asleverage for additional funding.

33. Additional Opportunities to AdvanceTexas Behavioral Health Policy • Build on momentum created by the Texas Judicial Council’s Mental Health Committee. • Do more to address Texas’s behavioral health workforce emergency. • Address the tragic impacts of opioids and other substance use on Texans, their families, and their communities.

34. The truth is: mental illness affects more people than you may think, and we need to talk about it. It’s Okay to say…”  okaytosay.org