Meeting the Mental Health Needs of Texans:

The State of Mental Health Challenges and Innovations in Texas

Sam Shore, LMSWDirector, Mental Health TransformationMental Health and Substance Abuse Division

Page 2

Overview

• Identify key data points that indicate the mental health needs and challenges of Texans

• Describe Innovations In Policy, Programs and Practices that are being tested, or widely deployed, to address the needs of Texans

Needs and Challenges

Page 3

Mental Illness Strikes More Americans Each Year Than Other

Serious Illnesses

0

5

10

15

20

25

30

% A

du

lts

Mental Illness

Serious Mental Illness

CVD Diabetes Cancer Asthma

CDC BRFSS, SEER Cancer Statistics Review, 1975-2002, “Prevalence, Severity, and Co-morbidity of 12-Month DSM-IV Disorders”  Arch Gen Psychiatry.  Vol. 62, June 2005

Page 5

Need Met for Community Mental Health Services in Texas

ADULT

2010Adult

Population (18+ years)18,789,238

2010Estimated Number with Serious and

Persistent Mental Illness

488,520

FY2010 Number Served in

DSHS-Funded Community Mental Health Services(including NorthSTAR)

156,880(33.6%)

Sources:2010 Adult (18+)/Child (9-17) Population from Demographic Analysis Unit, Research Division, HHSC, based on population projections for 18+ by the Texas State Data Center at the University of Texas (San Antonio).2010 Estimate of Adults with Serious & Persistent Mental Illness based on methodology from Federal Register, Volume 64, Number 121, Thursday, June 24, 1999, Notices, pages 33890-33897.2010 Estimate of Children with Severe Emotional Disturbance based on methodology from Federal Register, Volume 63, Number 137, Friday, July 17, 1998, Notices, pages 33661-38665.FY2010 Number of Adults/Children Served with Resiliency & Disease Management (Service Package 1-4) including NorthSTAR.

Prepared by: Decision Support Unit, Mental Health & Substance Abuse Division, DSHS.

Page 6

Need Met for Community Mental Health Services in Texas

CHILDREN

Sources:2010 Adult (18+)/Child (9-17) Population from Demographic Analysis Unit, Research Division, HHSC, based on population projections for 18+ by the Texas State Data Center at the University of Texas (San Antonio).2010 Estimate of Adults with Serious & Persistent Mental Illness based on methodology from Federal Register, Volume 64, Number 121, Thursday, June 24, 1999, Notices, pages 33890-33897.2010 Estimate of Children with Severe Emotional Disturbance based on methodology from Federal Register, Volume 63, Number 137, Friday, July 17, 1998, Notices, pages 33661-38665.FY2010 Number of Adults/Children Served with Resiliency & Disease Management (Service Package 1-4) including NorthSTAR.

2010Child

Population (9-17 years)

3,094,475

2010Estimated Number

with Severe Emotional

Disturbance154,724

FY2010Number Served in

DSHS-Funded Community Mental Health Services(including NorthSTAR)

44,787(28.9%)

Prepared by: Decision Support Unit, Mental Health & Substance Abuse Division, DSHS.

2,76

3 3,43

1

3,60

0

3,73

6

3,90

6

4,00

2

4,03

8

4,11

6

4,35

8

4,34

4

4,49

8

4,59

7

4,79

8

5,05

5

5,11

9

5,14

8

5,09

8

5,17

0

5,26

5

5,40

8

5,56

9

5,67

3

5,96

7

6,24

1

6,46

2 7,14

2

7,36

4

7,68

1

8,03

1

8,11

3

8,43

2

8,74

1

8,92

1

9,23

4

9,42

2

9,65

9

222

306

349

355

350

358

364

352

484

491

464

475

455

459

476

480

523

519

572

604

588

582

546

512

524

684

711

676

598

548

500

563

607

521

468

311

2,98

5 3,73

7

3,94

9

4,09

1

4,25

6

4,36

0

4,40

2

4,46

8

4,84

2

4,83

5

4,96

2

5,07

2

5,25

3

5,51

4

5,59

5

5,62

8

5,62

1

5,68

9

5,83

7

6,01

2

6,15

7

6,25

5

6,51

3

6,75

3

6,98

6 7,82

6

8,07

5

8,35

7

8,62

9

8,66

1

8,93

2

9,30

4

9,52

8

9,75

5

9,89

0

9,97

0

0

2,000

4,000

6,000

8,000

10,000

12,000

Se

p-0

7

Oc

t-0

7

No

v-0

7

De

c-0

7

Ja

n-0

8

Fe

b-0

8

Ma

r-0

8

Ap

r-0

8

Ma

y-0

8

Ju

n-0

8

Ju

l-0

8

Au

g-0

8

Se

p-0

8

Oc

t-0

8

No

v-0

8

De

c-0

8

Ja

n-0

9

Fe

b-0

9

Ma

r-0

9

Ap

r-0

9

Ma

y-0

9

Ju

n-0

9

Ju

l-0

9

Au

g-0

9

Se

p-0

9

Oc

t-0

9

No

v-0

9

De

c-0

9

Ja

n-1

0

Fe

b-1

0

Ma

r-1

0

Ap

r-1

0

Ma

y-1

0

Ju

n-1

0

Ju

l-1

0

Nu

mb

er

of

Pe

rso

ns

Wa

itin

g

Adults Children Total

Adults and Children Waiting for DSHS-Funded Community Mental Health Services

Increasing

Source: DSHS Mental Retardation and Behavioral Health Outpatient Warehouse (MBOW), 10/07/10.Prepared by: Decision Support Unit, Mental Health & Substance Abuse Division, DSHS.

Smoking among BH Population

• Persons with behavioral health conditions, defined as mental illness and/or substance abuse disorders, accounted for 44% of all cigarettes smoked in the United States (Lasser, et.al., JAMA,2000)

• Adults with BH disorders account for 25% of population and consume almost 2X the cigarettes as general pop. (SAMHSA/NSDUH, March 20, 2013)

• Adults with BH disorders are twice as likely to be smokers

Page 8

Adverse Childhood Experiences:The impact of trauma on health

outcomes

Many chronic diseasesin adults are determined

decades earlier, in childhood.

Page 10

Their risk factors are alsoreliable markers for

antecedent problems.

““In my end is my beginningIn my end is my beginning..”” T.S. Eliot - QuartetsT.S. Eliot - Quartets

Dismissing them as “bad habits” or“self-destructive behavior” totallymisses their function.

What is conventionallyviewed as a problem

is actually a solution to an unrecognized prior adversity.

The risk factors underlyingthese adult diseases areeffective coping devices.

Premature mortality and excess morbidity are typically the result of a small number of common diseases.

ACE = Parental Loss

Evidence from ACE Study Suggests:These chronic diseases in adults are determined decades earlier, by the experiences of childhood.

Affective Response

Evidence from ACE Study Suggests:

Risk factors for these diseases are initiated

during childhood oradolescence . . .

Seeking to Cope

Evidence from ACE Study Suggests:

..... and continue into adult life.

Outcome: social and biomedical damage

Another possible outcome.

Evidence from ACE Study Suggests:

Adverse childhood experiences are the most basic basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs.

Challenges

Page 21

Page 22

Texas Health Regions

PHR 1816,900

PHR 2557,300

PHR 36,220,000

PHR 41,067,800

PHR 10765,800

PHR 9540,100

PHR 82,321,000

PHR 111,965,000

PHR 72,565,600

PHR 5766,100

PHR 65,416,800

Delaware

South Dakota

Wyoming

Nevada

West Virginia

Vermont

Indiana

Hawaii

Alaska

Maryland

Utah

Source: Center for Health Statistics, Department of State Health Services and U.S. Census Bureau, State and County Quick Facts

Page 23

State Mental Health Facilities

+ Austin State Hospital

+ +

+

+

+

+++ Terrell State Hospital

+ Rusk State Hospital

North Texas State Hospital(Vernon/Wichita Falls)

Big Spring State Hospital

Waco Center for Youth

Kerrville State Hospital

San Antonio State Hospital

El Paso Psychiatric Center

Rio Grande State Center

+

Approximately 10 beds per 100,000 population (2008)

Page 24

Texas Community Center Service Areas

Source: Texas Council of Community MHMR Centers, Inc.

The behavioralhealth care that Americans receive

The behavioral health care thatwe know to be effective

Recovery/ResiliencePromising and

Evidence Based Practice

Information Technology

Bridging the Quality Chasm

Page 26

Challenges

• Increasing Population• In last decade Texas grew by more than entire population of Vermont and

Arkansas combined (U. S. Census)• Increase in diversity - culturally and linguistically

• Uninsured Individuals• Texas has highest number of uninsured in all of the 50 states• Lack of insurance is disincentive to seek care early - people are further in

their disease when they seek help

• Workforce Shortages• 60% of licensed professionals in the state are located in Houston, San Antonio and Ft.

Worth (DSHS survey of LMHA’s excluding NorthSTAR)• In rural areas one licensed professional may be covering six or more counties-not

uncommon (DSHS survey of LMHA’s excluding NorthSTAR)• Provider population is aging

Page 27

Mental Health HPSAs

Innovations

Page 28

Page 29

Innovations in Programs and Practices

• Focus on Recovery and Resiliency (wellness and strengths versus illness and deficits – internal activation)

• Person Centered Recovery Planning• Wrap Around Planning• Use of evidence based and promising

practices• Trauma-informed care and trauma-specific tx

Page 30

Innovations in Programs

• Self Directed Care• Peers and Family Support Services• Consumer Operated Service Programs• Veterans Services that target trauma• Jail diversion programming• Employment, Education and Housing• Integrated Care across service type and

settings

Page 31

Innovations in Use of Technology

Information Technology• Electronic Health Record• Data Sharing and interoperable Systems• Use of Technology to Improve Access to Services

• Telemedicine for Psychiatric Services• Training

• Distance Learning• Online Resource for Educators to I.D. and respond

to signs and symptoms of suicide risk

Page 32

Innovations in Financing

• Center for Medicare and Medicaid Services (CMS)• Money Follows the Person (MFP)• Demonstration to Maintain Independence and

Employment (DMIE)• 1915 (c) Medicaid Waiver for Children's Services –

Youth Empowerment Services (YES)• Medicaid Incentives for Prevention of Chronic

Disease (MIPCD)• 1115 Transformation Waiver

Page 33

The 1115 Transformation Waiver

• Five year demonstration waiver (2011-2016)• Managed care expansion

• Allows statewide Medicaid managed care services• Includes pharmacy carve-in and dental managed care

• Under the waiver, historic Upper Payment Limit (UPL) funds and additional new funds are distributed to hospitals and other providers through two pools:• Uncompensated Care (UC) Pool

• Costs of care provided to individuals who have no third party coverage for the services provided by hospitals or other providers (beginning in first year).

• Medicaid Shortfall - The unreimbursed cost of Medicaid inpatient and outpatient hospital services furnished to Medicaid patients.

• Delivery System Reform Incentive Payments (DSRIP)• Support coordinated care and quality improvements through 20

Regional Healthcare Partnerships (RHPs) to transform care delivery systems (beginning in later waiver years).

Delivery System Reform Initiatives

• Category 1: Infrastructure• Examples: telemedicine, improve service availability (hours,

locations, mobile clinics), increase access to crisis stabilization, workforce enhancement

• Category 2: Innovations• Examples: Targeted interventions for special populations,

integration of primary care and behavioral health, peer support, improve transition from inpatient

• Category 3: Outcomes • Related to Cat 1 or 2 projects. Examples: Reduce

preventable readmissions, improve management of chronic conditions

Page 34

1115 Funding Distribution

Page 35

DY = Demonstration YearFY 2011 UPL hospital payments: $2.8

billion per year.

1115 Transformation Progress

• 20 Regional Healthcare Partnerships (RHPs), anchored by a public hospital or related entity have submitted DSRIP projects• 1,335 DSRIP projects were proposed ($9.9 billion = 91% of

available DSRIP funds)• Projects received from 224 hospitals, 38 community mental health

centers, 20 local health departments, and 18 physician practices (included 12 affiliated with academic health science centers)

• Projects include infrastructure (e.g., expand specialty care capacity) and innovation (e.g., patient navigation, chronic care management)

• All 20 regions submitted behavioral health category projects (320).• Behavioral health projects are estimated to represented over 16

percent of the total value of Category 1 and 2 projects (preliminary data)

Page 36

What is MIPCD?

• Medicaid Incentives for Prevention of Chronic Disease (Sec 4108 ACA)

• Competitive five year federal grant opportunity from Centers for Medicare and Medicaid Services (CMS). No state match required.

• Funds demonstration projects that use evidence-based incentives to help Medicaid clients adopt healthy behaviors, improve outcomes

• Projects must address at least one of the following goals:• tobacco cessation, • controlling or reducing weight, • lowering cholesterol, • lowering blood pressure, or • avoiding onset of diabetes or improving management of diabetes.

MIPCD State Projects

STATE TOBACCO CESSATION

WEIGHT LOSS

LOWERING CHOLESTEROL

LOWERING BLOOD PRESSURE

DIABETES MANAGEMENT OR PREVENTION

CA X X

CT X

HI X X

MN X X

MO X X

NV X X X X

NH X X

NY X X X

TX X X X X X

WI X

What is WIN?

• Wellness Incentives and Navigation (WIN) – Texas’ MIPCD Project

• $9.9 million grant• Medicaid & State Health Services partnership• Project imbedded in HHSC delivery system• Randomized Controlled Trial in Harris Service

Delivery Area for Medicaid Managed Care• 1,250 participants

4040404040

Target Population

• Medicaid Managed Care (STAR+PLUS) members, ages 21 – 55 who:• Live in the Harris service delivery area

(Harris, Austin, Waller, Fort Bend, Montgomery, Wharton, Brazoria, Galveston and Matagorda Counties)

• Are not receiving Medicare• Have either –

• serious mental illness, OR • behavioral + chronic health conditions

41

Why WIN?

• Risk - People with behavioral health conditions are significantly more likely to suffer chronic physical disease, and to die at a younger age. (29 years earlier than other Texans.)

• Cost – Behavioral health conditions contribute significantly to higher medical costs (readmissions, ER visits, etc.)

• Opportunity - STAR+PLUS is Texas Medicaid’s dominant health care delivery system for adults with disabilities. Significant potential for large scale change, if successful.

42

Research Structure

• Randomized trial• Intervention, Control and Comparison Groups• Intervention and Control Groups in the Harris SDA• Comparison Groups reside outside of Harris• Why a comparison group?

• Even in randomized trials, there can be bias in terms of who agrees to enroll

• Allows comparison of study participants to the larger STAR+PLUS population

43

Indicators

• Development and achievement of personal health goals

• Improved health as measured by • Changes in blood pressure• Changes in weight and BMI• HbA1c control

• Improved health care use (e.g., reduced potentially preventable inpatient admissions, readmissions, and emergency dept. visits)

• Better adherence to treatment such as:• Initiation and maintenance of treatment for alcohol dependence• Initiation and maintenance of treatment for depression• Appropriate use of asthma medications• Comprehensive diabetes care

44

WIN Interventions

• Person-centered wellness planning with professional health navigators, who are trained in Motivational Interviewing (MI) techniques.

• Wellness Recovery Action Planning training (WRAP) to enable participants with more severe mental illnesses to take full advantage of wellness planning.

• Flexible wellness account to support specific health goals defined by the participant in the individual wellness plan. ($1150 / yr., administered through the navigator)

45

Flexible Purchases: Examples

• Devices that promote wellness goals (e.g., digital scale, BP monitor, mobile device and / or app for physical activity, etc.)

• Transportation to wellness activities (e.g., support groups, gym, etc.)

• Subscriptions or memberships to promote wellness (e.g., YMCA, fitness magazine)

• Behavioral Interventions not currently covered by STAR+PLUS (e.g., relaxation, visualization, etc.)

• Individual wellness education• Family-based Wellness Training and Interventions• Nutritional or Medical Food • Other items approved by the Harris Project Manager

Thank You!Sam Shore, LMSW

512-206-5237

Sam.shore@dshs.state.tx.us